Team-Tested Practices

The new goal was dramatic: Reduce hospital stays to 23 hours for total joint patients.

Renee Portillo, RN, was worried.

“It was a shocker. Our staff was used to patients going home in two to three days,” says Portillo, former assistant clinical director and management co-lead of the 7 South medical-surgical team at Fontana Medical Center in Southern California.

The accelerated time frame meant that the unit’s nurses, who care for total joint patients following surgery, would have less time to prepare them for discharge. They’d also need to help choreograph care across multiple departments—Orthopedics, the operating room, Physical Therapy, Home Health—from pre-admission to discharge.

Who best to help the team through this change? The team itself.  

“We used our UBT to help change the culture,” Portillo says.

Wave of the future

“We helped our nurses be successful by having them anticipate patients’ needs and prepare them for discharge,” says Enrique Rivero, RN, a surgical nurse and UNAC/UHCP member who is the team’s union co-lead.  

Fontana is among a growing number of hospitals across the United States to offer a combination of shorter hospital stays and more outpatient care for hip and knee replacement patients. The trend is driven by less-invasive surgical techniques, improved pain management and rehabilitation practices, and patients’ desire to return home as soon as possible.

“There were a lot of challenges. A lot of it had to do with bringing people together,” says Mary Hurley, MD, chief of Orthopedics, who championed the new approach. “They all had to buy in and be willing to support this in order to have a successful program.”   

The new approach, which Fontana introduced in January 2014 after months of researching best practices, gets patients walking within hours of surgery and enables them to recover within the comfort of their own homes. The initiative takes advantage of Kaiser Permanente’s integrated model of care and is designed to improve clinical outcomes and reduce costly hospital stays.

On a warm fall afternoon, nearly 35 children are bouncing off the walls as they get ready to leave the classroom and head out to their elementary school’s garden. They’re all members of an after-school garden club and cooking class called Edible Olympic. It’s the brainchild of Maria Peyer, an oncology nurse and team co-lead at the Longview Kelso Medical Office in Kaiser Permanente’s Northwest region and her husband, elementary school teacher Michael Bixby.

The kids can barely contain their excitement as Bixby tries to calm them down so they can listen to the afternoon’s agenda.

“The sooner you settle down and be quiet, the quicker I can finish what I need to say and you can get outside,” he implores the class.

Quickly, the hubbub settles. Bixby goes over what needs to be done: plant blueberry bushes, dig a hole for a tree, and remove bamboo sticks. He also reviews the Garden Guidelines, which include listening with respect, walking (no running) in the garden, and asking for permission before picking anything. Then he asks, “Whose garden is it?” and gets a resounding and loud, “Ours!” as everyone heads outside to get to work.

The students attend Olympic Elementary School in Longview, Washington. They don’t have many advantages: More than 20 percent of the city’s population is below the federal poverty line, and 90 percent of the school’s students participate in the free or reduced-price lunch program. Many experience food insecurity regularly, not knowing if they’ll have enough—or any—food to eat.

Income-related health disparities

There are well-documented health disparities related to low income, and these kids are at risk. Edible Olympic is helping address that vulnerability, teaching the kids about healthy food and how to prepare it, laying the foundation for good eating habits that last a lifetime. It’s an example of how partnership principles expand naturally and necessarily into the community; the new 2015 National Agreement includes commitments to jointly work on improving the health of the communities we serve.

The Longview project grew out of a Kaiser Permanente adult cooking class recommended for oncology patients, one that focuses on a plant-based diet. Peyer says that after moving to Longview, she and her husband were struck by the limited resources available to the children in the community.

“We wanted to affect change as directly as possible,” says Peyer, an OFNHP/ONA member. “So we dove headfirst into Edible Olympic. We didn’t want to spend time in meetings, we just wanted to get in the dirt and the kitchen—and that’s what we did.”

She sought support from Thriving Schools, one of Kaiser Permanente’s Community Benefit programs. She forged partnerships with the school’s Parent-Teacher Organization and the Lower Columbia School Gardens, a nonprofit that helps schools create garden programs. Local stores donated money. High school students from Longview and Portland also are participating.

“The kids, their parents and the greater community have embraced the efforts and confirmed that our hunches were right,” Peyer says.  “Good, healthy, real food, prepared simply, with love and in community, can be life transforming.”

Members of the Oncology unit-based team are supporting the project, too, donating money and time; four KP employees help staff the cooking class.

“Volunteering in the community gives us at KP a chance to share our skills and our approach to supporting good health,” says Elizabeth Engberg, the Northwest’s Thriving Schools program manager. “It also helps us learn about our members—where they live, work, learn and play, because that’s a huge part of what affects their health. Schools are the best place to do this.”

Overwhelming participation

The program has had overwhelming and unexpected participation.

“The idea was that this project would launch with eight to 10 kids. We had 60 kids come to the information session,” Peyer says, which prompted an instant expansion from one to two sessions. The kids work in the garden on Thursday afternoons, and on Fridays, they walk across the field to the middle school, where they are able to use the home economics classroom for cooking class. The sessions run for five weeks and end with a celebration where the kids cook a complete meal and share with their friends and family.

The first session got under way last spring. A grassy patch of the school’s property was selected as the site for the garden, and the children got seeds started indoors. As weather allowed, the ground was prepared. While they waited for their seedlings to be ready to plant, the kids were introduced to kitchen safety and how to prepare the food they were just beginning to grow.

In the cooking class, kids have a healthy snack, then work in small groups to prepare the dish of the week. When the cooking is done, they gather together  and enjoy their meal. The kids leave with a bag of groceries so they can cook the meal at home.

“In some cases, this may be the healthiest meal the family may eat during the week,” Peyer says.

On that fall day out in the garden, the kids in the second session organized quickly after studying the garden map Bixby brought along for reference. They divided themselves into groups and got to work with shovels, buckets and plants to complete the day’s activities.

One of the choices they faced was whether to extend the blueberries to the fence or stop a few feet in to allow for a foot path. Several kids piped up with ideas. The decision got made after 11-year-old Christian Aguibar offered his opinion.

“We can grow more things if we don’t have a walkway,” Christian said, “so let’s not have one.”

Like casts and splints, X-rays are a routine part of patient care in the Orthopedics department at South Bay Medical Center. Unfortunately, missed copays for those X-rays were becoming common as well.

“Patients will get their X-rays done at the end of the visit—and then walk out without realizing that they owe a copay,” says Christopher Kresch, department administrator for Orthopedics and the team’s management co-sponsor. At other times, patients will unexpectedly need X-rays during their visit, and because the orders are placed during the exam, the charges are not captured during check-in.

So the team borrowed a practice from the Los Angeles Medical Center and developed a check-in sheet that shows, at a glance, if a patient has an outstanding X-ray copay. The team also adjusted its workflow to ensure that a staff member walks the patient to the front desk to pay the fee by the end of the visit.

Here’s how the process works:

The receptionist gives the check-in sheet to each patient at the start of the visit. As patients travel through the clinic to receive care, the form goes with them, enabling staff to conduct “warm hand-offs” by writing notes to each other about the patient’s care. When a copay is owed, the last person to interact with the patient escorts him or her to the receptionist.

“It helped us in a lot of different ways, much more than we thought it would,” says Naomi Guerrero, an Orthopedic technician and SEIU-UHW member who is the team’s union co-lead. “Now we can’t live without it.”

Side benefits

After introducing the check-in sheet, the team saw almost immediate improvement in copay collection. In July 2014, missing copays—known as the total collected variance—totaled $2,166. Between August and November 2014, the total collected variance fell to just $533, a whopping 75 percent improvement. Those numbers are holding steady. The department is averaging a 50 percent increase in copay collections through third quarter 2015.

Besides boosting copay collection, the check-in sheet helped the team improve patient care. Unexpected benefits include:

• Keeping patients informed of delays and expected wait times improved patient satisfaction scores. Positive patient responses about staff communication on the Ambulatory Satisfaction Questionnaire (ASQ) rose from 48.67 between August and December 2013 to 57.74 for the same time frame in 2014. The regional target is 54.5.
• Direct booking—when a staff member makes the first appointment for a patient referred to a specialty department—soared from 38 percent of all referrals in July 2014 to 68 percent by November 2014, exceeding the regional goal of 40 percent.

• An increased percentage of patients who receive bone density screenings. In 2013, 89.7 percent of eligible patients received the screening; that rose to 91.9 percent in 2014. The regional target is 85 percent.

Finding the right solution

Before adopting the check-in sheet, the team sought input from a group of staff members and physicians in the department. Incorporating their voices gave them ownership of the project and enabled the team to create a check-in sheet that worked for everyone. For example, physicians rejected an early draft featuring a detailed checklist in favor of blank space to write their orders. And receptionists vetoed an early color-coding system as “too confusing.”

“We learned a lot as we went through our tests of change,” says Guerrero. “We learned there are changes that don’t work out.”

Adoption takes time

Once team members were happy with the check-in sheet, they spread it to the rest of the department. Convincing their peers to consistently use the check-in sheet took time.

“The medical assistants were resistant because they saw the check-in sheet as an extra step,” says UBT representative Zackry Ellis, a physician assistant and member of UNAC/UHCP.

Some providers also were hesitant to use the form, preferring to speak with staff. That’s when the team turned to Anthony Leone, MD, the department’s physician chief, for help.

“He helped us sway others to try it out,” Guerrero says.

Once staff members understood the benefits of the check-in sheet—enhanced copay collection, improved workflow and better patient care—they all began to use it consistently.

Patients are reaping the benefits of the new form, too.

“Because of the check-in sheet, we’re communicating more with our members,” says UBT representative Esmeralda Montes, a lead medical assistant and SEIU-UHW member. “They feel happy and cared for, and that’s our ultimate goal.”

“This whole project was a mere idea written on a piece of paper only a few months ago,” says Juan Piantino, MD, “and now it’s a reality.”

Shortly after Dr. Piantino, a neurologist, came to Kaiser Permanente in July 2014, he was approached by another member of the department—Debbie Newcomb, an electro-neurodiagnostic technologist and UFCW Local 555 member. Newcomb’s work includes performing electroencephalograms (EEGs), a test that monitors a patient’s brain waves and helps diagnose patients with epilepsy.

She was interested in implementing ambulatory EEGs (AEEGs), an advanced technology that is relatively new. Because the test is conducted over a longer time period than a routine EEG, it is more likely to capture events that provide the medical team with information needed for a good diagnosis. AEEGs also are less expensive than an inpatient telemetry EEG. But Newcomb needed a physician partner to move forward.

“I wasn’t intimidated about approaching him,” says Newcomb, who’s the labor co-lead of the neurology UBT. “The partnership has given me the confidence to speak up—and in fact, I consider it part of my role as a union steward.”

Swift implementation

Dr. Piantino had experience with the test with other health care systems—as did Newcomb—and was enthusiastic. The pair began figuring out how the test could be implemented in the Northwest region. Newcomb collaborated with the staff at the Stanford Comprehensive Epilepsy Center to understand the specific details of its program. She worked with KP Purchasing to identify the type and cost of the machines that would be needed.

Armed with information, Dr. Piantino met with leadership of the Northwest Permanente Medical Group—and within a few short months, in December 2014, the region was equipped to do continuous ambulatory EEGs.

So far this year, 16 patients have had their treatment guided by the ambulatory EEG as outpatients. Because the test is administered with a camera, the physician reading the results can see the patient in real time and correlate the brain activity to the physical movements of the patient. In addition, being able to conduct the test in the patient’s own environment avoids a potentially stressful and expensive hospital stay.

One adult patient had been in and out of the Emergency department five times in two weeks. Newcomb performed the ambulatory EEG on him; he had five events, all pseudo-seizures. “He is now seeing the proper doctor for his problems—no more trips to the ED,” Newcomb says.

By the end of July, the program already had paid for the cost of equipment. The benefits of an accurate diagnosis for the patient are immeasurable.

“It was the positive attitude and the willingness to improve patient care that made this happen in record time,” says Dr. Piantino.