Level 5: High-Performing UBT

Angela Chandler and Nee Tang, Pharm.D., didn’t like what they were seeing.

The team co-leads for the West Los Angeles Ambulatory Care Pharmacy crouched beside Camille Wong, scrutinizing her posture as the pharmacist and UNAC/UHCP member sat typing at her computer.

After a quick huddle, the pair worked together to adjust Wong’s chair until she was sitting in the ideal position to protect her from pain—and a potential injury.

“I didn’t know I could adjust my chair this way. It feels good,” Wong said appreciatively, her feet resting flat on the floor and her legs bent at the appropriate 90-degree angle.

Shift in culture

Such peer safety rounds are one of the hallmarks of a dramatic shift in culture for the team, a shift that has built engagement and created a workplace where frontline workers feel confident speaking up. The department went 3½ years without injuries and earned a national workplace safety award earlier this year.

“We’re all in it together, and we’re all here for each other,” says Chakana Mayo, a pharmacy technician and UFCW Local 770 member who is the team’s workplace safety champion.  

But the situation was not always so bright.

In 2011 and 2012, the department experienced a spate of workplace injuries. Employees, who spend most of their time on phones and computers, were sometimes reluctant to report pain—including one who suffered a repetitive motion injury so severe that it required two surgeries and time off from work.

“It was really a wake-up call,” says Tang, a pharmacy supervisor and the team’s management co-lead. “We needed to make sure that everyone feels comfortable enough to speak up when they have a problem.”

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.”