Frontline Workers

Do you doubt you can lead changes that make Kaiser Permanente a better—and safer—place to give and get care?

A small group of nurses at the San Diego Medical Center showed that leading change is, in fact, part of their job.

Brittni Demers, RN, and three of her colleagues spearheaded a successful effort to reduce needlestick injuries, and now their expertise is being tapped throughout Kaiser Permanente to bring the voice of frontline workers to safety initiatives.

Demers, a member of UNAC/UHCP, is on KP’s National Sharps Safety Committee. It is one of the many sourcing and standards teams that advises KP on everything the organization buys—and it is the only one with union representation. As such, it gives the caregivers who actually use needles, scalpels and other sharps a way to influence purchasing decisions. It also impacts workplace safety and tools workers use every day.

From July to December 2013, a huge remodeling project at the hospital shut down two medical-surgical units, leaving several nurses temporarily without anywhere to work. Demers and RNs Jessica Heffern, Leanne Vitacco and Lucas Pepin got together to tackle a problem that had been concerning them: needle and sharps injuries. By July 2014, the team’s project had led to an astounding 76 percent decrease in needlestick injuries in inpatient nursing units. There were similar improvements for all sharps injuries throughout the San Diego service area.

Here’s what the team did:

Peer-to-peer training

Only two years out of nursing school, Demers quickly saw that “real life” didn’t always comport with what she had learned in her classes. “You go to school, you learn correct techniques, then you go into a hospital and it’s different,” she says. “People like doing things their way.” The team devised a quick refresher for nurses, by nurses, that emphasized what the evidence and research said about safe needle handling. The nurses traveled from unit to unit in the hospital, and to some outlying clinics, to make their case. “When you emphasize safety—our own and the patients’—and provide the supplies, then people will do it,” she says.

“The peer-to-peer approach was effective because the team understood the nurses’ day-to-day concerns,” says Mark Trask, the director of environmental health and safety in San Diego. “There is empathy and understanding, which allows for more dialogue.” In addition, because the trainers were registered nurses, they could spell other nurses for the 10-minute refresher. More than 700 nurses, physicians and lab techs took the training.

Standardize supplies

While demonstrating safe needles to other units, the team members often would hear, “Oh, we don’t have that one.” So they got to work standardizing the needles throughout the medical center. “We went through every single medication room,” says Demers. “They became supply chain experts,” says Trask. By adjusting the types and amounts of equipment, they also reduced waste and saved money.

Share expertise

These nurses now participate in incident investigations when there is a needlestick injury, which is an important part of the region’s workplace safety program. Plans are in the works to spread the training to primary care departments in the ambulatory setting.

Identify resources

Demers’ participation on the National Sharps Safety Committee extended her reach system-wide. The committee field tests safety sharps in every KP region to identify products that most effectively prevent injuries. Based on user feedback, the committee selects the highest-rated safety sharps as KP’s national standard.

Why did the four frontline nurses step up? For Demers, the answer is easy: “You have to be focused on safety when you have a needle in your hand.”

On her last day at work before going on maternity leave, something started going wrong with Juanita Ichinose’s pregnancy—and she found herself in an ambulance, on her way to the Downey Medical Center. Her husband, Trav, followed in his car. The images from an ultrasound foretold a grim story: Juanita was expecting twins, but one of the boys was not moving. “Code Pink” began blaring from the overhead speakers as she was wheeled to the operating room. What caregivers and the family feared came to pass. One twin survived, but the other did not.

“We had some moments with our other son,” says Trav Ichinose. “Then I went to see Teo. He weighed a pound and a half. The doctor told me, ‘He is very small.’”

Thus began Teo Ichinose’s four-month stay in the neonatal intensive care unit, a journey that led his father to become an active member of the department’s parent advisory council. Today, Teo is a happy 4-year-old, obsessed with his toy airplane from the latest Disney movie. And his father continues to bring the voice of the patient to Downey’s NICU unit-based team, where his input has helped shape numerous improvements.

UBTs exist to include all voices—employees, managers and physicians—in efforts to improve performance. And some UBTs are bringing in one more crucial voice: the patient’s.

To be sure, there are UBT members who resist. Objections range from “we don’t have time” to “patients can’t possibly know how our department runs.” But for others, it is a step that literally brings the patient-and-member focus of the Value Compass to life.

“UBTs have a lot of expertise. They know what is and isn’t working,” says Hannah King, director for service quality for unit-based teams. “What is missing is the perspective of the user, someone who might be afraid or in pain. We don’t know what they go through before and after they come to us. So we need to ask.”

Read on to see how UBTs have included patients and members in their work and improved performance.

Whose handoff is this, anyhow?
Downey NICU finds a way to keep parents involved during shift changes

During his son’s four-month stay in the NICU, Trav Ichinose became concerned that parents were prevented from visiting during shift changes, when the Nurse Knowledge Exchange Plus occurs.

“Parents want to maximize their time with their babies, and the policy was undermining that,” he says.

Nurses wanted to integrate parents into the process but also needed to prevent interruptions. “During the report, the parents tended to interject,” says Marnie Morales, RN, the team’s union co-lead and a UNAC/UHCP member. “That was a safety issue,” because it is important nurses not get sidetracked.

So, together with Ichinose and the parent advisory council, UBT members devised a system that met the needs of caregivers and parents. There would be “quiet time,” when parents listen and jot down notes while the outgoing nurse updates the incoming nurse. Once they’re done, it’s the parents’ turn to discuss their baby’s care with the nurses.

In testing the process, the nurses realized they needed to be able to discuss sensitive information out of the parents’ earshot—if, for example, there was a domestic violence situation or mental health problems in the family. So they came up with a discreet cue that signals the need to step away.

“The patient is getting better care because there is better communication. Information that wasn’t getting shared before is now,” Morales says. “As nurses, we get so involved with charting that we forget the patient is sitting there. Now, we are explaining as we are doing it because the parent is there watching.”

The change gave the team a boost in its satisfaction scores, which rose from 74 percent in the third quarter of 2012 to 88 percent one year later. It works to maintain the scores by holding refresher trainings with staff.

“With long stays like ours, your emotional resilience is tested to the max,” Ichinose says. “There are things that happen in the NICU setting that can undermine that resilience—or bolster it. Bolstering our ability to take in information, to be physically and emotionally present for the care of our child, affects our satisfaction with the care.”

Preserving pride, preventing falls:
A comment provides a San Diego team with fresh insight

Why do patients fall when they are in the hospital? Is it because they are elderly? Or under the influence of medications that affect their balance? The leaders, physicians and nurses at the San Diego Medical Center considered a range of possibilities and tried everything in the usual playbook, posting pictures of falling leaves on patient doors and using color-coded armbands to indicate fall risk. But nothing was working.

Then the UBT on the 5 West medical-surgical unit cared for a patient who was a member of the facility’s patient advisory council—and they asked his wife for her opinion. She said her husband—normally a self-sufficient, strong man—was too embarrassed to call a nurse to help him to the bathroom, especially given that he was wearing a flimsy, possibly revealing hospital gown.

That “aha” moment led the UBT to take a new approach: No one walks alone. Instead of trying to figure out who is at risk for falling, caregivers would treat everyone as a fall risk and provide assistance. The pilot program was so successful that it is being spread to the entire hospital. Before the campaign began in November 2012, the hospital had been averaging 16 falls a month. In June 2014, that figure was 3.4 a month.

Seeing the experience through the patient’s eyes was the key to the solution.

“I felt as if I was part of the team, and my input was just as valuable as any other member’s,” says Pat, the patient’s wife (last name withheld at her request). “If you go to patients with the attitude that they will be helping you do your job better, you will get an honest evaluation of what can be done to help, and they can make your job easier and more rewarding.”

Reluctant to change?
Some ideas for including patients as part of a UBT

Sheryl Almendrez, the management co-lead of the Definitive Observation Unit (also called a step-down unit) at the San Diego Medical Center, acknowledges that caregivers on her team were hesitant to have a patient join its improvement work: “They were interested, but were they ready to hear ‘the real truth’?” And what if a chronic complainer ate up valuable time?

As it turns out, there was little to fear. Patients’ requests were reasonable. For example, they want nurses to give them a heads-up when using an ear thermometer. “We’re used to it,” says Almendrez, but they may not know what it is. “They may think it’s an injection coming at them.”

For the Urgent Care unit in Largo, Md., listening to patients’ feedback about long wait times when coming in with a sore throat led that UBT to work with colleagues in the lab to fast-track tests for strep throat.

“Our team was very hesitant about bringing a member in because there could be more complaints than real feedback,” says Donna Fraser, RN, the team’s union co-lead and a member of UFCW Local 400. Making it clear why it was including patients helped: “We told the patient that we want to know what we are doing wrong, because how else will we improve?”

Morales of the Downey NICU says she no longer flinches from criticism, whether or not it’s phrased “constructively.”

 “Some of the people we have on our advisory council are the ones who complained the most,” she says. “You know what? They became the advocates for all the other babies. They helped us change a lot of things on our unit for the better.”

Kaiser Permanente is inviting patients and families into the boardroom to talk turkey. There’s no sugar-coating a bad experience or making excuses for less-than-stellar service. Listening to our patients has become a core value, and patient advisory councils are one of the ways KP is bringing the patient into the conversation to improve care.

“There are over 35 advisory councils and over 400 patient advisors throughout the organization,” says Hannah King, the director of service quality for unit-based teams.

In the Northwest, as in other regions, the work being done by the councils is affecting outcomes. Within six months of the formation of the Oncology Patient Advisory Council, for example, oncology patient satisfaction scores climbed 6.5 percent. One change prompted by patient feedback was a fresh look at a procedure that sometimes is used in the course of a surgical breast biopsy. After hearing from patients about the pain they were experiencing, physicians standardized the wire localization procedure to reduce pain.

One of the newest councils in the Northwest was created to help serve the region’s growing Hispanic population. Patients on the council have been involved in a video project that will be ready to share with staff by year-end. In the video, Latino patients talk directly to KP care teams about their culture, providing insights into how to build trust and develop good provider-patient relationships.

Patients who serve on the councils are not paid to participate. “These are people who are invested in helping us succeed,” says Jonathan Bullock, program manager for Patient and Family Centered Care Programs in the Northwest.

Given the complexity of an organization as big as Kaiser Permanente, there’s been a learning curve for patients as well. At a recent council meeting in the Northwest, patients expressed frustration that a suggestion to improve signage hadn’t happened. As it turned out, their idea had been incorporated into the master plan—but there’s a schedule for updating signage, and the clinic they were familiar with wasn’t due yet for a refresh.

The word “rapid” stopped Kathy Stafford, RN, and made her ask more questions.

Stafford, the UBT co-lead and charge nurse for the Regional Infusion Center in the Northwest, had been reading an email from a Colorado colleague. The colleague wondered whether the center was using a new protocol for Remicade, an infusion drug prescribed for such diseases as Crohn’s, rheumatoid arthritis and psoriatric arthritis. The Colorado infusion center was trying a new “rapid” Remicade delivery method and looking to see what the experience of others had been.

The Northwest still was using the standard method, and Stafford, a member of the Oregon Nurses Association, was instantly curious. A regular Remicade infusion takes 3½ hours—three hours for the delivery of the drug, and then, to be sure there are no adverse effects, the patient has to wait 30 minutes before being discharged. The new protocol reduces that to a total of 1½ hours.

The gift of time

“If there is anything we can do to speed up infusions for our patients,” Stafford says, “it would be a service to them and, at the same time, save the organization money.”

In short, Stafford was putting the patient at the center of her decision making, bringing the Value Compass to life. The rapid Remicade protocol improves the patient’s care experience and improves service, quality, affordability and staff satisfaction:

• Patients spend less time in the clinic, since both the drug administration time and post-infusion wait time are reduced.
• Because patients are spending less time in the clinic, more patients can be seen. Up to 16 hours of patient chair time could be opened up every day.
• Because the clinic can accommodate more patients, fewer patients will be redirected for treatment in the Emergency department or at the regional Oncology department, improving those departments’ ability to serve their primary patients.

“Any chance we have to be more effective is worth it, so we can spend more time with our patients,” Stafford says.

Making it happen

Following up on the initial email inquiry, Stafford learned the evidence-based practice already was being used in Colorado and the California regions. She and Greg Frazier, the assistant department administrator and UBT management co-lead, pushed ahead with getting the protocol approved for use in the Northwest, benefitting all the region’s eligible patients.

“There was no stopping Kathy,” Frazier says. “She knew who to talk to in the organization and how to move things along….

“Our team is always looking at how to do things better, and to take care of the patient the best we can,” Frazier continues. Noting that the infusion team is highly motivated and self-directed, he offered words of encouragement to those who see an opportunity they want to pursue.

“Don’t turn away from a challenge. Ask questions,” he says. “It may not work, but look into it first before you discount it.”

Stafford credits the team for getting the new protocol approved so quickly, despite a complex approval process that included meetings with both physicians and pharmacists.

“Without the enthusiasm and involvement of the infusion RN team, this would not have gone as smoothly,” she says. “We found out about the protocol in March and we began implementation in May. That’s pretty fast.”