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In 2011, the Medical Records unit-based team in the Northwest received 1,222,361 pages of outside records that required indexing into patients’ electronic medical records—a staggering 725,000 more pages than it received in 2010.

Yet team members met and mastered the challenges facing them, whittling down an enormous backlog and reducing the turnaround time for processing from 62 days in December 2010 to three days by December 2011—benefiting both their internal customers and KP’s members and patients. And they’re sustaining that success.

The steady increase had been debilitating. Overtime hours went through the roof, with more than 2,450 hours logged in 2010. The 37 team members work 24 hours a day, seven days a week and have seven different work classifications. Staff members were worn out. Piles of paperwork were stacked high, waiting for processing. Morale was at an all-time low.

The case illustrates vividly that service is not just a bedside issue at Kaiser Permanente. For a variety of reasons, many KP members see outside providers—and when those providers submit paper or electronic records with the patient’s medical information to Kaiser Permanente, the records have to get indexed into KP HealthConnect. If there’s a delay, the patient’s regular physician may be missing important information the next time the member is seen at KP.

“When the clinician needs medical information on their patients in order to treat their current medical condition, we’re able to provide updated and accurate records,” says the team’s union co-lead, Kathleen Boland, a data quality clerk and SEIU Local 49 member. And, she notes, members aren’t having to repeat critical tests and procedures, saving them time and money.

Things started to change when, through unit-based team training, team members learned such skills as process mapping and how to understand data. They created SMART goals (specific, measurable, attainable, realistic/relevant, time-bound), started huddling and developed a greater understanding of roles and responsibilities.

The team receives more than 700 different types of documents, so variation was rampant. Team members developed cheat sheets to standardize how documents should be prepped for indexing and to get everyone to use the same process for each task. They also cross-trained and helped each other out when someone was on vacation or ill.

“In the beginning,” says Bruce Corkum, RN, a UBT resource team specialist, “they didn’t share the work. Then they started understanding how they could help each other work toward the same goal.”

Not only did the backlog disappear, but the need for overtime is nonexistent now, they’ve improved attendance and “morale has improved,” says Burgandy Muzzy, a health records clerk and member of SEIU Local 49. People are happy to be at work.

“People are talking about us in a positive way now,” says manager Debbie Lang, “instead of as ‘those people who lose everything.’ ”

Cheryl Kusmits has been a licensed practical nurse for 16 years at Ohio’s Fairlawn Internal Medicine department, a small clinic with a close-knit staff known for its personal service. She loves her job and prides herself on doing it with compassion and a smile.

Kusmits knows all the longtime patients, and they know her. At least, she thought they did. Then she was trained in the service practice known as AIDET—Acknowledge, Introduce, Duration, Explanation and Thank you.

“Until I started saying, ‘My name is Cheryl,’ I didn’t realize, ‘Oh gosh, they see me all the time but I never say my name,’” she says.

When Kusmits introduced herself to a regular patient, he responded he’d been coming there for years and knew her face but had never known her name. It was nice, he said, to finally “meet” her.

Kusmits, who had her doubts about AIDET’s value, was sold on the service training right then.

There’s more to service than being nice

Top-notch service is not just the purview of five-star hotels or, where they still exist, full-service gas stations. These days consumers expect superlative service from their health care providers—and rightly so. No matter how technically superior the care, an inconsiderate or simply indifferent provider spoils the experience. Patients deserve healing, not just fixing.

As a result, providing stellar service to patients and members has never been more important for Kaiser Permanente. Our survival in the competitive health care market rests not only on the quality of care but also the quality of the service we provide to our members. The better the overall experience, the more likely we are to retain current members and gain new ones—ensuring the strength and stability of our model of care, which in turn leads to long-term job security.

“Members’ and patients’ own experiences, or the stories they hear from friends and family, make a huge difference in whether people choose Kaiser Permanente,” says Vickie Cavarlez, an LMP senior labor liaison for public- and private-sector accounts. “As unit-based teams develop, they are making a real difference in the story we can tell.”

The good news is that unit-based teams working to provide our members with the best service possible at every touch point in the system don’t have to start from scratch—they can get a big jump ahead, fast, by taking advantage of KP-endorsed programs with proven track records. Here are the stories of two instances where such programs, AIDET and Nurse Knowledge Exchange Plus—which was pioneered by KP’s Innovation Consultancy—have had dramatic effects.

Could your team be next?

AIDET: More than a surface polish

In 2010, management, physician and union co-leads for all of Ohio’s unit-based teams were trained in the tactic known as AIDET to pump up the region’s service. As a small market that competes in the shadow of the renowned Cleveland Clinic, KP’s Ohio region must go above and beyond in quality of service and care provided.

“We don’t have a physician on every corner. So you have to make it up somewhere, and we make it up in quality and service,” says John Hightower, manager for organizational excellence in Ohio. “It’s part of who we are and who we’re trying to be.”

The region turned to AIDET because of its simplicity. At its core, the training is about communication behaviors and basic courtesy– from acknowledging a patient’s presence with eye contact to explaining that a physician is running late.

Fairlawn Primary Care, where Kusmits is the UBT union co-lead, always had received good service ratings from patients—with scores ranging from 81 percent to 83 percent—but the facility had experienced a small dip in 2010 after it moved offices, dropping to 75 percent. So when nurse manager Paula Hadley, the team’s management co-lead, heard about the AIDET training, she talked with her co-leads—Kusmits and Keith Novak, MD—and volunteered Fairlawn as a pilot site. Initially, reviews were mixed.

“Well, I thought, I’m nice all the time. We’ve always had high scores. I thought, ‘How can I do any better?’” recalls Kusmits, an OPEIU Local 17 member. “But we did. It was kind of amazing when it all happened.”

Fairlawn saw its service scores jump by 10 percentage points within a couple of months after it began using the AIDET behaviors. Office wait scores jumped from 67 percent in January 2011 to 76 percent in August the same year. In the area of staff courtesy and helpfulness, Fairlawn started at 83 percent at the beginning of 2011 and is currently at 89 percent.

The service tool is not a script. It’s not about just being nicer. It’s a set of behaviors, Hightower stresses, that enhances communication and shows respect for the patient.

“And not doing it like a robot,” Hadley says. “It’s genuinely using the behaviors so it’s part of what they are doing every day.”

Of course, there are still those times when an experience isn’t perfect. In such “service recovery” cases, having AIDET under the belt is even more critical. Ohio saw this firsthand at the start of 2012, when it reduced its extensive outside provider network and redirected patients to Permanente physicians. Suddenly patients who had longstanding relationships with outside primary care physicians had to switch to a Permanente primary care physician.

Going above and beyond in service was never more essential.

“I can only tell you that there are some members who are going to be upset no matter what,” Hadley says. “And how we treat them—even if (we’re not giving them) the answer they want—will make a difference in the outcome.”

The power of a seamless handoff

While AIDET provides a foundation for superior service regardless of location, providing a good care experience at the bedside takes additional skills. In the hospital setting, providing a seamless handoff between revolving shifts of caregivers is critical, as is keeping patients informed, involved and confident in their care. Which is where Nurse Knowledge Exchange Plus comes into play.

Longtime nurse Jennifer Toledo remembers “the old days”—which were really only a few years ago—on her medical-surgical unit at Panorama City Medical Center in Southern California. When the registered nurses would change shifts, the incoming nurses would crowd into a conference room and listen to the charge nurse give a brief report on each of the patients. “And we’d all take notes,” says Toledo, a member of UNAC/UHCP.

The practice never sat well with Toledo. “There was no way to validate what the charge nurse was saying,” she says. “And, there were no patients involved.”

Today, shift change on the fourth floor med-surg units is radically different. Incoming and outgoing nurses pair off in patient rooms for the “Nurse Knowledge Exchange Plus”—a structured, in-depth, in-person handoff that puts the patient at the center. Use of NKE Plus has increased nurse time at the bedside by nearly 19 percent and is improving nurse communication service scores among unit-based teams at Kaiser Permanente hospitals in Southern California.

With NKE Plus, the outgoing nurse introduces the incoming nurse to the patient before going off shift. Together, they review and update the patient’s in-room care board. They go over the plan of care, and make sure the patient understands it and has a chance to provide input. Some units use catchy acronyms—this is Kaiser Permanente, after all—such as HEAL to help nurses remember all the elements they need to review (High-alert medications, Environment, Alarms, Lines and drains).

This strategy “encourages more participation from the patient and gives them the security of knowing that someone is looking after them,” Toledo says. “We all agree on the plan, and we can correct misperceptions right then and there.”

Eric Zambrano, a relatively new nurse, agrees with his more seasoned colleague. “It makes the patients less anxious,” he says. “Patients know the plan for the day. It gives them comfort because they are not wondering what is going to happen next.”

NKE Plus “has catapulted our HCAHPS and nurse communication scores” at Woodland Hills, says Nancy Tankel, the nurse executive there, referring to the federal Hospital Consumer Assessment of Healthcare Providers and Systems survey. In fact, between January 2011 and January 2012, HCAHPS scores on a set of questions measuring the quality of nurse communication jumped from 71 percent strongly positive responses to nearly 82 percent. And the staff is as satisfied as the patients.

“I’ve had one nurse tell me, ‘I can sleep at night,’ ” says Tankel.

Lasting impressions

Ultimately, beyond the critical role stellar service plays in Kaiser Permanente’s survival, providing the best experience we can, for every patient and every member, every time, is simply the right thing to do. It’s core to Kaiser Permanente’s mission.

From the moment our members come into contact with Kaiser Permanente, whether online, by phone or in any of our facilities, our interactions with them build or break their trust and loyalty. Providing for a great care experience goes beyond correct diagnoses and treatments. It means asking ourselves if we are looking someone in the eye; if we are examining whether our protocols and procedures make sense, not just for us, but for the members who have to navigate them; and if we are taking care that the many handoffs we make along the way are clear and seamless for our patients and their families.

“We want to keep our patients,” says Ohio LPN Kusmits. “So we need to make them happy and make them feel like we care. And we do care. We need to make sure they’re aware of that.”

To learn more about AIDET, NKE Plus and other evidence-based practices aimed at improving the experience for patients and members, please visit the National Service Quality website.

Have you ever broken your glasses just days before leaving for vacation? Or before your driving test? Or before a big, important meeting?

You’re not alone—for the frontline staff and managers at Kaiser Permanente’s Vision Essentials clinics throughout Southern California, encountering patients facing these situations is a regular occurrence. The problem was, they had no way to speed up orders for new glasses. Patients ended up unhappy. Some would simply take their prescription to a competitor who promised glasses in a day.

The Vision Essentials business council—the regionwide Labor Management Partnership governing body with representatives from five unions and managers from optometry, ophthalmology, retail clinics and the optical lab—decided something had to be done. Their solution? The express service program.

Piloted in the Fontana and San Diego medical center areas, it allows patients to get their glasses in three days instead of the usual seven for a small fee. The service is so successful, it will be rolled out to the entire region by the summer.

Red Sharpies and gold spray paint

The keys to success were red Sharpies, gold spray paint and the tools provided by the Labor Management Partnership. The Value Compass—with the patient at the center—provided a key organizing principle.

“We were asking, ‘How do we improve our turnaround time?’ ” says Jeff Zeidner, the optical lab manager. “It might not be possible to improve our overall turnaround time, so let’s be selective about this.”

Alex Mendez, labor co-chair of the lab’s unit-based team, says, “We knew our customers needed some sort of express service.”

But a lofty ideal about putting the patient at the center does not magically re-engineer a huge supply chain involving 42 retail clinics spread over hundreds of miles and a manufacturing plant that churns out 7,000 pairs of glasses every day, five days a week, from 5 a.m. to 10 p.m.

When some of the labor members of the business council broached the idea of an express service, they were met with skepticism.

It can’t be done

“There was a lot of, ‘We can’t do that’ and ‘It’s too expensive,’ ” says Mary Cavanaugh, an optometrist and labor representative. Cavanaugh is a member of the Kaiser Permanente Association of Southern California Optometrists (KPASCO), which is part of UNAC/UHCP. 

Finally, the council asked the optical lab UBT to propose ideas on how to make express service a reality. The catch: The service couldn’t delay turnaround time for normal orders, couldn’t increase breakage rates and couldn’t require more staff or overtime.

The brainstorming commenced.

“Everyone had different ideas about prices and parameters,” recalls Mendez, a member of SEIU UHW.

Should the promised turnaround be one day? Two? Three? How about charging an extra $10? That might attract too many requests. Maybe $50? The UBT recommended $50. Another idea to emerge from the brainstorming—shimmery gold spray paint on the trays containing the express order lenses, so they could be easily spotted in the lab and moved to the head of the line.

Conveyer belts and lazy susans

The Vision Essentials optical lab is quite literally on the wrong side of the railroad tracks in an industrial section north of downtown Los Angeles, sharing a service road with a strip club. Hefty pieces of plastic that look like clear hockey pucks begin their journey here. Brightly colored bar-coded bins, including the gold ones, carry the lenses-to-be along conveyer belts for their various stops. Four huge lazy susans hold the tools for smoothing and polishing. The grinding machine spews out big puffs of white shavings that look like fake snow. At the end of the process, optical technicians pop the lenses into frames. Then the glasses are off to the shipping department to head back to where their trip began—the clinic where a grateful patient will pick them up.  

The frontline staff and managers at the Fontana Medical Center, where the first pilot was launched, were an integral part of planning and executing the express service initiative. After all, they were the ones who dealt directly with disappointed customers. The opticians there contributed another color coding trick: They annotated express orders with a red Sharpie.

“It’s like a hot potato,” says Nadia Arce, a receptionist and a member of Steelworkers 7600. Attractive tent cards on the receptionists’ desks announce the availability of express service.

Express service adds an extra step for the clinic-based staff, who now have to call the lab to ensure the materials needed for rush job lenses are available.

“We don’t want to promise something we can’t deliver,” says Mikhail Mgerian, an optician at Fontana and a member of Teamsters Local 166.

Building rapport

Trissy Basin, the business line manager, estimates there are about 150 express service clients out of 20,000 jobs a year; regionwide, the number of express jobs per year is expected to be 5,200. While the numbers aren’t huge, she says, “the process of doing an express job is significant.”

The process of creating the program in partnership also was significant.

“It is a lot better having the LMP,” says Chris Leyva, the management co-lead of the optical lab’s unit-based team, who has worked at Kaiser Permanente for 18 years. “There isn’t the banging of heads. The partnership smoothes our rapport.”

Adds his labor co-lead Mendez, “I feel comfortable giving my input and feel it gets taken into consideration.”

Danny Pollack, an optometrist and labor co-chair of the business council, says the union’s shared leadership role meant proponents of express service had a venue to keep pressing until the issue got taken up.

“It was perseverance, not pounding on the table,” says Pollack, a KPASCO member. “This project is a great example of how labor can initiate an idea and, with the support of management, roll out a new service that benefits our members.”

For more than a year, the service scores at the Moreno Valley Optometry department zigged and zagged in no discernable pattern. Asked whether receptionists were helpful and courteous, 100 percent of patients answering the Ambulatory Service Questionnaire gave the highest score one month.

But two months later, only 78 percent of respondents were that enthusiastic. Two months after that, scores were back up into the 90s. The huge swings were discovered in May 2011 by Stephanie Valencia, the department’s new manager, who excavated two years’ worth of data.

“We had never looked at it before,” she says. “There was no trend. The scores were inconsistent.” Worse, says Valencia, the feedback from the most recent months was headed “on a downhill streak.”

Working with labor co-lead Gina Hitt, an optician and a member of Teamsters Local 166, Valencia and the unit-based team gathered information and set a baseline. For two days in September, the medical assistants asked all patients whether they found the receptionists to be helpful and then tallied the results.

The team used these to measure the effectiveness of a rapid string of small tests of change. These included adding a smile, positive tone of voice and eye contact on successive days. Each of those days, Hitt and her colleagues asked patients whether their receptionist was courteous and helpful. With each successive effort, the chorus of “yes” got louder and more effusive.

The act of simply examining the service scores seemed to set the team on an upward trajectory: The April 2011 score of 79.55 percent jumped to 89.09 percent in September and then 92.73 percent in October.

 “It is so neat to see how involved people are,” Valencia says. “Everyone is in sync.”

So, that’s a happily-ever-after story, right? Once upon a time, there was an optometry team in Southern California that never looked at its service scores. Suddenly, team members learned their scores were inconsistent and heading in the wrong direction. They focused on key data and tried out small tests of change. Their new practices boosted the score. Everyone lived happily ever after.

This happens every day with every UBT throughout all of Kaiser Permanente.

Right?

Maybe not.

Some UBTs are adept at using data to guide their attempts to improve performance, whether it be raising service scores, reducing infections, creating a safer workplace or boosting attendance. But for others, fear and anxiety about data and numbers are a significant obstacle on teams’ path to high performance.

In order to qualify as a Level 4 team on the Path to Performance, the team has to collect its own data and review it to see whether changes are helping improve performance. To ascend to Level 5, teams must be measuring their progress using annotated run charts.

But what if you break out in a cold sweat and experience shortness of breath at the sight of anything vaguely resembling math or numbers? Do you simply resign yourself (and your team) to being roadkill on the Path to Performance?

No. Read on.

1) Realize you are plenty smart enough.  

Kaiser Permanente, like all large health care organizations, collects and stores vast amounts of data in a variety of complex databases and websites. It employs people with a huge variation in their knowledge of and comfort with data. Just because you’re not at ease with numbers now doesn’t mean you never can be.

Even Bob Lloyd, the executive director of performance improvement at the Institute for Healthcare Improvement, an independent nonprofit in Massachusetts, jokingly refers to statistics as “sadistics.”

Luckily, the data you will need to turbocharge your team’s efforts to improve performance is probably a lot less complex than you fear.

 “It’s not really ‘math’ with formulas, statistics and calculations,” says Michael Mertens, a Kaiser Permanente performance improvement mentor in Southern California. “It’s mostly about before and after, addition and subtraction.”

2) Whether you acknowledge it or not, you collect data every day.  

 “My role in the tests of change has been soliciting feedback from the patients,” says Hitt, the Moreno Valley optician. She didn’t need a computer program or spreadsheet. A piece of paper and pencil did the trick. 

 “We are all data collectors,” proclaims Stacy Dietz, the UBT consultant for regional operations in Southern California. “And every day, we alter our behavior based on data.” For instance, we ask, “What is the temperature outside?” Then we decide whether to wear a wool turtleneck or tank top. We ask, “What is the length of my commute?” Then we decide whether it makes more sense to drive or take the train.

If you can collect and analyze data to determine your wardrobe, you can also do it to improve the performance of your team.

3) Before diving into the numbers, focus on the “why.”

As the new Kaiser Permanente ads challenge viewers, “Find your motivation.” For unit-based teams, the Value Compass offers a handy cheat sheet on motivation: The patient is at the center. Every data point on every chart represents the impact—positive or negative—that a Kaiser Permanente team had on a patient.

IHI’s Bob Lloyd explains there are three distinct reasons in health care for collecting and examining data:

• For research, such as KP’s recent study that found women in their late 60s who break a bone are five times more likely to die within a year than women that age who do not break a bone.
• For judgment, a category that would include the federal government’s recent rankings of Medicare insurance plans on quality and service (several KP plans got five out of five stars). This category also includes scores that determine whether or not a medical center or department earns its Performance Sharing Program (PSP) bonus.
• For improvement.

This last is the reason UBTs should be collecting and examining data.

 “The purpose of measurement in quality improvement work is for learning, not judgment,” Lloyd says. 

Data answers questions like, “How are we doing right now?” “Over time, are we getting better? Or getting worse?” “Is our small test of change making a difference? Or not?” In the absence of data, we have a tendency to fall back on relying on guesses, gut instinct, anecdotes—and to blame or give credit to specific individuals, justifiably or not.

 “You need data. Otherwise, you don’t have any solid information,” Hitt says. “You just have word of mouth.”

4) Only gather the data you actually need.

The holy grail of data for UBTs is the run chart. Don’t let the name throw you. It’s simply a chart that tracks some number (say, a service score, or number of last-minute sick calls) over time (day, week, month, quarter).

 “The most crucial question to ask is, ‘What are the few, vital pieces of information that are important?’ ” says Dennis Benton, executive director of the Panorama City Medical Center in Southern California. Any graph or data set that requires its intended audience to get special training to read is probably too complex for the task at hand, he says.

 “You can do a quick, just-in-time training at a UBT meeting,” says Benton. “We do it in leadership rounds. I point to the graphs and talk about them.” 

Run charts make it clear at a glance how your team's tests of change are working. Use this tool to walk through how to make one.

4 1/2) But, get the data often enough to support your improvement efforts.

For most teams’ small tests of change, data that can be collected daily, weekly or—at most—monthly will be most useful. Waiting for quarterly reports is generally not going to cut it. The Moreno Valley Optometry department did not wait for the Ambulatory Service Questionnaire results—which are posted monthly—to come in. It’s called the Rapid Improvement Model, folks. Not the Slow-as-Molasses Improvement Model.

Bottom line: The data should be useful for the team and be determined by the team.

5) Think art class, not math class.

 “I hate numbers,” admits Jenny Yang, a receptionist at the Moreno Valley Optometry department and a member of the UBT’s representative group. When the notion of using service scores to guide improvement first came up, Yang says she told her teammates, “I’m not going to do it. Make someone else do it.”

To help others like Yang, Benton says, when it comes to data, “Make a picture out of it. I am a big believer in graphs. With a graph, you can say, ‘We dipped here. What is the reason? What can we do about it?’ You can look at a trend relative to the goal.”

 “Graphs are visual,” Valencia adds. UBT members have a variety of learning styles and preferences: “Everyone learns differently.”  

And think in terms of moving video, not still photographs that capture single moments in time. IHI’s Lloyd asks, would nurses measure an ICU patient’s vital signs only when the patient arrived and when she left the unit? Or would they monitor vitals constantly via a telemetry machine? The second option is better, so caregivers can intervene in real time to help the patient’s recovery.  

6) You didn’t like art class? How about creative writing?

Numbers can tell a story. “There is narrative in data,” says Nancy Duarte, the author of “Slide:ology” and “Resonate,” two popular books about how to give compelling and memorable presentations. “What makes the numbers go up and down? How big are the numbers? How do the numbers contrast with other information?”

Yang agrees. Graphs with data “give you key points, high points and low points and trends,” she says. As a member of the representative UBT, Yang—a member of Steelworkers Local 7600—sees herself as a storyteller: “My audience is the UBT. The graphs help UBT members make sense of everything.”

Hey, if you liked math class, more power to you. “I love math,” says Hitt. “I am a number cruncher. But for me, charts and graphs? Not so much.”

7) It’s OK to ask for help.

So that graph you pored over in your UBT meeting is still making you break out into a cold sweat?

 “It’s OK to find a safe place to say, ‘I don’t get this,’ ” says UBT consultant Stacy Dietz. That might not be in a big group, but it could be one on one with a trusted peer.

Mertens, the Southern California performance improvement mentor, says the best way to learn to use data is to try it out. At the request of Susie Bulf, a UBT consultant, Mertens led a training for UBT co-leads in Fontana on how to create a run chart. He led an in-class exercise using sample data—and then another exercise where each team used its own data.

 “You get over the anxiety by doing it the first time,” Mertens says.

Each KP region boasts a roster of experienced performance improvement mentors. In addition, most UBT consultants have had some training in performance improvement strategies.

“What’s holding you back?”

Fresno Medical Center leaders asked their 50 unit-based teams that question directly late last year, at the same time they asked the teams to assess themselves on the new Path to Performance standards.

The answers mirrored what facilities everywhere say are challenges: training and sponsorship. Of the seven attributes of high-performing teams laid out in the Path to Performance, those two are consistently the most problematic.

Across the organization, many teams had their Path to Performance ranking lowered as a result of the 2010 year-end assessment—including Fresno, which UBT Tracker identified as having the highest percentage of high-performing teams in the organization. Fresno saw its number of Level 5 teams drop by more than half, from 27 to 14.

But Fresno had a plan for 2011.

“Early on, when we got a look at the Path to Performance, we created a strategy,” says Rick Senneway, Fresno’s director of performance improvement. “The Path to Performance helped focus us. (It) became very clear what we needed to work on.”

Even before they had the assessment results, Fresno leaders devised a 2011 UBT strategy for team development and performance improvement. It includes specific steps for moving teams at both ends of the spectrum along the Path to Performance.

“We’re engaged with our union partners at all levels,” says Jose DeAnda, medical group administrator. “At the UBT departmental level, (and) at the LMP Council level, by having each council member be a sponsor of UBTs and by having the sponsors report out at council meetings on how UBTs are performing.”

The goals were twofold: Move at least six teams up from Level 3 to Level 4 or 5 by the end of 2011, and help five teams achieve measurable improvement. Year-end assessments were not yet finalized when Hank went to press, but there’s optimism about the results.

“We did some good projects this year, and our affinity groups really helped,” says Navneet Maan, Fresno’s UBT consultant, referring to a system where teams working on similar projects met and shared ideas.

With a mandate to increase the number of high-performing teams by 20 percent in 2012, other teams and facilities might glean some ideas from Fresno’s three-pronged approach. 

Improve the support network for teams

One of the first things Fresno did was to revamp its sponsor network, including:

• Assigning sponsors to work in labor and management pairs and matching them so they share similar work areas;
• Reducing the number of teams sponsors work with to no more than four;
• Establishing new agreements that give sponsors more flexibility for how they meet with teams (in person or via email); and
• Setting quarterly deadlines for reporting on team status at LMP Council meetings.

The new agreements clearly defined expectations for sponsors, says Lynn Campama, Fresno’s assistant medical group administrator: “The role of the sponsor is about the performance of teams,” not about team management. “Everybody is accountable.”

Rather than trust that sponsors know how to be effective, Fresno used council meetings as a training opportunity. Sponsors received updated materials, ranging from a new form to help teams with meeting basics to information on the use of metrics and SMART (strategic, measurable, attainable, realistic/relevant, time-bound) goals. They also got forms to help collect team success stories and to help teams better manage UBT Tracker, the organization-wide system that helps teams report on and find effective practices.

In addition, “local resource network” members documented their particular expertise—be it UBT development, performance improvement, issue resolution and interest-based problem solving, attendance, service and workplace safety—and were assigned to teams needing that expertise.

“We took sponsorship to the next level,” says Lorie Kocsis, Fresno’s union partnership representative, LMP Council union co-lead and SEIU UHW member. “We tried to make their role easier for them to understand and to help them feel that they aren’t alone.”

Ron Barba, the director of the outpatient pharmacy and sponsor for the respiratory, inpatient and outpatient and surgery specialties teams, has noticed the difference.

“They gave us the training we needed to help the teams,” Barba says. “I feel more effective.”

Improve team training

To address training gaps identified by the teams, Fresno developed a brochure that puts all the offerings in one place—classroom, “just in time” and web-based training available through KP Learn—and groups the offerings by audience. That makes it easy to see what’s available for team members and what’s there for union and management co-leads.

At the same time, a request form for just-in-time training was developed, and both the brochure and the form were posted on Fresno’s intranet website. A clear process for requesting training was put in place, with team members instructed to submit their requests to Kocsis and Maan.

It didn’t stop there: Teams also got training in key partnership and performance improvement methods. A one-hour, just-in-time version of the eight-hour Consensus Decision Making (CDM) course was conducted with teams that requested or needed it. Teams working on non-payroll projects, such as reduction of inventory, were encouraged to take Northern California’s new business literacy training.

“Training had been one of our big downfalls keeping teams from higher performance,” says Debby Schneider, Fresno’s LMP consultant.

The brochure has heightened awareness of what’s available.

 “It helps us see at a glance what we need to take,” says Jeannine Allen, the administrative services supervisor and co-lead for the Adult Medicine UBT. “It’s been kind of a road map.”

Prioritize projects

To maximize the teams’ performance improvement impact, Fresno guided them toward projects that were achievable, would impact facility or regional goals, and were aligned with the Value Compass.

Teams used a  prioritization matrix to help them pick projects. That exercise sharpened teams’ focus and enabled members to “see how the work they are doing impacts the entire service area—not just their departments,” says Maan.

Teams shared ideas with their sponsors, who connected teams with other resources, including the experts in the newly established local resource networks and the affinity groups.

The experience of the Health Information Management team illustrates why such connections are invaluable. Its SMART goal was to improve customer service by way of a survey. Jeremy Hager, a care experience leader, was assigned to help the team.

He introduced the fishbone diagram to the team co-leads to help them identify which metrics the team should focus on to reduce customers’ complaints. He also helped them correctly interpret survey data. 

The affinity groups also helped teams. The six unit-based teams that made attendance a priority, for example, received tips, tools and specific training around the “six essentials of good attendance” identified by Ann Nicholson, LMP attendance leader for Northern California.

They also looked at their data going back several years, which “really made a difference,” says Eileen Rodriquez, assistant manager for OB/GYN. “It was an ‘aha’ moment.”

The team is meeting its attendance goals. With 6.17 sick days per full-time employee as of the first pay period in December, the team members exceeded the region-wide goal of 6.50. What made the difference? Managers are more flexible, and workers are more aware of the impact of missed days.

Staff members “feel comfortable coming to us,” says Norma Costa, department manager—and the team’s union co-lead, Lisa Madrigal, a medical assistant and SEIU UHW member, concurs.

“I know that if I need to take time off, I can go to my manager and talk with her about it and that she’ll do everything she can to accommodate me,” Madrigal says.

What's next?

Attendance will continue to be a focus of the facility’s UBT strategy for 2012—as will making it easier to use UBT Tracker. Refreshers on UBT basics will be provided, new tools introduced, and new affinity groups created.

And while local union steward elections will affect the sponsor pairings, sponsors will continue to get training and will continue to serve on the LMP Council in labor and management pairs.

The patient in the operating room was moaning and suffering sudden seizures. A half-dozen caregivers crowded around him, attempting to stabilize him as they watched his vital signs on a monitor.

This might have been a normal June afternoon in the OR at Sunnyside Medical Center in the Northwest region—except the patient was a mannequin. The staff members were being videotaped as part of a simulation to help operating room personnel learn and practice effective techniques for keeping patients safe during and after surgeries. Afterward, they did a debrief, discussing what worked and what didn’t with their unusual patient.

It’s all part of how this regional surgical services team, composed of the co-leads of several unit-based teams at different ambulatory care centers and at Sunnyside, operates. From 2009 to 2010, for example, it reduced the rate of surgical site infections by an impressive 32 percent. These results came from implementing proven practices for reducing infections, such as safety simulations, hand hygiene and clipping (rather than shaving) patients’ hair at the surgical site.

They also came from an explicit effort to change the culture standing in the way of patient safety. A 2010 safety summit involved everyone in the associated departments—from surgeons to techs to EVS workers, inpatient and ambulatory. Team members shared best practices and discussed ways to have an open dialogue so that when something isn’t right, each person has the accountability and the freedom to speak up.

 “In the past,” says surgeon Waleed Lutfiyya, “everyone had a single role and couldn’t break out of that role. There were defined borders about what someone could say. That can create obstacles.”

Now, he says, “The idea is that by working together as a team, everyone has an equal role with the patient. Everyone is equally important.”

The summit included a presentation on the importance of developing a culture of safety.

 “Team behaviors do matter,” says Lutfiyya. “Team behaviors affect clinical outcomes.”

Research backs him up. A 2009 study published in The American Journal of Surgery tracked nearly 300 observations by RNs of operations at four Kaiser Permanente sites. The conclusion: Patients whose surgical teams exhibited fewer teamwork behaviors were at a higher risk for death or complications. These observable behaviors revolved around information sharing during various phases of surgery.

In short: Patient safety depends on good communication. From there, it’s easy to see that, since unit-based teams provide a structure and the tools for improving team communication, they are a path to improving patient safety.

Perfectly logical, right? Yet only a tiny fraction of UBT projects aim to improve patient safety, according to data in UBT Tracker, the programwide system for reporting on unit-based teams.

What’s going on? Patient safety projects seem like ideal candidates for unit-based teams, touching all four points of the Value Compass. Keeping patients safe from harm delivers on best quality and best service. Such projects address affordability: In the Northwest, the decrease in infections for the specific procedures being monitored has resulted in an estimated cost avoidance of $220,000. Patient injuries can be devastating to individual and team morale, so intentional efforts to minimize them help create the best place to work.

And who benefits or suffers most if teams do or don’t take on this work?

 “We all owe it to the patient,” says Doug Bonacum, Kaiser Permanente’s vice president of Safety Management. “We need to find ways to help people reach deep down and say, ‘I am not comfortable, I have a safety concern.’ It is top down and bottom up. It has to be both.”

When top-down transforms into teamwork

The fact is, there is plenty of work going on throughout Kaiser Permanente on patient safety. Much of it, however, has a top-down, mandatory quality to it—with little or no emphasis on involving frontline staff on how to go about meeting the goals and improving performance.

In the Northwest, for example, switching to a new dress code based on Association of periOperative Registered Nurses (AORN) recommendations was a top-down mandate. One of the changes included replacing the skull cap, which did not always cover all of a person’s hair, with a bouffant cap.

 “We assumed, ‘Well, this is the right thing to do for the patient,’ and staff would just do it,” says Claire Spanbock, the regional ambulatory surgery director, acknowledging the limits of the approach. But, “We had people we had to tell again and again. We realized we were making a big change and not involving them….We got there, but it was tough.”

In contrast, when it came to hand hygiene, members of the regional OR UBT sat down together and revised the audit tool several times before settling on the best version.

 “You are never going to do this until you have the hearts and minds of the staff,” says Spanbock.

When the right eye is the wrong eye

One reason relatively few teams are working on patient safety may be that until a team has strong communication skills in place—developed in the course of working on simpler improvement projects—its members may shy away from high-stakes efforts.

The Northeast Ohio ophthalmology team already was one of the highest-performing UBTs in the Ohio region when it decided to not take the team’s clean safety record for granted. Its co-leads—the ophthalmologist, ophthalmic technicians and manager—worked together to implement a patient safety briefing immediately prior to all eye procedures.

The idea is an enhanced version of a timeout, when a surgery team pauses before a procedure to engage in a structured communication with the patient to verify key information. It came from the ambulatory surgery center at the Parma Medical Center, where several ophthalmology staff members work.

 “We just felt that it would be wise to be proactive,” says Ralph Stewart, MD, the team’s physician co-lead. “There’s no danger of cutting off a leg in our department, but you do need to think about right eye or left eye.”

The team already had worked together to improve wait times and courtesy and helpfulness of staff, so had built the trust and free-flowing communication culture that is at the heart of patient safety efforts. It embraced the idea and, after resolving concerns about the time the safety briefing would take, began brainstorming about what the ophthalmology timeout would be like.

 “We split into two different groups that included physicians and technicians, and we discussed which part was going to be the responsibility of the ophthalmologist and which was going to be the responsibility of the technician,” says Renee Paris, a lead ophthalmic technician and an OPEIU Local 17 member.

 “It took us a couple of months to get it together,” says Bonna Gochenour, an RN and the team’s management co-lead. “We had to create some ‘smart phrases’ to help us with documentation. When the technician goes into the room with the patient, they’re going to confirm with the patient which eye it is, and the tech puts a little smiley face over the correct eye.” The doctor then does a second verification before beginning the procedure.

In late January, in a textbook small test of change, the team piloted the safety briefing for one month with one physician and one tech.

After a few adjustments—like making sure each procedure room has its own supply of the stickers—the UBT implemented the procedure throughout the department, which encompasses teams at four different facilities in three counties.

Sandy Cireddu, a certified ophthalmic technician and the team’s labor co-lead, is proud of the accomplishments. She thinks the open channel of communication developed through the UBT has been critical to its success.

 “Everybody needs to be heard,” says Cireddu, a member of OPEIU Local 17, “and everyone needs to feel you’re on equal ground when you’re discussing these things, so that you can get buy-in.”

Surgical site infections down

At the Woodland Hills Medical Center in Southern California, a campaign to reduce surgical site infections in the labor and delivery department is working.

The department dropped from a rate of five surgical site infections per 100 caesarean sections performed in the second quarter of 2009 to none in the second quarter of 2010.

After a brief rise, the rate headed down again; at the end of the first quarter of 2011, it was less than one per 100. Moreover, the only infections since the third quarter of 2009 have been superficial; there have been no deep or organ-space infections.

The campaign includes a focus on pre-op skin prep, educating new moms on post-op wound care, prophylactic antibiotics, hand hygiene, and trying to reduce traffic flow of staff and families near the operating rooms.

And, as in the Northwest, the effort included enforcement of the AORN guidelines for surgical attire. Out went the skull caps sewn by Min Tan, an obstetrics tech and SEIU UHW member, who helped her colleagues spice up their scrubs by making them custom caps with their favorite patterns—anything ranging from the L.A. Lakers basketball team to spicy-colored chili peppers.

She took the new dress code in stride. “The Labor Management Partnership is about fixing things,” says Tan. “It helps us in not finger-pointing and blaming. It’s not as intimidating as ‘the old days.’ ”

The department’s labor co-lead, Robin Roby, an RN and UNAC/UHCP member, agrees.

 “We are becoming part of the solution,” she says. “You feel like you are more involved with what goes on in the unit.”

That involvement is what makes UBTs a foundation for improving patient safety; engagement is the key to effective implementation.

Louise Matheus, the department administrator at Woodland Hills’ labor and delivery unit, acknowledges that focusing on reducing infections was a management decision. But, she says, the department’s progress in controlling infections “is a UBT effort because we involved the whole staff” in implementing the changes.

And Matheus makes it clear she’s looking forward to the day when frontline physicians, managers, nurses and techs use the leverage created by unit-based teams to accelerate improvements in patient safety.

When that day comes, she says, “It won’t be small test of change—it will be large test of change.”