Senior Orange County executive shares keys to success
The 2 North-South medical-surgical units in San Diego were identified as high-injury departments.
One year, the combined team saw 16 patient-handling injuries. Before that, the number was 18. Repetitive back and shoulder injuries were most common. As a result, management was told to eliminate injuries—fast.
The first step in the action plan required staff members to undergo Workplace Safety training on how to conduct safety observations. Each person then conducted three observations a week on teams turning patients and submitted those observations to a collection box in the department. The observations were logged into the Workplace Safety web-tracking tool.
Previously, only charge nurses and managers conducted the observations. But getting everyone involved kept proper patient-handling techniques constantly at the forefront of team members’ minds.
Getting buy-in from staff members was another challenge, so it didn’t feel like another thing on top of their regular workload.
“Make sure you communicate—and with some degree of consistency—to everyone,” nurse manager and RN Erlinda Aquino says. “And hard-wiring it so people understand it’s not just the flavor of the month.”
The UBT adapted a checklist of key things that should be done when turning a patient, such as ensuring a patient’s bed rails have been lowered. Turn-team captains referred to this checklist at every patient turning.
To help morale and maintain safe patient-handling techniques, the UBT set small, attainable goals the department could celebrate.
The team had a pizza party when it reached the first 100 days without an injury, then again after accruing no injuries for the month of July, which historically had been the units’ highest injury month.
“In the beginning, you have to consistently remind people,” says Tess Patiag-Limcuando, RN. “People felt that doing those steps just added to the time, not realizing that it would cost them a whole lot more time if they hurt themselves.”
It was also important to focus on the positive.
“Instead of emphasizing the negative, present it like, ‘I care about you; I want you to be safe.’ Versus: ‘You’re in trouble,’” Aquino says.
San Diego's 2 North-South Medical-Surgical team dramatically reduces patient-handling injuries by having all staff members conduct regular safety observations.
Patients and specimen samples showing up without orders was a common occurrence at the East Denver Medical Office lab.
In some cases, orders weren’t in the system because there was confusion between the provider and the nurse about who ordered the test. Other times, patients were directed to the lab without verification of a lab order; and orders simply expired.
This lack of follow-through was inconvenient for the patient, who would have to go back to his or her doctor, or wait for a lab employee to contact the department. In some cases, the patient would have to make a second trip.
So, the East Denver team decided to crack down and got a little creative.
They developed an “enforcement” theme and dressed up in police uniforms to issue citations to “violators” as they tracked patients with no orders.
Departments with the most improvement were honored with coffee and donuts. Those that met the criteria for sustained success were recognized with lunch.
OB/GYN went from 42 “violations” in a seven-week period to 34 in a 10-week period. Pediatrics went from 16 occurrences to a single one in similar time frames.
“At first, we didn’t give them (other departments) the specific data,” lab clinical manager Lucy Tyler says. “Then OB asked for it so we started giving it to everyone.”
The team found by tracking the data, they discovered who needed help, and they worked with that team to solve the problem. By showing each department when they were sending patients and specimens to the lab without orders, they could see they were part of the problem.
In some cases it was a surprise.
“This work supports X-ray and pharmacy, too,” phlebotomist Alma Lahti says. “It’s improving orders in other departments.”
Lab UBT in Colorado worked on a fun and innovative way to eliminate the problem of patients showing up at the lab but the orders weren't in the system.
Getting patients where they need to go is essential to the operation of a hospital.
But the process of moving them around for tests, X-rays and other services can be a major source of delay, congestion and patient dissatisfaction.
Members of the Inpatient Transport team at the San Jose Medical Center were assigned to specific departments and different floors. Some locations were busier than others, and some transporters were tasked with more work.
And the waits for patients were at best unpredictable. Nurses and technicians often resorted to pushing occupied beds themselves, rather than waiting for a transporter. Workplace injuries rose and attendance became problematic.
San Jose transporter Dharmesh Patel lobbied for a centralized dispatch system, where calls would come into one place and transporters would wait for assignments. The unit-based team agreed to the project, and it worked.
After the change, transporters completed 68 percent more patient trips per day. Timing also improved. Transporters reached the patient’s location within five minutes of the call 90 percent of the time, as the average response time went from about four minutes to 2.46 minutes.
Savings were found in both reduced overtime and sick days.
With fewer nurses and technicians chipping in to transport patients, the team shaved an estimated $200,000 in annual costs for less overtime. In two years, workplace injuries dropped from seven to one, and sick days decreased from a rate of more than 11 days per employee to save another $15,000.
“Overtime is down, sick time is down and the patients are happy,” Patel says.
A San Jose Medical Center UBT has improved patient flow and throughput with a centralized dispatch system for transporters. The new system makes inpatient transport more efficient, effective and safe.
Various interventions have been implemented to increase the rate of colon cancer screenings, including at-home Fecal-Immunochemical Tests or FIT kits. These kits are mailed or handed to patients identified as age- or risk-appropriate and can be completed in the privacy of the member’s own home.
The FIT kit doesn’t require a doctor’s appointment and is returned directly to the lab in a prepaid envelope. Patients who have positive FIT kit results for occult blood are referred for further testing.
“A long time ago, there was no way to track these people,” Kari Russitano, medical assistant, SEIU UHW, says. “Kaiser has done a lot to improve cancer screenings.”
But getting members to take and return the test remains a problem.
In 2009, the Union City Medical Center fell short of its 71 percent return rate goal for colorectal screenings. Kaiser Permanente routinely mass mails the kits to members identified through the electronic medical records database. But many members either don’t return the tests or the ones they return aren’t legible.
“Thirty percent were thrown away because we couldn’t read their name or the medical record number,” Deborah Hennings-Cook, RN, manager, Internal Medicine, says.
Clinical coordinator, Vimi Chand, Department of Internal Medicine, adds, “Obviously mailing alone wasn’t working, so we decided to contact members by phone or secure email. And it worked.”
Of the 1,754 members contacted, more than 63 were referred for further screening.
Having the medical assistants and receptionists make the calls was a hard sell at first, but their peers in the unit-based team stressed the preventive nature of the test.
“It didn’t seem like extra work, because we collaborated together and educated each other to think of it as if ‘this could be your family member,’” Sophia Opfermann, receptionist, OPEIU Local 29, says. “A lot of staff didn’t know what the FIT kits were for, so we educated them about that, too.”
Then frontline staff came up with the idea for the note cards—bright fluorescent notes that read: “This test detects early signs of COLON CANCER.”
“Knowing that many people don’t understand the importance of the test, they made the verbiage strong about ‘saving lives’ and ‘help us help you,’" Hennings-Cook says. "It was something they wanted to do, and it worked.”
One challenge was adding the phone calls and emails to the medical assistants’ existing workload. Lists of patients who hadn’t responded were provided to medical assistants but some had more than others.
“We heard a little bit of flak when the lists first came out and some MAs had huge lists, but they helped each other and just did it,” Chand says.
In the end, the bottom line was helping patients.
“By collaborating together and educating each other, we are helping to saving lives,” Opfermann says.
Internal Medicine team in Northern California increases cancer screenings with the personal touch.
The team in the Head and Neck Surgery/Audiology department at the South Bay Medical Center had been compiling monthly reports about missed second blood pressure checks.
And this can be a critical point for a patient’s care because high blood pressure is often called “the silent killer.” Those who have it often don’t exhibit symptoms until it’s extremely high, and untreated hypertension can lead to heart disease, stroke and kidney problems.
But the team reviewed the numbers without a follow-up plan.
So, they decided to have morning huddles several days a week to explain the screenings and follow with plans of action.
“We discuss why this is important and what it means to our members, that it can save lives, especially for those who haven’t been diagnosed,” says Kathy Malovich, the department administrator.
UBT leaders provided team members with their individual performance scores on administering needed second blood pressure tests. They customized training and other follow-up plans, including coaching the team on procedures for Proactive Office Encounters (a process that takes advantage of a member’s visit to ensure the member gets any needed tests or appointments).
At huddles, they discussed the importance of controlling high blood pressure for patients. They emphasized that not only was it a strategic clinical goal but a Performance Sharing Program (PSP) goal for the medical center.
“People think they’ve done the second test because they know they should have,” says Leroy Foster, who was the department administrator when the test of change began. “Maybe they got distracted by any number of things.” Foster said the hard data helped motivate the team.
With a low of 35 percent for second blood tests, each team member jumped to 92 percent or better in a year. Four of the six team members hit 100 percent. In 10 months, team scores for second blood tests went up from 84.8 to 92.1 percent.
Huddling was also a key to success.
“I used to think, ‘you guys have way too many meetings,’” Jennell Jones, the union co-lead, says. “But now I see how meeting keeps people connected.”
A speciality department at South Bay Medical Center learns the value of routine screenings and gets results.
The San Diego Ophthalmology group had earned the dubious reputation as a high-injury department.
They had a quarterly injury rate of 23.6 and problems ranged from carpel tunnel to back issues. The majority of complaints was caused by sitting at the computer for long periods, typing and doing repetitive motions like using a mouse.
Medical assistants and technicians also frequently complained about having trouble navigating the cluttered, unsafe vision lanes—the small alcoves where nurses and medical assistants evaluate patients before escorting them to exam rooms.
Being flagged a high-injury department, the team was determined to identify the causes of the injuries and how to prevent them from occurring.
The department took Workplace Safety training and instituted a number of measures to identify and fix potential hazards at all four ophthalmology departments. Those measures included ergonomic evaluations, new chairs and foot rests, and installing stretch break software on all computers.
They conducted regular safety checks and created the “I Spy” program, which has previously injured workers conducting safety observations to identify potential problems.
The team also revamped the department’s vision lanes.
These often were cramped and potentially unsafe environments with electrical cables stretched across the narrow floor. Computers and blood pressure carts created additional tripping hazards.
“You had to maneuver around patients and wheelchairs, and generally feel confined, waiting to trip or bend wrong,” says Anna Garcia, a medical assistant and UBT member.
So, they mounted blood pressure machines and KP HealthConnect computers on the walls, instead of using carts. They purchased new chairs for patients, particularly for older patients who have difficulty getting into narrow spots or are in wheelchairs.
By moving power outlets closer to the mounted equipment, electrical cords were no longer in the way. And they painted the walls that ophthalmologists used during eye examinations.
“The nice thing is if I need to maneuver now, it’s not a move I’m going to regret later on when I get home, when my back is hurting,” Garcia says.
Ophthalmology went 335 days without an injury.
But keeping workplace safety in everyone’s awareness was a challenge.
“The equipment makes a difference, but our behavior also makes a difference. It takes a while for that to happen. It doesn’t happen overnight,” Vickie Lance, assistant department administrator says.
Feedback from people outside the UBT also proved invaluable.
“I’ve been in this department for 15 years and I didn’t know there was a problem. Once we saw it on paper, it made a big impact,” Lance said. “And the visual picture of before and after is wonderful. It makes us feel like we’ve accomplished something.”
San Diego's ophthalmology team reduced ergonomic workplace injuries while also clearing their vision lanes, which had posed serious safety hazards for medical assistants and patients.
Registration reps at two medical offices in the Northwest were struggling to get their work done.
Their job aids were inadequate. And these can prove critical in busy clinics, by providing help with tasks like adding a walk-in patient to the schedule, incorporating additional insurance information or processing payments.
But disorganization, improper documentation and an unclear process meant staff members frequently had to stop and interrupt a co-worker (slowing his or her work down) to find out how to do such tasks—all while the member waited.
So staff members started a “plan, do, study, act” improvement process.
As a first step, they held a meeting and registration representatives brought all their job aids from their desks, often just stacks of paper in no particular order. In the meeting, they tried to find specific documents and were timed.
The average time it took to locate a document was 26 seconds, and worse, the reference document often couldn’t be found.
The team decided to organize their job aid books in a consistent manner. No matter where a registration representative was sitting, every book was the same. Staff also created instruction sheets on some processes that complemented the job aids.
Included in the new policy and procedure binders were colored job aids with cover sheets in alphabetical order, and also a step-by-step instruction sheet.
“We’ve heard nothing but good feedback from doing this improvement,” supervisor Colleen Moore says. “Staff have more confidence because they are figuring out the answers to their questions instead of asking.”
After implementing the changes, the team tested the process again and located the correct reference document each time in an average time of three seconds.
Interested in a quick and easy check in next time you go to the doctor? Registration representatives in the Northwest found that getting organized helped them help the patient better.
The folks at the Denver Regional Pharmacy found their unit-based team to be a major improvement over the steering committee it replaced.
Team members found the committee to be unwieldy, and felt it largely bred distrust and miscommunication between union and management.
So, they regrouped.
A major problem they had encountered was the time pharmacy technicians wasted researching prescriptions that weren’t properly "batched." Often missing was the required electronic stamp from a pharmacist that tracks and closes the prescription.
Technicians spent roughly 1-4 hours a day per pharmacy tracking down misbatched prescriptions. The team aimed to cut that time by 50 percent.
"The biggest thing is if you view your situation as a failure you'll never succeed," management co-lead Luanne Petricich says. "When something is not working that's where your opportunity is. Don't be afraid to change something if it's not working."
The team modified the way pharmacists attached their electronic signature. That saved technicians hours of research time and freed them to spend more time with patients. Almost immediately the team saw a drop in the number of prescriptions that needed to be researched.
In the two pharmacies where the team instituted new batching practices, they saw a 75 percent drop in the number of prescriptions requiring research. The new protocol was introduced to 20 pharmacies in the region, and 70 percent of those saw similar gains.
This collaborative effort produced positive results as their projects improved customer service and affordability. The new UBT also gained some hard-earned trust.
Since that success, the regional team has become a model and a sponsor for smaller, pharmacy-specific UBTs launched in the region.
"I like the focus on efficiencies and waste because it ends up translating to a better work environment for employees," Petricich says. "Especially with this project, we found the technicians were doing redundant work that did not provide job satisfaction. So taking that away allowed for more time with patients, which is what many would rather be doing."
Regional Pharmacy UBT in Colorado uses PDSA to improve 'batching' procedure.
The Mammography Department at Sunnyside Medical Center was seeing about 370 patients per week, but 25-30 percent of those appointments were running behind schedule.
Appointments ran late because information was missing from the file, additional forms were needed or the wrong test had been ordered. This cost the technologist additional time tracking down information or following up on needed documentation during the patient’s appointment, which had a cascading effect.
The unit-based team (UBT) realized that many of the issues causing delays during appointments could be handled in advance of the patient's arrival. The team came up with the idea of setting time aside every afternoon for a technologist to review the following day's orders.
"Many times patients who are coming in for an appointment are here because something has shown up on a prior screening and their anxiety and stress levels are high,” Cheryl Maize, manager of Mammography, and UBT co-lead says. “By streamlining our appointments and ensuring appointments run on time, we are hoping to allay some of that stress."
Initially, a 3-4 p.m. window was set, but as staff began to test the new process, they learned that starting the work that late in the afternoon was not ideal.
In some cases, they needed to return phone calls or required additional information, and they couldn't get everything done by the end of the day. The team pushed up the pre-work orders to a 1-2 p.m. time slot and the results improved.
In addition, the team implemented a "double-check" system at 4 p.m., so orders were again reviewed to make sure any outstanding items had arrived and everything was ready for the patient's appointment the following day.
The technologist reviewing the orders also would leave notes in the file if there was something the technologist who was seeing the patient needed to know.
Patient experience improved with the new process. Appointments were on time, and technologists were better prepared to work with their patients because the orders had been reviewed in advance.
"The implementation of the screening of orders 24 hours prior to patient arrival has allowed us to maintain our allotted appointment times and has made it easier to accommodate surprises such as late arrivals and walk-ins," Laura Wellnitz, technologist, and UBT labor co-lead says.
Eventually, a technologist was checking orders and printing out appropriate paperwork for diagnostic mammograms one day in advance of the appointments. This eliminated 10-20 minutes per appointment. As a result, most diagnostic appointments were completed in the scheduled 30 minutes, so subsequent appointments started on time.
Other staffers also preferred the new process. They decided to take turns verifying and reviewing orders, which provided a welcome break in the daily routine.
Mammography UBT implements case review process, reducing late appointments for patients.