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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.”

Affordable Care Act (ACA)

The comprehensive federal health care reform law enacted in March 2010.

Coinsurance

The percentage of charges a member pays when receiving a covered service. The member’s health plan coverage pays the balance up to the health plan’s allowance. Coinsurance amounts vary depending on the member’s plan and the service provided.

Copayment

The fixed dollar amount a member pays when receiving certain covered services or prescriptions. The member’s health insurance pays the rest. Copayments vary depending on the member’s plan and the service provided.

Cost share

The portion of charges for a service or prescription that the member is responsible for paying, such as a copayment, coinsurance or deductible payment.

Deductible

The fixed amount a member must pay in a calendar or contract year for certain health care services before the member’s health insurance begins to pay.

Dependent

A family member, such as a spouse, child or partner, who is covered under a policyholder or subscriber’s plan.

Federal financial assistance (subsidy)

Financial assistance in the form of reduced premiums and reduced out-of-pocket expenses to provide help for some people to pay for health coverage or care. The government will pay part of the premium and the out-of-pocket expenses directly to the health plan issuer. Usually determined by income level and family size.

Grandfathered plan

A group health plan that was created or an individual health insurance policy that was purchased on or before March 23, 2010. Grandfathered plans are exempted from many changes required under the Affordable Care Act.

Health care reform

A general term for the major health policy changes put in place by the federal Affordable Care Act of March 2010 and any state laws passed to put it in place.

Health Insurance Marketplaces

Government-run online markets, formerly called Health Insurance Exchanges, where individuals and small businesses will be able to compare and enroll in health plans, get answers to questions, and find out if they are eligible for financial assistance or special programs.

The marketplace

A common nickname for the Health Insurance Marketplaces, also called “exchanges.”

Medicaid

A government insurance plan for the poor and disabled; in California, it’s known as Medi-Cal.

Out-of-pocket expenses

These include the copayments, coinsurance and/or deductible payments members make for the health care services they receive, as opposed to the premium they pay each month to their insurers.

Pre-existing conditions

Medical conditions that a person has before he or she applies for a new health insurance policy.

Premium

The amount a member and/or the member’s employer pays, usually each month, for health care coverage.

Q: What is health care reform?

A: The term “health care reform” refers to the Affordable Care Act—the federal law that was passed in March 2010—as well as any state laws passed to put it in place. These laws are intended to help more people get affordable health care coverage and receive better medical care.

Q: What are the Health Insurance Marketplaces?

A: Marketplaces, sometimes called “Exchanges,” will be state- or federal- run online markets where many people can buy health care coverage. It will be available to people who are uninsured or who buy insurance on their own. They will be able to compare and choose health plans offered by private companies, get answers to questions, and find out if they are eligible for financial assistance or special programs. The marketplaces will also operate a Small Business Health Options Program (SHOP) where small employers can purchase coverage for their employees. Coverage purchased there will be effective Jan. 1, 2014, or later.

Q: Does a person have to buy from the marketplaces?

A: No, not necessarily. The marketplace is just one of the ways people can shop for health coverage. People can still get coverage through their employer or directly from an insurance company. A member will have to buy coverage through the Marketplace to apply for subsidized coverage, however.

Q: Will Kaiser Permanente coverage be available through the marketplaces?

A: Kaiser Permanente intends for our plans to be available in the marketplaces, but individuals don’t have to buy from the marketplaces. A person can still buy directly from Kaiser Permanente or continue to get coverage through his or her employer.

Q: Can anyone get health care coverage?

A: Yes, the ACA requirement regarding guaranteed availability applies to all individuals. Insurance companies can no longer deny coverage because a person has a medical condition, and no one has to pass a medical exam to qualify for coverage.

Q: Who has to buy health insurance?

A: The Affordable Care Act requires most U.S. citizens and those lawfully present to have a basic level of health coverage starting Jan. 1, 2014. There will be some exceptions for financial hardship, religious objection, immigration status and certain other circumstances.

Q: What if a person can’t afford to buy health care coverage?

A: The federal government may provide financial assistance to help a person pay for health coverage if he or she can’t afford it. This is usually determined by a person’s income level and family size. Individuals will be able to find out if they qualify for financial assistance when the Health Insurance Marketplaces launch in October.

Q: What can frontline workers do to prepare for health care reform?

A: Take advantage of every opportunity to become informed. Attend trainings (on KP Learn or in person), read communications and ask questions. Visit kp.org/reform, and refer friends, family and members to the site, too.

With changes this fall promising to bring more health care coverage to millions of Americans—and many more members to Kaiser Permanente—unit-based teams are helping to get member services in top shape.

Managing diseases, slashing wait times and cutting out the high cost of waste are naturally on the radar for caregivers’ UBTs. But operations teams also are working behind the scenes to make sure our services are seamless.

For instance, one team at the California Service Center in San Diego is working to make sure new members have a good “onboarding” experience. Its project aims to make sure that what an employer purchases for its employees is what those workers get when they show up at a medical center for the first time, ID cards in hand. No one wants a new member arriving at a Kaiser Permanente facility and being asked to fork out an unexpected copayment or, worse, being denied a service outright.

“This is the kind of solution that is—and should be—generated from the front line,” says Demetria Williams, a service center manager and the Contract team’s management co-lead.

KP's dual role

Kaiser Permanente is unusual in that we provide both insurance coverage and health care, and so how administrative services are handled affect a member’s overall impression of the organization. The Contracts team enrolls employer groups, entering the details of the lengthy contracts—copay amounts, covered medicines, vision care allowances and so on—that will apply to every employee covered by that particular contract. That sets the stage for the individual employee’s enrollment with Kaiser Permanente. If it’s all done correctly, everything goes smoothly when the new member arrives at one of our facilities.

The job is tough. About 18 account administration representatives refer to the signed contracts they’ve received from Sales and Account managers as they enroll a new employer group—or update an existing one—so the employees will get the right services. The account administration representatives contact the sales people when they find inconsistencies—when, say, the plan that was selected doesn’t include vision coverage, even though the associated contract calls for it.

“We would pick up the phone, but we were not connecting,” Williams says. “We were speaking different languages. We didn’t know what they wanted; they didn’t see what we saw.”

Despite the meticulous work, the team faced a 65 percent discrepancy rate—entries that are likely to cause problems for members when they seek care. So the Contracts UBT used the plan, do, study, act steps to track where the data was misaligned and trace it to specific parts of the process—and team members decided on a small test of change, hosting a “Day in the Life of a Contract” with members of the Sales and Marketing team.

Part of the difficulty was that sales managers and service reps work on different computer systems, with no connection between them. The competing systems were a swamp of alphabet stew: CIDARS, LOB, PA. Since merging the two systems into one isn’t in the offing, staff members found a solution at the unit-based team level.

Cutting through jargon

During two days of face-to-face meetings, the two sides cut through the sea of baffling acronyms and buzzwords and created a cheat sheet of common, acceptable codes.

Jeannie Athey, the Contract team’s union co-lead, an account administration representative for nine years and an OPEIU Local 30 member, said the UBT project was like a foreign student exchange. “We hadn’t seen their system before,” she says—and it was eye opening.

It’s too soon to have updated metrics, but Athey says anecdotal reports indicate the reps need fewer phone consults with sales managers and there has been less frustration between the two groups.

“Members can’t be enrolled until we’ve done our job of setting up the group contract,” says Sherri Saunders, the service center’s operations manager and the team’s sponsor. “If they’re not enrolled, they can’t get services. The contracts are legal documents. We have to get them right the first time, for our members.”

Do corporate leaders understand the lives of working people? Some do. In the long history of Kaiser Permanente, several executives—including Henry J. Kaiser himself—worked their way up from poverty. Clifford Keene, MD, was another. In a 1985 interview, he described his roots:

“I came from a very humble family. My father was a factory foreman at best....During the summer I always worked. I sold papers or worked in factories doing minor tasks. Then, when I was fourteen I went to work in the steel industry as a steel construction punk, an apprentice first....I would find myself doing construction all over western New York State. I became a connecter; that is, a person who gets up on the steel and puts it together. I became accustomed to being up in the air and being up high, although I was always frightened of being up in the air. I don't think anyone is not frightened when you're way up in the air and the steel moves. It's a situation that commands your respect and gets your attention, I can tell you. I earned quite good money and continued to do that until I was a sophomore in medical school.”

The experience stayed with him throughout his life. He reflected on it when commenting on a successful infant bowel surgery while serving as a cancer specialist at the University of Michigan State Hospital at the end of the 1930s:

“When I was in the army I further developed my interest in bowel surgery, and reconstruction of all kinds, and also in plastic procedures, orthopedic procedures, all of which were an extension of my interest in doing things with my hands. I [had been] a steel worker* and it was satisfying to correct things with my hands.”

An open, supportive environment is one aspect of a workplace where workers can point out problems when they see them.

But to ensure the support doesn’t evaporate in the stress of a busy day, there needs to be more than the expectation that people will do the right thing. There needs to be a solid system in place that formalizes the commitment to speak up.

A Radiation Oncology team in Northern California knows this firsthand. From the time the South San Francisco Cancer Treatment Center opened in May 2009, its leaders worked to establish a culture that encouraged staff members to speak up when they saw something wrong and to provide input on process improvements. The center didn’t have a clear-cut mechanism for doing this, however; it was fostered through leaders’ encouragement and role modeling.

Then in 2010, a mistake was made—relatively small, but a HIPAA violation: A patient was accidentally given a printout with the personal information of another patient. The member returned the paper to the receptionist, and no lasting harm was done. But it highlighted the fact that staff members needed a way to record process failures, empowering them to address issues large and small, says Marcy A. Kaufman, the center’s Radiation Oncology administrator.

A protocol that calls for submitting a Responsible Report form was already in place for those times when an error reaches the patient. “But we wanted to create something where everyone can give input at all parts of the process,” Kaufman says.

Stop the Line

So the unit-based team created what its members call Stop the Line. If a radiation therapist or anyone else in the department encounters anything that deviates from the workflow or compromises care, he or she first acts to ensure patient safety, if such action is needed—and then fills out the Stop the Line form to document the incident. The focus is not on individual error but on what can be done to improve the system to prevent similar mistakes in the future.

“It’s a chance to look at the system to see if it is doing its job—are the checks and balances working? Or do we need to bring to the UBT and come up with a different workflow?” Kaufman says.

At monthly staff meetings, the team pulls out a binder with the Stop the Line reports and discusses the incidents and any follow-up actions taken. That discussion is important not only as a way to close the loop but also because it demonstrates to staff members that their voices were heard. The forms don’t drop into a black hole never to be heard of again.

“You have to constantly be talking about this to keep the momentum going,” Kaufman says.

The process applies to all staff, including physicians.

“In the field of medicine where, in general, it is quite hierarchical, it’s even more imperative we have a system like this to encourage every member of the department to speak up, regardless of title, to make sure we’re giving the best patient care,” says Amy Gillis, MD, the center’s chief of Radiation Oncology.

Dr. Gillis recalled the wrong-patient information episode. The initial assumption was that one of the medical assistants, who normally handle such paperwork, had made the mistake. This time, however, the culprit was a physician.

Staff members hesitated, Dr. Gillis says, wondering, “ ‘Should I really write up a physician?’ ” As she notes, however, “We all need to have a greater awareness.”

“It really does take everyone’s buy-in to make it happen and be successful,” she says. In this case, what it took to convince staff was input from the physicians themselves, with the doctors saying, “Yes, please write that up.”

Successful practice spreads

Stop the Line has been so popular that the cancer center’s four sister centers in Northern California have adopted the practice.

South San Francisco Radiology also adopted the Stop the Line form and process, adapting it to meet its specific needs. The department does hundreds of thousands of scans a year, from mammograms to basic X-rays to CT scans. With such high volume, radiologic technologists often feel pressure to keep patients moving through in a steady flow.

“We needed to give technicians permission to do the right thing,” says radiologic technologist Donna Hayes, the department’s UBT union co-lead and an SEIU UHW member. “We wanted them to know it’s OK to stop the process for this. I think it helped that it also came from management.”

As at the cancer center, the process is not used in a punitive way. Instead, it’s used as a way to highlight and address glitches in the workflow—not only within the department, but also in other departments.

“We’ve been able to take the data back to the orthopedics chief or take ED-related issues back to ED,” says Ann Allen, the Radiology director. “We funnel back to those departments that are partners so they can help us make changes.”

The next step for UBTs—a step they are being challenged to take by top management and union leadership—is to make the leap from successful individual team projects to a systemic effort to implement proven practices throughout the organization.

Meantime, remember another bottom line: High-performing teams score more favorably on People Pulse questions related to efficiency and cost reduction, and high-performing teams are more likely to take on affordability projects.

Working with your colleagues to become a high-performing team is a sure step toward reducing waste and improving affordability. Being high performing will help Kaiser Permanente continue to assist and care for families and will help us ensure everyone has affordable health care.

Here are some ways that unit-based teams can help keep Kaiser Permanente affordable.

1: Build business literacy

The more teams know about the business of health care in general and of their own departments specifically, the better equipped they are to find savings. To that end, LMP’s Education and Training department is rolling out an economic literacy program in the coming year. Meantime, teams in both California regions have been using a curriculum developed by a multidisciplinary team in Northern California. The five-part course has caused some trepidation, since in the last two trainings teams go through their department’s budget line by line—but that’s exactly what gives the training its juice.

At the Fremont Medical Center in Northern California, the OR team took the training and instantly started looking for ways to save money. Co-leads Yolanda Gho, Operating Room nurse manager, and surgical tech Gus Garcia, an SEIU UHW steward, talk about the training, its benefits and how it inspired their team to do better. (For more on this team, click the Peer Advice link in the resources box.)

2: Be supply savvy

Teams that take the time to make a comprehensive assessment of their supplies—tracking inventory use, tidying up storage areas, streamlining ordering and so on—can save tens of thousands of dollars with hardly any pain.

For instance, the scientists in the Immunology department at Southern California’s regional reference lab use expensive chemicals, called reagents, to test whether patients have serious infections such as hepatitis and HIV. Cleaning out and meticulously organizing the department’s huge walk-in refrigerators allowed the team to order larger quantities of reagents at one time. Since employees have to test a sample from each shipment, fewer shipments mean fewer tests—saving staff time and expensive reagent. The work, which also means the team needs fewer rush shipments, is saving $50,000 a year.

Another example comes from the Head and Neck Surgery UBT at the Franklin Medical Office in Colorado, which kept trying small tests of change until it found a reliable way to prevent the disappearance of expensive surgical tools. Contracting with outside individuals or companies often is more expensive than having the same thing done in-house. “In-sourcing” can range from health education centers in Northern California using KP-produced pamphlets instead of costlier items from an outside company, saving $64,000, to the Ohio region opening new micro-clinics so patients in the suburbs can see KP physicians instead of non-Permanente providers. (For more on this team, click "Losing Streak Ends for UBT" in the resources box.)

3: Bring it home

Contracting with outside individuals or companies often is more expensive than having the same thing done in-house. “In-sourcing” can range from health education centers in Northern California using KP-produced pamphlets instead of costlier items from an outside company, saving $64,000, to the Ohio region opening new micro-clinics so patients in the suburbs can see KP physicians instead of non-Permanente providers. (For more on the Ohio region's work, click on "Micro-Clinics, Macro-Partnership" in the resources box.)

4: Collect the money we’re owed

Health care in general and Kaiser Permanente in particular is filled with mission-driven people. But KP can’t sustain its mission if we don’t collect the money we’re owed.

In Colorado, the Medicare Risk Business Services UBT members spotted and fixed a technical problem with incomplete physician signatures on patient charts, which allowed them to bring in more than $10 million in Medicare revenue that otherwise never would have been collected. In Santa Rosa, Calif., the patient services representatives in the Emergency Room analyzed data and did some role playing with one another to reduce discomfort about asking for co-payments.

Figuring out issues like these takes tenacity, as the Patient Financial Services team in the Mid-Atlantic States discovered when it set out to fix problems with workers’ compensation claims. (For more on this team, click "Closing a Financial Gap" in the resources box.)