UBT Co-Leads

Sometimes the best way to spread effective practices is to spread experienced people. That’s what happened when the Alpharetta Ob-Gyn UBT in Georgia zoomed from Level 1 to Level 4 in just 10 months after two nurses from two different high-performing UBTs transferred there at the same time.

Jane Baxter and Ingrid Baillie had been UBT co-leads at two different clinics when they each got a new job with the Alpharetta Ob-Gyn department. They both drew on their experiences to guide their new team when they became co-leads at Alpharetta. “We knew the steps in the process and what to expect,” says Baxter, the department’s charge nurse.

Fledgling teams should begin with small performance improvement projects, they say. “We started with the low-hanging fruit,” says Baillie, RN, a member of UFCW Local 1996. “You don’t need to reach for the stars right out of the box.”

Pick your projects wisely

And, says Baillie, there’s no need to look any further than Kaiser Permanente’s organization-wide and regional priorities to find plenty of ideas for performance improvement projects—and a wealth of data that is being collected regularly.

“KP makes no secret about what is important to it,” says Baillie. “From that alone, you have all the data you need.”

For instance, the Alpharetta team’s first efforts were to improve clinic start time and get a second blood pressure test for patients with high initial readings. “These are important to KP, and they helped us gel as a team,” says Baillie.

“Small wins help develop confidence,” says Baxter. Now the team is taking on more complex cross-departmental initiatives, such as trying to make available online the big packet of paperwork patients need to complete before a first Ob-Gyn visit.

Getting physicians involved also has been part of this UBT’s success. You won’t find doctors who think UBTs are just for clinic staff on this team, says Baxter.

“Our providers are very invested,” she says. “They take minutes at meetings. We are all on an equal playing field.”

It started with a question from Oncology RN Tom Fought, a member of the Oregon Federation of Nurses and Health Professionals (OFNHP), at the Interstate Medical Office in the Northwest.

Why, he wondered, was primary tubing used for low-reaction drugs instead of the less-expensive short or secondary tubing?

That prompted the department’s unit-based team to start an improvement project that wound up saving $25,000 a year.

When patients come in for chemotherapy or other infusion medications, the drugs are administered via an IV: The bag holding the medication is hung on a pole, with a line that goes into the patient’s vein. When primary tubing is used, the valve to stop the flow of medication is very close to the patient’s body.

If the drugs being used have a high potential for an adverse reaction, it’s essential to use primary tubing, so that if there is an emergency and the line has to be shut, only a very little additional medication reaches the patient.

Appropriate times for less expensive options

When the short tubing or secondary tubing is used, the valve to stop the flow of medication is farther from the patient. In this situation, if the valve is closed, more medication is in the line and will flow into the patient until the tube is empty. These types of tubing are appropriate when the medication has a low potential for a negative reaction.

Primary tubing is $4.10 per unit, short tubing is $3.65 and secondary tubing is 65 cents. The costs add up if primary tubing is used when it’s not necessary.

“I had no idea that we would be saving the unit that much money by conforming the tubing,” Fought says.

This team alone was able to save $25,000 a year. If every Kaiser Permanente oncology infusion department adopted this practice, the savings would be dramatic.

“This was such an easy tweak—we just needed to think outside of the box,” says Lacey Anderson, RN, the Infusion Team Lead and a member of OFNHP, who was involved in the project. “The team realized this was such a great idea and wondered, ‘Why haven’t we been doing this all along?’”

Greater camaraderie

Heidi Rolf, the department manager and the UBT’s management co-lead, is proud of the work the team has accomplished. She attributes the success to the leadership of the team and notes that since the team has advanced to a Level 4 on the Path to Performance, team members have more camaraderie and are more engaged.

“At first it was a little difficult to change the habits of the nursing staff,” Fought says. “Within a few weeks, we had everyone on board and our tubing project took off.”

South San Francisco allergy team’s specialty may be allergens and hay fever, but that didn’t prevent it from helping to improve patients’ screening rates for cancer, too.

It didn’t happen all at once—some staff members were skeptical at first. Scheduling a screening appointment for a wheezing patient didn’t seem right.

“At first people would say things like, ‘You know, I really don’t feel comfortable saying to a patient, “Oh, you’re due for mammography” when they’re sneezing and congested and here for allergies,’” says Alva Marie Aguilera, the department’s supervisor and management co-lead for the unit-based team.

Screenings as strategy

But part of delivering on Kaiser Permanente’s Total Health promise is to identify health risks and signs of disease as early as possible. Regular screenings for such diseases as high blood pressure, diabetes, and colorectal, cervical and breast cancers are an important part of our strategy.

That means caregivers and employees in seemingly unrelated departments—not just those in, say, internal medicine—have a role to play, and KP HealthConnect® provides them with a powerful tool.

Any time a patient is seen, a “proactive office encounter” message pops up in the member’s electronic record if he or she is due for a health screening or if important health data needs to be updated. It doesn’t matter what the reason is for the current visit or which department the patient is being seen in. 

The members of South San Francisco allergy department took the important work of taking the next step to heart: Following up on the prompt and offering to schedule the patient for the screening or asking the necessary questions to fill in missing information.

Scripts and reminders

To help make sure those things happened consistently, the team tried some small tests of change:

• It created a general script to help broach the questions with patients and posted laminated cards on computers to serve as reminders.
• Aguilera reports the weekly screening numbers so staff members know how they are doing and where they missed opportunities to follow through on the HealthConnect® prompts.

The small changes had a big impact. Before the team started the project in February 2012, it followed through on the prompts 80 percent of the time. In the first two months of the project, that jumped to 90 percent. By early 2013, the prompts were being followed up on 95 percent of the time and held steady at that rate for the rest of the year.

It wasn’t just staff members who were uncertain of the practice in the early days.

“At first it was kind of surprising to patients,” says medical assistant Lidia Vanegas-Casino, a member of SEIU UHW and the UBT’s union co-lead. “So we had to explain to them: ‘It’s a way to help you, and to keep up with the things you need done. It’s a proactive approach to keeping you healthy.’”

Positive example

It was one of KP’s own commercials that convinced team members of their important role in keeping patients healthy. Aguilera showed the ad that features KP member Mary Gonzalez, who had gone in—fittingly—for an allergy appointment when the receptionist noticed she was due for a mammogram and booked an appointment for her. The screening picked up a mass, and Gonzalez subsequently learned she had breast cancer. The early detection helped ensure a positive result.

It wasn’t a primary care or OB-GYN department that got her that screening. It was allergy.

“It really hit home for people,” Aguilera says. “If it wasn’t for the allergy receptionist who took that time, we don’t know what would have happened. That was a big encouragement.”

On one level, the pediatric clinic at Georgia’s Panola Medical Center Offices is like any other pediatric clinic. Babies squawking and squealing are part of the soundtrack—and under that, there’s the murmur of parents and nurses cooing to get the little ones to stop crying.

But the Panola clinic’s unit-based team stands out. Its members work at one of the several pediatric clinics in KP’s Georgia region that have significantly improved preventive care and screenings for their young patients, who range in age from newborn up through their teens.

The pediatric teams have achieved these goals in the midst of competing demands by staying laser-focused on a handful of quality measures in the Healthcare Effectiveness Data and Information Set, or HEDIS.

“Our projects are usually HEDIS-related,” says Panola’s labor co-lead, Sheryl Boyd, a licensed practical nurse and member of UFCW Local 1996. “HEDIS is so measurable.”

The work is a good example of how, instead of driving an agenda from the top down, achieving a goal can be inspired by engaging frontline teams in understanding how they contribute to KP’s brand promise of total health.

“The teams are not ‘being told what to do,’ but rather they see the big picture and see what they can do to affect it,” says David Jones, MD, Georgia’s physician co-lead for UBTs. Dr. Jones says he and his labor and management LMP counterparts stay abreast of Georgia’s regional goals and priorities, then work with UBT consultants to communicate those to frontline teams.

“We incorporate UBTs as a lever to execute our clinical goals,” says Dr. Jones, creating a vital loop of communication and support.

Collaboration pays off

One of the Panola UBT’s successes has been to increase the number of girls getting the human papillomavirus vaccine (HPV) by their 13th birthday. The vaccine can help prevent a virus that increases the risk of cervical cancer.

The project kicked off in October 2011. At the time, the team wasn’t tracking how many of the girls in the target population had received the vaccination, which is delivered in a series of three shots over six months. The team’s initial goal was to get 5 percent of the girls eligible for the shot vaccinated. In the first six months, the team succeeded in getting 10 percent of the target population started on the series—and by October 2013, nearly 20 percent had gotten the complete series, a significant achievement. While it has yet to reach the national HEDIS average for the vaccination, the team is steadily closing the gap.

Team members achieved these results by working with the clinic’s information technology staff to get a list of patients—11- and 12-year old girls—who needed the vaccine. They contacted parents and made appointments. In the exam room, nurses discussed HPV and the importance of the vaccine with patients and their parents.

And they worked with their IT colleagues again, modifying the computer system so they could book appointments six months in advance. That allowed them to act on a crucial step—scheduling visits for the two follow-up booster shots right then and there.

The parent education was extremely important, says Erica Reynolds, the charge nurse and management co-lead.

“Some parents think we want people to come back in for appointments because we want the co-payments,” she says—but in fact, if the shots aren’t completed in the proper time period and the immunization series needs to be started all over, it requires even more visits. To avoid that, she says, “Scheduling a nurse visit for the second and third vaccines has become a part of our workflow.”

Hard-wiring success

That kind of hard-wiring of successful practices is the holy grail of performance improvement.

As labor co-lead Boyd puts it, “Our projects are not ‘projects.’ They are ongoing.”

In addition, Dr. Jones says, the integration of partnership and performance is taking place at all levels in the region.

For example, he says, physician leaders “integrate the Labor Management Partnership and performance improvement into existing meetings so it is not viewed as outside those discussions.”

As a result, when Georgia earned a five-star Medicare rating in fall 2013 for the first time—bringing all of KP’s regions into that rarified club of health care excellence—Rob Schreiner, MD, the region’s executive medical director, specifically credited UBTs and the culture of continuous improvement for the achievement.

Driven by those two engines, says Schreiner, “We’ll improve quality, service and affordability at a tempo that exceeds that of our competitors.”

See what other teams are doing to find success in Total Health.