High performance

Course description

Team Leadership for Co-leads is designed to bring labor, management and physician co-leads together to facilitate conversations about the performance of their unit-based teams. The co-leads receive information about high-performing unit-based teams at Kaiser Permanente and then review a 360 feedback tool to use with their teams after the course. Participants will learn a basic coaching model and practice role playing UBT coaching scenarios. Participants also will learn the fundamentals of how people adapt to change, review a change management model for leaders, and make agreements on how to manage change in their role with their unit-based teams. In addition, participants will learn the fundamentals of Emotional Intelligence and how to use “EQ” when leading change.

Path to Performance

Level 3, 4, 5

Duration

8 hours

Who should attend

This course is intended for participants who are experienced co-leads of unit-based teams. Job categories who should attend union, management and physician co-leads.

Course requirements

• Labor Management Partnership Orientation (LMPO)
• Co-Lead Workshop
• Labor and management co-leads attend the training together

Last year, the outpatient procedure unit-based team at Capitol Hill Medical Center rewrote the instructions it sends to patients scheduled
for a colonoscopy. A patient who found the earlier directions confusing played a leading role in the process.

The new instructions helped reduce by 20 percent the number of colonoscopies that needed to be repeated. Involving the patient was “a transformational experience
for the team,” says Jennifer Walker, RN, lead UBT consultant and improvement advisor in the Mid-Atlantic States region.

It also showed the power of a new provision of the 2015 National Agreement. 

Health care costs too much. The cost of care threatens Kaiser Permanente’s social mission to provide affordable, quality health care to all.

There are no simple solutions, but KP has many advantages that others do not—including our integrated model of care that can better manage and prevent illness; a prepaid, nonprofit structure that keeps revenue in the system to better serve members and patients; and unit-based teams. As they create the best place to work, UBTs are continuously improving quality, service and affordability at the front lines of care.

This report highlights many ways that unit-based teams are getting results that matter to members and patients. Affordability of care, one of the issues that matters most to members, was the fastest-growing focus area for UBTs in 2012 (see Figure 1).

Teams launched nearly 1,400 efficiency and cost-reduction projects last year, more than doubling the number of such projects undertaken in 2011.

That bodes well for the future, because the number and effectiveness of UBTs’ performance improvement projects increase as teams develop. For instance, UBTs that are rated high performing—defined as reaching Level 4 or 5 on the UBT Path to Performance—are three times more likely than Level 1 teams to take on cost-reduction projects, using proven tools such as process mapping, the “6S” performance improvement tool, and spaghetti diagrams (see Figure 2).

And these teams are getting results. Waste- and cost-reduction projects can yield immediate savings of $20,000 to $50,000. Spread across the organizations, these efforts could save more than $100 milliion a year. Some examples of the work being done:

• At the Baldwin Park Medical Center Laboratory in Southern California, phlebotomists worked to reduce the use of more expensive butterfly needles, substituting standard needles when they will work—saving more than $45,000 in 2012. Other labs are also doing this; potential savings if implemented program-wide: $2 million.
• The Fremont Medical Center Operating Room team in Northern California, after taking business literacy training and looking at their own costs and budget, identified wasteful practices in the use of ready-made surgical supply packs, saving about $34,000 a year. Potential savings if implemented program-wide: $750,000.
• The Point Loma Primary Care team at the San Diego Medical Center in Southern California applied 6S to organize supplies and standardize ordering, saving more than $20,000 in 2012. Potential savings if implemented program-wide: $4.2 million.

As these examples show, individual teams can implement improvements that can save a significant amount of money in their own corner of the system. As practices spread among the 3,500 unit-based teams now working across Kaiser Permanente, the savings can add up quickly.

Achieving the full cost-saving potential of UBTs will not be automatic. More teams need to take on cost and waste issues. Even with the jump last year, only one-fifth of UBTs undertook such projects. Successful practices must be spread more systematically across departments, facilities and regions. And more teams need the kind of business training that led the Fremont OR team to act.

But those changes are coming. “The growing number of cost saving and efficiency projects are helping build a culture of savings and waste reduction among high-performing teams across KP,” says Peter Nixon, director of metrics and analytics, Office of Labor Management Partnership.

High-performing UBTs outscored others on two questions in the 2012 People Pulse survey regarding employee views of their department’s efficiency. (see Figure 3). Members of high-performing teams are more likely to say their departments have efficient work procedures and seek improvements to reduce costs.

“These findings suggest that members of high-performing teams see waste reduction and efficient work processes as part of their job,” Nixon says. “That is good news, because it’s the discretionary effort, commitment and intelligence of frontline teams that gets results.”

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.”

For San Jose Medical Center’s inpatient pharmacy, the road to becoming a high-performing team first required a step—actually a jump—backward.

When the unit-based team was launched in 2010, it quickly was rated at Level 4 on the Path to Performance, the scale for evaluating a team’s effectiveness. The highest level is 5.

“We took it seriously and followed the process,” says Anita Nguyen, inpatient pharmacy director.

Then, in 2012, Nguyen, along with the team’s management and union co-leads, met with UBT consultants to assess their team performance. As they ticked down the list of questions and started to contradict one another, it became painfully clear: They were not the high-performing team they had previously thought.

“As a team we couldn’t answer the questions,” Nguyen says. “It was embarrassing.”

They were knocked down to a Level 1—the most fundamental rating.

Today, the team is a true Level 5, a highly functioning team that recently completed a successful stockroom project to reduce how many drugs are wasted, which is saving more than $10,000 a year. The success is a direct result of opening the department’s budget to the team, which only came about after team members started speaking frankly with one another.

The team’s downgrading was a painful, humbling blow, but most members agree that the assessment was valuable in putting the team on track to do this work and to earning the highest performance rating.

“I was not aware of what a UBT could really do for staff and managers,” Nguyen says. “We recognized the failure and I said, ‘I need you. Let’s work together.’”

Transforming teams

Inpatient pharmacy was one of several teams that shared their transformation stories at an event in July at San Jose Medical Center for national Labor Management Partnership leaders. The meeting spotlighted the medical center’s innovative approach to evaluating UBTs and supporting them in delivering the best care possible to Kaiser Permanente members.

Every quarter, San Jose UBT union and management co-leads sit down with their union and management sponsors, and with UBT consultant Heather Williams and Union Partnership Representative Eric Abbott, who support UBTs for the service area. Together they compare the team’s development against the traits outlined in the Path to Performance, including communication among team members and the status of improvement projects. The group then develops a plan for closing gaps, removing barriers and advancing to the next level.

The power of the process is in asking the critical questions, says Joan Mah, the UBT consultant for the San Rafael Medical Center, which has adopted the assessment practice. “Can your team members talk about the metrics? Kinda, sorta? Well if they can’t, we need to connect them with the skills to learn how. The whole point of this is supporting and strengthening. It’s an honest conversation.”

The assessment requires time and commitment from all parties, but by many accounts it is well worth the investment. In addition to San Rafael, which is seeing teams transformed through the process, the approach is being piloted in the Diablo and the Central Valley service areas.

The leap forward

For San Jose inpatient pharmacy, as candid and rigorous as the evaluation process was, it was also invaluable.

“We had to talk about what we really wanted,” says union co-lead Gubatan, an SEIU-UHW steward. “We basically said, ‘Let’s be truthful now. Let’s really do the work.’ ”

The team dramatically improved communication, developed trust, and engaged its members in the journey toward improvement.

“Everyone is empowered to contribute to this process,” Nguyen says. “Before, nobody questioned. Now everyone is empowered to question. With that, people feel like they really belong to the process.”

Kaiser Permanente and the Coalition of Kaiser Permanente Unions set an ambitious goal in the 2012 National Agreement: to have 75 percent of all unit-based teams achieve high performance by year-end 2014—for good reason. As teams develop, they deliver better, more affordable care and a better work experience.

There’s work to be done. More than 60 percent of teams in Georgia, Hawaii and the Northwest are meeting the goal, but overall, just 52 percent of KP’s 3,500 UBTs program-wide were rated high performing as of June 30.

The good news is that nearly 1,800 teams across KP have hit their mark, built performance improvement into their everyday work, and are showing other teams how to do the same.

Modeling the way

The Perioperative UBT at Ontario Medical Center in Southern California is one of those teams.

“It’s about having everyone involved and engaged,” says Michelle Tolentino, RN, one of the Perioperative UBT’s union co-leads and a member of UNAC/UHCP. “We attended UBT training together, got results on our first project (safely reducing patient stay times) and kept rolling.”

The 11-member representative team, which covers more than 60 nurses, surgical techs, medical assistants and others, reached Level 5 on the five-point Path to Performance soon after forming in 2012. Like many other teams in the region, it saw its rating drop in 2013 after a labor dispute led union members to suspend their UBT involvement. When the issue was resolved, the team regrouped and quickly regained its Level 5 rating.

The secret sauce

The team does a few key things right that helped it achieve and now maintain its high performance. Those can be modeled by other teams aspiring to Levels 4 and 5 status:

• Performance improvement tools: “Using our performance improvement tools—process mappings; run charts; plan, do, study, act cycles—keeps us all sharp,” says Mary Rodriguez, assistant clinical director and UBT co-lead. “That’s been key for us: understand the process and use the tools.”
• Constant tests of change: The Perioperative team now has seven active tests of change, most focusing on improving affordability and workflow efficiency. “Our projects often build off of other projects,” says Rodriquez. For instance, a recently completed project helped reduce turnaround time in the OR from 28 minutes to 20 minutes in three months. In a parallel project, the number of patients receiving medication at least 30 minutes before surgery—the ideal time for most patients—increased from 70 percent to 85 percent. Such projects draw on the whole team’s skills and perspectives, she says.
• Physician involvement: Shawn Winnick, MD, an anesthesiologist, assistant clinical director and UBT member, points to another key to success: “Physician presence on a (clinical) UBT is extremely important,” he says. “It brings a different perspective to projects.”

Calling UBTs “the single most powerful vehicle we have at KP to empower employees and lead change,” he notes that physician leaders at the medical center have supported UBT development and helped overcome barriers.

“Staff and physicians need to have the time to consistently make it to UBT meetings,” he says. “Even if it means bringing in someone to cover part of a shift, that is more than paid back by the cost savings and organizational benefits that come out of UBTs.”

The benefits accrue to the workforce as well as patients.

“We have a say in our work process,” says Robert Kapadia, a certified registered nurse anesthetist and member of KPNAA. “I come to the table as an equal partner and advocate for others on the team, and for our patients. Our UBT is a way to solve problems and move forward, not just complain.”

Dr. Winnick adds: “There’s not a single member of our team who hasn’t contributed an idea or helped make us better. That’s a measure of a performance. We all have different skills and perspectives, and we bring all of that to our team.”

Want to supercharge efforts to improve performance and help reach Kaiser Permanente’s strategic goals? Then bring unit-based team leaders together for a summit.

UBT consultants at several facilities in Southern California have organized summits that focused on Performance Sharing Program (PSP) goals, performance improvement strategies and affordability projects. All say they are seeing results in the forms of more robust UBT projects, clearer SMART goals, and stronger alignment between top medical center leadership and the work of UBTs.

After seeing teams improve service scores, reduce workplace injuries and save more than $160,000 in just four months in the San Diego service area, Sue Smith, a senior UBT consultant, concludes, “The overall experience was wonderful. Many teams had an exciting opportunity to network with other teams and learn new skills in a fun way.”

This spring, San Diego Medical Center hosted a UBT affordability summit, which brought together co-leads for a half-day to build the skills to tackle a new PSP goal for 2014 in the region: to increase the percentage of UBTs that successfully complete a project with hard dollar savings or improved revenue capture. (The projects are reviewed by finance departments to ensure they could lead to cost savings.)

Seated around large tables, UBT co-leads played a spirited game of “KP-opoly,” which offered a crash course in the organization’s finances. They heard from a UBT whose work resulted in cost savings. And they had time to work on driver diagrams and process maps for their own team’s affordability projects.

Co-leads gain PI skills

The year before, San Diego leaders—inspired by an event at the Riverside Medical Center—had held a more general, daylong UBT summit. That event brought UBT co-leads together for intensive training on performance improvement tools and created a space for them to refine their existing projects. Deadlines were set for finalizing driver diagrams and process maps, beginning tests of change and formulating sustainability plans.

The effort culminated in a UBT fair that showcased the projects that had begun as mere inklings at the summit: The ultrasound UBT demonstrated how it had gone injury-free for six months (it had been having at least one injury per month); the diagnostic imaging department boosted patient satisfaction scores from 87 percent in May 2013 to 93 percent in December.  

Leaders at the Woodland Hills Medical Center followed the same playbook, hosting an LMP summit in April that launched an array of of affordability projects to be showcased at a UBT fair scheduled for mid-July.

Mobilizing on PSP

At Fontana and Ontario medical centers, UBT staff used the summit model to mobilize the workforce around all of the region’s PSP goals. Top leaders from both management and the unions kicked off the day, then gave subject matter experts each 10 minutes to discuss the goal (whether it be service, workplace safety, attendance, etc.) and challenge co-leads to take on a performance improvement project to tackle it. A highlight was an impassioned and dramatic account from Roy Wiles, president of Steelworkers Local 7600, about a union member who did such a good job of saving up unused sick time that he recently retired with a five-figure nest egg in his Health Reimbursement Account.

The key to attracting co-leads to the summits, the consultants say, is to plan well in advance and to enlist top leadership to encourage participation. That lets managers and employees make plans for attending while ensuring their departments’ operational needs are met.

“This is part of their work,” says Priscilla Kania, senior UBT consultant at Ontario. “Your leaders are inviting you. People are excited to be in the room with top leaders.”