LMP Focus Area

The patient in the operating room was moaning and suffering sudden seizures. A half-dozen caregivers crowded around him, attempting to stabilize him as they watched his vital signs on a monitor.

This might have been a normal June afternoon in the OR at Sunnyside Medical Center in the Northwest region—except the patient was a mannequin. The staff members were being videotaped as part of a simulation to help operating room personnel learn and practice effective techniques for keeping patients safe during and after surgeries. Afterward, they did a debrief, discussing what worked and what didn’t with their unusual patient.

It’s all part of how this regional surgical services team, composed of the co-leads of several unit-based teams at different ambulatory care centers and at Sunnyside, operates. From 2009 to 2010, for example, it reduced the rate of surgical site infections by an impressive 32 percent. These results came from implementing proven practices for reducing infections, such as safety simulations, hand hygiene and clipping (rather than shaving) patients’ hair at the surgical site.

They also came from an explicit effort to change the culture standing in the way of patient safety. A 2010 safety summit involved everyone in the associated departments—from surgeons to techs to EVS workers, inpatient and ambulatory. Team members shared best practices and discussed ways to have an open dialogue so that when something isn’t right, each person has the accountability and the freedom to speak up.

 “In the past,” says surgeon Waleed Lutfiyya, “everyone had a single role and couldn’t break out of that role. There were defined borders about what someone could say. That can create obstacles.”

Now, he says, “The idea is that by working together as a team, everyone has an equal role with the patient. Everyone is equally important.”

The summit included a presentation on the importance of developing a culture of safety.

 “Team behaviors do matter,” says Lutfiyya. “Team behaviors affect clinical outcomes.”

Research backs him up. A 2009 study published in The American Journal of Surgery tracked nearly 300 observations by RNs of operations at four Kaiser Permanente sites. The conclusion: Patients whose surgical teams exhibited fewer teamwork behaviors were at a higher risk for death or complications. These observable behaviors revolved around information sharing during various phases of surgery.

In short: Patient safety depends on good communication. From there, it’s easy to see that, since unit-based teams provide a structure and the tools for improving team communication, they are a path to improving patient safety.

Perfectly logical, right? Yet only a tiny fraction of UBT projects aim to improve patient safety, according to data in UBT Tracker, the programwide system for reporting on unit-based teams.

What’s going on? Patient safety projects seem like ideal candidates for unit-based teams, touching all four points of the Value Compass. Keeping patients safe from harm delivers on best quality and best service. Such projects address affordability: In the Northwest, the decrease in infections for the specific procedures being monitored has resulted in an estimated cost avoidance of $220,000. Patient injuries can be devastating to individual and team morale, so intentional efforts to minimize them help create the best place to work.

And who benefits or suffers most if teams do or don’t take on this work?

 “We all owe it to the patient,” says Doug Bonacum, Kaiser Permanente’s vice president of Safety Management. “We need to find ways to help people reach deep down and say, ‘I am not comfortable, I have a safety concern.’ It is top down and bottom up. It has to be both.”

When top-down transforms into teamwork

The fact is, there is plenty of work going on throughout Kaiser Permanente on patient safety. Much of it, however, has a top-down, mandatory quality to it—with little or no emphasis on involving frontline staff on how to go about meeting the goals and improving performance.

In the Northwest, for example, switching to a new dress code based on Association of periOperative Registered Nurses (AORN) recommendations was a top-down mandate. One of the changes included replacing the skull cap, which did not always cover all of a person’s hair, with a bouffant cap.

 “We assumed, ‘Well, this is the right thing to do for the patient,’ and staff would just do it,” says Claire Spanbock, the regional ambulatory surgery director, acknowledging the limits of the approach. But, “We had people we had to tell again and again. We realized we were making a big change and not involving them….We got there, but it was tough.”

In contrast, when it came to hand hygiene, members of the regional OR UBT sat down together and revised the audit tool several times before settling on the best version.

 “You are never going to do this until you have the hearts and minds of the staff,” says Spanbock.

When the right eye is the wrong eye

One reason relatively few teams are working on patient safety may be that until a team has strong communication skills in place—developed in the course of working on simpler improvement projects—its members may shy away from high-stakes efforts.

The Northeast Ohio ophthalmology team already was one of the highest-performing UBTs in the Ohio region when it decided to not take the team’s clean safety record for granted. Its co-leads—the ophthalmologist, ophthalmic technicians and manager—worked together to implement a patient safety briefing immediately prior to all eye procedures.

The idea is an enhanced version of a timeout, when a surgery team pauses before a procedure to engage in a structured communication with the patient to verify key information. It came from the ambulatory surgery center at the Parma Medical Center, where several ophthalmology staff members work.

 “We just felt that it would be wise to be proactive,” says Ralph Stewart, MD, the team’s physician co-lead. “There’s no danger of cutting off a leg in our department, but you do need to think about right eye or left eye.”

The team already had worked together to improve wait times and courtesy and helpfulness of staff, so had built the trust and free-flowing communication culture that is at the heart of patient safety efforts. It embraced the idea and, after resolving concerns about the time the safety briefing would take, began brainstorming about what the ophthalmology timeout would be like.

 “We split into two different groups that included physicians and technicians, and we discussed which part was going to be the responsibility of the ophthalmologist and which was going to be the responsibility of the technician,” says Renee Paris, a lead ophthalmic technician and an OPEIU Local 17 member.

 “It took us a couple of months to get it together,” says Bonna Gochenour, an RN and the team’s management co-lead. “We had to create some ‘smart phrases’ to help us with documentation. When the technician goes into the room with the patient, they’re going to confirm with the patient which eye it is, and the tech puts a little smiley face over the correct eye.” The doctor then does a second verification before beginning the procedure.

In late January, in a textbook small test of change, the team piloted the safety briefing for one month with one physician and one tech.

After a few adjustments—like making sure each procedure room has its own supply of the stickers—the UBT implemented the procedure throughout the department, which encompasses teams at four different facilities in three counties.

Sandy Cireddu, a certified ophthalmic technician and the team’s labor co-lead, is proud of the accomplishments. She thinks the open channel of communication developed through the UBT has been critical to its success.

 “Everybody needs to be heard,” says Cireddu, a member of OPEIU Local 17, “and everyone needs to feel you’re on equal ground when you’re discussing these things, so that you can get buy-in.”

Surgical site infections down

At the Woodland Hills Medical Center in Southern California, a campaign to reduce surgical site infections in the labor and delivery department is working.

The department dropped from a rate of five surgical site infections per 100 caesarean sections performed in the second quarter of 2009 to none in the second quarter of 2010.

After a brief rise, the rate headed down again; at the end of the first quarter of 2011, it was less than one per 100. Moreover, the only infections since the third quarter of 2009 have been superficial; there have been no deep or organ-space infections.

The campaign includes a focus on pre-op skin prep, educating new moms on post-op wound care, prophylactic antibiotics, hand hygiene, and trying to reduce traffic flow of staff and families near the operating rooms.

And, as in the Northwest, the effort included enforcement of the AORN guidelines for surgical attire. Out went the skull caps sewn by Min Tan, an obstetrics tech and SEIU UHW member, who helped her colleagues spice up their scrubs by making them custom caps with their favorite patterns—anything ranging from the L.A. Lakers basketball team to spicy-colored chili peppers.

She took the new dress code in stride. “The Labor Management Partnership is about fixing things,” says Tan. “It helps us in not finger-pointing and blaming. It’s not as intimidating as ‘the old days.’ ”

The department’s labor co-lead, Robin Roby, an RN and UNAC/UHCP member, agrees.

 “We are becoming part of the solution,” she says. “You feel like you are more involved with what goes on in the unit.”

That involvement is what makes UBTs a foundation for improving patient safety; engagement is the key to effective implementation.

Louise Matheus, the department administrator at Woodland Hills’ labor and delivery unit, acknowledges that focusing on reducing infections was a management decision. But, she says, the department’s progress in controlling infections “is a UBT effort because we involved the whole staff” in implementing the changes.

And Matheus makes it clear she’s looking forward to the day when frontline physicians, managers, nurses and techs use the leverage created by unit-based teams to accelerate improvements in patient safety.

When that day comes, she says, “It won’t be small test of change—it will be large test of change.”

After a false start, the diagnostic imaging department at Woodland Hills Medical Center has found its stride. Its results are impressive: By drawing on the wide experience of the team, it’s improving workflow and boosting attendance.

To get those results, the department created one large UBT with several subcommittees and involved a physician champion. Two radiology summits, which were held to set priorities, included the whole team: 

• More than 160 employees and physicians who see a quarter-million patients a year.
• Staff in eight far-flung clinics as well as throughout the medical center. They range in age from late teens to 40-year veterans of Kaiser Permanente.
• Team members in eight areas of expertise, including ultrasound, MRI, CAT scan, nuclear medicine, mammography, general x-ray, and special procedures.  

From confusion to clarity

At first, the team’s diverse skills and experience flummoxed the department-based team (the term Woodland Hills uses instead of unit-based team).  

“We didn’t know the scope of our work,” says Selena Marchand, a lead sonographer and labor co-lead. “The old DBT got stalled talking about things like the doctors’ parking lot.”

A secret society?

In addition, says Marchand, the representative group—which was working without a facilitator—didn’t communicate with its co-workers about the DBT’s projects. “They thought we were some sort of secret society,” says Marchand, a member of SEIU UHW. 

The team restructured in October 2009, electing one delegate from each “modality,” as the areas of expertise are known, to the representative group.

“Pushing responsibility and accountability back to different modalities has been one of our successes,” says Mike Bruse, the department administrator and management co-lead. “We’re focused on things that we can control in our department.”

Summits get everyone involved

The co-leads convened two department-wide summits to focus on improving team performance and set priorities. Staff members brainstormed about what the challenging issues facing the department were and wrote them on flip chart pages on the wall. Then, each employee attached a sticky note to the issues that most concerned them. The team and managers set out to tackle the seven issues that received the most tags. As the work got under way, progress reports were posted in the employee break room to keep everyone on the team—not just the representatives—informed.

Better workflow

The department also improved the way it distributes film to radiologists, so that patients’ results get to primary care physicians faster. Before the change, technicians were forced to constantly interrupt doctors to read films. Now, there is a tally sheet on each radiologist’s door indicating how many films he or she is reading. This allows techs to know who is available to read a film—and allows radiologists to work undisturbed. An aide to the technologists tracks the process, acting as a traffic controller.

“It was a relatively simple thing that improved satisfaction and patient care a lot,” says Mark Schwartz, MD, who represents physicians on the UBT. “And it didn’t cost any money.”

Better attendance

The team also improved attendance, decreasing last-minute sick calls by 14 days from the end of 2009 to October 2010. They beat the Lab Department in a friendly competition two quarters in a row and were rewarded with a barbeque. To do this, team members simplified presentation of attendance data and posted up-to-the-minute metrics.  

Beyond these gains, management co-lead Bruse says the most significant change is employees’ confidence in their own ability to make improvements.

“Our meetings used to be ‘complain to Mike,’ ” he said. “These days, when people see a problem, they take steps to solve it themselves.”

What happens when teams truly walk a mile in their patients’ shoes? They often discover their own actions are making that mile a rocky one for patients—and as a result make huge breakthroughs in the way they deliver care.

In the case of South San Francisco’s multidepartmental pre-admission team, observing their processes from the other side of the gurney spurred them to dramatically streamline the pre-surgery and admitting process for patients. With the member at the forefront of their thinking, the team members turned a two-inch-thick packet of confusing, redundant information into a streamlined, one-page checklist. And a funny thing happened—while redesigning the process to help patients, the team improved the way it works.

“Patients would often get confused and weren’t sure what the next step in the process was,” says Brian Tzeng, MD, the Peri-operative Medicine director. “We realized we didn’t have a clear path for the patient to follow.”

Other teams throughout Kaiser Permanente are making similar realizations, framing their performance improvement work by asking the question, “What’s best for the patient?” If a possible solution doesn’t work well for the member and patient, then there’s more brainstorming to be done. These teams are taking the Value Compass to heart—organizing their work not just around the four points but examining what they’re doing from the patient’s perspective.

What does that mean for frontline teams? At the San Diego Medical Center, the Emergency Department sees up to 300 patients every 24 hours. Physicians and staff members are always on the go, delivering on the ultimate bottom line—saved lives. What could be more important? Clinical quality is high; patients are seen in a timely manner and the rate of unscheduled return visits is good.

Yet the results of a recent patient satisfaction survey bothered the team. The department scored well overall, but their patients gave it only 63 percent approval on one question: While you were in the Emergency Department, were you kept informed about how long the treatment would take?

Managers newly charged with co-leading unit-based teams sometimes need to build team cohesion before diving into the nitty-gritty of setting goals and improving performance.

Brenda Johnson, optical site supervisor at the South Bay Medical Center in Southern California, has found a way to do just that—and improve her staff’s eating habits at the same time.

Inspired by a presentation at a regional leadership conference hosted by Jeffrey Weisz, MD, executive medical director of the Southern California Permanente Medical Group, she launched a healthy eating club in her department. Every week, staffers chip in $12 each—and get four healthy, fresh-cooked meals in return.

At the early spring meeting, Dr. Weisz discussed Kaiser Permanente’s Healthy Workforce initiative and distributed a booklet listing the calorie count of hundreds of food items.

Making change easier

“I looked at the book, and I thought, ‘Oh, my goodness,’” said Johnson, shocked at the number of calories in some of her favorite foods.

“I looked around at my employees,” she said. “Some have health issues. Some drink sodas by the 32-ounce cup every day.” The medical center is ringed by mini-malls with fast food restaurants. “We’ve been eating the same stuff for years,” she said. “The only question was who’s going to go pick it up.”

Gil Menendez admits he was one of the 32-ounce-cup soda drinkers—a habit he gave up when he joined the club. Menendez, an optical dispenser, SEIU UHW member and  labor co-lead of the UBT, was so motivated by the changes in his lunchtime habits that he also began a strict diet and exercise routine. He’s lost 20 pounds.

New ways to work together

Johnson cautions that the healthy eating club isn’t a diet club. She picks recipes out of a pamphlet produced by the California Department of Public Health, Champions for Change, and prepares the ingredients at home. Others sometimes prepare recipes from their families and cultures. She combines ingredients in the morning, steams them in a slow cooker the staff keeps at work, and a meal is ready by lunchtime.

“I have to cook for my family anyway,” says Johnson. At home, “We’ve changed our habits because of high blood pressure. I prepare this food with love because I’m preparing it for both of my families: my family at home and my family at work.” 

About 15 to 20 people participate in the club each week, up from 10 when it first began in May 2010. In addition to its health benefits, the club has helped her department be more productive and collegial, says Johnson.

“It’s going strong,” adds Mendez. “It brings us together.”

Looking for ways to make the Sand Canyon Surgicenter in Irvine more efficient, Albert Olmeda wound up learning a lot about blue wrap—like the fact that it makes up nearly 20 percent of the waste generated by hospital surgical services. 

The lead Central Services technician and SEIU UHW member also learned that this heavily used hospital product, an industrial strength plastic used to maintain the sterility of medical and surgical instruments until opened, is not biodegradable and persists in the environment. 

But recycled blue wrap can be sold as raw material for use in the production of other plastic products. Today, the surgicenter’s unit-based team has gone green with a blue wrap recycling project that is not only saving money and protecting the environment, but also aiding the community. 

“The biggest problem with the blue wrap is when we throw it in the landfill, it’s there forever,” says Olmeda. “That’s a big concern especially considering how much blue wrap we use.” 

How recycling works

About 600 pounds of blue wrap is collected every week from the center’s six operating rooms. It is picked up free of charge and sorted by Goodwill of Orange County, which sells it to a Houston recycling services company. The company reprocesses the plastic into beads that are used in various products, including railroad ties, pallets and artificial siding for decks, docks and houses. 

The surgicenter has been recycling its blue wrap and plastic bottles since September 2009, reducing the facility’s solid waste disposal fee by 10 percent annually. The savings amount to a modest $5,880—but there’s a greater payoff. Proceeds from the sale of blue wrap and other recyclable products enable Goodwill to provide education and training programs for developmentally and physically disabled adults, including a state-of-the-art fitness center. 

Peter Bares, business development manager for Goodwill of Orange County, says the relationship with Kaiser Permanente has gone beyond expectations. “It is kind of the perfect storm because of the nature of what we do and why we do it and the materials that the hospital generates,” he says. 

Getting buy-in

As the frontline staff person responsible for the surgery center’s blue wrap disposal, Olmeda—and his fellow UBT members—championed the recycling cause, educating the staff at weekly in-services and UBT huddles.  The team got the rest of the department on board by integrating the blue wrap recycling process without creating additional tasks. 

“We figured if we changed workflows, staff wouldn’t want to do it.” says UBT co-lead Nicole Etchegoyen, a surgery scheduler and SEIU UHW steward. “But if we asked them, ‘How would this work best for you?’ then everyone would get involved, and they did.” 

The team members designated a single container for blue wrap in each operating room. They also placed a larger bin for collecting multiple bags of discarded blue wrap near the soiled utility room, where the trash is taken on its way out of the surgery center. 

“It’s not a big deal,” EVS worker and SEIU UHW member George Sollars said, hoisting bags. “We just carry it over here on our way out this door. It’s one of the easiest jobs. And it’s for a really good cause.” 

No trash, just recycling 

The hardest part was making make sure that other trash didn’t make it into the blue wrap recycling containers accidentally. Labeling the containers with signs reading ‘Recycling Blue Wrap Only’ helped, as did regular reminders by UBT members. 

Now, everyone in the operating rooms—from doctors, nurses and surgical techs to nursing assistants and EVS workers—makes sure that the blue wrap containers aren’t contaminated with other trash, Etchegoyen says. 

Olmeda does periodic spot checks. “Everybody who plays a role in the operating room has to look out to make sure no trash is going inside the containers,” he says. “It’s a team-building thing.” 

“If it wasn’t for the UBT, this wouldn’t be happening,” said Ramin Zolfagar, MD, department head and UBT member. “We are helping the environment by ‘going blue,’ so to speak, and the end result is gym equipment for the disabled—which makes it all the more worthwhile.” 

After learning about the project at a recent Orange County UBT fair, other departments are thinking about emulating it. 

Visit the Goodwill of Orange County website to find out more about their work.

The lady who talks to you from inside your GPS has found a new home, it seems, in the robotic carts deployed in the newly rebuilt Los Angeles Medical Center.

Instead of guiding you to your destination, she’s moving linen and trash along the long hallways and underground tunnels. By herself. Her gentle yet firm computerized voice tells workers in a docking room when the cart is ready to be filled, and sensors ensure she doesn’t run anyone over. She even can detect whether there are passengers in the staff elevators and patiently waits for the next empty one.

The robotic carts reduce wear and tear on the muscles and joints of the medical center’s Environmental Services (EVS) attendants. They are just one example of how managers and union members at this Southern California hospital are taking the lead in improving workplace safety for EVS departments.

Historically, EVS is a high-injury department because the job involves a lot of bending, lifting and moving equipment—not to mention working with hazardous chemicals. But the EVS department at Los Angeles Medical Center made such remarkable progress in reducing workplace injuries in 2009, its members earned a special bonus as part of the Performance Sharing Program (PSP). So did the EVS departments in Riverside and in Panorama City, which boasts the lowest injury rate in the region.

“Everyone wants to beat Panorama City,” laughs Manuel Covarrubias, the building services manager there. “It’s a friendly competition.”

But more important than the good-humored rivalry is the confidence these teams inspire in their counterparts. “They know it can be done,” Covarrubias says.

Even Kaiser Permanente’s oft-stated goal of a workplace free of injuries isn’t as far off as might be thought: The EVS department at the Eastside Service area in the Northwest region hasn’t had a single injury for two straight years. Regionwide, the EVS departments improved their collective injury rate by a remarkable 65 percent for the reporting year ending Sept. 30, 2009.

Management and union co-leads on these successful unit-based teams credit specific safety techniques, such as pre-shift stretching, and better equipment, such as microfiber mops and motorized carts. But they also say the communication and team-building skills they use by working in partnership are crucial to building not only systems of safety, but a culture of safety.

'Our opinons matter'

Before, “It was just coming to work, doing whatever, and then leaving,” says Sandra Pena, the EVS labor co-lead at Riverside and United Steelworkers Local 7600 member.

“Now, it’s like there’s feedback back and forth all the time. It’s more of a team.”

“It makes you feel good as an employee to make improvements,” says Eva Gonzalez of Panorama City. “We know our opinions matter. We know we are not talking to the wall.”

Dilcie Parker, the labor co-lead at the LAMC EVS department, recalls how things were in 1999, when partnership started taking hold at her facility. “When we first began meeting, it was, ‘You sit on that side of the table, I sit on this side.’ I once arrived at a meeting and said, ‘I don’t sit next to management.’ You could feel the hate in the room.”

Management co-lead Villalobos doesn’t disagree. “Before, we couldn’t stand each other,” he says. “There was screaming.”

The turnaround, both say, came as a result of the LMP training the whole team received—from mapping root causes to issue resolution—and persistence.

“We started seeing the benefits in better quality and better attendance,” says Abraham Villalobos. “The reduction in injuries didn’t just happen this year. It’s about understanding the things we need. If we don’t get along, we can’t come up with projects to work on.”

This doesn’t mean everyone is holding hands and singing “Kumbaya.”

“There are still issues we disagree about,” says Parker. “But before, we used to get nothing solved. Now, issues get solved and they are off the table.” Recently, Parker, Villalobos and the team were in a meeting, crammed together in a tiny conference. The woman who once refused to even sit next to a manager found herself saying, “Look, Abraham, we’re actually touching.”

For information about EVS teams in Southern California, contact Dave Greenwood, workplace safety program director, at Dave.B.Greenwood@kp.org; for more information about workplace safety for EVS teams in the Northwest, contact Lori Beth Bliss, regional EVS manager, at Lori.B.Bliss@kp.org.