Colorado

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.”

The Molecular and Cytology Lab unit-based teams in Stapleton, Colorado, were facing a challenging trifecta. Increased membership, changes in guidelines from the Centers for Disease Control and Prevention (CDC) and slow work processes made it tough to quickly process two widely used tests.

Membership in the Colorado region has grown by more than 60,000 members since 2013 in part because of the Affordable Care Act. Total membership in the region is now at its highest ever, with more than 600,000 members. The influx of new members is a strain on the system, and teams are digging in deeply to meet those members’ needs, from the first point of contact in the medical office to the last encounter as they pick up their prescriptions on the way out.

The lab teams are feeling the pressure, too—especially since they also process samples for the Georgia region, which is expected to grow, and they still do some work for facilities in the former Ohio region, which was sold to another health plan last year.

“We knew there would be an increase in the number of tests we would be doing. We also knew that our process was very labor intensive,” says Roxanne Whitesides, the Molecular and Specialty Testing manager. “Already this year, we’ve increased our workload 10 percent because of an increase in membership.”

Preventive care approach

The screens in question are for the human papillomavirus (HPV) and the Papanicolaou (Pap) test. Both detect disease at an early stage when treatment is highly effective, and so are central to Kaiser Permanente’s preventive care approach. As of June this year, the Molecular and Cytology teams—each of which has a role in processing the screens—already had processed 23,300 Pap screens and 16,800 HPV screens.

Meanwhile, CDC guidelines on HPV were revised in recent years and now recommend that women age 30 to 64 have an HPV screening and that girls as young as 11 receive the vaccine. The agency says HPV is the most common sexually transmitted infection in the United States. Some strains can cause cancer, and the CDC says about 21,000 of the HPV-related cancers each year could be prevented by the vaccine.

Because of the changed recommendations, even before the enrollment jump, the labs were seeing an increase in the number of HPV screens they processed. In 2012, the labs processed 650 HPV screens a month. By this spring, the monthly average had more than quadrupled: the average for March, April and May 2014 was 2,800 per month. In May alone, 3,354 samples were processed.

Labor-intensive processes

The final hurdle the teams faced was that their processes were labor intensive, requiring significant hands-on time from the technician. There was frequent back and forth between the Cytology and Molecular departments, which caused delays and interruptions. The complex work processes added to the pressure of the growing workload and caused frustration and tension.

The teams began an intensive study of what other labs were doing, including researching the latest technology. They visited other sites and vendors and decided to go with a cutting-edge Roche instrument. The pathologists—who work closely with the labs—supported getting the new equipment, and the lease was fast-tracked for installation. The instrument was in place within two months.

At that point, the teams set to work to figure out how their processes would change with the new equipment.

Cross-training provides insights

“We trained each other on the new equipment and on the processes within the two departments,” said Luann Martin, a cytology technologist, UFCW Local 7 member and co-lead of the Cytology unit-based team. “I could appreciate things going on in both departments.”

The collaboration between the Molecular and Cytology departments enabled them to improve their work processes and interactions—and ensured that as one problem was fixed, another wasn’t created.

“It’s important to keep talking. People have different expectations and comfort levels,” says Beth Fisher, a medical technologist, UFCW Local 7 member and co-lead of the Molecular UBT. “Be patient with one another,” says Melissa Baca, a cytologist lab assistant, SEIU Local 105 member and union co-lead of the Cytology UBT.

Most important, Fisher says, the new equipment is enabling the teams to meet the growing demand.

“The big payoff is that we're able to process all those HPV samples in less than half the time it used to take, so we've been able to absorb the workload increase with no new staff,” she says. “And we're able to identify the HPV strains that are most linked with cervical cancer as part of the initial screening. That saves money, because we don't have to send out all the positives for additional testing.”

As more and more unit-based teams answer the call to improve affordability for health plan members, they are finding new tools that can help manage their cost-improvement projects.

One such tool, a handy spreadsheet, can help teams track and report their cost savings.

Teams track own savings

Developed by UBT consultants and financial analysts in Colorado and later adopted by UBTs in the Northwest, the tool can help teams determine the economic benefits of a performance improvement project with little or no assistance from a consultant or sponsor.

“It’s a great add-on to teams’ reporting in UBT Tracker,” says Luanne Petricich, chief pharmacist, Pharmacy Professional Affairs, in Colorado and a sponsor of 12 UBTs in the region. “It can be a very impactful way for co-leads to show their teams and others what their savings were and how they achieved them.”

In addition, teams can now record their financial results directly into UBT Tracker thanks to a new data field, Annual ROI, that allows teams to share how much money a project saved or generated. The field can be found under the Project Details tab (see graphic below).

Click to enlarge.

Tool use spreads

Petricich sends the spreadsheet to any of her teams working on a cost-reduction or efficiency project to help them document their results.

One team that used the tool was the pharmacy UBT at Baseline Medical Offices in Boulder. The team had completed an inventory-reduction project that far surpassed its goal—which was to reduce its drug inventory by 10 percent, or $50,000, in three months. By adjusting order quantities to better match usage and returning overstocked medication to the mail order pharmacy for use before the expiration date, the team saved $143,000—nearly three times its original goal.

“It’s important to track your results, and this tool can help teams do that in a simple way,” says Don Larson, Baseline’s pharmacy supervisor. “It’s something we would use the next time we do a similar project.”

For at least one Colorado facility, workplace safety started with awareness. And building awareness was a team effort.

Wheatridge Medical Office, with about 140 employees, had three workplace injuries in the first half of 2013. The Wheatridge Safety team, representing departments across the facility, agreed that was unacceptable. But team members weren’t sure where to start, and the team lacked a management representative, making it hard to find time or resources to implement ideas.

That changed when Jeanne Kraft, RN, nurse manager for Internal Medicine, joined the safety team. The team adopted two ideas that had worked elsewhere. One was to host a safety fair, following a tried-and-true format: People visited several booths where they got information and answers to a quiz on basic safety practices. Everyone who completed the quiz then got a ticket for a barbecue lunch on the patio.

Improve service scores. Reduce waste. Retain members. Gain new members. Cut wait times. Work safer. Perfect patient safety. Innovate care.

Teams are juggling constantly, trying to meet their own objectives, move forward on initiatives related to facility, regional and national goals, and comply with regulatory requirements—all in a competitive economic environment.

When the curve ball comes sliding in, it can be one thing too many, derailing a strong team or keeping a struggling team at ground level. So a host of unit-based team supporters are turning their attention to strategies to help unit-based teams prioritize competing demands—from personalized mentoring to intensive workshops for co-leads.

“I see my role as taking away the noise and the chaos…to help them figure out, ‘Realistically, how many things can we work on at once?’” says Denise Johnson, San Jose Medical Center continuum of care administrator and a UBT sponsor. “I have to help them not be crazy, because we don’t want a lot of projects that don’t make a difference.”

Here are four strategies for helping teams.

Strategy #1: Planning pays off

Every year, labor and management sponsors at the San Jose Medical Center sit down with their UBT co-leads to develop an operating plan. The plan flows from Kaiser Permanente’s organizational goals as well as from regional goals, facility priorities, and the needs of the department. Each sit-down includes the service area’s UBT consultant and its union partnership representative. Projects emerge naturally from that plan, with teams turning to the Value Compass and a tool called a PICK chart to fine-tune their priorities.

“They have to figure out what’s in their sphere of influence,” says Eric Abbott, the area’s union partnership representative. “What are the things they can change, and of those things, how much time do they have?”

When Johnson became sponsor of one San Jose team, it was immediately clear to her the UBT had too much on its plate. She worked with the team to winnow eight projects down to two.

“In my experience, people get bogged down with the to-do list and sometimes don’t stop and think about what’s really on that list and what effort does it serve,” she says. “They thought I was crazy. They came from a mentality where ‘more is better.’”

Strategy #2: Urgency can be a tool

Two years ago, San Diego’s interventional anesthesia unit-based team was humming along in its performance improvement work when it got hit with the news that co-pays for patients who suffer from chronic pain would be increasing sharply.

The 14-member team responded with a new service project, a multiphase communication plan to help members understand the new co-pay and their options. And then the next wave broke: The team learned it had a matter of days to move into a new specialty services building. It suspended the co-pay project to plan for and complete the move.

One key performance improvement tool—a process map—proved instrumental. The team created a detailed map that laid out every piece of work that needed to be done in preparation for the transition, from changing procedures to adapting to a new phone system to altering workflows based on the new floor plan.

“They simply became a single-issue team,” says their UBT consultant, Sylvia Wallace, of the 2011 move.

With the process map in hand, the team spotted an opportunity to weave communication about the new co-pays together with communication about the move. As a result, it didn’t miss a beat in providing its members with critical information about available financial assistance.

The comprehensive plan helped the unit’s service scores hold steady through the transition—and then increase at the new facility. The moving plan became a template for other departments, which are still moving into the Garfield Specialty Center.

“Everyone participated. All types of ideas were solicited and implemented,” says Grace Francisco, the assistant department administrator and the management co-lead at the time. “Everyone has a role and accountability for each step.”

Strategy #3: Take time to train

Teams stand a better chance of weathering competing demands when they have a solid understanding of partnership principles and processes as well as performance improvement tools and methods.

In Colorado, the UBT consultants used LMP Innovation grant funds to host a two-day workshop centered on two regional priorities. Co-lead pairs from throughout the region learned how best to serve new members and improve the affordability of KP care by reducing waste and inefficient practices. They walked away with a variety of team improvement tools and resources.

“We are trying to set the teams up to be successful by giving them the time to focus on topics that could have a huge impact in the region in the next few years,” says Linda Focht, a UBT consultant and UFCW Local 7 member.

In San Diego, regular UBT summits bring co-leads together for intensive sessions on given topics. Service area and local union leaders play a major role in structuring the agenda, so the team development matches up with high-level strategy. The joint planning creates a full picture, one that resonates better at the front line and sets up teams to work on projects that make a difference to KP’s reputation.

“Leaders see a lot more than what we see,” says Jenny Button, director of Business Strategy and Performance Improvement in San Diego. “Leaders see what is going on with the competition. They see across all of the different metrics we are working toward. They see at a broad level where our biggest gaps are.”

Strategy #4: One-on-one attention counts

At San Jose Medical Center, sponsors like Johnson and Hollie Parker-Winzenread, an assistant medical group administrator, are coaching UBTs one on one in performance improvement tools to help them set priorities.

 “Teams like to jump to the solution,” says Parker-Winzenread. “But they struggle with the process….The gain falls apart, because the process is not strong.”

San Jose’s clinical laboratory UBT is a success story, jumping from a Level 1 to a Level 4 in less than a year after new co-leads worked together to reach joint agreement on the department’s priorities. The team started with tests of change that made strides in attendance. Today, it has moved on to complex projects that require shifting schedules to accommodate demands for getting lab results earlier in the day.

Guidance from their sponsors has helped keep team members on track.

“We’d come up with all of these ideas and projects, and they made suggestions and really helped prioritize what we worked on so we didn’t bite off more than we could chew,” says Antoinette Sandez, a phlebotomist, the team’s union co-lead and an SEIU UHW member.

“You have to help teams to believe in the process,” Johnson says. “As a sponsor I can’t rush the process and say harder, faster, move, move, move. That won’t get us what we want in the long run. Because we’re looking for sustainability.”

Richmond Medical Center Pediatrics knew that “pretty good” wasn’t good enough in 2012. The department’s service scores hovered stubbornly around 88 percent. Its unit-based team members knew they could do better and distinguish themselves from competitors.

“We wanted to give KP members that ‘wow’ experience,” says manager Cynthia Ramirez—to make them glad they chose Kaiser Permanente and to give them reasons to stay with us.

So the UBT, knowing the system can be frustrating when you’re unfamiliar with it, created a project that would take the mystery out of the process. In doing so, the team also hoped to debunk any idea that KP is an impersonal health care factory. 

“We need to not just look at our work as a job all the time,” says union co-lead Jill Sandino, a medical assistant and SEIU UHW member. “It’s kindness from the gate.”

Time for our A game

With major elements of the Affordable Care Act going into effect this fall, focusing on a member’s total experience with KP has never been more important. After years of preparation, how we respond to the challenges and opportunities will make a big difference for our organization and for our members. And every UBT can get ready by figuring out where its processes aren’t the best—or are merely OK—and getting to work on improving them.

“For the first time in our history, how well we do fundamental business operations—billing, copayment collection, customer service—has the potential to overshadow the health care we deliver in driving overall member satisfaction,” especially because more members will have plans with deductibles, says Larry Sirowy, KP’s executive director for market research. Sirowy and others have been working to figure out the characteristics of the people who will become members through health care reform—and what we need to do to be able to provide all our members, new and old, with the care they need.

Without a crystal ball, no one can say exactly how Kaiser Permanente will be affected. But one thing everyone is anticipating is an influx of new members—and we know that if new members stay with us after the first year, we’re likely to keep them as members in future years. So in the months ahead, we need our A game, and we need to bring it to every aspect of our work.

The good news is UBTs are already working—and seeing results—on a variety of projects that will improve our ability to provide new members with excellent service and care as well as reaffirm current members’ decision to choose KP.

Richmond’s "wow" experience

To ensure new patients have a topnotch visit, for example, the Richmond Pediatrics UBT created a workflow that involves everyone. It starts with the receptionist spotting the new member flag in KP HealthConnect and giving the person a customized welcome. In the exam room, the medical assistant provides a welcome packet—offered in Spanish or English—with basic department information, critical phone numbers and instructions on how to sign up for kp.org. Department manager Ramirez comes by to introduce herself and share her business card.

The physician caps it off by welcoming the patient to his or her practice and touting the great teamwork in the department.

“This reinforces that they’re in good hands, and we’re a family and know everyone by name,” Ramirez says.

The new workflow is making a difference: The department’s service scores increased from 88.3 percent satisfaction at year-end 2012 to 95.1 percent in the first quarter of 2013.

“Starting with a small Rapid Improvement Model project has made a big impact,” Ramirez says. “It gives us the momentum to be ready for whatever comes next.”

Unexpected consequences

In January, Georgia’s Douglasville Medical Office got a dress rehearsal in receiving a flood of new patients when the local city government signed on with KP.

“I hadn’t realized how large this group was,” says pharmacist manager Adaora Oraefo, until, at the end of 2012, “we started to see a dip in our service scores.”

Douglasville is a tiny clinic, so patients are supposed to check in with the pharmacist to confirm their prescription before heading to the lab for tests. But often, no one told them that—so when they did get to the pharmacy, they had to wait 10 or 15 minutes while the prescription was filled.

Not surprisingly, since members assumed their prescription would be ready when they were done with their lab work, complaints starting coming in.

“I would step out in the waiting room and talk them through the process,” Oraefo says. “I saw an opportunity to improve.”

The pharmacy began working with the nurses to make sure they explained the clinic’s routine to patients. The facility expanded on the work by holding open house events for new members.

“They were so much happier, especially when they were able to see me as their pharmacy manager,” Oraefo says. “It made a difference. People were thinking, ‘These people are taking the time to show us what’s going on.’”

Understanding KP’s offerings

One element of preparing for health care reform is becoming educated about the law and its provisions, so we can help members understand the changes, too.

Since 2010, Colorado’s patient registration associates (PRAs) have seen an increase in the number of patients with deductible health plans, which often have significant payments associated with them. More experienced with KP’s HMO plans, which feature the familiar copay arrangement, the PRAs didn’t feel confident talking to members about deductible plans.

Since the Health Insurance Marketplaces that open this fall are expected to bring even more members with those types of plans, the PRAs made a proactive decision to educate themselves.
 
“While there will be a number of different types of plans, the concepts don’t change,” says patient registration manager Jeffrey Clayman. “Improving their confidence in their ability to talk about these plans was a natural fit.”

The regional PRA UBT held a training that included actors playing the patients and members, so the staff could practice realistic encounters. The clerks gained experience in explaining the costs and how the plans work—and they also got practice in how to respond when someone gets upset at an unexpected bill.

“We tried to learn how to be more aware of how we communicate to patients,” says PRA Diana Wagner, a member of SEIU Local 105 and the regional UBT’s union co-lead. “I treat patients the way I would want to be treated—which is businesslike. But the service quality person made a point, that you need to treat patients the way they want to be treated.”

Tim Kieschnick, a Kaiser Permanente executive consultant who has been working to understand how our member demographics will be changing, says that currently, many members with deductible plans don’t realize they have a deductible.
 
“They’ll pay a $25 copay,” he says, “and then four months later, they get a bill for $1,300”—and they’re shocked.

 “The goal should be no surprises,” he says. “How you do that is something we’re all trying to figure out.”

Sustaining improvement

The other challenge, of course, is to sustain a successful change.

With the many demands of a busy Pediatrics department, co-leads Ramirez and Sandino admit it can be easy to forget to use the new member workflow. To keep the momentum going, Ramirez provides a reminder in the team’s morning huddle if a few days have passed without seeing a new patient.

And Sandino says she tries to “be like a cheerleader.”

“We need members to have our jobs,” Sandino says. “Health care reform is a reality—it’s beyond KP, and it’s beyond the unions. I was never a cheerleader, but I’m a cheerleader at Kaiser around this.”