Frontline Physicians

Quan Nguyen, DO, learned in seventh grade how devastating a workplace injury can be. His father, a carpenter, severed part of his thumb when he lost control of the power saw he was using. The accident put him out of work for a time and forced the family to stretch its skintight budget even further.

Years later, the memory inspired him to join Orange County’s Workplace Safety Steering Committee, says Dr. Nguyen.

“I’ve witnessed, firsthand, how things at work can lead to pain and suffering for the person and his family,” says Dr. Nguyen, a physical medicine and rehabilitation physician at the Chapman Medical Offices in Orange, California. “We’re like a big family at work and I don’t want to see people hurt.”

Team visits worksites to improve safety

As the sole physician on the 12-member committee, Dr. Nguyen uses his singular perspective to engage physicians and others to build a culture of workplace health and safety.

“He’s very unique,” says Jim Ovieda, assistant medical group administrator and the committee’s management tri-chair. “He brings another voice of authority to the conversation.”

Four years ago, Dr. Nguyen helped form the Tiger Team, a task force of union members and managers who visit units with high injury rates and offer expert advice on how to reduce risks. They developed a simple process to identify and address workplace hazards at the local level (see “Five Tips for Workplace Safety Site Visits”).

“It’s not a punishment. We’re there to help departments succeed and to help our staff and physicians to be safe,” says Dr. Nguyen, who named the Tiger Team in honor of “Tigger,” the fictional tiger character who bounces around and helps others.

Collaborating with frontline union members is vital to keeping everyone safe, says Dr. Nguyen.

“There seems to be two cultures inside the hospital – the physician and non-physician. We’re trying to bridge those two cultures by bringing together a diversity of voices to improve the culture of health and safety for everyone,” says Dr. Nguyen. 

Host teams say the visits and ensuing discussions help create an environment where everyone feels comfortable speaking up—essential to building safety into daily work.

Partnership approach gets results

The team aims for six site visits a year and had conducted 31 visits as of November 2015. Most of those departments reported significantly fewer injuries in the months after the visit; many reduced injuries by 50 percent or more. The approach has gained attention region-wide and other medical centers in Southern California are adopting the practice. The team also presented its partnership approach at the 2016 National Workplace Safety Summit.

“It’s a way of taking the pulse of the department,” Ronald Jackson, a medical assistant, SEIU-UHW member and the steering committee’s labor tri-chair, says of the team's site visits.

“We bring a fresh set of eyes to the department,” says Albert Alota, workplace safety coordinator for Orange County.

Three practical solutions

Recently, the committee’s labor and management members sat side by side reviewing workplace safety records for the Irvine Medical Center’s recovery room. The department had accrued nine injuries in as many months, three of them involving employees and gurneys. The team identified several hazards related to work space and storage and recommended ways to fix them. For example:

• To address heavy traffic down narrow hallways and around blind corners: Provide standardized traffic flow for gurneys, mirrors at key intersections and a recognized verbal cue to alert bystanders to passing gurneys and equipment
• To unclog crowded patient bays that forced staff to work at laptops in busy hallways: Install wall-mounted computers and exam stools to replace the office chairs in the room
• To reduce injuries caused by incorrect use of new gurneys: Ask vendors to help train staff how to safely operate new equipment

Employees appreciate the attention. “It’s good to have the team come in,” says Sol Estrella, RN, a staff nurse and UNAC/UHCP member. “It shows that management and higher-ups are responding to our staff needs.”

For the second year in a row, the Northwest region experienced the fewest workplace injuries of any hospital-based region in Kaiser Permanente. The Northwest ended the 2011 reporting year with a 15 percent improvement over injury rates in 2010. (The two California regions, Hawaii and the Northwest operate hospitals, while Colorado, Georgia, the Mid-Atlantic States and Ohio do not.)

Workplace Safety Committee co-leads Marilyn Terhaar and Susan McGovern Kinard attribute the region’s success to several factors:

• Real-time information. Terhaar sends safety alert emails to managers, stewards, UBT co-leads and safety champions. The alerts list the injuries for the prior week and offer safety tips and resources.
• Goals at the frontline. Keeping injury rates low is a regional goal and a PSP goal. Unit-based teams are encouraged to work on these workplace safety issues prior to tackling other goals.
• Culture change. Safety conversations have become part of the workplace culture. If an employee sees someone not working safely or a hazard in the work area, she or he speaks up, knowing the problem will be addressed.
• Investigation. The approach to safety is proactive. The Employee Health and Safety department investigates the root cause of an accident and tries to make sure the accident does not happen again.

High cost to both employees and KP

Employee injuries are significant in several ways. An injured employee may lose pay and time at work, and a department may have to work short, which may impact patient care. And there’s a financial impact on the organization—which eventually could affect member premiums.

 “The cost to open a workers’ compensation claim is about $1,200 on average,” says Terhaar. “Once you start adding in medical and surgical costs, the expenses can soar.”

Indemnity claims—those claims that cover employees with more serious injuries that require a longer time off—average $21,000.

 “That’s one of the reasons we have such a laser focus on safe patient handling. The risk to the employee for injury is so great,” explains McGovern Kinard.

Prevention

The Northwest region employs a well-constructed safe patient handling program. New employees are trained on safe patient handling, and more than 1,000 employees were retrained in 2011. Hospital and clinic policies require staff to move patients using safe handling techniques and equipment.

 “We have mobile lifts and overhead lifts at Kaiser Sunnyside Medical Center and will have the same equipment at our new hospital opening next year,” says Paulette Hawkins, RN, a workplace safety consultant. “In addition, all medical and dental clinics have mobile lifts and receive annual hands-on refresher training on request.”

Members of the workplace safety committee aren’t resting on their laurels. This year, they plan to bring the focus of safety to the UBT level.

“Most teams can solve their own issues,” say McGovern Kinard. “There’s been an increase in awareness that’s been growing steadily over the last five years. Our numbers say it all.”

For nearly a year now, the Neonatal Intensive Care unit at the Fontana Medical Center has welcomed parents 24 hours a day, thanks to a unit-based team that put the patients’ needs first.

Since April 5, 2011, parents have been able to stay on the unit with the newest member of the family regardless of the hour and even during shift changes and rounding.

“The belief in family-centered care is put into action here,” says management co-lead Annette Adams, RN. “Nothing should come between parents and babies.”

Team members put themselves in the shoes of the parents whose children are treated on the unit: The distress of having a newborn baby staying anywhere other than right by your side, of having to leave your baby in the hands of strangers, and being told when you could come and see your own child.

Making it better for parents

Keeping the service point on the Value Compass in mind, the team looked inward to tackle the problem of concerned parents lacking 24-hour access to the unit.

The UBT began by researching what it takes to have successful open visitation in the NICU and what the benefits are for members and patients. The team found that many NICUs were not truly open to parents 24 hours a day, as parents were asked to leave during change-of-shift reports and physician rounds.

The UBT concentrated on how to make sure parents could remain, despite the concerns.

Shift reports are done at the bedside. But the NICU is one big room where anyone can hear anything. Team members researched how to solve this problem by asking how other Los Angeles-area NICUs, such as Cedars-Sinai Medical Center, handle shift reports without compromising privacy.

Involved in shift hand-offs

Not only do parents now get to see their babies whenever they desire, they are also asked to participate when the physicians round and during the change of shift hand-off, which gives them the opportunity to meet the nurse assuming care of their baby.

“The belief that family-centered care is an essential part of each family’s experience was the driving philosophy behind the progressive move in visiting policy,” says Sheila Casteel, RN, the NICU team’s labor co-lead and UNAC/UHCP member.  

The representative team members enlisted help from the rest of the unit by introducing the concept through the monthly staff newsletter and giving presentations at staff meetings.

Unit staff members were asked for their ideas about how to overcome barriers—real and perceived. Some of the practices adopted included:

• moving the staff hand-off huddle outside the unit to the conference room
• making the relief and admitting nurse available to answer parent questions during hand-offs

Colorado

Thanks to a diligent chart review process, the Medicare Risk Business Services unit captured an additional $10.3 million last year in Medicare reimbursements unclaimed in 2010. The hospitals Kaiser Permanente contracts with in the region were submitting documentation with incomplete physician signatures, which prevented KP from submitting the bills for reimbursement. The technical error causing the problem was corrected, but the team had to review 26,000 hospital inpatient notes for 2010. The total collected is more than three times what the team predicted when it began correcting the error.

Georgia

When staffers at the Cumberland Medical Office Building pharmacy in Atlanta open bottles of pills to dispense prescriptions, the bottle is supposed to be marked with a big X, a flag for reordering. But often, a pharmacist or pharmacy tech would find only a few pills left in unmarked, open bottles, not enough to fill a patient’s prescription. So the team brainstormed ways to ensure the bottles are properly marked, including posted reminders and giving everyone his or her own marker. The number of unmarked bottles fell from 30 to zero the first week; went back up the next week; then dropped back down and stayed down—lowering costs and improving service.

Hawaii

When the Honolulu clinic’s Obstetrics and Gynecology team members realized patients were waiting six minutes or more for routine injections, they decided to designate one nurse each week as the “shot nurse,” whose priority duty is giving shots, and one as a “floor nurse,” who helps direct patients to the shot nurse and pitches in when it’s busy. Whiteboards let staff know who is filling the roles. The team has dropped member wait times to an average of 3.2 minutes.

 Mid-Atlantic States

Unit-based team storyboards, a homemade “test of change” video shot by the Radiology UBT on its efforts to boost co-pay collections, and a roomful of enthusiasm and healthy snacks marked the inaugural UBT Expo in the Mid-Atlantic States region. A dozen teams at Largo Medical Center in Maryland—from Adult Medicine to Vision Essentials—exhibited projects on service, quality, best workplace and affordability. When attendees weren’t networking at the exhibits, they heard formal presentations from teams, who were introduced by their sponsors.

Northern California

The Redwood City Medical Center inpatient pharmacy is celebrating success after sustaining, for more than six months, a dramatic reduction in the rate of medications administered late (a half-hour past their scheduled time) in the medical-surgical wards. Previously, 26 percent were late; now, the range is 12 percent to 15 percent. Working with the med-surg nurse manager, the team began using color-coded bins to distinguish new medications from discontinued ones and delivering medications 15 minutes before the hour in which they are scheduled to be administered. These and other changes have improved communication and give nurses more information about where to retrieve the medications.

Northwest

By focusing on hospital quiet and Nurse Knowledge Exchange, the Women and Newborn Care arena at Sunnyside Medical Center has earned recognition as one of the best of its kind the throughout Kaiser Permanente, improving its HCAHPS Overall Hospital rating by 17.5 in 2011. The report rooms—where staff members congregate and talk—have doors that close automatically, and nurses try to respond to all call lights within three dings. “A patient does not belong to one nurse, but the whole department,” says Dory Schutte, RN, a member of OFNHP and one of the UBT’s co-leads. In addition, Nurse Knowledge Exchange at shift changes and having nurses join physicians and midwives on rounds has improved communication and patient satisfaction.

Ohio

Giving post-procedure snacks to patients is standard, but Ohio’s Gastroenterology department realized it was averaging $750 to $800 a month on snacks, well over budget. After Carol Zimmerman became manager, the UBT implemented small but key changes: Eliminating rarely eaten snacks, replacing more expensive items (Oreos) with less expensive choices (graham crackers), and removing temptation by keeping supplies locked out of sight. Zimmerman also began to regularly share the department’s budget and costs with staff. The team noticed an impact within two months, with hundreds of dollars saved in short order. Reviewing the budget is now a standing part of team meetings.

Southern California

Faced with the teams using linens inappropriately, Panorama City Medical Center’s Materials Management unit-based team set out to educate other hospital staff about the costs involved—reminding them not to use linens to mop up spills or as makeshift tablecloths and to refrain from overstocking linen in patient rooms. Managers and union leaders worked together to develop a storyboard and presentations and reviewed linen usage and stocking levels with individual departments. The result? The overall costs of linen for Maternal Child Health, one of the first departments targeted, were reduced by 6.8 percent, more than three times the original goal.

Colorado

When people go to school to learn how to perform X-rays or take blood pressure, they don’t generally expect they’ll be bonding with colleagues while getting their commercial driver’s licenses or that putting on snow chains will be part of their job. But members of the “mobile coach” unit-based team, who travel to clinics that do not offer mammograms on site and who are in charge of every aspect of running a mammography lab on wheels, took these tasks on and more. Their unusual assignment is improving the quality of care—they screen an average of 15 patients a day and performed 2,584 exams in 2012, finding 12 cancers.

Georgia

The Pharmacy team at the Cumberland Medical Offices cut labeling costs by more than 50 percent by improving accuracy in printing prescription labels. Techs now take a medication off the shelf before typing in the prescription or passing it off to a pharmacist. This helps them select the right code from the National Drug Code database—reducing the need to reprint labels and the associated medication information sheets that are given to patients. Within three months of the change, the number of incorrect codes on labels went from 13 a week to zero. Spending on labels dropped from $1,355 in November 2011 to $569 in March 2012, and monthly shredding costs dropped from $90 to $30. 

Hawaii

The Gerontology specialty team at the Honolulu clinic uses a distinctive combination of red and blue tape to keep its nursing staff free of accidental syringe needle sticks, which can lead to serious disease. More than a year ago, the team set a goal to have no more than three sticks a year—the number of incidents in the previous year. But telling busy caregivers not to rush was not enough. Today, a designated area blocked off by the tape signals to other staff that a nurse needs to concentrate fully on preparing an injection or disposing a needle. The UBT reinforces the warning with signs and a monthly safety message. There have been no needle sticks since October 2012.

Mid-Atlantic States

When busy patients kept canceling appointments, the Baltimore Behavioral Health unit-based team had to find a way to address the no-shows, which were having a negative impact on the clinic’s workflow. In June 2012, 32.7 percent of open slots for new referrals went unused. Then the team stepped in with personal reminder calls and letters, as well as in-person coaching during the after-visit summary review about—yes—how to cancel an appointment. Once patients learned how easy it is to use kp.org to cancel an appointment and understood how other members benefit from the newly opened slots, the no-show rate dropped to 25 percent in February 2013.

Northern California

When parcels arrive at the Fremont Medical Center, they are placed onto a conveyor that rolls them into a warehouse, where they are processed and staged for delivery. Before the conveyor was installed—a suggestion made by UBT member Pablo Raygoza, a storekeeper and SEIU UHW member—workers had to do a lot of bending and lifting to pick boxes up, handling each one multiple times. The improvement was part of a three-year effort to increase worker safety by redesigning and streamlining work processes. As of March 2013, the effort had kept the Supply Chain department injury free for more than 660 days and earned it this year’s regional President’s Workplace Safety Award.

Northwest

The Northwest welcomed 2013 with a recommitment to the region’s hospital’s unit-based teams at a three-day Value Compass Refresh meeting, attended by more than 300 UBT co-leads, subject matter experts and regional leaders. Groups explored subjects like overtime, process improvement and patient flow. In the end, hundreds of potential projects were identified by co-leads and subject matter experts to take back to their UBTs for discussion and next steps. Representatives from the Operating Room UBT discussed opportunities to improve communication with surgeons. On hand was Imelda Dacones, MD, the chief medical officer of the Westside Medical Center (slated to open this summer). She listened with an eager ear and asked questions of the teams to help understand the challenges. “All the physicians who have privileges at the new hospital,” she says, “will go through the Patient Safety University training.”

Ohio

Members regularly complained about long waits for prescriptions at the Parma Pharmacy, so the unit-based team decided to map the prescription-filling process using a spaghetti diagram. The tangled web of lines captured in the drawing told the story and pointed to the root cause of the problem: Pharmacists did a lot of unnecessary walking and backtracking. The primary culprit was walking to and from the technicians, who are located in the front of the pharmacy, to deliver prescriptions. The team decided to move pharmacists closer to the techs—a small change that gives pharmacists more time to dedicate to filling prescriptions and shaved wait times by 84 seconds, or 14 percent.

Southern California

The eight-person nephrology unit at the Stockdale Medical Offices has always exceeded regional goals for its discipline and prided itself on the care it provides its kidney transplant patients—but it got a rude awakening in January 2012, when it saw fresh data from the regional renal business group. The team was merely average. Team members got busy, analyzing the metrics and scouring patient records. To help flag the care each patient needs, they turned to the Proactive Office Encounter functions in KP HealthConnect™. They hosted a special short-term clinic just for transplant patients. Nurses made outreach calls. And the percent of patients getting five key services shot up—flu shots (up 50 percentage points), dermatology appointments (up 32 points), renal ultrasounds (up 22 points), annual follow-up visits (up 25.5 points) and lab work (up 26 points).

Yes, I’d be happy to. Yes, I can do that. Yes, of course, yes.

Stepping up to the plate, being engaged, working hard—in a workplace that fosters continuous learning and improvement, these are qualities we prize in our colleagues and cultivate in ourselves.

And, in a sprawling, complex organization like ours, with myriad initiatives and projects, these traits can be our undoing. If we say yes to everything, we wind up spread too thin. Spread too thin, we lose effectiveness. Trying to regain the ground we think we should already have covered, we go faster and faster, start to spin our wheels and—burn ourselves out.

We do it as individuals, and we do it in our unit-based teams, too: Yes, we can do that. Yes, we’ll take that on. And then there’s too much to do and an effort to improve sputters out.

There are lots of techniques for individuals to manage competing demands. As UBTs mature, they and their mentors are getting savvy about the importance of having teams set priorities, too.

Developing teams don’t always have the confidence it takes to say no. In “From Frenzied to Focused,” Denise Johnson, the continuum of care administrator at San Jose Medical Center, notes that we have a tendency to think more is better. She and other UBT supporters are helping their teams map out the path forward, teaching them to discriminate (in all the best senses of that word)—to know when to say “yes” and when “no, not now” is in order.

Fewer, well-chosen projects have a greater impact on Kaiser Permanente’s quality of care, service and affordability. And not being constantly frazzled certainly helps create a better place to work, too.

This time, I was the patient. I’m confident I received the right care at the right time. The removal of a suspicious polyp may have averted colon cancer a few decades hence. I’m grateful for that.

But I wouldn’t say I was “at the center” of my care team’s processes. My interaction brought home for me the theme of this issue of Hank, how we can improve care by asking members to participate in performance improvement. Previous patients could have told my team:

The instructions given to members on prepping for a colonoscopy don’t mention that the effects of the purgatives might take two hours to arrive—and then arrive so urgently you’d better be three steps from the toilet. The prep sheet should note what you can do to be ready.

In the clinic itself, the row of patients lined up on their gurneys don’t need to overhear nurses, somewhat frustrated, adapting to staffing changes. Problem solving is good, but save those discussions for staff areas.

In the procedure room, introduce yourselves—and keep pleasantries appropriate. In my case, one of two nurses remained anonymous. The doctor introduced himself but asked, “How are we doing today?” The “we” was a wrong note; he and I were having distinctly different days

Body and spirit are intertwined, and so, too, are quality and service. Our bodies need “best quality,” our spirits need “best service.” Best care addresses both. Patients know better than anyone what best service looks like. Find ways to invite their voices into your team’s work.

Colorado

Spurred on by a Performance Sharing Program goal, UBTs in the region are focusing on affordability and efficiency by taking on improvement projects with identified cost savings or revenue capture. Teams are finding ways to work together. For example, the Stapleton Cytology and Molecular lab teams increased productivity by cross-training and solving problems together. As of August 2014, the teams are processing five times more HPV screenings a month than in 2012. The region also is celebrating strong membership growth.

Georgia

Clinicians know a lot about medicine and less about the health insurance benefits their patients have. Members of the unit-based team at the Douglasville Medical Office knew that frustrated patients. They set out in July 2013 to improve the staff’s understanding of member benefits through an ambitious 12-week training session. Before starting the weekly classes, staff members scored an average of 68.5 percent on a test about member benefits. By the end of October, their average score was 95 percent. The team credits its newfound business literacy for boosting service scores, which helped Kaiser Permanente retain a major city account and win a new one. 

Hawaii

More than 1,000 new health plan members joined Kaiser Permanente this summer, thanks to the collaboration between Kaiser Permanente and the Coalition of KP Unions to grow KP membership. The effort started in May with a strong presence at a conference of the Hawaii Government Employees Association—one of six unions covered by the state Employees’ Retirement System, KP Hawaii’s largest customer. Conference delegates visited the KP booth, took Body Mass Index (BMI) readings and participated in a KP-sponsored walk. KP followed up with mailers to prospective members, presentations to union retirees, invitations to tour KP facilities and more. Lynn Ching, labor liaison for the Labor Management Partnership in Hawaii, and Troy Tomita, a KP senior account manager, worked on the project together. “It’s a great headstart for open enrollment in October,” Ching says. 

Mid-Atlantic States

Members of the Ambulatory Surgery Center unit-based team in Gaithersburg, Md., not only are putting the patient at the center of every effort, but also bringing the patient’s family members and friends into the fold. The team created a perioperative liaison role, in which a staff person is assigned to a patient and acts as point person, updating a patient’s friends or family members throughout the patient’s journey through the surgery center. After creating the new role in February 2014, the surgery center’s service scores jumped from 75.8 percent in January 2014 to 88.8 percent in April 2014.

Northern California

Fremont Medical Center employees took all obstacles in stride when it came to adding physical activity to their workday as part of the KP-wide Instant Recess® week in early August. Nearly 200 Fremont workers Hula-Hooped, boxed, danced, hop-scotched and jump-roped as part of the facility’s Instant Recess obstacle course. Usually, Instant Recess is a 5- to 10-minute activity done to music, but it also can be any kind of fun activity that gets people moving. The San Francisco, Richmond and San Rafael medical centers were among the other Northern California locations that joined in the week of Instant Recess, which was organized by national and regional Workforce Wellness programs and the union coalition.

Northwest

Working through unit-based teams, the region has launched a new focus on affordability. The UBT Resource Team is leading the charge by providing such resources as a project template and performance improvement tools, including 6S and the Waste Walk, as it works with teams. In addition, teams can reach out to subject matter experts in finance, purchasing and other areas for assistance. The region’s UBT Data Team will calculate the return on investment of the efforts and enter that information into UBT Tracker. Some teams, such as the Rockwood Medical Office Patient Registration UBT, are working on reducing paper registration forms to cut down on waste and save money.

Southern California

Leaders at the South Bay Medical Center hosted a performance improvement fair for unit-based teams this summer, aimed at giving teams the tools they need to reach levels 4 and 5 on the Path to Performance. After grabbing some healthy snacks at the sign-in table, UBT co-lead pairs sat with an improvement advisor or UBT consultant and got customized advice on how to move their projects forward. For instance, the union co-lead from a medical-surgical unit reviewed data collection techniques at one table, while at another, food and nutrition team members filled out a fishbone diagram for their efforts to collect errant cafeteria trays. Co-leads got help entering their projects into UBT Tracker, then left with a packet of performance improvement tools.