Southern California

As a union partnership representative (UPR) from UFCW Local 770, Annamarie Marin helps support 72 unit-based teams at the West Los Angeles Medical Center. Last year, she helped the Oncology team overcome low morale to move from Level 2 to Level 4—and it’s now on the cusp of achieving Level 5. Marin recently was interviewed about her role as a UPR by LMP Communications Manager Sherry Crosby.

Q. What experiences helped prepare you for your position?

A. I have been part of UBTs since 2005. I started as a co-lead and then became an executive sponsor. This experience helped me tremendously, because I can relate to the teams on a personal level. I have been in the exact same place, dealing with similar challenges.

Q. What is your approach to working with teams?

A. Some teams need team-building exercises, while others need to learn to trust one another and share information on projects. Starter teams don’t know how to create agendas or structure meetings, so I help facilitate their meetings. The most important thing is making sure I’m available and that teams have what they need to succeed.

Q. What early challenges did the Oncology team face?

A. They were struggling with membership involvement and morale was low. Nobody wanted to participate in meetings.

Q. How did you help the team succeed?

A. I helped staff members understand that the UBT is not there to add work to their plate. Eventually, we got a group to participate in team meetings.

We went through different trainings and started on small projects. First, they focused on staff morale. Staff members practiced expressing appreciation for each other until it became part of the team's culture. Then they moved to an affordability project. That was a pivotal point in that team’s development, because the idea came from a labor partner.

It shows team members are involved in decision making and contributing to the department’s success.

Q. What was key to the team’s success?

A. I helped the team members understand their work through a different lens—what the function of a UBT is, and their role in it. They realized they have a great department and an engaged manager. It was really about helping them understand their value to each other.

Early in her nursing career, Yvonne Roddy-Sturm, now the chief nursing executive at Ontario Medical Center in Southern California, saw that caregiver diversity—or lack of it—matters.

“I saw differences in how some providers cared for people,” she says. “It wasn’t just based on race—economic status, language, lots of things came into play. We all make assumptions about others.”

The consequences of such assumptions are serious, impacting the quality of care a patient receives and leading to a wide range of health disparities.

In the 30 years Roddy-Sturm has been with Kaiser Permanente, our member and patient population has become more diverse—as has our workforce. And that’s helped KP deliver high-quality, patient-centered care.

“Patients who can relate to their caregiver are more likely to follow their treatment regimen,” says Roddy-Sturm. “They’re more likely to ask questions of people who are more like them.”

The Labor Management Partnership plays a significant role in building the skills, cultural competence and work environment needed to serve KP’s diverse patient population.

For example:

• Unit-based teams provide a more inclusive workplace and give staff members a safe place to speak up.
• Two LMP-sponsored educational trusts provide tuition assistance, paid time off and career counseling to help employees move up the career ladder.

And there’s more. Many departments, including Ontario’s nursing department, make their diverse teams part of the hiring process.

“We always start with the skills required to do the job,” says Roddy-Sturm. “Then our panel members bring their own insights and diversity to the discussion. They look for fit, flexibility, compassion and empathy, as well as skill. We try to live our values.”

Brandon Johnson was close to giving up on his dream of becoming an X-ray technician.

Born with sickle cell disease, a genetic blood disorder that primarily affects African-Americans, the 35-year-old Southern California man was forced to drop out of school for semesters at a time.

But thanks to the sickle cell care team at the Inglewood Medical Offices, Johnson is now on medication that reduces complications. Last fall, he was able to complete his studies, and he has started looking for a radiology job.

“They got me on a plan to keep me out of the hospital,” says Johnson, who drives 60 miles one way from his Riverside home to see his doctor in Inglewood, even though other providers are closer. “If I didn’t have my health, I wouldn’t be where I am today.”

Johnson’s success is not uncommon for the Level 5 unit-based team, a group of physicians, managers and employees that provides personalized care for nearly 500 sickle cell patients in Southern California. About 300 of the region’s adult patients are treated directly by the team. Its approach is working—only five of the 300 needed frequent hospitalization and emergency care in the past year.

“Our goal is to keep sickle cell patients out of the hospital by giving them the care they need,” says Pippa Stewart, Inglewood’s department administrator.

Stigmatized as drug addicts

Nationwide, about 70,000 people have sickle cell disease, which can cause chronic anemia, acute pain, infections and stroke. Although most are African-American, the disease also affects people of Indian, Middle Eastern, Hispanic and Mediterranean heritage. Patients often get stigmatized as drug addicts when they ask for narcotics to deal with their pain.

The current UBT grew out of a team that was established in 1999; before that, there was no comprehensive treatment program for KP’s sickle cell patients.

“Ninety percent of patients were getting their primary care in the emergency room,” says Shirley Brown, RN, a UNAC/UHCP member and the team’s care manager. Patients saw as many as 17 doctors as they went from appointment to appointment.

Now, the 12-member UBT—which includes four physicians, two registered nurses, a physician assistant, a pharmacist and a social worker—helps patients control symptoms by offering pain management care, providing resources such as a case manager, and urging them to keep appointments, which help minimize visits to the emergency room and hospital.

Team members coordinate with and help train the KP providers who care for the region’s remaining 200 patients. Last fall, Brown helped lead a session for 70 registered nurses from around the region. Osbourne Blake, MD, an internist and the team’s lead physician, provides regular updates to fellow physicians. “We’re trying to get everyone on the same page,” says Dr. Blake. A recent test of change focused on reducing the number of patients who miss appointments. For three months, Brown and a co-worker called patients every day to remind them about upcoming visits. The calls helped. The team’s “no-show appointment” rate dropped from 20 percent in May 2015 to 14 percent in August 2015.

Dramatic improvement

“They all know you personally,” says Ryan Hull, a 27-year-old TV production assistant and film student. A few short years ago, he suffered frequent crises that required immediate medical attention. After he and his physician co-created a pain management program, his health improved dramatically.

“They did everything they could to find out what regimen works for me,” Hull says of staff members, who greet him by first name and offer walk-in appointments to accommodate his sometimes unpredictable schedule. “They figured out the perfect way to treat me.”

Like casts and splints, X-rays are a routine part of patient care in the Orthopedics department at South Bay Medical Center. Unfortunately, missed copays for those X-rays were becoming common as well.

“Patients will get their X-rays done at the end of the visit—and then walk out without realizing that they owe a copay,” says Christopher Kresch, department administrator for Orthopedics and the team’s management co-sponsor. At other times, patients will unexpectedly need X-rays during their visit, and because the orders are placed during the exam, the charges are not captured during check-in.

So the team borrowed a practice from the Los Angeles Medical Center and developed a check-in sheet that shows, at a glance, if a patient has an outstanding X-ray copay. The team also adjusted its workflow to ensure that a staff member walks the patient to the front desk to pay the fee by the end of the visit.

Here’s how the process works:

The receptionist gives the check-in sheet to each patient at the start of the visit. As patients travel through the clinic to receive care, the form goes with them, enabling staff to conduct “warm hand-offs” by writing notes to each other about the patient’s care. When a copay is owed, the last person to interact with the patient escorts him or her to the receptionist.

“It helped us in a lot of different ways, much more than we thought it would,” says Naomi Guerrero, an Orthopedic technician and SEIU-UHW member who is the team’s union co-lead. “Now we can’t live without it.”

Side benefits

After introducing the check-in sheet, the team saw almost immediate improvement in copay collection. In July 2014, missing copays—known as the total collected variance—totaled $2,166. Between August and November 2014, the total collected variance fell to just $533, a whopping 75 percent improvement. Those numbers are holding steady. The department is averaging a 50 percent increase in copay collections through third quarter 2015.

Besides boosting copay collection, the check-in sheet helped the team improve patient care. Unexpected benefits include:

• Keeping patients informed of delays and expected wait times improved patient satisfaction scores. Positive patient responses about staff communication on the Ambulatory Satisfaction Questionnaire (ASQ) rose from 48.67 between August and December 2013 to 57.74 for the same time frame in 2014. The regional target is 54.5.
• Direct booking—when a staff member makes the first appointment for a patient referred to a specialty department—soared from 38 percent of all referrals in July 2014 to 68 percent by November 2014, exceeding the regional goal of 40 percent.

• An increased percentage of patients who receive bone density screenings. In 2013, 89.7 percent of eligible patients received the screening; that rose to 91.9 percent in 2014. The regional target is 85 percent.

Finding the right solution

Before adopting the check-in sheet, the team sought input from a group of staff members and physicians in the department. Incorporating their voices gave them ownership of the project and enabled the team to create a check-in sheet that worked for everyone. For example, physicians rejected an early draft featuring a detailed checklist in favor of blank space to write their orders. And receptionists vetoed an early color-coding system as “too confusing.”

“We learned a lot as we went through our tests of change,” says Guerrero. “We learned there are changes that don’t work out.”

Adoption takes time

Once team members were happy with the check-in sheet, they spread it to the rest of the department. Convincing their peers to consistently use the check-in sheet took time.

“The medical assistants were resistant because they saw the check-in sheet as an extra step,” says UBT representative Zackry Ellis, a physician assistant and member of UNAC/UHCP.

Some providers also were hesitant to use the form, preferring to speak with staff. That’s when the team turned to Anthony Leone, MD, the department’s physician chief, for help.

“He helped us sway others to try it out,” Guerrero says.

Once staff members understood the benefits of the check-in sheet—enhanced copay collection, improved workflow and better patient care—they all began to use it consistently.

Patients are reaping the benefits of the new form, too.

“Because of the check-in sheet, we’re communicating more with our members,” says UBT representative Esmeralda Montes, a lead medical assistant and SEIU-UHW member. “They feel happy and cared for, and that’s our ultimate goal.”