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“What’s holding you back?”

Fresno Medical Center leaders asked their 50 unit-based teams that question directly late last year, at the same time they asked the teams to assess themselves on the new Path to Performance standards.

The answers mirrored what facilities everywhere say are challenges: training and sponsorship. Of the seven attributes of high-performing teams laid out in the Path to Performance, those two are consistently the most problematic.

Across the organization, many teams had their Path to Performance ranking lowered as a result of the 2010 year-end assessment—including Fresno, which UBT Tracker identified as having the highest percentage of high-performing teams in the organization. Fresno saw its number of Level 5 teams drop by more than half, from 27 to 14.

But Fresno had a plan for 2011.

“Early on, when we got a look at the Path to Performance, we created a strategy,” says Rick Senneway, Fresno’s director of performance improvement. “The Path to Performance helped focus us. (It) became very clear what we needed to work on.”

Even before they had the assessment results, Fresno leaders devised a 2011 UBT strategy for team development and performance improvement. It includes specific steps for moving teams at both ends of the spectrum along the Path to Performance.

“We’re engaged with our union partners at all levels,” says Jose DeAnda, medical group administrator. “At the UBT departmental level, (and) at the LMP Council level, by having each council member be a sponsor of UBTs and by having the sponsors report out at council meetings on how UBTs are performing.”

The goals were twofold: Move at least six teams up from Level 3 to Level 4 or 5 by the end of 2011, and help five teams achieve measurable improvement. Year-end assessments were not yet finalized when Hank went to press, but there’s optimism about the results.

“We did some good projects this year, and our affinity groups really helped,” says Navneet Maan, Fresno’s UBT consultant, referring to a system where teams working on similar projects met and shared ideas.

With a mandate to increase the number of high-performing teams by 20 percent in 2012, other teams and facilities might glean some ideas from Fresno’s three-pronged approach. 

Improve the support network for teams

One of the first things Fresno did was to revamp its sponsor network, including:

• Assigning sponsors to work in labor and management pairs and matching them so they share similar work areas;
• Reducing the number of teams sponsors work with to no more than four;
• Establishing new agreements that give sponsors more flexibility for how they meet with teams (in person or via email); and
• Setting quarterly deadlines for reporting on team status at LMP Council meetings.

The new agreements clearly defined expectations for sponsors, says Lynn Campama, Fresno’s assistant medical group administrator: “The role of the sponsor is about the performance of teams,” not about team management. “Everybody is accountable.”

Rather than trust that sponsors know how to be effective, Fresno used council meetings as a training opportunity. Sponsors received updated materials, ranging from a new form to help teams with meeting basics to information on the use of metrics and SMART (strategic, measurable, attainable, realistic/relevant, time-bound) goals. They also got forms to help collect team success stories and to help teams better manage UBT Tracker, the organization-wide system that helps teams report on and find effective practices.

In addition, “local resource network” members documented their particular expertise—be it UBT development, performance improvement, issue resolution and interest-based problem solving, attendance, service and workplace safety—and were assigned to teams needing that expertise.

“We took sponsorship to the next level,” says Lorie Kocsis, Fresno’s union partnership representative, LMP Council union co-lead and SEIU UHW member. “We tried to make their role easier for them to understand and to help them feel that they aren’t alone.”

Ron Barba, the director of the outpatient pharmacy and sponsor for the respiratory, inpatient and outpatient and surgery specialties teams, has noticed the difference.

“They gave us the training we needed to help the teams,” Barba says. “I feel more effective.”

Improve team training

To address training gaps identified by the teams, Fresno developed a brochure that puts all the offerings in one place—classroom, “just in time” and web-based training available through KP Learn—and groups the offerings by audience. That makes it easy to see what’s available for team members and what’s there for union and management co-leads.

At the same time, a request form for just-in-time training was developed, and both the brochure and the form were posted on Fresno’s intranet website. A clear process for requesting training was put in place, with team members instructed to submit their requests to Kocsis and Maan.

It didn’t stop there: Teams also got training in key partnership and performance improvement methods. A one-hour, just-in-time version of the eight-hour Consensus Decision Making (CDM) course was conducted with teams that requested or needed it. Teams working on non-payroll projects, such as reduction of inventory, were encouraged to take Northern California’s new business literacy training.

“Training had been one of our big downfalls keeping teams from higher performance,” says Debby Schneider, Fresno’s LMP consultant.

The brochure has heightened awareness of what’s available.

 “It helps us see at a glance what we need to take,” says Jeannine Allen, the administrative services supervisor and co-lead for the Adult Medicine UBT. “It’s been kind of a road map.”

Prioritize projects

To maximize the teams’ performance improvement impact, Fresno guided them toward projects that were achievable, would impact facility or regional goals, and were aligned with the Value Compass.

Teams used a  prioritization matrix to help them pick projects. That exercise sharpened teams’ focus and enabled members to “see how the work they are doing impacts the entire service area—not just their departments,” says Maan.

Teams shared ideas with their sponsors, who connected teams with other resources, including the experts in the newly established local resource networks and the affinity groups.

The experience of the Health Information Management team illustrates why such connections are invaluable. Its SMART goal was to improve customer service by way of a survey. Jeremy Hager, a care experience leader, was assigned to help the team.

He introduced the fishbone diagram to the team co-leads to help them identify which metrics the team should focus on to reduce customers’ complaints. He also helped them correctly interpret survey data. 

The affinity groups also helped teams. The six unit-based teams that made attendance a priority, for example, received tips, tools and specific training around the “six essentials of good attendance” identified by Ann Nicholson, LMP attendance leader for Northern California.

They also looked at their data going back several years, which “really made a difference,” says Eileen Rodriquez, assistant manager for OB/GYN. “It was an ‘aha’ moment.”

The team is meeting its attendance goals. With 6.17 sick days per full-time employee as of the first pay period in December, the team members exceeded the region-wide goal of 6.50. What made the difference? Managers are more flexible, and workers are more aware of the impact of missed days.

Staff members “feel comfortable coming to us,” says Norma Costa, department manager—and the team’s union co-lead, Lisa Madrigal, a medical assistant and SEIU UHW member, concurs.

“I know that if I need to take time off, I can go to my manager and talk with her about it and that she’ll do everything she can to accommodate me,” Madrigal says.

What's next?

Attendance will continue to be a focus of the facility’s UBT strategy for 2012—as will making it easier to use UBT Tracker. Refreshers on UBT basics will be provided, new tools introduced, and new affinity groups created.

And while local union steward elections will affect the sponsor pairings, sponsors will continue to get training and will continue to serve on the LMP Council in labor and management pairs.

I am a big proponent of the team approach to medicine. That’s why I am an active participant of my department’s unit-based team.

As the physician co-lead for the Pediatrics unit-based team, I participate in the UBT meetings both to give and to receive ideas. Ideally, a physician brings to a UBT the vision on how to work together to provide the best possible patient care, support for the management co-lead, and the willingness and openness to listen to what other people have to say. 

According to Dr. Atul Gawande, noted author and surgeon, it used to be that doctors were trained to be cowboys. They worked alone and saved the day. In today’s world, what people really need are pit crews, teams of people where everyone’s function is vital to the overall success of the enterprise. Medicine is no longer an individual endeavor—it has grown so complex and multifaceted that no physician can know everything. So we need to foster the team approach to give our patients the best possible care. 

When I first came to Kaiser nearly 10 years ago, the thing I heard that really stuck with me was the KP Service Quality credo: “Our cause is health. Our passion is service. We’re here to make lives better.” I immediately connected with it and have used it to filter everything I do. 

In other words, I always ask myself: Does what we are doing support our cause, passion and goal? If it does, then it’s usually worth doing. 

Advice to other physicians  

• Say "thank you" and say "please." Really go out of your way to appreciate someone who comes up with an idea that has made your life easier. And do it publicly.
• Make time for daily huddles with your staff.
• Create an environment in which people feel free to share their ideas. One of the worst forms of waste is unused creativity.
• Give people the benefit of the doubt; pause and reflect when you feel yourself getting upset.
• Think outside the box. Go to staff members who aren’t at the nursing station to help out when needed. This gives the whole team a sense of ownership over patient care. 

Bottom line? Being a leader isn’t just about being in charge. Just because you’re a physician doesn’t mean you have to spearhead all of the work. If you really want to make a difference or a change, you have to include the entire staff. The work will get done better, faster and easier if we work together. And if you believe in the work that you are doing, then teamwork is a natural expression of patient care.

In health care, there is no such thing as “normal business hours.” Babies insist on being born at 3 a.m. A car crash or bursting appendix can land a patient in the Emergency Room at noon or midnight or 5 a.m. To prevent infections, the cleanliness of hospital rooms is just as important at 4 a.m. as at 4 p.m.

So what’s a unit-based team to do? Full participation in a team’s performance improvement work from all members on all shifts can send service and quality scores soaring—while shifts left out in the cold can drag down a whole department. It’s hard enough ensuring all members of a single shift are on board.

But getting everyone onboard around the clock is a daunting challenge. Shifts that pass in the night may be oblivious to the other’s particular challenges and culture. They might not fully understand how their own work affects the other shift’s workflow. Rivalries and finger-pointing can ensue.

NIGHT OWLS IN THE LAB

As the double doors swing open, cold night air blasts into the receiving bay at the Regional Reference Laboratory in North Hollywood, California. Employees are ready, bundled up in knit scarves and hoodies. It’s 11:30 p.m. on a mid-February night, and couriers are delivering gray cooler bags filled with vials and tubes of specimens from all over Southern California. Clinics from Kern County in the north to San Diego, nearly 180 miles south, have closed for the evening. Now all of those blood tests and urine samples have to be processed and analyzed so providers can detect disease or spot the warning signs of a developing chronic condition.

At the specimen processing department, the graveyard shift is the busiest. “We’re like the mailroom,” says Leland Chan, supervisor and management co-lead. More than 10,000 specimens go to the automated chemistry department during the graveyard shift, compared with about 4,300 in the morning and nearly 9,000 at night.

Michael Aragones, the labor co-lead, likens the three shifts to gears all rotating together and powering each other forward. But not so long ago, the gears were getting jammed up.

Building resentments

Something was going on: Staff members on each shift thought the workload wasn’t being distributed equally—and they were getting the short end of the stick. Employees with different duties on the same shift felt the same way about their peers.

“There was a lot of ‘back talk’ between the shifts,” says Aragones, a lab assistant II and member of SEIU UHW. “People would say, ‘How come they are doing this or that?’ and ‘How come I have so much work?’ ”

The unit-based team was the vehicle for improving the workflow. Team members from all shifts got involved collecting, collating and analyzing data about the specimen count, hour by hour.

Riverside EVS attendant Virginia Gonzalez, a United Steelworkers Local 7600 member.

The results revealed why employees were feeling overworked: Between 2008 and 2010, the number of specimens going to bacteriology, for instance, increased from fewer than 4,000 to more than 5,000. Moreover, the time of night that most specimens arrived had changed. The lab used to see a big spike around 9:30 p.m.; now the rush came about 11 p.m. So the team adjusted the start and end time of the graveyard shift to match the flow of work coming in.

“At first, there was a lot of resistance,” Chan says, with employees worried about child care arrangements and traffic. The data, however, “gave us a better understanding of the workflow,” which let staff members see why they were being asked to make changes. “It was the UBT that helped solve that.”

 “It wasn’t managers saying, ‘Well, you just have to,’ ” Aragones says. “We have to look at workflow for the whole department, not just one shift. It’s like a spider web. You pull one strand, and it affects the whole thing.”

Now that the work is flowing better, the UBT is working on new initiatives.

“The UBT makes my life easier,” says Chan. “It allows me to work more closely with the crew because we are on equal terms. Sometimes, as a manager, you don’t have all the answers. They do the work, they are the experts.”

COOKING UP CAMARADERIE

It is 7:15 p.m. in the kitchen of the Downey Medical Center. “Huddddlllle!” shouts Francisco Vargas, a gentle giant of a man. The sound of his booming voice echoes off the tile floors and stainless steel work surfaces. One of about 20 SEIU UHW members working the night shift in the Food and Nutrition department, Vargas gathers the troops before they begin to wash dinner trays and deliver late meals to patients.

Assistant Department Administrator Patricia Villareal and her union partner Amelia Cervantes review new data on the team’s improvement projects, such as cooking less soup on weekends so less is wasted, and give a reminder about clocking in accurately.

The huddle ends with a team cheer—“Work hard, stay positive!”—and with that, food service kitchen worker Nancy Rudeas, an SEIU UHW member, and a colleague scurry off to prepare two late dinner trays. They double-check to see that a patient’s special request for green tea is being filled (it is).

“I love doing this,” Rudeas says, heading up on the elevator.

A few late tray deliveries have become a fact of life for the department, a consequence of abandoning set meal times in favor of a “room service” model: Patients simply make a phone call when they are ready for a meal, just like a hotel guest might.

This patient-centered innovation meant the workflow changed. Foreseeable peaks and valleys in cooking and cleaning became a less predictable, variable demand. Tasks that once had been the domain of one shift or the other “leaked” into the next shift. Tensions rose among employees as the distribution of work was thrown into flux.

“Because we have a UBT, we could sit down together and ask, ‘How can we get this resolved?’ ” says Villareal.

Together, the team experimented with adjusting start times for different jobs in the department until it settled on a mix that’s working. “The morning picks up for the night shift, and the night shift picks up for the morning,” she says.

From OK to great

The department set out to improve its customer service scores in September 2008. Though a respectable 86.7 percent of patients surveyed agreed with the statement “the people serving my meals were polite and professional,” that was nonetheless among the lowest scores in the Southern California region.

Together, the UBT members came up with a script that encourages food service workers to introduce themselves by name, ask if they can open any containers, and—most crucially—ask if there is anything else they can get for the patients. By consistently using the script, by October 2010, the score shot up to 99 percent.

Night-shift workers like Rudeas have contributed to that success. The shifts share information in huddles and bulletin boards.

“What goes on during the day, we know at night,” she says. “And what goes on at night, they know during the day.”

A SWEEPING SUCCESS

The Environmental Services department at Riverside Medical Center is continuing its winning streak: In 2010, it went 260 days without a workplace injury. The UBT received a huge banner congratulating it on the achievement, and the co-leads thought it would be nice if each team member signed it before hanging it up.

The banner remained out for a few days to make sure all staffers had a chance to sign—including the workers who come in at 11 p.m. for the graveyard shift. Only then was the banner hung up on the unit wall.

“This made a huge difference,” says Angel Pacheco, who will become the new management co-lead in May and who himself works the night shift. “This actually shows that everyone is involved and can take pride and ownership.” After all, performance metrics are measured by department, not shift, and night shift workers contributed to creating a safer workplace as much as their day shift counterparts.

The EVS team posts a flipchart sheet after every monthly UBT meeting with three to four important items of information to pass on to the rest of the staff. Each shift reviews the sheet at a daily huddle held at the beginning of each shift. The quick review of UBT business, including key performance metrics, follows the team’s stretching exercises that have helped reduce workplace injuries and won it recognition throughout KP.

The sheet hangs on the door of the supply closet, where each staff member comes when starting work to get carts, trash bags and keys to the offices they have to clean. This strategic placement ensures workers from all shifts have access to the daily UBT updates.

Face time matters

Face-to-face communication augments written communication and helps build the camaraderie that helps teams improve performance. For instance, Pacheco makes a point of visiting the night workers in the outlying medical office buildings—he drives an hour to Temecula to see one employee.

“It’s worth it,” he says. “I just take the time to reflect on things.”

Paula Cunningham, an EVS attendant and member of Steelworkers Local 7600, is one of four union members on the 6 p.m. to 2 a.m. shift responsible for passing information from the UBT’s representative group meeting to her shift colleagues.

“They trust us to deliver the information to them,” says Cunningham, whose work schedule is adjusted so she can attend representative group meetings in the early afternoon. “We talk frequently and rely heavily on huddles.” Other night shift workers also rotate into the group’s meetings.

Because he’s an on-call employee, Robert Casillas works all the shifts, so he has insights into what makes each shift unique.

The morning shift is more hectic, he says. The evening work is much calmer. More people are cleaning sections solo, but they pass one another in the hallways and share information with each other then.

“We have our communications plan, which we share with the other staff,” Casillas says. “We don’t want anyone to think we’re hiding stuff. And when the information comes from us, it’s less like a demand from management. It’s more about figuring out ideas to help us do our work.”

Sometimes, seeing the hospital at the end of the day as they do, it is night shift employees who spur the entire department into action.

The night workers noticed the hospital was running low on privacy curtains. When the ones soiled during the day were taken down, there were not enough from the laundry to replace them. Cunningham brought the information to the representative group, and the co-leads secured more curtains.

“What affects the night shift,” she says, “usually affects all of us.”

"Anyone who has never made a mistake has never tried anything new."

—Albert Einstein

This is the story of a team that never failed a test of change. No matter what the team members did, rapid improvement cycle after rapid improvement cycle, every small test tried was a better jewel than the one before. They received an A for their PDSAs.

They were fearless—in their imaginations. The only problem with the team’s brilliant tests of change was that they never got tested, never got to the stage where stumbling or failed ideas might have real consequences. There was no learning, no innovation, no growth—just intriguing ideas that remained bottled.

In health care, it’s still frowned upon to talk about failures or things that don’t work out perfectly for fear the information will be used against the people involved. But even in a high-stakes industry where the consequence of some decisions means life or death, there is plenty of room for improving performance by learning from small failures.

Using small failures as learning opportunities is the cornerstone of creating a learning organization. Small failures are at the heart of the Rapid Improvement Model and its plan, do, study, act cycles.

“Despite the increased rate of failure that accompanies deliberate experimentation, organizations that experiment effectively…are likely to be more innovative, productive and successful,” writes Amy Edmondson, a professor at Harvard Business School, in a December 2004 article in the Quality and Safety in Healthcare Journal.

This in fact is a story of false starts: the story of unit-based teams and employees throughout Kaiser Permanente who already are learning, developing and innovating from missteps or downright unsuccessful small tests of change.

From projects that changed direction after data contradicted the original premise, to tests of change that were tweaked or abandoned all together, workers describe how they tried a small improvement that didn't turn out as expected and still gained from the experience. And even, eventually, found success.

Learning to fail

At San Diego Medical Center’s Nuclear Medicine department, the unit-based team decided its first test of change project would look at reducing the number of redundant heart scans, which technologists were certain were wasting time and resources.

In November 2009, team members began to track the number of repeat scans to establish a baseline. They figured repeats would be at least 25 percent of the heart scans. After a month of logging the scans, however, they discovered something quite different.

“The number of repeat heart scans was actually between 7 to 10 percent,” says the UBT’s labor co-lead, Jessica Larson, a tech assistant and OPEIU Local 30 member.

The team’s hypothesis was amiss. It switched gears.

Since several of the staff recommendations for test of change projects related to heart scans, the team focused next on the variation in the instructions patients were given. If team members gave identical instructions, they might be able to all but eliminate repeat heart scans.

“The test of change at that point was to make sure everyone was following the protocol,” says Randy Andres, a nuclear medicine technologist and OPEIU Local 30 member.

The team created laminated handouts with one set of clear instructions that technologists and receptionists were to hand out to every patient before a scan.

“We did that for a few weeks, and found it was a lot more complicated than we anticipated,” Larson says. “You had inpatients, outpatients, observation-unit patients….Forms were getting misplaced because patients would leave them in the waiting rooms or in their purse. Or people weren’t even giving them out.”

During the same time, a supply shortage meant the department had to switch the type of injectable radioactive isotope it was using. The change meant a whole new set of protocols. Compounding it all, the department’s longtime manager retired.

It was time to shelve the test of change.

But was it a waste of time? Not at all, say Larson and Andres. Both say it provided valuable information about the department’s work flow—as well as practical knowledge of how to conduct tests of change.

“This was a very good teaching experience for us,” Andres says. “We didn’t even know about tests of change before this. It’s not simply a matter of just changing something. You have to go through this process.”

Too much of a good thing

Further north at Redwood City Medical Center, the Gastroenterology department discovered you can have too much of a good thing.

Contracting with an Oregon company that specializes in mass outreach calls, the department began using automatic robocalls to reach patients ages 50 to 75 who were due or overdue for colorectal screenings.

“We had to think outside the box,” says Julie Dalcin, director of medicine. “This was a way to reach a lot of people.”

The first round of robocalls went out in November 2009, with some 10,000 calls made. They reached 97 percent of the members who were due for the tests—but there was a problem. The calls were made within a span of three hours, and the response overwhelmed the department and the facility. The voicemail box the team had set up in advance barely helped; it could take only 50 messages.

“We got bombarded by calls from patients calling back with questions or requests. Our operator was inundated,” says manager Isabel Uibel. “Physicians in other departments were also bombarded with calls. People…were like, ‘What’s going on?’”

Michele Coons, a medical assistant and SEIU UHW member, was devoted to returning the calls and to mailing “FIT kits,” the at-home stool tests that help detect early signs of colorectal cancer, to those who had requested them.

“Many people had a lot of questions,” Coons says. “‘Why did I get this call?’ ‘What does a FIT kit test mean?’”

It took a week to figure out a system for getting back to all the patients, she says.

“I think at the end of day you have to be willing to try,” Uibel says. “And forgive yourself for the time you put into something that didn’t work. And don’t lose motivation. But also know when…you’ve got to say, ‘We’re not going down the right path at all.’”

In some workplaces, what had happened would be labeled a disaster. But not in Redwood City. The essential idea was sound. For the second round of calls, the team addressed the overwhelming response by having the calls made over a two-week period.

“We didn’t think we needed to throw the baby out with the bathwater,” Uibel says. “We just had to keep tweaking to make the system work for us.”

Too good to be true

When it came to how quickly patient messages are responded to, the Internal Medicine at the East Denver Medical Office in Colorado was pretty close to bottom—only 8 percent of patient advice calls were answered within an hour. The team members were open to trying anything, and after several small tests of change, they hit on something so ridiculously simple that some people resisted it.

Nurses tape neon orange cards with the patient message to the door of the exam room where the doctor is working. The doctor sees the message on the way out of the room and goes back to his or her office to respond.

Within the first three months of the test, the department saw message turnaround times soar to 30 percent answered within the hour.

“You had some tangible symbol that you were trying to make these numbers move. It was a great motivator,” says Christopher Hicks, MD, the team’s physician co-lead. “It was different. It wasn’t something that was happening electronically.”

Then they hit a wall.

“We were sitting around threshold or target and then would drop back down,” explains Olivia Wright, supervisor and management co-lead. “We were just hovering around 20 to 30 percent.”

The team brainstormed about why it couldn’t move the number above 30 percent.

Someone suggested one reason could be that the call center opened at 7 a.m. and most of the staff didn’t start until 8 a.m. They were starting the day already behind the curve with waiting messages. Two nurses changed their schedule and started coming in at 7:30 a.m. That seemed to help: 52 percent of patient messages got a reply within an hour.

“You’ve got to give something a shot,” Wright says. “The first thing you come out of the gate with isn’t necessarily going to be the end-all be-all, but you’ve got to start somewhere.”

One of the most surprising lessons for the entire department was the fact that small changes could have such a large impact.

“There was a sense of disbelief,” Wright recalls. “We had to reassure the team that the volume of work hadn’t gone down or that it wasn’t because of the time of year. We’ve sustained these results since May, and it finally started to sink in that small, subtle changes really are the reason for these results.”

Failure is part of experimentation

Experts who study organizations like health care and the airline industry corroborate the importance the process of experimentation plays in organizational learning.

“Under conditions where there’s a lot of uncertainty and constantly moving parts and work is customized or unique, the only way to make it work is to allow the right level of leeway for teams…to experiment thoughtfully,” Edmondson says. In the long run, lasting success comes from a willingness to try new things; but, if you try new things, you're going to fail sometimes.

This isn’t license for projects based on haphazard hypotheses, but it underscores the fact that performance improvement methods such as the Rapid Improvement Model are made for small failures. Because the process allows for quick experimentation, with results evaluated within 30 to 60 days, there is little to lose.

Barbara Grimm, senior vice president of the Labor Management Partnership, would have people ask themselves a few questions that can help them weigh the possibility of failure.

“Have you reasoned through the consequences? That is key,” Grimm says. “Do you have the patient’s interest absolutely there? Do you have a plan if it doesn’t go well?”

Edmondson argues there are two key reasons health care organizations still resist learning from small failures: The culture often discourages questions, challenges, or admissions of error, and a demanding workload and pace force staff to rely on quick fixes when something doesn’t work, instead of systematic problem solving.

That is changing at Kaiser Permanente with the commitment to providing frontline staff with training and support to conduct root cause analysis and problem solving with RIM, RIM+ and other performance improvement tools. And unit-based teams give staff members the place and time to do this work.

John August, executive director of the Coalition of Kaiser Permanente Unions, believes the

true purpose of the Labor Management Partnership is to recognize the mission of KP and the mission of the unions are at profound risk due to the economic, competitive and public policy environment in which we operate.

“We must continually remind everyone in the organization that the why of what we do in partnership is driven by this fundamental recognition and agreement,” August says. “If we don’t make the effort to discuss the reasons why we’re doing this, people will get the impression that people are just being asked to do something. And being asked to do something doesn’t create an atmosphere of safety.”

Edmondson says the sense of safety will further develop when we learn to accept and work with our limitations.

“People need a sense of psychological safety, and frankly a sense of humor about our humanness,” Edmondson says. “Somewhere along the line we get socialized and begin to buy into the absurd notion that we should be perfect.”

Back at the lab

In San Diego, Larson thinks even if the tests of change didn’t work exactly as planned, it gave the team something even more important—the beginning of a different work culture.

“Being able to work on small tests of change enabled us to get past what’s always been,” Larson says. “There are people who have been here longer than I’ve been alive and so are accustomed to the way it was always done. But trying something new can save us time, and save the company money, and can be better for the patient. So I found it nice to look at it like, ‘Let’s try just this little thing and it might just make it better.’”

Larson is certain the eventual reward will outweigh any frustrations in wrong hypotheses or failed tests.

“Either you find you can fix something or you can’t, and you just move on,” Larson says. “Just keep trying. Because ultimately, it’s going to be a success in the end.”

Hemaxi Khalashi isn’t afraid of strange smells. As a clinical lab scientist, her nose is in all kinds of odd odors. But the stench that filled her corner of the Northern California Regional Lab one recent morning put her and many of the other lab workers on edge.

“It was like a bad, old gassy smell, or something deteriorating,” Khalashi said. “I asked my supervisor to walk with me to that corner of the room and asked her what she smelled, and she said, ‘Something dead—rotten.’”

The lab employees quickly fingered the culprit—a new instrument that tests blood samples for Hepatitis B—but they needed a solution, and fast. Their first step: to huddle.

The 15-minute meeting gave lab workers the chance to air their concerns, and provided managers with the opportunity to let the team know the vendor already had been contacted and would be coming by that day. Khalashi spoke up and asked what could be done, right away, to help those who worked near the machine. The section manager suggested masks, which are always available for lab employees.

“Huddles are usually the starting point for getting something done,” said Larry Ratto, a lab assistant and SEIU UHW-West member whose desk is the rallying spot for such meetings. “They are really good for making immediate change—and they never last more than 15 minutes, tops.”

In short order that morning, an issue that might have caused an undercurrent of anxiety was aired and laid to rest. Lab employees and managers determined test results weren’t being compromised and that the odor, though unpleasant, was harmless—and thanks to the huddle, everyone knew it. They later decided to install an air purifier next to the instrument and developed new procedures for handling its waste. The two steps have mitigated the smell.

The lab workers’ instinct to huddle, which stemmed from a year’s worth of practice, is one shared by many high-performing teams throughout Kaiser Permanente. The most successful unit-based teams, those that improve performance and meet goals, are using huddles regularly and effectively—and not just when a major problem needs to be solved.

Huddles aren’t a substitute for the training and skill-building that members of unit-based teams need as they shift into new ways of working—training and skills that help create the learning environment where frontline workers are engaged in decision making and see the connection between their work and larger, strategic outcomes.

But those who study group dynamics say routine huddles can give teams the opportunity to get good at solving problems together when the stakes are low—practice that increases the odds of solving problems successfully when the stakes are high. Frequent, candid conversations, these experts say, create working environments conducive to improvement and change.

“I see it in our group,” said Denise Ja, microbiology section manager. “Huddles have improved our communication, our camaraderie and our teamwork.”

Amy Edmondson, a Harvard Business School professor whose research examines what factors foster outstanding performance in health care settings, says huddles are a way of building what sociologists call “social capital.” In other words, they build social connections that produce real value by increasing productivity.

“The more we know each other and…(have) exchanged our thinking, the more we’ve just connected as human beings—the better we do,” said Edmondson, who led two workshops at this spring’s Union Delegates Conference.  “If we’re friends, I will make that extra little cognitive effort to think, ‘Oh, I wonder why she thinks it’s that way?’ Or, ‘I wonder why she sees it that way?’”

The willingness to extend that extra effort can make a world of difference in solving problems, creating a healthy work environment—and improving patient outcomes.

Many shapes and sizes

In Northern and Southern California, 79 percent of high-performing UBTs were huddling as of November 2009. Just 30 percent of newly established teams were doing the same. Once a team has gotten trained in the Rapid Improvement Model and other fundamental techniques, huddles can be an addition that helps improve working relationships.

Huddles mean different things to different departments. Some teams meet daily; others do it weekly. Many departments convene at the same time and same place; others are more spontaneous. Most huddles are short.

Part of what makes huddles effective is that they create frequent, regular opportunities for all the members of the unit-based team—the people whose work naturally draws them together—to come together and contribute ideas.

And they have a casualness that makes even the most reticent team member comfortable speaking up.

“I think because we’re close together in physical proximity, people feel less inhibited,” Ja said. She finds that in more formal meetings, some team members hold back. But when the team huddles in the work area, she said, “It’s kind of a hustle-bustle, and people are anxious to put their two cents in.”

Ja’s team usually huddles every Friday. But during the height of the H1N1 epidemic, the number of specimens the lab handled skyrocketed from 30 to 900 per day, and the team resorted to meeting daily and sometimes even hourly.

As team members worked frantically to devise a new system for tracking samples, the huddles became the place to test new ideas. It was in a huddle that someone suggested a coding system using letters, but the team quickly ran through the alphabet. The team members huddled and re-huddled until they were using a combination of letters, dates and numbers.

Huddles helped the lab workers keep up with the onslaught of work, pulling off what had seemed impossible.

“Everyone contributed ideas,” said Mark Stanley, microbiology director. “We depended on everyone’s knowledge.”

Figurative huddle

Even teams whose members don’t all work in the same location find that huddling works.

Colorado’s asthma care coordinators are spread out across the region, and usually see each other only two or three times a month. But when the department of seven launched a big push to improve the refill rate of an asthma control medication among children, team members decided to huddle once a week over the phone.

During their phone chats, which usually ran 30 to 45 minutes, team members related their progress in reaching out to members ages 5 to 17 who had not refilled their prescription in four months. Developing a habit of sharing their best practices, successes and failures with colleagues made the team members more accountable, said Kristie Wuerker-Delange, RN, an asthma care coordinator and member of UFCW Local 7.

“It’s kind of an, ‘Uh oh, I have to get this done because we’re going to talk to everybody, and they are going to want to know what I’ve been doing for the week,’” she said.

During one huddle, for example, asthma care coordinator Cindy Lamb told the team she had found that promoting the convenience of the mail-order pharmacy, giving members the telephone number to the regular pharmacy, and providing the member’s prescription number helped patients get their refills faster.

Within eight months, the refill rate of inhaled corticosteroids leapt nearly 20 percentage points, from 43 percent in March 2009 to 60 percent in January 2010—a feat that would not have taken longer without their huddles, Wuerker-Delange said.

“They kept the team focused on the same goal,” said Lamb, a member of UFCW Local 7. 

While other teams have the benefit of simply moseying over to a colleague’s desk, meeting over the phone has its pluses.

“I feel like people open up a bit more,” Wuerker-Delange said. “They are more apt to say a certain thing if someone’s not looking at them.”

Morning ritual

For the Family Medicine department at the Culver Marina Medical Offices campus in Southern California, huddles are part of the morning routine, like brushing your teeth after breakfast.

At 8:25 a.m., Department Administrator Barbara Matthews pokes her head into team members’ offices, her cue that it’s time to convene in the hallway. Patients already are beginning to arrive, so huddles rarely last more than five or 10 minutes.

Doctors, nurses, medical assistants—everyone who is working that day—attend. Co-leads use the time to relay who is working, share a workplace safety message, offer service reminders and more.

“I am upset if I can’t make our morning huddles,” said Krystle Harris, a medical assistant and SEIU UHW-West member. “If I am screening a patient and have to miss it, then I’ll ask one of my co-workers, ‘Aw man, what was the huddle about?’”

Matthews said in the beginning it wasn’t easy getting everyone to huddle and some team members still might choose not to attend if given that option.

But she thinks it’s no coincidence that since the department started huddling a year ago, its hospitality scores have increased, from 83 percent in December 2008 to approximately 89 percent in December 2009.

Other shifts, more subtle but just as significant, are taking place as well. Gene Oppenheim, MD, the physician in charge of the Culver Marina Medical Offices, notes that employees who frequently used to arrive five or 10 minutes late are on time now. Matthews says team members like Harris, who used to say little during meetings, are doing a lot more talking.

That’s a clue that team members are confident their views are valued and they aren’t afraid they may get in trouble for sharing their thoughts—two key characteristics that research shows leads to high performance.

One day recently Harris overheard licensed vocational nurse Jolavette Pye, an SEIU UHW-West member, trying to schedule a specialist appointment for a patient.

The specialist was booked for quite some time, but Pye called back a week later and sure enough, there was a cancellation.

“I brought it to the huddle to congratulate her,” Harris said. “She went out of her way—and the patient was really happy.”

Harris said she thinks sharing with the team the praise she’s overheard co-workers receiving from a patient helps morale, so she does it whenever she can.

“I am shy and I don’t like to speak around a lot of people,” Harris said. “But I am beginning to speak up and discuss little things that are on my mind. I’m just more comfortable in the huddle setting.” 

Have questions about huddling you’d like to bounce off one of the team co-leads interviewed for this article? Email Denise.Ja@kp.org, Concepcion.Savoy@kp.org, Kristine.Wuerker-Delange@kp.org, Deana.L.Parker@kp.org or Barbara.J.Matthews@kp.org for their thoughts.

9 reasons to huddle

1. Resolves small problems before they become big problems.
2. Provides real-time collaboration.
3. Makes it easier for employees to speak up, due to informal nature.
4. Encourages people to raise questions and share ideas.
5. Increases the pool of ideas for addressing an issue.
6. Leads to better communication through frequent communication.
7. Improves staff morale.
8. Lays the foundation for taking on big problems by providing routine practice at solving small problems.
9. Keeps you warm on cold days.

New to huddling?

Here are some tips to help you get the most out of your huddles.

• Get the group’s attention. Set a positive tone. Use people’s names.
• Describe the plan or topic for discussion, including relevant background information and contingencies.
• Explicitly ask for input. Have a two-way conversation. Effective team leaders continuously invite others into the conversation.
• Encourage ongoing monitoring and cross-checking.
• Specifically ask people to speak up if they have questions or concerns.

Some ideas of what to discuss:

• Observed workplace safety issues that everyone can learn from.
• Other departments’ work that may impact the team’s work that day.
• Small tests of change to resolve identified issues and help improve performance.
• How everyone is doing and who may need extra support that day.
• New policies or procedures or other changes.

—From the Sponsor and Leader Resource Guide for UBTs.
 

‘Huddles have improved our communication, our camaraderie and our teamwork.’

Denise Ja, microbiology section manager, Northern California Regional Lab

Surgical checklists improve patient safety, strengthen team dynamics

In high-risk industries—including aviation and high-rise construction as well as health care—surgeon and best-selling author Atul Gawande has found that a good checklist not only specifies common sense safety measures, it also ensures “that people talk to one another about each case, at least just for a minute before starting,” he writes. “[It is] basically a strategy to foster teamwork—a kind of team huddle.”

A major theme of Gawande’s latest book, The Checklist Manifesto: How to Get Things Right, is that the best checklists are not just a top-down set of tasks for others to follow. They’re a tool for better team communication, coordination and inquiry. Read more about using checklists here.