Best practices

When the internal medicine UBT at the Los Angeles Medical Center decided to focus its efforts on African Americans with hypertension, not all team members initially were comfortable with targeting patients by race for special outreach. “We worried about how patients would react,” says union co-lead Marilyn Lansangan.  

However, when they invited African-American patients to a special clinic, they were thrilled with the results. Not only did patients show up, the team made progress toward its goal of closing the gap between African-American patients with their hypertension under control and those of other races. “The barrier was not the patients. The barrier was us,” says Lansangan.

Closing care gaps

Nationwide, nearly 45 percent of African Americans suffer from high blood pressure—a rate much higher than other racial and ethnic groups. The condition tends to develop earlier in life and is likely to be more severe for them. There is some recent research from the National Institutes of Health that suggests genetics may play a part. Such social and economic factors as discrimination and poverty also may contribute. Whatever the reason, health care organizations—including Kaiser Permanente—are working to reduce the disparity.

When Jose Saavedra, M.D., the physician champion on hypertension at LAMC , heard that colleagues at Downey Medical Center held a special outreach clinic for African-American members with high blood pressure, he encouraged the internal medicine UBT to try it as well.

Targeted outreach

Team members generated a list of their African-American patients with a certain threshold of uncontrolled hypertension. LVNs and social workers called patients every day, inviting them to the special clinic. The success of the outreach calls surprised everyone. “Even when we just left a message, people would come to our clinic,” said Elenita Petrache, assistant administrator and one of the management co-leads.

At the event, clinicians educate patients about hypertension, then take their blood pressure. Depending on the results, patients queue up for a short chat with either a doctor or a nurse, who can adjust their prescription or schedule a more in-depth appointment. Patients who successfully control their blood pressure get a certificate. Everyone gets a swag bag containing an apple, bottle of water, DVD about hypertension, and information about diet and sodium.

Improving teamwork

Gayle McDow, who attended the clinic in late April, says it make sense for KP to reach out to African-American patients. "The numbers suggest that this issue is more prevalent in our community," she says.

The project also built cohesion among UBT members who work on different floors, says Petrache. “It helped two parts of the department develop a better relationship because we have common goal,” she says. “There is communication between the teams. It’s a beautiful thing.”

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.”

The patient at the center of the Value Compass isn’t always a KP member, as two Colorado RNs proved on a flight home from the Mid-Atlantic States region last fall—and the experience they shared in the air also brought a fresh appreciation of their shared values and commitment to partnership.

Debbie Zuege, Colorado’s senior director of Nursing and Women’s Health, and Becky Sassaman, a nurse at the Arapahoe After-Hours clinic in Denver, work together as co-leads for the Nursing Partnership Council but had never teamed up clinically. That changed on their return flight from the Mid-Atlantic States, where they had talked about partnership with a group of union stewards.

Shortly after takeoff, Zuege was settling in and starting to read a magazine when something caught her eye.

“A flight attendant came down the aisle, holding an oxygen tank,” Zuege said. She alerted Sassaman, and they joined the flight attendant, who was tending to a woman lying down in the aisle. The woman was pale, sweating excessively and seemed confused. She’d been sick to her stomach. Two physicians on the flight joined in to help move her to the back of the plane.

The hastily formed team concluded the woman was dehydrated. Her pulse was weak. They elevated her feet and gave her liquids to drink; Sassaman placed an IV into her hand to administer fluids they found in the onboard medical kit, and Zuege administered oxygen. The woman responded well, with her pulse and color returning to normal. The doctors and nurses decided she’d be fine for the duration of the flight, and the attendant rearranged passengers so Sassaman could sit with her. The team kept the IV in place, suspending the fluids from a hanger hooked to the overhead bin, and gave her medicine for her nausea. Zuege and the two physicians checked in throughout the flight.

“The lady was so incredibly sweet and grateful,” says Sassaman, who helped her get clean, found her jacket and even lent her a pair of workout pants. “She kept saying ‘Thank you’ and ‘How can you do this?...I made a scene.’ I told her we are nurses, and it is what we do.”

Cheryl Kusmits has been a licensed practical nurse for 16 years at Ohio’s Fairlawn Internal Medicine department, a small clinic with a close-knit staff known for its personal service. She loves her job and prides herself on doing it with compassion and a smile.

Kusmits knows all the longtime patients, and they know her. At least, she thought they did. Then she was trained in the service practice known as AIDET—Acknowledge, Introduce, Duration, Explanation and Thank you.

“Until I started saying, ‘My name is Cheryl,’ I didn’t realize, ‘Oh gosh, they see me all the time but I never say my name,’” she says.

When Kusmits introduced herself to a regular patient, he responded he’d been coming there for years and knew her face but had never known her name. It was nice, he said, to finally “meet” her.

Kusmits, who had her doubts about AIDET’s value, was sold on the service training right then.

There’s more to service than being nice

Top-notch service is not just the purview of five-star hotels or, where they still exist, full-service gas stations. These days consumers expect superlative service from their health care providers—and rightly so. No matter how technically superior the care, an inconsiderate or simply indifferent provider spoils the experience. Patients deserve healing, not just fixing.

As a result, providing stellar service to patients and members has never been more important for Kaiser Permanente. Our survival in the competitive health care market rests not only on the quality of care but also the quality of the service we provide to our members. The better the overall experience, the more likely we are to retain current members and gain new ones—ensuring the strength and stability of our model of care, which in turn leads to long-term job security.

“Members’ and patients’ own experiences, or the stories they hear from friends and family, make a huge difference in whether people choose Kaiser Permanente,” says Vickie Cavarlez, an LMP senior labor liaison for public- and private-sector accounts. “As unit-based teams develop, they are making a real difference in the story we can tell.”

The good news is that unit-based teams working to provide our members with the best service possible at every touch point in the system don’t have to start from scratch—they can get a big jump ahead, fast, by taking advantage of KP-endorsed programs with proven track records. Here are the stories of two instances where such programs, AIDET and Nurse Knowledge Exchange Plus—which was pioneered by KP’s Innovation Consultancy—have had dramatic effects.

Could your team be next?

AIDET: More than a surface polish

In 2010, management, physician and union co-leads for all of Ohio’s unit-based teams were trained in the tactic known as AIDET to pump up the region’s service. As a small market that competes in the shadow of the renowned Cleveland Clinic, KP’s Ohio region must go above and beyond in quality of service and care provided.

“We don’t have a physician on every corner. So you have to make it up somewhere, and we make it up in quality and service,” says John Hightower, manager for organizational excellence in Ohio. “It’s part of who we are and who we’re trying to be.”

The region turned to AIDET because of its simplicity. At its core, the training is about communication behaviors and basic courtesy– from acknowledging a patient’s presence with eye contact to explaining that a physician is running late.

Fairlawn Primary Care, where Kusmits is the UBT union co-lead, always had received good service ratings from patients—with scores ranging from 81 percent to 83 percent—but the facility had experienced a small dip in 2010 after it moved offices, dropping to 75 percent. So when nurse manager Paula Hadley, the team’s management co-lead, heard about the AIDET training, she talked with her co-leads—Kusmits and Keith Novak, MD—and volunteered Fairlawn as a pilot site. Initially, reviews were mixed.

“Well, I thought, I’m nice all the time. We’ve always had high scores. I thought, ‘How can I do any better?’” recalls Kusmits, an OPEIU Local 17 member. “But we did. It was kind of amazing when it all happened.”

Fairlawn saw its service scores jump by 10 percentage points within a couple of months after it began using the AIDET behaviors. Office wait scores jumped from 67 percent in January 2011 to 76 percent in August the same year. In the area of staff courtesy and helpfulness, Fairlawn started at 83 percent at the beginning of 2011 and is currently at 89 percent.

The service tool is not a script. It’s not about just being nicer. It’s a set of behaviors, Hightower stresses, that enhances communication and shows respect for the patient.

“And not doing it like a robot,” Hadley says. “It’s genuinely using the behaviors so it’s part of what they are doing every day.”

Of course, there are still those times when an experience isn’t perfect. In such “service recovery” cases, having AIDET under the belt is even more critical. Ohio saw this firsthand at the start of 2012, when it reduced its extensive outside provider network and redirected patients to Permanente physicians. Suddenly patients who had longstanding relationships with outside primary care physicians had to switch to a Permanente primary care physician.

Going above and beyond in service was never more essential.

“I can only tell you that there are some members who are going to be upset no matter what,” Hadley says. “And how we treat them—even if (we’re not giving them) the answer they want—will make a difference in the outcome.”

The power of a seamless handoff

While AIDET provides a foundation for superior service regardless of location, providing a good care experience at the bedside takes additional skills. In the hospital setting, providing a seamless handoff between revolving shifts of caregivers is critical, as is keeping patients informed, involved and confident in their care. Which is where Nurse Knowledge Exchange Plus comes into play.

Longtime nurse Jennifer Toledo remembers “the old days”—which were really only a few years ago—on her medical-surgical unit at Panorama City Medical Center in Southern California. When the registered nurses would change shifts, the incoming nurses would crowd into a conference room and listen to the charge nurse give a brief report on each of the patients. “And we’d all take notes,” says Toledo, a member of UNAC/UHCP.

The practice never sat well with Toledo. “There was no way to validate what the charge nurse was saying,” she says. “And, there were no patients involved.”

Today, shift change on the fourth floor med-surg units is radically different. Incoming and outgoing nurses pair off in patient rooms for the “Nurse Knowledge Exchange Plus”—a structured, in-depth, in-person handoff that puts the patient at the center. Use of NKE Plus has increased nurse time at the bedside by nearly 19 percent and is improving nurse communication service scores among unit-based teams at Kaiser Permanente hospitals in Southern California.

With NKE Plus, the outgoing nurse introduces the incoming nurse to the patient before going off shift. Together, they review and update the patient’s in-room care board. They go over the plan of care, and make sure the patient understands it and has a chance to provide input. Some units use catchy acronyms—this is Kaiser Permanente, after all—such as HEAL to help nurses remember all the elements they need to review (High-alert medications, Environment, Alarms, Lines and drains).

This strategy “encourages more participation from the patient and gives them the security of knowing that someone is looking after them,” Toledo says. “We all agree on the plan, and we can correct misperceptions right then and there.”

Eric Zambrano, a relatively new nurse, agrees with his more seasoned colleague. “It makes the patients less anxious,” he says. “Patients know the plan for the day. It gives them comfort because they are not wondering what is going to happen next.”

NKE Plus “has catapulted our HCAHPS and nurse communication scores” at Woodland Hills, says Nancy Tankel, the nurse executive there, referring to the federal Hospital Consumer Assessment of Healthcare Providers and Systems survey. In fact, between January 2011 and January 2012, HCAHPS scores on a set of questions measuring the quality of nurse communication jumped from 71 percent strongly positive responses to nearly 82 percent. And the staff is as satisfied as the patients.

“I’ve had one nurse tell me, ‘I can sleep at night,’ ” says Tankel.

Lasting impressions

Ultimately, beyond the critical role stellar service plays in Kaiser Permanente’s survival, providing the best experience we can, for every patient and every member, every time, is simply the right thing to do. It’s core to Kaiser Permanente’s mission.

From the moment our members come into contact with Kaiser Permanente, whether online, by phone or in any of our facilities, our interactions with them build or break their trust and loyalty. Providing for a great care experience goes beyond correct diagnoses and treatments. It means asking ourselves if we are looking someone in the eye; if we are examining whether our protocols and procedures make sense, not just for us, but for the members who have to navigate them; and if we are taking care that the many handoffs we make along the way are clear and seamless for our patients and their families.

“We want to keep our patients,” says Ohio LPN Kusmits. “So we need to make them happy and make them feel like we care. And we do care. We need to make sure they’re aware of that.”

To learn more about AIDET, NKE Plus and other evidence-based practices aimed at improving the experience for patients and members, please visit the National Service Quality website.

Have you ever broken your glasses just days before leaving for vacation? Or before your driving test? Or before a big, important meeting?

You’re not alone—for the frontline staff and managers at Kaiser Permanente’s Vision Essentials clinics throughout Southern California, encountering patients facing these situations is a regular occurrence. The problem was, they had no way to speed up orders for new glasses. Patients ended up unhappy. Some would simply take their prescription to a competitor who promised glasses in a day.

The Vision Essentials business council—the regionwide Labor Management Partnership governing body with representatives from five unions and managers from optometry, ophthalmology, retail clinics and the optical lab—decided something had to be done. Their solution? The express service program.

Piloted in the Fontana and San Diego medical center areas, it allows patients to get their glasses in three days instead of the usual seven for a small fee. The service is so successful, it will be rolled out to the entire region by the summer.

Red Sharpies and gold spray paint

The keys to success were red Sharpies, gold spray paint and the tools provided by the Labor Management Partnership. The Value Compass—with the patient at the center—provided a key organizing principle.

“We were asking, ‘How do we improve our turnaround time?’ ” says Jeff Zeidner, the optical lab manager. “It might not be possible to improve our overall turnaround time, so let’s be selective about this.”

Alex Mendez, labor co-chair of the lab’s unit-based team, says, “We knew our customers needed some sort of express service.”

But a lofty ideal about putting the patient at the center does not magically re-engineer a huge supply chain involving 42 retail clinics spread over hundreds of miles and a manufacturing plant that churns out 7,000 pairs of glasses every day, five days a week, from 5 a.m. to 10 p.m.

When some of the labor members of the business council broached the idea of an express service, they were met with skepticism.

It can’t be done

“There was a lot of, ‘We can’t do that’ and ‘It’s too expensive,’ ” says Mary Cavanaugh, an optometrist and labor representative. Cavanaugh is a member of the Kaiser Permanente Association of Southern California Optometrists (KPASCO), which is part of UNAC/UHCP. 

Finally, the council asked the optical lab UBT to propose ideas on how to make express service a reality. The catch: The service couldn’t delay turnaround time for normal orders, couldn’t increase breakage rates and couldn’t require more staff or overtime.

The brainstorming commenced.

“Everyone had different ideas about prices and parameters,” recalls Mendez, a member of SEIU UHW.

Should the promised turnaround be one day? Two? Three? How about charging an extra $10? That might attract too many requests. Maybe $50? The UBT recommended $50. Another idea to emerge from the brainstorming—shimmery gold spray paint on the trays containing the express order lenses, so they could be easily spotted in the lab and moved to the head of the line.

Conveyer belts and lazy susans

The Vision Essentials optical lab is quite literally on the wrong side of the railroad tracks in an industrial section north of downtown Los Angeles, sharing a service road with a strip club. Hefty pieces of plastic that look like clear hockey pucks begin their journey here. Brightly colored bar-coded bins, including the gold ones, carry the lenses-to-be along conveyer belts for their various stops. Four huge lazy susans hold the tools for smoothing and polishing. The grinding machine spews out big puffs of white shavings that look like fake snow. At the end of the process, optical technicians pop the lenses into frames. Then the glasses are off to the shipping department to head back to where their trip began—the clinic where a grateful patient will pick them up.  

The frontline staff and managers at the Fontana Medical Center, where the first pilot was launched, were an integral part of planning and executing the express service initiative. After all, they were the ones who dealt directly with disappointed customers. The opticians there contributed another color coding trick: They annotated express orders with a red Sharpie.

“It’s like a hot potato,” says Nadia Arce, a receptionist and a member of Steelworkers 7600. Attractive tent cards on the receptionists’ desks announce the availability of express service.

Express service adds an extra step for the clinic-based staff, who now have to call the lab to ensure the materials needed for rush job lenses are available.

“We don’t want to promise something we can’t deliver,” says Mikhail Mgerian, an optician at Fontana and a member of Teamsters Local 166.

Building rapport

Trissy Basin, the business line manager, estimates there are about 150 express service clients out of 20,000 jobs a year; regionwide, the number of express jobs per year is expected to be 5,200. While the numbers aren’t huge, she says, “the process of doing an express job is significant.”

The process of creating the program in partnership also was significant.

“It is a lot better having the LMP,” says Chris Leyva, the management co-lead of the optical lab’s unit-based team, who has worked at Kaiser Permanente for 18 years. “There isn’t the banging of heads. The partnership smoothes our rapport.”

Adds his labor co-lead Mendez, “I feel comfortable giving my input and feel it gets taken into consideration.”

Danny Pollack, an optometrist and labor co-chair of the business council, says the union’s shared leadership role meant proponents of express service had a venue to keep pressing until the issue got taken up.

“It was perseverance, not pounding on the table,” says Pollack, a KPASCO member. “This project is a great example of how labor can initiate an idea and, with the support of management, roll out a new service that benefits our members.”

The theme of the 2012 Union Delegates Conference was “You Gotta Move”—and Amy Edmondson’s advice for the delegates was “you gotta learn.”

The Harvard Business School professor studies what she calls “learning environments.” To support innovation and teamwork, it’s essential the Labor Management Partnership and unit-based teams foster learning environments throughout Kaiser Permanente.

Imagine the ideal learning environment: People feel free to take risks. They feel psychologically safe. They believe they won’t be punished or humiliated for speaking up with ideas, questions, concerns or mistakes. “Without that kind of psychological safety, it’s very hard for an organization to learn,” says Edmondson.

Now imagine the opposite of a learning environment, one where no one speaks up. “Nobody ever got fired for being silent,” says Edmondson. “And yet many bad things happen as a result of silence. Silence is a strategy for individuals to stay safe, but not necessarily for patients to stay safe or for organizations to stay vibrant.”

Creating a learning environment is up to leaders—to those people with influence, whether or not they have a formal leadership role.

“Leaders have to go first,” Edmondson says. They “have to be willing to ask questions themselves, invite participation, acknowledge their own fallibility, and to explicitly state we don’t know everything yet.” These behaviors help an environment where others can take the risks of learning.

But, she cautions, “The learning environment doesn’t live at the ‘organization’ level. For the most part, there are pockets of learning environments.…In a large, complex system, answers don’t come from central headquarters or the CEO. The answers come from the people at the front line doing the work.”

A labor management partnership like the one at Kaiser Permanente “is an important foundation” for building a learning environment, says Edmondson. “A true partnership is completely consistent with the context for mutual learning.”

Both management and union UBT co-leads can help create a learning environment by articulating the unit’s or department’s purpose and goals “in a meaningful way that touches hearts and minds, that motivates and encourages,” she says.

They can—and must—also reduce the fear people experience that makes them reluctant to speak up. The LMP helps develop and support people, helping them be their best and most courageous, Edmondson says.