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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.”

I am one of the chairs the LMP leadership team, along with a union colleague from UFCW and two management leaders. I’m also the co-lead of the Woodland Hills’ union coalition. In addition, I’m a full-time certified registered nurse anesthetist in the operating room. To be an effective labor co-lead takes three things: time, collaboration and planning.

Time

I have been doing partnership work at Woodland Hills for 10 years. People respect the time I’ve invested. You have to be on fire for this because it’s an enormous responsibility. It’s going to cost you time, angst and effort. And you can’t build relationships passing in the hall. You have to make the investment of face time. That means showing up at the LMP council meetings, monthly, from 8:00 a.m. to noon.

Planning Ahead

It is important to bring in and plan for new blood. At Woodland Hills, we rotate the labor co-chair in our leadership team every two years. I believe this allows everyone to have a say. It builds trust and experience. And it ensures buy-in from each union—and each segment of each union. We build-in mentorship. For three months, the new person sits in and the current co-lead shows that person the ropes.

We also did this in the Kaiser Permanente Nurse Anesthetist Association when I was president in 2006. I would go with new facility reps to meetings. 

Collaboration

We really foster union efforts at the medical center level. We’ve got a group of long-term union coalition people and our unions speak with a single, powerful voice. There have been issues between unions, and we had to work things out until cooler heads prevailed. People say ‘I’m sorry’ and move on.

Working with management is both easy and difficult. It’s easy because they are so partnership oriented and respectful of the unions, and they welcome input. They lead by influence—not by authority by virtue of where they are on the food chain—just like we do. It is difficult sometimes because it requires us to work hard as partners. Sometimes it would be easier to just go along with their recommendations, but then we wouldn’t really be doing our jobs as union leaders. At certain points, you have to say, ‘Well, let me think about that,’ and ask your constituents what they think.

Hospitals are traditionally very hierarchical. The partnership is such an opportunity to have a voice.

Imagine developing a severe cough and teeth-chattering chills. You want to be seen by a doctor but no one really understands you: Not the call center operator with whom you try to make an appointment; not the receptionist who checks you in; not the medical assistant who takes your temperature and blood pressure. Not even the doctor who speaks quickly and uses complicated medical terms.

“When you come in for medical care, it’s already like a foreign land,” says Kathleen Kearney, the manager and the UBT co-lead for the Obstetrics and Gynecology department at San Jose Medical Center.  “If you don’t speak English, it can be downright frightening.”

Giving patients better access

Kaiser Permanente has long been committed to providing language access in the form of interpretive services for its non-English speaking members. The Ob/Gyn unit-based team in San Jose has taken the additional step of creating a Spanish-speaking module, a sort of one-stop shop for Spanish-speaking patients.

The idea for the module came from Joseph Derrough, MD, who recognized that good patient care involves more than just the patient and the physician in the exam room. It includes each interaction, from making an appointment to checking in and being assigned a room.

“I realized that we had a significant percentage of patients who only spoke Spanish, and we could do better service to them by providing linguistic and culturally competent care,” Dr. Derrough says. “We had staff that spoke Spanish, but they weren’t all in the same place. My vision was that we could create a clinic module where, from registration to examination, the patient was spoken to in her own language.”

Making it happen

The unit-based team made it happen.

“From the time they walk in the door, every patient should receive the same level of care regardless of the language they speak,” says Glenda Morrison, a medical assistant, SEIU UHW chief shop steward and the UBT co-lead.

But in the beginning, the frontline staff members, including Morrison, were skeptical.

“Since we were already serving Spanish-speaking patients in our clinic, the question we were asking was, ‘Why is this needed?’ ” Morrison says.

But a visit to the Spanish-speaking Medicine module at the Santa Clara campus made them believers. That module has been in place for five years.

“When I saw it in action, a light went off—and I realized that by not speaking to our Spanish-speaking members in their own language, we weren’t providing them with the same care as we were our English-speaking members,” Morrison says.

Overcoming obstacles

Once the team decided to take on the project, it faced some challenges. Offices had to be moved and medical assistants had to be reassigned.

“We had a lot of meetings and a lot of nervous people,” Morrison says.

But again, the Santa Clara example eased fears: “Once they saw how it worked in Santa Clara, we got by-in from the staff and it was easier,” Kearney says.

The module, which opened Sept. 29, includes signage and literature in Spanish. The staff members, from the receptionists and medical assistants to the doctors, are fluent Spanish speakers.  Word about the new module went out through Spanish-speaking television news and newspaper reports. And there was a grand opening.

It’s going well so far, Kearny says, noting that “we have three Spanish-speaking providers each day, and they have appointment capacity for about 20 patients.”

Next steps

Now, the team is looking for ways to quantify the benefits of the new module. It’s hoping to be able to collect patient satisfaction data specifically from Spanish-speaking members to assess the impact, Kearney says.

“If it shows success, we’ll pass the idea on to other teams,” she says.

Meanwhile, the unit is looking at how it can provide culturally competent care for its other monolingual patients.

“We don’t what a certain group to feel singled out,” Morrison says. “We just want them to feel comfortable.”

The employees in Charitable Health Coverage Operations (CHCO) felt good about their Northern California department’s mission—but not so good about how long it took sometimes to help the thousands of low-income children who benefit from KP-subsidized health care.

The department handles the eligibility paperwork for a KP program that provides health coverage to people who don’t qualify for employer-based health coverage or public programs like Medicaid. At the team’s low point in 2005, it had a six-month applications backlog.

“Our primary customers are children,” said Nancy Waring, CHCO customer care manager. “We have over 80,000 children, most of them low income. About 50 percent of our population is Spanish speaking. And the program is completely subsidized by Kaiser.”

Too large a group

In the past, one representative unit-based team encompassed the whole department.  Because employees within the same department were doing very different types of work—processing mail, entering data, processing enrollments, providing customer service, and servicing the regions outside of California—they didn’t share a single set of problems. So the UBT tended to work on departmentwide problems like attendance.

But the single UBT struggled.

 “We basically failed from 2006 to 2009 to do anything,” says Suber Corley, the department’s director, “simply because we were looking at too large a group trying to solve too large a problem.”

So they reorganized. The department now has five UBTs that correspond with employees’ functions.

Setting priorities

The smaller teams set their sites on a number of changes, but they also coordinated with each other on one common goal: to process every application by the 20th of the month.

In their UBT, the mail-room employees decided to look at priorities differently.

“We identified that what we really needed to do was to have a prioritization scheme for every week of the month,” says Victor Romero, CHCO operations manager. He explains that during the first week of January, a recertification application that’s due on April 1 would be low priority in the mail room, whereas a new application—which would need to be processed by January 20 for insurance coverage to begin on February 1—would be high priority. After the 20th, attention moves to the low-priority documents.

The data entry, scanning and enrollment UBTs came up with other solutions, too.

“We instituted several changes in how the application is handled,” says Carl Artis, an enrollment processor team lead and OPEIU Local 29 shop steward. “If we couldn’t process an application, the application was sent back to the customers very early so they could make necessary corrections. We also streamlined our process—there were some things we were doing twice, which wasn’t necessary.”

Artis emphasizes that the changes were developed jointly by frontline workers and managers.

“I have to admit they (the managers) have some really great ideas,” he says, “and they were really able to listen to some great ideas.”

It worked. In October, for the first time in the department’s history, the team was able to process all its new applications by the 20th, so coverage for those applicants could start in November.

“The end result is that poor children did not go without health coverage,” Romero says.

Addressing burnout

In addition to the project to reduce the amount of time it takes to process new applications, the smaller teams have taken on other projects, like reducing burnout among customer service agents who spend all day answering phone calls. They’ve also done charity work together, raising funds to provide school supplies for low-income students at a local high school.

Artis passes on the story of his department’s flourishing UBTs to other members of Local 29.

“I’ve heard some people say, ‘Oh, that’s too much work to take on,’ or, ‘We don’t have the resources we need to address the issue’ or ‘Management would never go for that,’ ” Artis says. “But what I’ve learned is—just try it, and don’t be afraid to fail.”

I have worked at Kaiser Permanente for 33 years, starting as a distribution worker in materials management. Being on the front lines helped me better understand the challenges staff face—and helped me, in my current role, see what it takes to spread and sustain change in a complex organization.

When we launched our first unit-based teams in 2007, I knew they could give our managers and teams a powerful tool for change. But to achieve their full potential, UBTs need the support of leaders at every level. In working with UBTs every day, I have found five practices that can help teams achieve their goals, and have helped me be a more effective leader.

Have patience

I’m not a patient person by nature, and it took a visit to the world-class health care system in Jonkoping, Sweden, for me to see that it takes patience to sustain meaningful change. When you’re solving problems in a team-based workplace, real systemic change takes time. But it also takes hold deeper into the organization.

Really see the work

Spend time with a UBT, or hear teams present their test of change, to understand what they’re working on and how you can support them. There’s no way you can feel the excitement and energy from the team members and not feel proud and motivated by their work.

Spread good work

In Orange County—which has two large hospitals, in Irvine and Anaheim—we expect all teams to continually test and then spread their ideas and successful practices. We call it “One OC” and we talk about it all the time. You’re never going to achieve greatness globally if you don’t spread good work locally.

Provide tools

Early on we formed an Integrated Leaders group of senior labor and management leaders who meet monthly to monitor and assist our 107 UBTs. If a team is struggling, the IL group doesn’t descend on them and try to fix the problem. We provide tools and resources that help the team work through a problem and get results. For instance, we put together a UBT Start-up Toolkit with information on everything from setting up teams to finding training. We’re also looking at toolkits on fishbone diagramming, conducting small tests of change and providing rewards and recognition. And we’re asking how to make it easier for teams to access resources quickly—for instance by identifying go-to people for questions on budgeting, patient satisfaction metrics and so on.

Then, get out of the way

 I have a saying: “Hire great people, give them the coaching and mentoring they need, then get the heck out of their way and let them do what they were hired to do.” I think that works at all levels of the organization, whether or not people are your direct hires. You don’t tell people to make a change or streamline a process without any encouragement or support, but you don’t need to micromanage them either. Delivering great health care is not just a job. It is a calling. Whether you’re a housekeeper preventing infection or a surgeon treating cancer, people’s lives are in our hands. That shared mission drives us to be the best.