Best Place to Work

Early in her nursing career, Yvonne Roddy-Sturm, now the chief nursing executive at Ontario Medical Center in Southern California, saw that caregiver diversity—or lack of it—matters.

“I saw differences in how some providers cared for people,” she says. “It wasn’t just based on race—economic status, language, lots of things came into play. We all make assumptions about others.”

The consequences of such assumptions are serious, impacting the quality of care a patient receives and leading to a wide range of health disparities.

In the 30 years Roddy-Sturm has been with Kaiser Permanente, our member and patient population has become more diverse—as has our workforce. And that’s helped KP deliver high-quality, patient-centered care.

“Patients who can relate to their caregiver are more likely to follow their treatment regimen,” says Roddy-Sturm. “They’re more likely to ask questions of people who are more like them.”

The Labor Management Partnership plays a significant role in building the skills, cultural competence and work environment needed to serve KP’s diverse patient population.

For example:

• Unit-based teams provide a more inclusive workplace and give staff members a safe place to speak up.
• Two LMP-sponsored educational trusts provide tuition assistance, paid time off and career counseling to help employees move up the career ladder.

And there’s more. Many departments, including Ontario’s nursing department, make their diverse teams part of the hiring process.

“We always start with the skills required to do the job,” says Roddy-Sturm. “Then our panel members bring their own insights and diversity to the discussion. They look for fit, flexibility, compassion and empathy, as well as skill. We try to live our values.”

Brandon Johnson was close to giving up on his dream of becoming an X-ray technician.

Born with sickle cell disease, a genetic blood disorder that primarily affects African-Americans, the 35-year-old Southern California man was forced to drop out of school for semesters at a time.

But thanks to the sickle cell care team at the Inglewood Medical Offices, Johnson is now on medication that reduces complications. Last fall, he was able to complete his studies, and he has started looking for a radiology job.

“They got me on a plan to keep me out of the hospital,” says Johnson, who drives 60 miles one way from his Riverside home to see his doctor in Inglewood, even though other providers are closer. “If I didn’t have my health, I wouldn’t be where I am today.”

Johnson’s success is not uncommon for the Level 5 unit-based team, a group of physicians, managers and employees that provides personalized care for nearly 500 sickle cell patients in Southern California. About 300 of the region’s adult patients are treated directly by the team. Its approach is working—only five of the 300 needed frequent hospitalization and emergency care in the past year.

“Our goal is to keep sickle cell patients out of the hospital by giving them the care they need,” says Pippa Stewart, Inglewood’s department administrator.

Stigmatized as drug addicts

Nationwide, about 70,000 people have sickle cell disease, which can cause chronic anemia, acute pain, infections and stroke. Although most are African-American, the disease also affects people of Indian, Middle Eastern, Hispanic and Mediterranean heritage. Patients often get stigmatized as drug addicts when they ask for narcotics to deal with their pain.

The current UBT grew out of a team that was established in 1999; before that, there was no comprehensive treatment program for KP’s sickle cell patients.

“Ninety percent of patients were getting their primary care in the emergency room,” says Shirley Brown, RN, a UNAC/UHCP member and the team’s care manager. Patients saw as many as 17 doctors as they went from appointment to appointment.

Now, the 12-member UBT—which includes four physicians, two registered nurses, a physician assistant, a pharmacist and a social worker—helps patients control symptoms by offering pain management care, providing resources such as a case manager, and urging them to keep appointments, which help minimize visits to the emergency room and hospital.

Team members coordinate with and help train the KP providers who care for the region’s remaining 200 patients. Last fall, Brown helped lead a session for 70 registered nurses from around the region. Osbourne Blake, MD, an internist and the team’s lead physician, provides regular updates to fellow physicians. “We’re trying to get everyone on the same page,” says Dr. Blake. A recent test of change focused on reducing the number of patients who miss appointments. For three months, Brown and a co-worker called patients every day to remind them about upcoming visits. The calls helped. The team’s “no-show appointment” rate dropped from 20 percent in May 2015 to 14 percent in August 2015.

Dramatic improvement

“They all know you personally,” says Ryan Hull, a 27-year-old TV production assistant and film student. A few short years ago, he suffered frequent crises that required immediate medical attention. After he and his physician co-created a pain management program, his health improved dramatically.

“They did everything they could to find out what regimen works for me,” Hull says of staff members, who greet him by first name and offer walk-in appointments to accommodate his sometimes unpredictable schedule. “They figured out the perfect way to treat me.”

For the past few years, unit-based teams have been driving a powerful transformation. It’s helping to control chronic diseases; assisting in the early detection of cancer; providing familiarity with a patient’s community; and enabling frontline employees to speak a patient’s language. It creates customized care for each of Kaiser Permanente’s more than 10 million members.

It isn’t a cool new gadget or something out of a sci-fi flick creating the change, but rather a modern care approach that takes into account the infinite number of ways KP members are unique—that emphasizes diversity and inclusion.

“All of us as individuals have all these different multicultural identities, and so do our patients,” says Ron Copeland, MD, senior vice president of National Diversity and Inclusion Strategy and Policy and chief diversity and inclusion officer. “We have to create high-performing teams that work together to deliver culturally responsive care that addresses those differences.”

Increasingly, the workers, managers and physicians working together in UBTs are considering the many facets of individual patients as they transform—in small and large ways—how they care for and serve those patients, using their knowledge and empathy to rethink how we deliver care.

As the stories in this issue of Hank illustrate, some of those changes are aimed at eliminating race- and gender-based health disparities. Other changes are taking place outside our medical facilities—working with school-age children, for example, to give them better food choices and teach them healthy habits that can last a lifetime. 

By doing this, UBT members are ensuring that Kaiser Permanente members are the healthiest they can be no matter their background or beliefs, language or gender, disability or economic status, whether they live in a big city or on a farm.

“UBTs have always led on innovating care by putting patients at the center, listening to them and customizing care for them,” says Hal Ruddick, executive director of the Coalition of Kaiser Permanente Unions. “This work strengthens and deepens that high-quality care.”  KP’s workforce is full of diversity, and UBTs are designed to draw on all employees’ perspectives in deciding how best to do the unit’s work. It’s a natural step to include our members’ and patients’ viewpoints as well. Understanding and considering the complexity of the patients and communities we serve directly affects quality of care and health outcomes.

“It’s about using our knowledge of differences as an advantage to better understand the patients we care for,” says Dr. Copeland. “Our goal is health care equity—so that all our patients achieve optimal health. For that to happen, it’s essential that we have approaches that account for our patients’ unique needs, preferences and living conditions.”

Colorado

The Colorado region is improving patient care and saving millions by providing high-risk patients extra attention after discharge, leading to a reduction in readmission rates. In the Post Acute Care Transitions (PACT) program, nurse practitioners visit patients in their homes after discharge from a hospital or skilled nursing facility, giving them a chance to alter the patient’s care plan if needed. The PACT team has visited approximately 4,200 high-risk patients since the program began in January 2013. At that time, 22 percent of high-risk patients were readmitted within 30 days, at a cost of $11.7 million. The PACT team has reduced readmission rates by 50 percent, saving Kaiser Permanente approximately $6 million since the program began.

Georgia

To make sure no good deed goes uncopied, the Georgia region launched a Spread and Sustain system to move best practices throughout the region—and showed off the results to KP’s board of directors at a UBT fair early last summer. Georgia took a spread blueprint from the Southern California region and fine-tuned it to meet its needs. Now its unit-based teams, sponsors and regional leaders identify projects with good spread potential, determine other locations where the new process could work, share the practice and check back to see how they’re being sustained. Several projects have been successfully spread region-wide—addressing such issues as hypertension, HPV vaccinations and lab specimen collection.

Hawaii

Hawaii is a beautiful place to live, but Kaiser Permanente members who live on the less-populated islands sometimes find it challenging to get the care they need. To address that, KP offers a special benefit called Travel Concierge Service. If health plan members need medical care that isn’t available on their island, KP assists them in traveling to the Moanalua Medical Center in Oahu or to a specialty care medical office. KP makes the travel arrangements and picks up the tab for travel, including airfare, shuttle service and discounted hotel rates. For minors who need specialty care, KP also pays for companion travel. “Our members love this service,” says Lori Nanone, a sales and account manager in the region.

Mid-Atlantic States

For several years, co-leads in the Mid-Atlantic States have compiled monthly reports of their UBT activities, goals and progress using Microsoft Word and Excel. Now, the region is rolling out a dashboard that automatically compiles the same information from UBT Tracker into an easy-to-reference SharePoint site, Kaiser Permanente’s new online social collaboration tool. The new dashboard will encourage more frequent updates to UBT Tracker and eliminate the need for co-leads to create separate documents, says Jennifer Walker, lead UBT consultant and improvement advisor. “Now the information we get is more timely and easier to assess,” Walker says. “Before, the information was up to a month old.”

Northern California

The Santa Rosa Medical Center Diversity Design committee is equipping employees with tools to help them provide better service to Spanish-speaking patients. The group, composed of labor and management, has been piloting a handout featuring a list of common Spanish phrases, such as ¿Necesita un intérprete? (“Do you need an interpreter?”), as well as instructions on using the phone interpreter system. The idea came from a Spanish-speaking patient on the facility’s Latino patient advisory committee, who recalled the time she was lost in the facility and no one could direct her in Spanish. The Spanish language flier is the latest in the committee’s work to help ensure all patients receive the same optimal service and care.

Northwest

Unit-based teams in the Continuing Care Services department are focusing on improving the experience for some of Kaiser Permanente’s most vulnerable members: those in skilled nursing facilities or receiving home health, hospice or palliative care. Teams are focusing on ensuring better transitions for patients as they go from inpatient to ambulatory care. By identifying issues before they become problems, labor and management hope to coordinate care more effectively, reduce emergency department visits and cut down on outside medical costs.

Southern California

Harmony comes easily when you use the tools of partnership. Just ask the Biohazards, a band of union members and a manager that uses partnership principles to guide performances. “We call ourselves an LMP project,” says Mary Anne Umekubo, a clinical laboratory scientist and Regional Laboratory assistant director who sings and plays percussion and guitar. She is among six band members who represent a variety of departments, shifts and unions, including SEIU-UHW and UFCW Local 770. Performing for friends and colleagues, band members use consensus decision making to choose songs, interest-based problem solving to fix mistakes and the Rapid Improvement Model to tweak performances. “We’re from different departments,” says drummer Eric Cuarez, a regional courier driver and SEIU-UHW member. “We come together to play music.”

Diversity and inclusion. Without both, we each tend to identify with our own clan—be it defined by race, gender, age, economic status, what have you—and all the other clans remain other.

Diversity without inclusion permits an accumulation of biases that leads to a world where, as one recent study showed, minority patients are up to 30 percent less likely to receive pain treatment in emergency rooms than whites, even though they report pain just as frequently. This matters: Pain slows healing and can create new health problems. Sadly, this huge gap in treating pain is just one example in a long list of health disparities linked to cultural biases.

Inclusion—finding what we have in common, appreciating diversity instead of ignoring differences—is key to eliminating disparities and delivering high-quality health care.

As Ron Copeland, MD, Kaiser Permanente’s senior vice president of National Diversity and Inclusion Strategy and Policy, says, “I don’t believe you can have passion for true quality or service excellence without also being genuinely passionate about diversity and inclusion practices. They’re one and the same.”

How do you get good at inclusion? Practice seeing what you have in common with others. The Labor Management Partnership’s unit-based teams—whose membership cuts across all demographics—do this daily as they use interest-based problem solving. As this issue of Hank shows, a natural next step is to address how to deliver the best possible care to all our members.

It takes only one person or one small group to spark meaningful change. Be that person. Be an active member of your team.

When one of her teams is able to leap over the roadblocks in its path with the grace of an Olympic hurdler, Charisse Lewis finds herself out of a job.

As a UBT consultant for the Baldwin Park Medical Center in Southern California, it’s an occupational hazard that she looks forward to—again and again. Like coaches everywhere, she enjoys seeing her teams take what they’ve learned and make it their own.

“I do a lot of mentoring,” says Lewis, who acts as coach, counselor and head cheerleader for her facility’s 68 unit-based teams, nudging them past milestones on the Path to Performance, the five-stage “growth chart” UBTs use to measure success. “I’m teaching teams how to function without me.”

For example, she recently helped a team of critical care nurses advance from Level 1 to Level 4 by using an array of strategies from team-building activities to involving union representatives. Another team advanced to Level 4 in part because she coached the management co-lead, who was new to Kaiser Permanente, in how to manage effectively in a partnership culture.

A team to help teams

Lewis doesn’t work alone. She’s part of Baldwin Park’s UBT Strategy Group, a SWAT team of union members and managers who target at-risk teams. That team’s goal is to help UBTs excel so they can drive performance to provide the best service, quality, affordability and job satisfaction. Low-performing teams, says Lewis, tend to suffer from poor communication, paltry trust and a lack of transparency.

“It’s hard to get past that stuff,” she says. “They flounder there. They don’t trust each other and it’s hard to be a team.”

Part of Lewis’s talent in helping turn teams around is her skill in assessing stumbling blocks and getting teams engaged with the right resources. She draws on her experience as an LMP coordinator, trainer and improvement advisor to nuture her teams.

“I don’t like to stare at that elephant in the room,” says Lewis. “If it’s a contract issue, then we need a contract specialist. If it’s an HR issue, let’s make sure that HR is involved. I like to address the problem and get the team’s leaders involved, from both labor and management.”

Tops in Southern California

Her approach speaks for itself. Baldwin Park has the highest percentage of high-performing teams in Southern California: Of 68 teams at Baldwin Park, 88 percent are at Levels 4 and 5 on the Path to Performance.

Her passion, integrity and ability to help others overcome their differences and work together to improve member and patient care has earned her praise from LMP leaders throughout Southern California—but Lewis, in turn, credits her success to the many people who support her efforts.

“I have the support of the regional LMP office, and I have a strong support system at the medical center,” she says. “It makes my job easier.”

For years, success eluded the Baldwin Park Critical Care team. Mired in distrust, staff members didn’t participate in unit-based team meetings. As recently as 2011, few in the 49-member department knew the team existed.

“I didn’t even know what UBT stood for,” says Sheryl Magpali, RN, a member of UNAC/UHCP and now the team’s union co-lead. “No one claimed to be part of it. It was pretty much nonexistent until 2013.”

With a new manager on board, interest in the UBT grew. Staff members from the Critical Care Unit and its sister department, the Step-Down Unit, elected 12 representatives, who in turn chose Magpali as the labor co-lead. Celso Silla, RN, the new department administrator, became the management co-lead.

Old issues die hard

It was rough going at first.

Attendance was spotty. When the team did meet, members focused on long-simmering grievances about labor and personnel issues. The team reached out to Charisse Lewis, Baldwin Park’s UBT consultant. While consultants often focus on helping teams with using the Rapid Improvement Model and designing tests of change, they also help teams learn to work as teams—clearing up issues that are distracting them from the work at hand.

Lewis’s first steps were to encourage the team’s union members to meet separately with a labor representative.

“That helped relieve the stressors of the union issues,” Magpali says.  Now, she says, “team meetings focus on changes that affect the unit, rather than things we have no control over.”

The department—nearly all nurses, but also including ward clerks, who are SEIU-UHW members and one of whom is a team representative—began building trust in other ways, too. At Lewis’s suggestion, staff members organized a bowling night and had dinner together. This summer, they held a backpack drive.

Moving the team forward

“Charisse has been good at guiding us—attending our meetings, observing and listening and seeing how we can do better,” says Silla.

Lewis didn’t stop with team-building activities. She coached Magpali, a soft-spoken nurse, to speak up during meetings and make her voice heard, and she helped Silla overcome his reluctance to leave his union co-lead in charge of meetings.

Once trust was established, the team could turn its attention to improving patient care, with remarkable results. UBT members have reduced central line-associated bloodstream infections from five in 2014 to none as of August of this year. Buoyed by that success, they are working to reduce catheter-associated infections.

Silla attributes the improvements to the culture of partnership and putting frontline employees in charge of decisions that affect their work.

“We would have been in limbo” without Lewis’s guidance, Silla says. “Now we’re on the same page. We can be a Level 5 in the future.”

The Mid-Atlantic States region has approximately 220 unit-based teams with more than 5,200 members. 

One problem, though: Some of those who belong to UBTs don’t know it.

The region’s seven UBT consultants, who made a commitment to work together as a UBT themselves, are trying to change that.

“Employees can’t contribute to the success of the team if they don’t know they are part of the team,” says Tracy Schrader, one of KP’s UBT consultants in the region, who is also an improvement advisor and OPEIU Local 2 member. “They don’t realize they can speak up.” 

From their travels around the Capital Beltway to team meetings and huddles, the consultants—each of whom supports about 35 teams—knew there was a disconnect for some UBT members. So when they established their own team’s 2015 goals, they planned two main tactics: to host several UBT Fairs to raise the profile of UBTs, and to improve communications so all UBT members know they are on a team.

The fairs, which the consultants originally were planning to hold at the region’s largest centers over the summer, would showcase the work of the teams at that facility and highlight such LMP initiatives and priorities as Total Health, Workplace Safety and the Ben Hudnall Memorial Trust, which provides a variety of resources for career-advancing education.

“We wanted to hold fairs that would have a strong impact,” says Jennifer Walker, RN, a lead UBT consultant and improvement advisor.

Surprising news

Then—just as happens with frontline teams—they received some data that surprised them. The 2014 People Pulse results showed that some locations the consultants thought would score poorly on UBT-related questions scored well and vice versa. Armed with that data, the consultants decided to hold the first five fairs at the centers that had the most teams with more than 10 percent of members answering “no” when asked “are you in a UBT?”

“It was a real eye-opener,” says Preena Gujral, another MAS UBT consultant and improvement advisor who’s a member of OPEIU Local 2. “Data is very important. It’s perception versus reality.”

The data also led the consultants to combine their two tactics:  The fairs would be the method for communicating the message that all work group members are indeed part of a UBT.

Walker, one of the region’s lead consultants, says it can be difficult to get the message across, especially with large departments. Unlike small departments where everyone participates in UBT meetings, larger departments typically have a core group of employees who attend UBT meetings as representatives of everyone on staff. Employees who aren’t representatives don’t always realize that they are part of the team, too.  

The energy and attendance of the first UBT Fair that the consultants sponsored, held at the end of June at the Fair Oaks Medical Center in Fairfax, Virginia, was higher than they expected, with more than 150 employees stopping by.

“The participation was fantastic,” says Wendy Williams, RN, a UBT consultant and member of UFCW Local 27.

Irene Taliaferro, a gastroenterology nurse practitioner, attended the fair at Fair Oaks in late August. She hadn’t realized she was a UBT member.

“I came to find out more about UBTs. Before I came to the fair, I knew nothing about them,” says Taliaferro. “We have a representative who goes to meetings. I don’t know much about it.”

Providing incentive—and a model

Steve Pereira, UBT consultant and improvement advisor, hopes the blitz of UBT Fairs gives workers like Taliaferro a better understanding of the partnership and an incentive to be more involved.

“People want to know more than their 9-to-5 jobs,” Pereira says. “This is the opportunity for that.”

Because of their commitment to use the same tools as frontline UBTs, the consultants have been using the Plan, Do, Study, Act cycle of the Rapid Improvement Model in planning and holding the fairs.

So, Walker says, “We structured it so the fairs happen before the annual People Pulse is taken again, in September”—that way, the fairs serve as a test of change. Will the communication provided by the fairs improve the score on the “I’m in a UBT” question?

“We’ll look for the next People Pulse results to validate whether this was the best way to go,” she says.

Watch for an update on the consultants’ efforts next year on LMPartnership.org, after the 2015 People Pulse results are in.