Best Place to Work

Imagine developing a severe cough and teeth-chattering chills. You want to be seen by a doctor but no one really understands you: Not the call center operator with whom you try to make an appointment; not the receptionist who checks you in; not the medical assistant who takes your temperature and blood pressure. Not even the doctor who speaks quickly and uses complicated medical terms.

“When you come in for medical care, it’s already like a foreign land,” says Kathleen Kearney, the manager and the UBT co-lead for the Obstetrics and Gynecology department at San Jose Medical Center.  “If you don’t speak English, it can be downright frightening.”

Giving patients better access

Kaiser Permanente has long been committed to providing language access in the form of interpretive services for its non-English speaking members. The Ob/Gyn unit-based team in San Jose has taken the additional step of creating a Spanish-speaking module, a sort of one-stop shop for Spanish-speaking patients.

The idea for the module came from Joseph Derrough, MD, who recognized that good patient care involves more than just the patient and the physician in the exam room. It includes each interaction, from making an appointment to checking in and being assigned a room.

“I realized that we had a significant percentage of patients who only spoke Spanish, and we could do better service to them by providing linguistic and culturally competent care,” Dr. Derrough says. “We had staff that spoke Spanish, but they weren’t all in the same place. My vision was that we could create a clinic module where, from registration to examination, the patient was spoken to in her own language.”

Making it happen

The unit-based team made it happen.

“From the time they walk in the door, every patient should receive the same level of care regardless of the language they speak,” says Glenda Morrison, a medical assistant, SEIU UHW chief shop steward and the UBT co-lead.

But in the beginning, the frontline staff members, including Morrison, were skeptical.

“Since we were already serving Spanish-speaking patients in our clinic, the question we were asking was, ‘Why is this needed?’ ” Morrison says.

But a visit to the Spanish-speaking Medicine module at the Santa Clara campus made them believers. That module has been in place for five years.

“When I saw it in action, a light went off—and I realized that by not speaking to our Spanish-speaking members in their own language, we weren’t providing them with the same care as we were our English-speaking members,” Morrison says.

Overcoming obstacles

Once the team decided to take on the project, it faced some challenges. Offices had to be moved and medical assistants had to be reassigned.

“We had a lot of meetings and a lot of nervous people,” Morrison says.

But again, the Santa Clara example eased fears: “Once they saw how it worked in Santa Clara, we got by-in from the staff and it was easier,” Kearney says.

The module, which opened Sept. 29, includes signage and literature in Spanish. The staff members, from the receptionists and medical assistants to the doctors, are fluent Spanish speakers.  Word about the new module went out through Spanish-speaking television news and newspaper reports. And there was a grand opening.

It’s going well so far, Kearny says, noting that “we have three Spanish-speaking providers each day, and they have appointment capacity for about 20 patients.”

Next steps

Now, the team is looking for ways to quantify the benefits of the new module. It’s hoping to be able to collect patient satisfaction data specifically from Spanish-speaking members to assess the impact, Kearney says.

“If it shows success, we’ll pass the idea on to other teams,” she says.

Meanwhile, the unit is looking at how it can provide culturally competent care for its other monolingual patients.

“We don’t what a certain group to feel singled out,” Morrison says. “We just want them to feel comfortable.”

Hemaxi Khalashi isn’t afraid of strange smells. As a clinical lab scientist, her nose is in all kinds of odd odors. But the stench that filled her corner of the Northern California Regional Lab one recent morning put her and many of the other lab workers on edge.

“It was like a bad, old gassy smell, or something deteriorating,” Khalashi said. “I asked my supervisor to walk with me to that corner of the room and asked her what she smelled, and she said, ‘Something dead—rotten.’”

The lab employees quickly fingered the culprit—a new instrument that tests blood samples for Hepatitis B—but they needed a solution, and fast. Their first step: to huddle.

The 15-minute meeting gave lab workers the chance to air their concerns, and provided managers with the opportunity to let the team know the vendor already had been contacted and would be coming by that day. Khalashi spoke up and asked what could be done, right away, to help those who worked near the machine. The section manager suggested masks, which are always available for lab employees.

“Huddles are usually the starting point for getting something done,” said Larry Ratto, a lab assistant and SEIU UHW-West member whose desk is the rallying spot for such meetings. “They are really good for making immediate change—and they never last more than 15 minutes, tops.”

In short order that morning, an issue that might have caused an undercurrent of anxiety was aired and laid to rest. Lab employees and managers determined test results weren’t being compromised and that the odor, though unpleasant, was harmless—and thanks to the huddle, everyone knew it. They later decided to install an air purifier next to the instrument and developed new procedures for handling its waste. The two steps have mitigated the smell.

The lab workers’ instinct to huddle, which stemmed from a year’s worth of practice, is one shared by many high-performing teams throughout Kaiser Permanente. The most successful unit-based teams, those that improve performance and meet goals, are using huddles regularly and effectively—and not just when a major problem needs to be solved.

Huddles aren’t a substitute for the training and skill-building that members of unit-based teams need as they shift into new ways of working—training and skills that help create the learning environment where frontline workers are engaged in decision making and see the connection between their work and larger, strategic outcomes.

But those who study group dynamics say routine huddles can give teams the opportunity to get good at solving problems together when the stakes are low—practice that increases the odds of solving problems successfully when the stakes are high. Frequent, candid conversations, these experts say, create working environments conducive to improvement and change.

“I see it in our group,” said Denise Ja, microbiology section manager. “Huddles have improved our communication, our camaraderie and our teamwork.”

Amy Edmondson, a Harvard Business School professor whose research examines what factors foster outstanding performance in health care settings, says huddles are a way of building what sociologists call “social capital.” In other words, they build social connections that produce real value by increasing productivity.

“The more we know each other and…(have) exchanged our thinking, the more we’ve just connected as human beings—the better we do,” said Edmondson, who led two workshops at this spring’s Union Delegates Conference.  “If we’re friends, I will make that extra little cognitive effort to think, ‘Oh, I wonder why she thinks it’s that way?’ Or, ‘I wonder why she sees it that way?’”

The willingness to extend that extra effort can make a world of difference in solving problems, creating a healthy work environment—and improving patient outcomes.

Many shapes and sizes

In Northern and Southern California, 79 percent of high-performing UBTs were huddling as of November 2009. Just 30 percent of newly established teams were doing the same. Once a team has gotten trained in the Rapid Improvement Model and other fundamental techniques, huddles can be an addition that helps improve working relationships.

Huddles mean different things to different departments. Some teams meet daily; others do it weekly. Many departments convene at the same time and same place; others are more spontaneous. Most huddles are short.

Part of what makes huddles effective is that they create frequent, regular opportunities for all the members of the unit-based team—the people whose work naturally draws them together—to come together and contribute ideas.

And they have a casualness that makes even the most reticent team member comfortable speaking up.

“I think because we’re close together in physical proximity, people feel less inhibited,” Ja said. She finds that in more formal meetings, some team members hold back. But when the team huddles in the work area, she said, “It’s kind of a hustle-bustle, and people are anxious to put their two cents in.”

Ja’s team usually huddles every Friday. But during the height of the H1N1 epidemic, the number of specimens the lab handled skyrocketed from 30 to 900 per day, and the team resorted to meeting daily and sometimes even hourly.

As team members worked frantically to devise a new system for tracking samples, the huddles became the place to test new ideas. It was in a huddle that someone suggested a coding system using letters, but the team quickly ran through the alphabet. The team members huddled and re-huddled until they were using a combination of letters, dates and numbers.

Huddles helped the lab workers keep up with the onslaught of work, pulling off what had seemed impossible.

“Everyone contributed ideas,” said Mark Stanley, microbiology director. “We depended on everyone’s knowledge.”

Figurative huddle

Even teams whose members don’t all work in the same location find that huddling works.

Colorado’s asthma care coordinators are spread out across the region, and usually see each other only two or three times a month. But when the department of seven launched a big push to improve the refill rate of an asthma control medication among children, team members decided to huddle once a week over the phone.

During their phone chats, which usually ran 30 to 45 minutes, team members related their progress in reaching out to members ages 5 to 17 who had not refilled their prescription in four months. Developing a habit of sharing their best practices, successes and failures with colleagues made the team members more accountable, said Kristie Wuerker-Delange, RN, an asthma care coordinator and member of UFCW Local 7.

“It’s kind of an, ‘Uh oh, I have to get this done because we’re going to talk to everybody, and they are going to want to know what I’ve been doing for the week,’” she said.

During one huddle, for example, asthma care coordinator Cindy Lamb told the team she had found that promoting the convenience of the mail-order pharmacy, giving members the telephone number to the regular pharmacy, and providing the member’s prescription number helped patients get their refills faster.

Within eight months, the refill rate of inhaled corticosteroids leapt nearly 20 percentage points, from 43 percent in March 2009 to 60 percent in January 2010—a feat that would not have taken longer without their huddles, Wuerker-Delange said.

“They kept the team focused on the same goal,” said Lamb, a member of UFCW Local 7. 

While other teams have the benefit of simply moseying over to a colleague’s desk, meeting over the phone has its pluses.

“I feel like people open up a bit more,” Wuerker-Delange said. “They are more apt to say a certain thing if someone’s not looking at them.”

Morning ritual

For the Family Medicine department at the Culver Marina Medical Offices campus in Southern California, huddles are part of the morning routine, like brushing your teeth after breakfast.

At 8:25 a.m., Department Administrator Barbara Matthews pokes her head into team members’ offices, her cue that it’s time to convene in the hallway. Patients already are beginning to arrive, so huddles rarely last more than five or 10 minutes.

Doctors, nurses, medical assistants—everyone who is working that day—attend. Co-leads use the time to relay who is working, share a workplace safety message, offer service reminders and more.

“I am upset if I can’t make our morning huddles,” said Krystle Harris, a medical assistant and SEIU UHW-West member. “If I am screening a patient and have to miss it, then I’ll ask one of my co-workers, ‘Aw man, what was the huddle about?’”

Matthews said in the beginning it wasn’t easy getting everyone to huddle and some team members still might choose not to attend if given that option.

But she thinks it’s no coincidence that since the department started huddling a year ago, its hospitality scores have increased, from 83 percent in December 2008 to approximately 89 percent in December 2009.

Other shifts, more subtle but just as significant, are taking place as well. Gene Oppenheim, MD, the physician in charge of the Culver Marina Medical Offices, notes that employees who frequently used to arrive five or 10 minutes late are on time now. Matthews says team members like Harris, who used to say little during meetings, are doing a lot more talking.

That’s a clue that team members are confident their views are valued and they aren’t afraid they may get in trouble for sharing their thoughts—two key characteristics that research shows leads to high performance.

One day recently Harris overheard licensed vocational nurse Jolavette Pye, an SEIU UHW-West member, trying to schedule a specialist appointment for a patient.

The specialist was booked for quite some time, but Pye called back a week later and sure enough, there was a cancellation.

“I brought it to the huddle to congratulate her,” Harris said. “She went out of her way—and the patient was really happy.”

Harris said she thinks sharing with the team the praise she’s overheard co-workers receiving from a patient helps morale, so she does it whenever she can.

“I am shy and I don’t like to speak around a lot of people,” Harris said. “But I am beginning to speak up and discuss little things that are on my mind. I’m just more comfortable in the huddle setting.” 

Have questions about huddling you’d like to bounce off one of the team co-leads interviewed for this article? Email Denise.Ja@kp.org, Concepcion.Savoy@kp.org, Kristine.Wuerker-Delange@kp.org, Deana.L.Parker@kp.org or Barbara.J.Matthews@kp.org for their thoughts.

9 reasons to huddle

1. Resolves small problems before they become big problems.
2. Provides real-time collaboration.
3. Makes it easier for employees to speak up, due to informal nature.
4. Encourages people to raise questions and share ideas.
5. Increases the pool of ideas for addressing an issue.
6. Leads to better communication through frequent communication.
7. Improves staff morale.
8. Lays the foundation for taking on big problems by providing routine practice at solving small problems.
9. Keeps you warm on cold days.

New to huddling?

Here are some tips to help you get the most out of your huddles.

• Get the group’s attention. Set a positive tone. Use people’s names.
• Describe the plan or topic for discussion, including relevant background information and contingencies.
• Explicitly ask for input. Have a two-way conversation. Effective team leaders continuously invite others into the conversation.
• Encourage ongoing monitoring and cross-checking.
• Specifically ask people to speak up if they have questions or concerns.

Some ideas of what to discuss:

• Observed workplace safety issues that everyone can learn from.
• Other departments’ work that may impact the team’s work that day.
• Small tests of change to resolve identified issues and help improve performance.
• How everyone is doing and who may need extra support that day.
• New policies or procedures or other changes.

—From the Sponsor and Leader Resource Guide for UBTs.
 

‘Huddles have improved our communication, our camaraderie and our teamwork.’

Denise Ja, microbiology section manager, Northern California Regional Lab

Surgical checklists improve patient safety, strengthen team dynamics

In high-risk industries—including aviation and high-rise construction as well as health care—surgeon and best-selling author Atul Gawande has found that a good checklist not only specifies common sense safety measures, it also ensures “that people talk to one another about each case, at least just for a minute before starting,” he writes. “[It is] basically a strategy to foster teamwork—a kind of team huddle.”

A major theme of Gawande’s latest book, The Checklist Manifesto: How to Get Things Right, is that the best checklists are not just a top-down set of tasks for others to follow. They’re a tool for better team communication, coordination and inquiry. Read more about using checklists here.