Quality

In health care, there is no such thing as “normal business hours.” Babies insist on being born at 3 a.m. A car crash or bursting appendix can land a patient in the Emergency Room at noon or midnight or 5 a.m. To prevent infections, the cleanliness of hospital rooms is just as important at 4 a.m. as at 4 p.m.

So what’s a unit-based team to do? Full participation in a team’s performance improvement work from all members on all shifts can send service and quality scores soaring—while shifts left out in the cold can drag down a whole department. It’s hard enough ensuring all members of a single shift are on board.

But getting everyone onboard around the clock is a daunting challenge. Shifts that pass in the night may be oblivious to the other’s particular challenges and culture. They might not fully understand how their own work affects the other shift’s workflow. Rivalries and finger-pointing can ensue.

NIGHT OWLS IN THE LAB

As the double doors swing open, cold night air blasts into the receiving bay at the Regional Reference Laboratory in North Hollywood, California. Employees are ready, bundled up in knit scarves and hoodies. It’s 11:30 p.m. on a mid-February night, and couriers are delivering gray cooler bags filled with vials and tubes of specimens from all over Southern California. Clinics from Kern County in the north to San Diego, nearly 180 miles south, have closed for the evening. Now all of those blood tests and urine samples have to be processed and analyzed so providers can detect disease or spot the warning signs of a developing chronic condition.

At the specimen processing department, the graveyard shift is the busiest. “We’re like the mailroom,” says Leland Chan, supervisor and management co-lead. More than 10,000 specimens go to the automated chemistry department during the graveyard shift, compared with about 4,300 in the morning and nearly 9,000 at night.

Michael Aragones, the labor co-lead, likens the three shifts to gears all rotating together and powering each other forward. But not so long ago, the gears were getting jammed up.

Building resentments

Something was going on: Staff members on each shift thought the workload wasn’t being distributed equally—and they were getting the short end of the stick. Employees with different duties on the same shift felt the same way about their peers.

“There was a lot of ‘back talk’ between the shifts,” says Aragones, a lab assistant II and member of SEIU UHW. “People would say, ‘How come they are doing this or that?’ and ‘How come I have so much work?’ ”

The unit-based team was the vehicle for improving the workflow. Team members from all shifts got involved collecting, collating and analyzing data about the specimen count, hour by hour.

Riverside EVS attendant Virginia Gonzalez, a United Steelworkers Local 7600 member.

The results revealed why employees were feeling overworked: Between 2008 and 2010, the number of specimens going to bacteriology, for instance, increased from fewer than 4,000 to more than 5,000. Moreover, the time of night that most specimens arrived had changed. The lab used to see a big spike around 9:30 p.m.; now the rush came about 11 p.m. So the team adjusted the start and end time of the graveyard shift to match the flow of work coming in.

“At first, there was a lot of resistance,” Chan says, with employees worried about child care arrangements and traffic. The data, however, “gave us a better understanding of the workflow,” which let staff members see why they were being asked to make changes. “It was the UBT that helped solve that.”

 “It wasn’t managers saying, ‘Well, you just have to,’ ” Aragones says. “We have to look at workflow for the whole department, not just one shift. It’s like a spider web. You pull one strand, and it affects the whole thing.”

Now that the work is flowing better, the UBT is working on new initiatives.

“The UBT makes my life easier,” says Chan. “It allows me to work more closely with the crew because we are on equal terms. Sometimes, as a manager, you don’t have all the answers. They do the work, they are the experts.”

COOKING UP CAMARADERIE

It is 7:15 p.m. in the kitchen of the Downey Medical Center. “Huddddlllle!” shouts Francisco Vargas, a gentle giant of a man. The sound of his booming voice echoes off the tile floors and stainless steel work surfaces. One of about 20 SEIU UHW members working the night shift in the Food and Nutrition department, Vargas gathers the troops before they begin to wash dinner trays and deliver late meals to patients.

Assistant Department Administrator Patricia Villareal and her union partner Amelia Cervantes review new data on the team’s improvement projects, such as cooking less soup on weekends so less is wasted, and give a reminder about clocking in accurately.

The huddle ends with a team cheer—“Work hard, stay positive!”—and with that, food service kitchen worker Nancy Rudeas, an SEIU UHW member, and a colleague scurry off to prepare two late dinner trays. They double-check to see that a patient’s special request for green tea is being filled (it is).

“I love doing this,” Rudeas says, heading up on the elevator.

A few late tray deliveries have become a fact of life for the department, a consequence of abandoning set meal times in favor of a “room service” model: Patients simply make a phone call when they are ready for a meal, just like a hotel guest might.

This patient-centered innovation meant the workflow changed. Foreseeable peaks and valleys in cooking and cleaning became a less predictable, variable demand. Tasks that once had been the domain of one shift or the other “leaked” into the next shift. Tensions rose among employees as the distribution of work was thrown into flux.

“Because we have a UBT, we could sit down together and ask, ‘How can we get this resolved?’ ” says Villareal.

Together, the team experimented with adjusting start times for different jobs in the department until it settled on a mix that’s working. “The morning picks up for the night shift, and the night shift picks up for the morning,” she says.

From OK to great

The department set out to improve its customer service scores in September 2008. Though a respectable 86.7 percent of patients surveyed agreed with the statement “the people serving my meals were polite and professional,” that was nonetheless among the lowest scores in the Southern California region.

Together, the UBT members came up with a script that encourages food service workers to introduce themselves by name, ask if they can open any containers, and—most crucially—ask if there is anything else they can get for the patients. By consistently using the script, by October 2010, the score shot up to 99 percent.

Night-shift workers like Rudeas have contributed to that success. The shifts share information in huddles and bulletin boards.

“What goes on during the day, we know at night,” she says. “And what goes on at night, they know during the day.”

A SWEEPING SUCCESS

The Environmental Services department at Riverside Medical Center is continuing its winning streak: In 2010, it went 260 days without a workplace injury. The UBT received a huge banner congratulating it on the achievement, and the co-leads thought it would be nice if each team member signed it before hanging it up.

The banner remained out for a few days to make sure all staffers had a chance to sign—including the workers who come in at 11 p.m. for the graveyard shift. Only then was the banner hung up on the unit wall.

“This made a huge difference,” says Angel Pacheco, who will become the new management co-lead in May and who himself works the night shift. “This actually shows that everyone is involved and can take pride and ownership.” After all, performance metrics are measured by department, not shift, and night shift workers contributed to creating a safer workplace as much as their day shift counterparts.

The EVS team posts a flipchart sheet after every monthly UBT meeting with three to four important items of information to pass on to the rest of the staff. Each shift reviews the sheet at a daily huddle held at the beginning of each shift. The quick review of UBT business, including key performance metrics, follows the team’s stretching exercises that have helped reduce workplace injuries and won it recognition throughout KP.

The sheet hangs on the door of the supply closet, where each staff member comes when starting work to get carts, trash bags and keys to the offices they have to clean. This strategic placement ensures workers from all shifts have access to the daily UBT updates.

Face time matters

Face-to-face communication augments written communication and helps build the camaraderie that helps teams improve performance. For instance, Pacheco makes a point of visiting the night workers in the outlying medical office buildings—he drives an hour to Temecula to see one employee.

“It’s worth it,” he says. “I just take the time to reflect on things.”

Paula Cunningham, an EVS attendant and member of Steelworkers Local 7600, is one of four union members on the 6 p.m. to 2 a.m. shift responsible for passing information from the UBT’s representative group meeting to her shift colleagues.

“They trust us to deliver the information to them,” says Cunningham, whose work schedule is adjusted so she can attend representative group meetings in the early afternoon. “We talk frequently and rely heavily on huddles.” Other night shift workers also rotate into the group’s meetings.

Because he’s an on-call employee, Robert Casillas works all the shifts, so he has insights into what makes each shift unique.

The morning shift is more hectic, he says. The evening work is much calmer. More people are cleaning sections solo, but they pass one another in the hallways and share information with each other then.

“We have our communications plan, which we share with the other staff,” Casillas says. “We don’t want anyone to think we’re hiding stuff. And when the information comes from us, it’s less like a demand from management. It’s more about figuring out ideas to help us do our work.”

Sometimes, seeing the hospital at the end of the day as they do, it is night shift employees who spur the entire department into action.

The night workers noticed the hospital was running low on privacy curtains. When the ones soiled during the day were taken down, there were not enough from the laundry to replace them. Cunningham brought the information to the representative group, and the co-leads secured more curtains.

“What affects the night shift,” she says, “usually affects all of us.”

After a false start, the diagnostic imaging department at Woodland Hills Medical Center has found its stride. Its results are impressive: By drawing on the wide experience of the team, it’s improving workflow and boosting attendance.

To get those results, the department created one large UBT with several subcommittees and involved a physician champion. Two radiology summits, which were held to set priorities, included the whole team: 

• More than 160 employees and physicians who see a quarter-million patients a year.
• Staff in eight far-flung clinics as well as throughout the medical center. They range in age from late teens to 40-year veterans of Kaiser Permanente.
• Team members in eight areas of expertise, including ultrasound, MRI, CAT scan, nuclear medicine, mammography, general x-ray, and special procedures.  

From confusion to clarity

At first, the team’s diverse skills and experience flummoxed the department-based team (the term Woodland Hills uses instead of unit-based team).  

“We didn’t know the scope of our work,” says Selena Marchand, a lead sonographer and labor co-lead. “The old DBT got stalled talking about things like the doctors’ parking lot.”

A secret society?

In addition, says Marchand, the representative group—which was working without a facilitator—didn’t communicate with its co-workers about the DBT’s projects. “They thought we were some sort of secret society,” says Marchand, a member of SEIU UHW. 

The team restructured in October 2009, electing one delegate from each “modality,” as the areas of expertise are known, to the representative group.

“Pushing responsibility and accountability back to different modalities has been one of our successes,” says Mike Bruse, the department administrator and management co-lead. “We’re focused on things that we can control in our department.”

Summits get everyone involved

The co-leads convened two department-wide summits to focus on improving team performance and set priorities. Staff members brainstormed about what the challenging issues facing the department were and wrote them on flip chart pages on the wall. Then, each employee attached a sticky note to the issues that most concerned them. The team and managers set out to tackle the seven issues that received the most tags. As the work got under way, progress reports were posted in the employee break room to keep everyone on the team—not just the representatives—informed.

Better workflow

The department also improved the way it distributes film to radiologists, so that patients’ results get to primary care physicians faster. Before the change, technicians were forced to constantly interrupt doctors to read films. Now, there is a tally sheet on each radiologist’s door indicating how many films he or she is reading. This allows techs to know who is available to read a film—and allows radiologists to work undisturbed. An aide to the technologists tracks the process, acting as a traffic controller.

“It was a relatively simple thing that improved satisfaction and patient care a lot,” says Mark Schwartz, MD, who represents physicians on the UBT. “And it didn’t cost any money.”

Better attendance

The team also improved attendance, decreasing last-minute sick calls by 14 days from the end of 2009 to October 2010. They beat the Lab Department in a friendly competition two quarters in a row and were rewarded with a barbeque. To do this, team members simplified presentation of attendance data and posted up-to-the-minute metrics.  

Beyond these gains, management co-lead Bruse says the most significant change is employees’ confidence in their own ability to make improvements.

“Our meetings used to be ‘complain to Mike,’ ” he said. “These days, when people see a problem, they take steps to solve it themselves.”

"Anyone who has never made a mistake has never tried anything new."

—Albert Einstein

This is the story of a team that never failed a test of change. No matter what the team members did, rapid improvement cycle after rapid improvement cycle, every small test tried was a better jewel than the one before. They received an A for their PDSAs.

They were fearless—in their imaginations. The only problem with the team’s brilliant tests of change was that they never got tested, never got to the stage where stumbling or failed ideas might have real consequences. There was no learning, no innovation, no growth—just intriguing ideas that remained bottled.

In health care, it’s still frowned upon to talk about failures or things that don’t work out perfectly for fear the information will be used against the people involved. But even in a high-stakes industry where the consequence of some decisions means life or death, there is plenty of room for improving performance by learning from small failures.

Using small failures as learning opportunities is the cornerstone of creating a learning organization. Small failures are at the heart of the Rapid Improvement Model and its plan, do, study, act cycles.

“Despite the increased rate of failure that accompanies deliberate experimentation, organizations that experiment effectively…are likely to be more innovative, productive and successful,” writes Amy Edmondson, a professor at Harvard Business School, in a December 2004 article in the Quality and Safety in Healthcare Journal.

This in fact is a story of false starts: the story of unit-based teams and employees throughout Kaiser Permanente who already are learning, developing and innovating from missteps or downright unsuccessful small tests of change.

From projects that changed direction after data contradicted the original premise, to tests of change that were tweaked or abandoned all together, workers describe how they tried a small improvement that didn't turn out as expected and still gained from the experience. And even, eventually, found success.

Learning to fail

At San Diego Medical Center’s Nuclear Medicine department, the unit-based team decided its first test of change project would look at reducing the number of redundant heart scans, which technologists were certain were wasting time and resources.

In November 2009, team members began to track the number of repeat scans to establish a baseline. They figured repeats would be at least 25 percent of the heart scans. After a month of logging the scans, however, they discovered something quite different.

“The number of repeat heart scans was actually between 7 to 10 percent,” says the UBT’s labor co-lead, Jessica Larson, a tech assistant and OPEIU Local 30 member.

The team’s hypothesis was amiss. It switched gears.

Since several of the staff recommendations for test of change projects related to heart scans, the team focused next on the variation in the instructions patients were given. If team members gave identical instructions, they might be able to all but eliminate repeat heart scans.

“The test of change at that point was to make sure everyone was following the protocol,” says Randy Andres, a nuclear medicine technologist and OPEIU Local 30 member.

The team created laminated handouts with one set of clear instructions that technologists and receptionists were to hand out to every patient before a scan.

“We did that for a few weeks, and found it was a lot more complicated than we anticipated,” Larson says. “You had inpatients, outpatients, observation-unit patients….Forms were getting misplaced because patients would leave them in the waiting rooms or in their purse. Or people weren’t even giving them out.”

During the same time, a supply shortage meant the department had to switch the type of injectable radioactive isotope it was using. The change meant a whole new set of protocols. Compounding it all, the department’s longtime manager retired.

It was time to shelve the test of change.

But was it a waste of time? Not at all, say Larson and Andres. Both say it provided valuable information about the department’s work flow—as well as practical knowledge of how to conduct tests of change.

“This was a very good teaching experience for us,” Andres says. “We didn’t even know about tests of change before this. It’s not simply a matter of just changing something. You have to go through this process.”

Too much of a good thing

Further north at Redwood City Medical Center, the Gastroenterology department discovered you can have too much of a good thing.

Contracting with an Oregon company that specializes in mass outreach calls, the department began using automatic robocalls to reach patients ages 50 to 75 who were due or overdue for colorectal screenings.

“We had to think outside the box,” says Julie Dalcin, director of medicine. “This was a way to reach a lot of people.”

The first round of robocalls went out in November 2009, with some 10,000 calls made. They reached 97 percent of the members who were due for the tests—but there was a problem. The calls were made within a span of three hours, and the response overwhelmed the department and the facility. The voicemail box the team had set up in advance barely helped; it could take only 50 messages.

“We got bombarded by calls from patients calling back with questions or requests. Our operator was inundated,” says manager Isabel Uibel. “Physicians in other departments were also bombarded with calls. People…were like, ‘What’s going on?’”

Michele Coons, a medical assistant and SEIU UHW member, was devoted to returning the calls and to mailing “FIT kits,” the at-home stool tests that help detect early signs of colorectal cancer, to those who had requested them.

“Many people had a lot of questions,” Coons says. “‘Why did I get this call?’ ‘What does a FIT kit test mean?’”

It took a week to figure out a system for getting back to all the patients, she says.

“I think at the end of day you have to be willing to try,” Uibel says. “And forgive yourself for the time you put into something that didn’t work. And don’t lose motivation. But also know when…you’ve got to say, ‘We’re not going down the right path at all.’”

In some workplaces, what had happened would be labeled a disaster. But not in Redwood City. The essential idea was sound. For the second round of calls, the team addressed the overwhelming response by having the calls made over a two-week period.

“We didn’t think we needed to throw the baby out with the bathwater,” Uibel says. “We just had to keep tweaking to make the system work for us.”

Too good to be true

When it came to how quickly patient messages are responded to, the Internal Medicine at the East Denver Medical Office in Colorado was pretty close to bottom—only 8 percent of patient advice calls were answered within an hour. The team members were open to trying anything, and after several small tests of change, they hit on something so ridiculously simple that some people resisted it.

Nurses tape neon orange cards with the patient message to the door of the exam room where the doctor is working. The doctor sees the message on the way out of the room and goes back to his or her office to respond.

Within the first three months of the test, the department saw message turnaround times soar to 30 percent answered within the hour.

“You had some tangible symbol that you were trying to make these numbers move. It was a great motivator,” says Christopher Hicks, MD, the team’s physician co-lead. “It was different. It wasn’t something that was happening electronically.”

Then they hit a wall.

“We were sitting around threshold or target and then would drop back down,” explains Olivia Wright, supervisor and management co-lead. “We were just hovering around 20 to 30 percent.”

The team brainstormed about why it couldn’t move the number above 30 percent.

Someone suggested one reason could be that the call center opened at 7 a.m. and most of the staff didn’t start until 8 a.m. They were starting the day already behind the curve with waiting messages. Two nurses changed their schedule and started coming in at 7:30 a.m. That seemed to help: 52 percent of patient messages got a reply within an hour.

“You’ve got to give something a shot,” Wright says. “The first thing you come out of the gate with isn’t necessarily going to be the end-all be-all, but you’ve got to start somewhere.”

One of the most surprising lessons for the entire department was the fact that small changes could have such a large impact.

“There was a sense of disbelief,” Wright recalls. “We had to reassure the team that the volume of work hadn’t gone down or that it wasn’t because of the time of year. We’ve sustained these results since May, and it finally started to sink in that small, subtle changes really are the reason for these results.”

Failure is part of experimentation

Experts who study organizations like health care and the airline industry corroborate the importance the process of experimentation plays in organizational learning.

“Under conditions where there’s a lot of uncertainty and constantly moving parts and work is customized or unique, the only way to make it work is to allow the right level of leeway for teams…to experiment thoughtfully,” Edmondson says. In the long run, lasting success comes from a willingness to try new things; but, if you try new things, you're going to fail sometimes.

This isn’t license for projects based on haphazard hypotheses, but it underscores the fact that performance improvement methods such as the Rapid Improvement Model are made for small failures. Because the process allows for quick experimentation, with results evaluated within 30 to 60 days, there is little to lose.

Barbara Grimm, senior vice president of the Labor Management Partnership, would have people ask themselves a few questions that can help them weigh the possibility of failure.

“Have you reasoned through the consequences? That is key,” Grimm says. “Do you have the patient’s interest absolutely there? Do you have a plan if it doesn’t go well?”

Edmondson argues there are two key reasons health care organizations still resist learning from small failures: The culture often discourages questions, challenges, or admissions of error, and a demanding workload and pace force staff to rely on quick fixes when something doesn’t work, instead of systematic problem solving.

That is changing at Kaiser Permanente with the commitment to providing frontline staff with training and support to conduct root cause analysis and problem solving with RIM, RIM+ and other performance improvement tools. And unit-based teams give staff members the place and time to do this work.

John August, executive director of the Coalition of Kaiser Permanente Unions, believes the

true purpose of the Labor Management Partnership is to recognize the mission of KP and the mission of the unions are at profound risk due to the economic, competitive and public policy environment in which we operate.

“We must continually remind everyone in the organization that the why of what we do in partnership is driven by this fundamental recognition and agreement,” August says. “If we don’t make the effort to discuss the reasons why we’re doing this, people will get the impression that people are just being asked to do something. And being asked to do something doesn’t create an atmosphere of safety.”

Edmondson says the sense of safety will further develop when we learn to accept and work with our limitations.

“People need a sense of psychological safety, and frankly a sense of humor about our humanness,” Edmondson says. “Somewhere along the line we get socialized and begin to buy into the absurd notion that we should be perfect.”

Back at the lab

In San Diego, Larson thinks even if the tests of change didn’t work exactly as planned, it gave the team something even more important—the beginning of a different work culture.

“Being able to work on small tests of change enabled us to get past what’s always been,” Larson says. “There are people who have been here longer than I’ve been alive and so are accustomed to the way it was always done. But trying something new can save us time, and save the company money, and can be better for the patient. So I found it nice to look at it like, ‘Let’s try just this little thing and it might just make it better.’”

Larson is certain the eventual reward will outweigh any frustrations in wrong hypotheses or failed tests.

“Either you find you can fix something or you can’t, and you just move on,” Larson says. “Just keep trying. Because ultimately, it’s going to be a success in the end.”