Departments

With changes this fall promising to bring more health care coverage to millions of Americans—and many more members to Kaiser Permanente—unit-based teams are helping to get member services in top shape.

Managing diseases, slashing wait times and cutting out the high cost of waste are naturally on the radar for caregivers’ UBTs. But operations teams also are working behind the scenes to make sure our services are seamless.

For instance, one team at the California Service Center in San Diego is working to make sure new members have a good “onboarding” experience. Its project aims to make sure that what an employer purchases for its employees is what those workers get when they show up at a medical center for the first time, ID cards in hand. No one wants a new member arriving at a Kaiser Permanente facility and being asked to fork out an unexpected copayment or, worse, being denied a service outright.

“This is the kind of solution that is—and should be—generated from the front line,” says Demetria Williams, a service center manager and the Contract team’s management co-lead.

KP's dual role

Kaiser Permanente is unusual in that we provide both insurance coverage and health care, and so how administrative services are handled affect a member’s overall impression of the organization. The Contracts team enrolls employer groups, entering the details of the lengthy contracts—copay amounts, covered medicines, vision care allowances and so on—that will apply to every employee covered by that particular contract. That sets the stage for the individual employee’s enrollment with Kaiser Permanente. If it’s all done correctly, everything goes smoothly when the new member arrives at one of our facilities.

The job is tough. About 18 account administration representatives refer to the signed contracts they’ve received from Sales and Account managers as they enroll a new employer group—or update an existing one—so the employees will get the right services. The account administration representatives contact the sales people when they find inconsistencies—when, say, the plan that was selected doesn’t include vision coverage, even though the associated contract calls for it.

“We would pick up the phone, but we were not connecting,” Williams says. “We were speaking different languages. We didn’t know what they wanted; they didn’t see what we saw.”

Despite the meticulous work, the team faced a 65 percent discrepancy rate—entries that are likely to cause problems for members when they seek care. So the Contracts UBT used the plan, do, study, act steps to track where the data was misaligned and trace it to specific parts of the process—and team members decided on a small test of change, hosting a “Day in the Life of a Contract” with members of the Sales and Marketing team.

Part of the difficulty was that sales managers and service reps work on different computer systems, with no connection between them. The competing systems were a swamp of alphabet stew: CIDARS, LOB, PA. Since merging the two systems into one isn’t in the offing, staff members found a solution at the unit-based team level.

Cutting through jargon

During two days of face-to-face meetings, the two sides cut through the sea of baffling acronyms and buzzwords and created a cheat sheet of common, acceptable codes.

Jeannie Athey, the Contract team’s union co-lead, an account administration representative for nine years and an OPEIU Local 30 member, said the UBT project was like a foreign student exchange. “We hadn’t seen their system before,” she says—and it was eye opening.

It’s too soon to have updated metrics, but Athey says anecdotal reports indicate the reps need fewer phone consults with sales managers and there has been less frustration between the two groups.

“Members can’t be enrolled until we’ve done our job of setting up the group contract,” says Sherri Saunders, the service center’s operations manager and the team’s sponsor. “If they’re not enrolled, they can’t get services. The contracts are legal documents. We have to get them right the first time, for our members.”

It’s not every day you hear of physicians offering to step in and help out staff in their assigned duties, but at the Primary Care department at Englewood Medical Office in Colorado, that’s exactly what happened.

The nursing staff, short-staffed due to medical leaves, “was overwhelmed,” says Kate Frueh, DO. Messages from patients were piling up in the electronic inbox in KP HealthConnect. Patients who might have been helped by phone or via email were coming in for appointments—making it hard for those who truly needed the in-person appointments to be seen.

“We think we’ve got some of the best nurses in the region,” says Larry Roth, MD. “We just thought, how can we help the nurses and, at the same time, help both ourselves and the patients?”

Physicians dive in

So the team brainstormed ideas, and the physicians offered to help clear the backlog.

“The nursing staff was flabbergasted,” says Linda Sawyer, RN, a member of UFCW Local 7 and the department’s labor co-lead. 

After testing a couple of time blocks and working together, the physicians began setting aside 30 minutes every morning to help triage messages and call patients back directly without getting the nurses involved—and they do it again in the afternoon.

As a result, the team consistently closes encounters within an hour more than 40 percent of the time. With more problems being resolved by phone, appointment slots have opened up and access for patients needing in-person appointments has improved. Morale in the department has improved, too—and the team recently won the Colorado region’s quarterly “Value Compass” award.

Meantime, team members have been working with Linda Focht, their UBT consultant, to boost their Path to Performance ranking—which was only at Level 2 late in 2012, despite functioning at a high level in most dimensions of the Path to Performance.

Common challenges

Focht says some of the challenges that held the team back are common across the program—a department reorganization (including a reduction in staff), new work procedures and gaps in team training. And there were new co-leads who were unfamiliar with the process for assessing team performance.

With some of those issues addressed in the first months of 2013, the team moved up to a Level 3 in the most recent ranking.

“The team members kept their focus on the goal of more streamlined work processes,” says manager Mary Watkins, RN, “and all of the staff of the Primary Care Department are helping each other to become more successful.”

 Watch a video about this team on the KP intranet.

An open, supportive environment is one aspect of a workplace where workers can point out problems when they see them.

But to ensure the support doesn’t evaporate in the stress of a busy day, there needs to be more than the expectation that people will do the right thing. There needs to be a solid system in place that formalizes the commitment to speak up.

A Radiation Oncology team in Northern California knows this firsthand. From the time the South San Francisco Cancer Treatment Center opened in May 2009, its leaders worked to establish a culture that encouraged staff members to speak up when they saw something wrong and to provide input on process improvements. The center didn’t have a clear-cut mechanism for doing this, however; it was fostered through leaders’ encouragement and role modeling.

Then in 2010, a mistake was made—relatively small, but a HIPAA violation: A patient was accidentally given a printout with the personal information of another patient. The member returned the paper to the receptionist, and no lasting harm was done. But it highlighted the fact that staff members needed a way to record process failures, empowering them to address issues large and small, says Marcy A. Kaufman, the center’s Radiation Oncology administrator.

A protocol that calls for submitting a Responsible Report form was already in place for those times when an error reaches the patient. “But we wanted to create something where everyone can give input at all parts of the process,” Kaufman says.

Stop the Line

So the unit-based team created what its members call Stop the Line. If a radiation therapist or anyone else in the department encounters anything that deviates from the workflow or compromises care, he or she first acts to ensure patient safety, if such action is needed—and then fills out the Stop the Line form to document the incident. The focus is not on individual error but on what can be done to improve the system to prevent similar mistakes in the future.

“It’s a chance to look at the system to see if it is doing its job—are the checks and balances working? Or do we need to bring to the UBT and come up with a different workflow?” Kaufman says.

At monthly staff meetings, the team pulls out a binder with the Stop the Line reports and discusses the incidents and any follow-up actions taken. That discussion is important not only as a way to close the loop but also because it demonstrates to staff members that their voices were heard. The forms don’t drop into a black hole never to be heard of again.

“You have to constantly be talking about this to keep the momentum going,” Kaufman says.

The process applies to all staff, including physicians.

“In the field of medicine where, in general, it is quite hierarchical, it’s even more imperative we have a system like this to encourage every member of the department to speak up, regardless of title, to make sure we’re giving the best patient care,” says Amy Gillis, MD, the center’s chief of Radiation Oncology.

Dr. Gillis recalled the wrong-patient information episode. The initial assumption was that one of the medical assistants, who normally handle such paperwork, had made the mistake. This time, however, the culprit was a physician.

Staff members hesitated, Dr. Gillis says, wondering, “ ‘Should I really write up a physician?’ ” As she notes, however, “We all need to have a greater awareness.”

“It really does take everyone’s buy-in to make it happen and be successful,” she says. In this case, what it took to convince staff was input from the physicians themselves, with the doctors saying, “Yes, please write that up.”

Successful practice spreads

Stop the Line has been so popular that the cancer center’s four sister centers in Northern California have adopted the practice.

South San Francisco Radiology also adopted the Stop the Line form and process, adapting it to meet its specific needs. The department does hundreds of thousands of scans a year, from mammograms to basic X-rays to CT scans. With such high volume, radiologic technologists often feel pressure to keep patients moving through in a steady flow.

“We needed to give technicians permission to do the right thing,” says radiologic technologist Donna Hayes, the department’s UBT union co-lead and an SEIU UHW member. “We wanted them to know it’s OK to stop the process for this. I think it helped that it also came from management.”

As at the cancer center, the process is not used in a punitive way. Instead, it’s used as a way to highlight and address glitches in the workflow—not only within the department, but also in other departments.

“We’ve been able to take the data back to the orthopedics chief or take ED-related issues back to ED,” says Ann Allen, the Radiology director. “We funnel back to those departments that are partners so they can help us make changes.”

Biggest challenges

A brisk walk by an able-bodied person from the unit to the train station takes about 15 minutes roundtrip—but struggling with an infirm patient in an outdated or inappropriately sized wheelchair could easily double that time.

Other issues included patient dissatisfaction, staff injuries and the added risk of patient treatment delays or falls, says labor co-lead Casa, noting that “we had to look at the problem from many angles.”

Background

The Capitol Hill Medical Center opened with great fanfare in 2011. Hailed as a beacon for affordable and accessible care just as the national debate heated up on these issues, the center attracted attention—and many new members. One key factor that made the new facility so attractive—its proximity to a major public transit station in the District of Columbia—also turned into a potential Achilles heel.

That was until the Adult Medicine UBT rolled in with the right solutions.

The Adult Medicine team started by using performance improvement charting tools to log the time each staff member took to transport a patient to and from the Union Station subway stop or to ancillary departments within the medical center.

The team discovered many of the elderly or wheelchair-using members struggled to make the long trek from the exit doors of Union Station to the waiting room of the Adult Medicine unit, a medical center starting point for most patients.

The team lobbied for new wheelchairs—and for a new transporter position, an OPEIU Local 2 member who transports many of the patients and coordinates the trips that staff members make to the other departments.

In addition, the team now calls ahead to the lab or pharmacy to ensure tests and medications will be ready, or nearly so, when the patient is brought in. It also gives patients red cards to signal their priority status to lab and pharmacy staff.