Efficient processes

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 next step for UBTs—a step they are being challenged to take by top management and union leadership—is to make the leap from successful individual team projects to a systemic effort to implement proven practices throughout the organization.

Meantime, remember another bottom line: High-performing teams score more favorably on People Pulse questions related to efficiency and cost reduction, and high-performing teams are more likely to take on affordability projects.

Working with your colleagues to become a high-performing team is a sure step toward reducing waste and improving affordability. Being high performing will help Kaiser Permanente continue to assist and care for families and will help us ensure everyone has affordable health care.

Here are some ways that unit-based teams can help keep Kaiser Permanente affordable.

1: Build business literacy

The more teams know about the business of health care in general and of their own departments specifically, the better equipped they are to find savings. To that end, LMP’s Education and Training department is rolling out an economic literacy program in the coming year. Meantime, teams in both California regions have been using a curriculum developed by a multidisciplinary team in Northern California. The five-part course has caused some trepidation, since in the last two trainings teams go through their department’s budget line by line—but that’s exactly what gives the training its juice.

At the Fremont Medical Center in Northern California, the OR team took the training and instantly started looking for ways to save money. Co-leads Yolanda Gho, Operating Room nurse manager, and surgical tech Gus Garcia, an SEIU UHW steward, talk about the training, its benefits and how it inspired their team to do better. (For more on this team, click the Peer Advice link in the resources box.)

2: Be supply savvy

Teams that take the time to make a comprehensive assessment of their supplies—tracking inventory use, tidying up storage areas, streamlining ordering and so on—can save tens of thousands of dollars with hardly any pain.

For instance, the scientists in the Immunology department at Southern California’s regional reference lab use expensive chemicals, called reagents, to test whether patients have serious infections such as hepatitis and HIV. Cleaning out and meticulously organizing the department’s huge walk-in refrigerators allowed the team to order larger quantities of reagents at one time. Since employees have to test a sample from each shipment, fewer shipments mean fewer tests—saving staff time and expensive reagent. The work, which also means the team needs fewer rush shipments, is saving $50,000 a year.

Another example comes from the Head and Neck Surgery UBT at the Franklin Medical Office in Colorado, which kept trying small tests of change until it found a reliable way to prevent the disappearance of expensive surgical tools. Contracting with outside individuals or companies often is more expensive than having the same thing done in-house. “In-sourcing” can range from health education centers in Northern California using KP-produced pamphlets instead of costlier items from an outside company, saving $64,000, to the Ohio region opening new micro-clinics so patients in the suburbs can see KP physicians instead of non-Permanente providers. (For more on this team, click "Losing Streak Ends for UBT" in the resources box.)

3: Bring it home

Contracting with outside individuals or companies often is more expensive than having the same thing done in-house. “In-sourcing” can range from health education centers in Northern California using KP-produced pamphlets instead of costlier items from an outside company, saving $64,000, to the Ohio region opening new micro-clinics so patients in the suburbs can see KP physicians instead of non-Permanente providers. (For more on the Ohio region's work, click on "Micro-Clinics, Macro-Partnership" in the resources box.)

4: Collect the money we’re owed

Health care in general and Kaiser Permanente in particular is filled with mission-driven people. But KP can’t sustain its mission if we don’t collect the money we’re owed.

In Colorado, the Medicare Risk Business Services UBT members spotted and fixed a technical problem with incomplete physician signatures on patient charts, which allowed them to bring in more than $10 million in Medicare revenue that otherwise never would have been collected. In Santa Rosa, Calif., the patient services representatives in the Emergency Room analyzed data and did some role playing with one another to reduce discomfort about asking for co-payments.

Figuring out issues like these takes tenacity, as the Patient Financial Services team in the Mid-Atlantic States discovered when it set out to fix problems with workers’ compensation claims. (For more on this team, click "Closing a Financial Gap" in the resources box.)

Fremont’s Operating Room team loved taking the first parts of Northern California’s business literacy training—so much so, it immediately requested the last two sessions, when teams pull out their budgets to review line-item expenses for the department. The review of payroll and non-payroll budgets has caused controversy and concern in some quarters, but the Fremont OR team not only took it in stride, it rode the momentum of the training by developing several performance improvement projects to reduce waste. One of those, streamlining its ready-made surgical supply packs, is projected to save roughly $34,000 a year. The Northern California training began rolling out in 2011. The first three sessions are a tutorial on the basics of Kaiser Permanente business, explaining such things as our integrated business model (how the various KP entities do business together), key sources of revenue, and business concepts like margin goals. The rubber meets the road in the final two sessions, with their look at the department’s financial realities. Team co-leads Yolanda Gho, Operating Room nurse manager, and Gus Garcia, a surgical technologist and SEIU UHW steward, talked with communications consultant Cassandra Braun about the training, its benefits and how it inspired their team to do better.

Q & A

Q. Were you concerned about sharing the department’s payroll and non-payroll budget with staff?

Gho: Not really. I thought, “Why don’t we highlight the areas where we have opportunities to improve, like sutures—ones we can improve on and have control over.” With payroll, my one concern was showing someone’s salary. But it was explained that they didn’t show individuals’ salaries. So I was totally on board.

Q. What was the staff’s reaction to the training?

Gho: The response was quite eye-opening. There was an audible gasp. When they saw [the red lines], they were like, “Oooh, I thought we were doing great. Why do we have all that red on the screen?” What’s great about this group is their minds immediately started running, thinking about what they could do.

Garcia: To me, it’s like: We can fix that, or come up with ideas (for fixing it). That is what melds it all together.

Q. Talk about your project to streamline surgical packs and how it was influenced by the business literacy training.

Garcia: Surgical packs have draping and supplies for each particular procedure. They’re ready-made. So you always had to add things or throw away things that you didn’t want, depending on the procedure. I was trying to see what we need or don’t need. I worked with the supplier and our teams, like general surgery, and I asked their opinion—“What do you need in this thing and what do you not need?” We streamlined the packs to have the bare minimum. So everyone uses everything in the pack.

Gho: After the training, Garcia wanted to revisit this issue, because he had brought this up before.

Garcia: The wheels were turning in my head. If we’re not using it, we’re wasting money.

Q. You also started work on reducing waste of sutures and other supplies?

Gho: Yeah, it was a culture change. In the past, as a nurse or tech, you were trained to always be ready. You were trained that the surgeons shouldn’t have to ask for something. Some people think that if they’re able to do that, they’re seen as efficient and anticipating the needs. But the world is different, the economy is different. Now we have to ask ourselves, “Do we need to have this open to look good or just in case a surgeon asks for it? Or is it OK not to open it, but to have it in the room and ready?” Before, we were all trained that way—anticipate, anticipate, anticipate. We now give ourselves a centering moment before we open sutures or supplies that are not needed immediately for a case.

Q. What advice would you give to other teams thinking about taking business literacy training?

Gho: My advice is to help educate your staff members by being transparent about information that affects them and the team. As a manager, I want to create awareness and understanding of the issues with my staff. It bridges the information and knowledge gap. The more we’re armed with information, the better decisions we make.

Garcia: If it was up to me, I’d have everyone take the class. I think it just gives you a different perspective. It breaks it down and gives you an overall view that staff members don’t get to see all the time. It keeps them informed.

Gho: People tend to complain about things but do nothing about it. In our UBT, you bring solutions. We’re doers. It’s our chance to do something.