Frontline Managers

Colorado

The Colorado region is improving patient care and saving millions by providing high-risk patients extra attention after discharge, leading to a reduction in readmission rates. In the Post Acute Care Transitions (PACT) program, nurse practitioners visit patients in their homes after discharge from a hospital or skilled nursing facility, giving them a chance to alter the patient’s care plan if needed. The PACT team has visited approximately 4,200 high-risk patients since the program began in January 2013. At that time, 22 percent of high-risk patients were readmitted within 30 days, at a cost of $11.7 million. The PACT team has reduced readmission rates by 50 percent, saving Kaiser Permanente approximately $6 million since the program began.

Georgia

To make sure no good deed goes uncopied, the Georgia region launched a Spread and Sustain system to move best practices throughout the region—and showed off the results to KP’s board of directors at a UBT fair early last summer. Georgia took a spread blueprint from the Southern California region and fine-tuned it to meet its needs. Now its unit-based teams, sponsors and regional leaders identify projects with good spread potential, determine other locations where the new process could work, share the practice and check back to see how they’re being sustained. Several projects have been successfully spread region-wide—addressing such issues as hypertension, HPV vaccinations and lab specimen collection.

Hawaii

Hawaii is a beautiful place to live, but Kaiser Permanente members who live on the less-populated islands sometimes find it challenging to get the care they need. To address that, KP offers a special benefit called Travel Concierge Service. If health plan members need medical care that isn’t available on their island, KP assists them in traveling to the Moanalua Medical Center in Oahu or to a specialty care medical office. KP makes the travel arrangements and picks up the tab for travel, including airfare, shuttle service and discounted hotel rates. For minors who need specialty care, KP also pays for companion travel. “Our members love this service,” says Lori Nanone, a sales and account manager in the region.

Mid-Atlantic States

For several years, co-leads in the Mid-Atlantic States have compiled monthly reports of their UBT activities, goals and progress using Microsoft Word and Excel. Now, the region is rolling out a dashboard that automatically compiles the same information from UBT Tracker into an easy-to-reference SharePoint site, Kaiser Permanente’s new online social collaboration tool. The new dashboard will encourage more frequent updates to UBT Tracker and eliminate the need for co-leads to create separate documents, says Jennifer Walker, lead UBT consultant and improvement advisor. “Now the information we get is more timely and easier to assess,” Walker says. “Before, the information was up to a month old.”

Northern California

The Santa Rosa Medical Center Diversity Design committee is equipping employees with tools to help them provide better service to Spanish-speaking patients. The group, composed of labor and management, has been piloting a handout featuring a list of common Spanish phrases, such as ¿Necesita un intérprete? (“Do you need an interpreter?”), as well as instructions on using the phone interpreter system. The idea came from a Spanish-speaking patient on the facility’s Latino patient advisory committee, who recalled the time she was lost in the facility and no one could direct her in Spanish. The Spanish language flier is the latest in the committee’s work to help ensure all patients receive the same optimal service and care.

Northwest

Unit-based teams in the Continuing Care Services department are focusing on improving the experience for some of Kaiser Permanente’s most vulnerable members: those in skilled nursing facilities or receiving home health, hospice or palliative care. Teams are focusing on ensuring better transitions for patients as they go from inpatient to ambulatory care. By identifying issues before they become problems, labor and management hope to coordinate care more effectively, reduce emergency department visits and cut down on outside medical costs.

Southern California

Harmony comes easily when you use the tools of partnership. Just ask the Biohazards, a band of union members and a manager that uses partnership principles to guide performances. “We call ourselves an LMP project,” says Mary Anne Umekubo, a clinical laboratory scientist and Regional Laboratory assistant director who sings and plays percussion and guitar. She is among six band members who represent a variety of departments, shifts and unions, including SEIU-UHW and UFCW Local 770. Performing for friends and colleagues, band members use consensus decision making to choose songs, interest-based problem solving to fix mistakes and the Rapid Improvement Model to tweak performances. “We’re from different departments,” says drummer Eric Cuarez, a regional courier driver and SEIU-UHW member. “We come together to play music.”

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.”

For years, success eluded the Baldwin Park Critical Care team. Mired in distrust, staff members didn’t participate in unit-based team meetings. As recently as 2011, few in the 49-member department knew the team existed.

“I didn’t even know what UBT stood for,” says Sheryl Magpali, RN, a member of UNAC/UHCP and now the team’s union co-lead. “No one claimed to be part of it. It was pretty much nonexistent until 2013.”

With a new manager on board, interest in the UBT grew. Staff members from the Critical Care Unit and its sister department, the Step-Down Unit, elected 12 representatives, who in turn chose Magpali as the labor co-lead. Celso Silla, RN, the new department administrator, became the management co-lead.

Old issues die hard

It was rough going at first.

Attendance was spotty. When the team did meet, members focused on long-simmering grievances about labor and personnel issues. The team reached out to Charisse Lewis, Baldwin Park’s UBT consultant. While consultants often focus on helping teams with using the Rapid Improvement Model and designing tests of change, they also help teams learn to work as teams—clearing up issues that are distracting them from the work at hand.

Lewis’s first steps were to encourage the team’s union members to meet separately with a labor representative.

“That helped relieve the stressors of the union issues,” Magpali says.  Now, she says, “team meetings focus on changes that affect the unit, rather than things we have no control over.”

The department—nearly all nurses, but also including ward clerks, who are SEIU-UHW members and one of whom is a team representative—began building trust in other ways, too. At Lewis’s suggestion, staff members organized a bowling night and had dinner together. This summer, they held a backpack drive.

Moving the team forward

“Charisse has been good at guiding us—attending our meetings, observing and listening and seeing how we can do better,” says Silla.

Lewis didn’t stop with team-building activities. She coached Magpali, a soft-spoken nurse, to speak up during meetings and make her voice heard, and she helped Silla overcome his reluctance to leave his union co-lead in charge of meetings.

Once trust was established, the team could turn its attention to improving patient care, with remarkable results. UBT members have reduced central line-associated bloodstream infections from five in 2014 to none as of August of this year. Buoyed by that success, they are working to reduce catheter-associated infections.

Silla attributes the improvements to the culture of partnership and putting frontline employees in charge of decisions that affect their work.

“We would have been in limbo” without Lewis’s guidance, Silla says. “Now we’re on the same page. We can be a Level 5 in the future.”

When it comes to metrics, even the best teams can get muddled.

At such times, a good team realizes it needs help—that it’s time to ask for assistance from someone with specialized skills. In the Northwest region, teams can turn to Ed Vrooman.

His enviable strength? An ability to crunch numbers, connect the dots and break down the complexity of the data so that unit-based teams get the information they need to do their work.

“It’s easy for teams to fall into analysis paralysis, where they dissect every data point. I work with them to know the why and the what,” says Vrooman, who started as a part-time phlebotomist 18 years ago at Portland’s now-long-gone Bess Kaiser Hospital. Today, he does double duty as a union partnership representative (UPR) for the Coalition of Kaiser Permanente Unions—he’s a member of SEIU Local 49—and as an improvement advisor.

A broad perspective

His atypical career path has given him an unusual outlook. In 2003, Vrooman took an extended leave of absence to work for Local 49, helping organize KP employees and other health care workers. After returning to KP, he became a labor partner and brought the coalition’s interests to the building of the new Westside hospital and other major regional projects.

“Partnership has allowed me to touch nearly every function within this organization,” Vrooman says. Working on the large initiatives got him more intrigued with the data side of the house—and led to his current position, which gives him an opportunity to use his skill with data and analytics. 

When he heard from the region’s UBT consultants that teams didn’t have the data they needed to work on projects, Vrooman became—along with the data analytics department and health plan leaders—a driving force in the creation of the region’s scorecards for teams. The STATIT scorecards (named after the electronic system that hosts them) enable teams to see their goals online and how they line up with the regional and PSP goals.

Co-leads’ gathering

Every year, Vrooman, along with the other two UPRs in the region—Bruce Corkum, RN, an OFNHP/ONA member, and Mariah Rouse of UFCW Local 555—present information on regional goals and budgets in one of the quarterly Steward Councils, which bring together the region’s UBT union co-leads and representatives from its four partnership unions. For the meeting on regional goals, the management co-leads are invited as well, providing a chance for team leaders to learn together how their teams can have an impact.

When he’s working directly with a team, Vrooman mentors and coaches its members on using improvement tools, from understanding the fundamentals such as SMART goals and entering projects into UBT Tracker to more advanced tools like process mapping. He asks his team members what they need to be successful.

“You don’t need a title to be a leader,” Vrooman tells them. “You lead from where you stand.”

The Family Practice unit-based team at the Sunset Medical Office in the Northwest was thrilled that its work to get members to sign up on kp.org was a success. But team members quickly grew dismayed when the onslaught of new signups had an adverse effect on patients’ experience.

The challenge began in 2014, when the team launched several projects to increase the number of Kaiser Permanente members signed up on kp.org, knowing that people who use kp.org usually give KP higher satisfaction scores. The office is located in Hillsboro, Oregon, near one of Intel’s campuses. Intel offers Kaiser Permanente as a health plan option, so the effort to get more people online made perfect sense.

But, on the flip side, the increased number of messages coming in through kp.org wound up increasing turnaround times for return emails and phone calls.

More than two-thirds on kp.org

The department now receives between 450 to 650 email messages per week. Seventy-one percent of its patients—29,000 members—are signed up on kp.org. The team sought to improve its turnaround time on messages by reducing the number of times staff members and physicians touched each message. Instead of multiple people working a message, each one is now triaged one time by either an LPN or RN. At the same time, the team decreased its time spent on messages per week from 13.6 hours to 10.9 hours.

Ed Vrooman, an improvement advisor and union partnership representative, coached team members on how to test and implement their improvements.

“We learned how to use process mapping, so we could identify where the holes were in how we were approaching the work,” says Eliseo Olvera, the assistant department administrator and the UBT’s management co-lead. “Ed knew where we could get the data we needed and help us understand it, so we could do the work.”

Vrooman also introduced the team to the 6S tool—sort, simplify, set in order, sweep, shine, standardize—to improve its work processes. The team broke into different workgroups and each group identified tests of change. Some of the ideas were abandoned, some were refined and adopted, and some still are being adapted.

Staying on track

“I tended to focus too much on the information and the numbers,” says Rikki Shene, a licensed practical nurse and SEIU Local 49 member who is the team’s union co-lead. “Ed helped keep us organized and simplified the data so that we could keep moving forward and accomplish something in our 45-minute UBT meetings.”

Vrooman’s role in the team has been critical for the team. He attends the co-lead planning sessions and UBT meetings. He stays in the background until needed—and then he speaks up.

“He’s part of our community,” says Olvera. “His expertise with data has been critical. It’s a gift.”

The Mid-Atlantic States region has approximately 220 unit-based teams with more than 5,200 members. 

One problem, though: Some of those who belong to UBTs don’t know it.

The region’s seven UBT consultants, who made a commitment to work together as a UBT themselves, are trying to change that.

“Employees can’t contribute to the success of the team if they don’t know they are part of the team,” says Tracy Schrader, one of KP’s UBT consultants in the region, who is also an improvement advisor and OPEIU Local 2 member. “They don’t realize they can speak up.” 

From their travels around the Capital Beltway to team meetings and huddles, the consultants—each of whom supports about 35 teams—knew there was a disconnect for some UBT members. So when they established their own team’s 2015 goals, they planned two main tactics: to host several UBT Fairs to raise the profile of UBTs, and to improve communications so all UBT members know they are on a team.

The fairs, which the consultants originally were planning to hold at the region’s largest centers over the summer, would showcase the work of the teams at that facility and highlight such LMP initiatives and priorities as Total Health, Workplace Safety and the Ben Hudnall Memorial Trust, which provides a variety of resources for career-advancing education.

“We wanted to hold fairs that would have a strong impact,” says Jennifer Walker, RN, a lead UBT consultant and improvement advisor.

Surprising news

Then—just as happens with frontline teams—they received some data that surprised them. The 2014 People Pulse results showed that some locations the consultants thought would score poorly on UBT-related questions scored well and vice versa. Armed with that data, the consultants decided to hold the first five fairs at the centers that had the most teams with more than 10 percent of members answering “no” when asked “are you in a UBT?”

“It was a real eye-opener,” says Preena Gujral, another MAS UBT consultant and improvement advisor who’s a member of OPEIU Local 2. “Data is very important. It’s perception versus reality.”

The data also led the consultants to combine their two tactics:  The fairs would be the method for communicating the message that all work group members are indeed part of a UBT.

Walker, one of the region’s lead consultants, says it can be difficult to get the message across, especially with large departments. Unlike small departments where everyone participates in UBT meetings, larger departments typically have a core group of employees who attend UBT meetings as representatives of everyone on staff. Employees who aren’t representatives don’t always realize that they are part of the team, too.  

The energy and attendance of the first UBT Fair that the consultants sponsored, held at the end of June at the Fair Oaks Medical Center in Fairfax, Virginia, was higher than they expected, with more than 150 employees stopping by.

“The participation was fantastic,” says Wendy Williams, RN, a UBT consultant and member of UFCW Local 27.

Irene Taliaferro, a gastroenterology nurse practitioner, attended the fair at Fair Oaks in late August. She hadn’t realized she was a UBT member.

“I came to find out more about UBTs. Before I came to the fair, I knew nothing about them,” says Taliaferro. “We have a representative who goes to meetings. I don’t know much about it.”

Providing incentive—and a model

Steve Pereira, UBT consultant and improvement advisor, hopes the blitz of UBT Fairs gives workers like Taliaferro a better understanding of the partnership and an incentive to be more involved.

“People want to know more than their 9-to-5 jobs,” Pereira says. “This is the opportunity for that.”

Because of their commitment to use the same tools as frontline UBTs, the consultants have been using the Plan, Do, Study, Act cycle of the Rapid Improvement Model in planning and holding the fairs.

So, Walker says, “We structured it so the fairs happen before the annual People Pulse is taken again, in September”—that way, the fairs serve as a test of change. Will the communication provided by the fairs improve the score on the “I’m in a UBT” question?

“We’ll look for the next People Pulse results to validate whether this was the best way to go,” she says.

Watch for an update on the consultants’ efforts next year on LMPartnership.org, after the 2015 People Pulse results are in.

I’ve had the privilege of working for Kaiser Permanente for more than 30 years, and it was clear to me from day one that there is something different about our organization and the people who work here.

We’re big, with more than 175,000 employees and 18,000 physicians who provide coverage and care for more than 10 million members. What makes us unique, though, is our mission—to provide high-quality and affordable health care and to improve the health of our members and the communities we serve—and the actions, behaviors and decisions we take to support our mission. We walk the talk.

Our success these past 70 years has been the result of a lot of tremendous work and effort, individually and collectively, by hundreds of thousands of people. Today, we are fortunate to have great people working in all parts of the organization who are well-informed, highly motivated and focused on fulfilling our mission. We have leaders at every level who are delivering better health for all.

Early in my career at Kaiser Permanente, I gained an appreciation for the important role labor has played throughout our history. In fact, labor plays a broader and very different role at Kaiser Permanente than it does in many companies across America. Part of the reason we have worked well with labor is that even when we’ve had disagreements, unions have demonstrated a lasting interest in the success of Kaiser Permanente and the employees they represent, especially during challenging times.

I also have a personal appreciation for the role of labor in our society. My father belonged to a carpenters union. Unions were a voice advocating for the American dream for my family—saying my father should get work, he should be fairly paid, he should be treated right. My father had the jobs he had and the job protection he had because of the unions stepping up and speaking out.

At Kaiser Permanente, we place a tremendous value on creating and maintaining an environment where people not only feel comfortable speaking out but are encouraged to do so—and the Labor Management Partnership unions are actively supporting this culture. We want everyone in this organization sharing their best thinking every day, so we can create the best experiences for our members and patients, no matter where, when or how they come in contact with Kaiser Permanente—which is the essence of One KP.

As we look to the future, we need to continue to bring our best thinking forward during a time of dramatic change in health care. We need to have the mindset that we are going to embrace this change and lead the industry in charting the course for 21st century health in this country, so we can carry on the legacy of Kaiser Permanente for many years to come.