Quality

Kaiser Permanente and the Coalition of Kaiser Permanente Unions set an ambitious goal in the 2012 National Agreement: to have 75 percent of all unit-based teams achieve high performance by year-end 2014—for good reason. As teams develop, they deliver better, more affordable care and a better work experience.

There’s work to be done. More than 60 percent of teams in Georgia, Hawaii and the Northwest are meeting the goal, but overall, just 52 percent of KP’s 3,500 UBTs program-wide were rated high performing as of June 30.

The good news is that nearly 1,800 teams across KP have hit their mark, built performance improvement into their everyday work, and are showing other teams how to do the same.

Modeling the way

The Perioperative UBT at Ontario Medical Center in Southern California is one of those teams.

“It’s about having everyone involved and engaged,” says Michelle Tolentino, RN, one of the Perioperative UBT’s union co-leads and a member of UNAC/UHCP. “We attended UBT training together, got results on our first project (safely reducing patient stay times) and kept rolling.”

The 11-member representative team, which covers more than 60 nurses, surgical techs, medical assistants and others, reached Level 5 on the five-point Path to Performance soon after forming in 2012. Like many other teams in the region, it saw its rating drop in 2013 after a labor dispute led union members to suspend their UBT involvement. When the issue was resolved, the team regrouped and quickly regained its Level 5 rating.

The secret sauce

The team does a few key things right that helped it achieve and now maintain its high performance. Those can be modeled by other teams aspiring to Levels 4 and 5 status:

• Performance improvement tools: “Using our performance improvement tools—process mappings; run charts; plan, do, study, act cycles—keeps us all sharp,” says Mary Rodriguez, assistant clinical director and UBT co-lead. “That’s been key for us: understand the process and use the tools.”
• Constant tests of change: The Perioperative team now has seven active tests of change, most focusing on improving affordability and workflow efficiency. “Our projects often build off of other projects,” says Rodriquez. For instance, a recently completed project helped reduce turnaround time in the OR from 28 minutes to 20 minutes in three months. In a parallel project, the number of patients receiving medication at least 30 minutes before surgery—the ideal time for most patients—increased from 70 percent to 85 percent. Such projects draw on the whole team’s skills and perspectives, she says.
• Physician involvement: Shawn Winnick, MD, an anesthesiologist, assistant clinical director and UBT member, points to another key to success: “Physician presence on a (clinical) UBT is extremely important,” he says. “It brings a different perspective to projects.”

Calling UBTs “the single most powerful vehicle we have at KP to empower employees and lead change,” he notes that physician leaders at the medical center have supported UBT development and helped overcome barriers.

“Staff and physicians need to have the time to consistently make it to UBT meetings,” he says. “Even if it means bringing in someone to cover part of a shift, that is more than paid back by the cost savings and organizational benefits that come out of UBTs.”

The benefits accrue to the workforce as well as patients.

“We have a say in our work process,” says Robert Kapadia, a certified registered nurse anesthetist and member of KPNAA. “I come to the table as an equal partner and advocate for others on the team, and for our patients. Our UBT is a way to solve problems and move forward, not just complain.”

Dr. Winnick adds: “There’s not a single member of our team who hasn’t contributed an idea or helped make us better. That’s a measure of a performance. We all have different skills and perspectives, and we bring all of that to our team.”

Sometimes the best way to spread effective practices is to spread experienced people. That’s what happened when the Alpharetta Ob-Gyn UBT in Georgia zoomed from Level 1 to Level 4 in just 10 months after two nurses from two different high-performing UBTs transferred there at the same time.

Jane Baxter and Ingrid Baillie had been UBT co-leads at two different clinics when they each got a new job with the Alpharetta Ob-Gyn department. They both drew on their experiences to guide their new team when they became co-leads at Alpharetta. “We knew the steps in the process and what to expect,” says Baxter, the department’s charge nurse.

Fledgling teams should begin with small performance improvement projects, they say. “We started with the low-hanging fruit,” says Baillie, RN, a member of UFCW Local 1996. “You don’t need to reach for the stars right out of the box.”

Pick your projects wisely

And, says Baillie, there’s no need to look any further than Kaiser Permanente’s organization-wide and regional priorities to find plenty of ideas for performance improvement projects—and a wealth of data that is being collected regularly.

“KP makes no secret about what is important to it,” says Baillie. “From that alone, you have all the data you need.”

For instance, the Alpharetta team’s first efforts were to improve clinic start time and get a second blood pressure test for patients with high initial readings. “These are important to KP, and they helped us gel as a team,” says Baillie.

“Small wins help develop confidence,” says Baxter. Now the team is taking on more complex cross-departmental initiatives, such as trying to make available online the big packet of paperwork patients need to complete before a first Ob-Gyn visit.

Getting physicians involved also has been part of this UBT’s success. You won’t find doctors who think UBTs are just for clinic staff on this team, says Baxter.

“Our providers are very invested,” she says. “They take minutes at meetings. We are all on an equal playing field.”

South San Francisco allergy team’s specialty may be allergens and hay fever, but that didn’t prevent it from helping to improve patients’ screening rates for cancer, too.

It didn’t happen all at once—some staff members were skeptical at first. Scheduling a screening appointment for a wheezing patient didn’t seem right.

“At first people would say things like, ‘You know, I really don’t feel comfortable saying to a patient, “Oh, you’re due for mammography” when they’re sneezing and congested and here for allergies,’” says Alva Marie Aguilera, the department’s supervisor and management co-lead for the unit-based team.

Screenings as strategy

But part of delivering on Kaiser Permanente’s Total Health promise is to identify health risks and signs of disease as early as possible. Regular screenings for such diseases as high blood pressure, diabetes, and colorectal, cervical and breast cancers are an important part of our strategy.

That means caregivers and employees in seemingly unrelated departments—not just those in, say, internal medicine—have a role to play, and KP HealthConnect® provides them with a powerful tool.

Any time a patient is seen, a “proactive office encounter” message pops up in the member’s electronic record if he or she is due for a health screening or if important health data needs to be updated. It doesn’t matter what the reason is for the current visit or which department the patient is being seen in. 

The members of South San Francisco allergy department took the important work of taking the next step to heart: Following up on the prompt and offering to schedule the patient for the screening or asking the necessary questions to fill in missing information.

Scripts and reminders

To help make sure those things happened consistently, the team tried some small tests of change:

• It created a general script to help broach the questions with patients and posted laminated cards on computers to serve as reminders.
• Aguilera reports the weekly screening numbers so staff members know how they are doing and where they missed opportunities to follow through on the HealthConnect® prompts.

The small changes had a big impact. Before the team started the project in February 2012, it followed through on the prompts 80 percent of the time. In the first two months of the project, that jumped to 90 percent. By early 2013, the prompts were being followed up on 95 percent of the time and held steady at that rate for the rest of the year.

It wasn’t just staff members who were uncertain of the practice in the early days.

“At first it was kind of surprising to patients,” says medical assistant Lidia Vanegas-Casino, a member of SEIU UHW and the UBT’s union co-lead. “So we had to explain to them: ‘It’s a way to help you, and to keep up with the things you need done. It’s a proactive approach to keeping you healthy.’”

Positive example

It was one of KP’s own commercials that convinced team members of their important role in keeping patients healthy. Aguilera showed the ad that features KP member Mary Gonzalez, who had gone in—fittingly—for an allergy appointment when the receptionist noticed she was due for a mammogram and booked an appointment for her. The screening picked up a mass, and Gonzalez subsequently learned she had breast cancer. The early detection helped ensure a positive result.

It wasn’t a primary care or OB-GYN department that got her that screening. It was allergy.

“It really hit home for people,” Aguilera says. “If it wasn’t for the allergy receptionist who took that time, we don’t know what would have happened. That was a big encouragement.”