LMP Concepts

Richmond Medical Center Pediatrics knew that “pretty good” wasn’t good enough in 2012. The department’s service scores hovered stubbornly around 88 percent. Its unit-based team members knew they could do better and distinguish themselves from competitors.

“We wanted to give KP members that ‘wow’ experience,” says manager Cynthia Ramirez—to make them glad they chose Kaiser Permanente and to give them reasons to stay with us.

So the UBT, knowing the system can be frustrating when you’re unfamiliar with it, created a project that would take the mystery out of the process. In doing so, the team also hoped to debunk any idea that KP is an impersonal health care factory. 

“We need to not just look at our work as a job all the time,” says union co-lead Jill Sandino, a medical assistant and SEIU UHW member. “It’s kindness from the gate.”

Time for our A game

With major elements of the Affordable Care Act going into effect this fall, focusing on a member’s total experience with KP has never been more important. After years of preparation, how we respond to the challenges and opportunities will make a big difference for our organization and for our members. And every UBT can get ready by figuring out where its processes aren’t the best—or are merely OK—and getting to work on improving them.

“For the first time in our history, how well we do fundamental business operations—billing, copayment collection, customer service—has the potential to overshadow the health care we deliver in driving overall member satisfaction,” especially because more members will have plans with deductibles, says Larry Sirowy, KP’s executive director for market research. Sirowy and others have been working to figure out the characteristics of the people who will become members through health care reform—and what we need to do to be able to provide all our members, new and old, with the care they need.

Without a crystal ball, no one can say exactly how Kaiser Permanente will be affected. But one thing everyone is anticipating is an influx of new members—and we know that if new members stay with us after the first year, we’re likely to keep them as members in future years. So in the months ahead, we need our A game, and we need to bring it to every aspect of our work.

The good news is UBTs are already working—and seeing results—on a variety of projects that will improve our ability to provide new members with excellent service and care as well as reaffirm current members’ decision to choose KP.

Richmond’s "wow" experience

To ensure new patients have a topnotch visit, for example, the Richmond Pediatrics UBT created a workflow that involves everyone. It starts with the receptionist spotting the new member flag in KP HealthConnect and giving the person a customized welcome. In the exam room, the medical assistant provides a welcome packet—offered in Spanish or English—with basic department information, critical phone numbers and instructions on how to sign up for kp.org. Department manager Ramirez comes by to introduce herself and share her business card.

The physician caps it off by welcoming the patient to his or her practice and touting the great teamwork in the department.

“This reinforces that they’re in good hands, and we’re a family and know everyone by name,” Ramirez says.

The new workflow is making a difference: The department’s service scores increased from 88.3 percent satisfaction at year-end 2012 to 95.1 percent in the first quarter of 2013.

“Starting with a small Rapid Improvement Model project has made a big impact,” Ramirez says. “It gives us the momentum to be ready for whatever comes next.”

Unexpected consequences

In January, Georgia’s Douglasville Medical Office got a dress rehearsal in receiving a flood of new patients when the local city government signed on with KP.

“I hadn’t realized how large this group was,” says pharmacist manager Adaora Oraefo, until, at the end of 2012, “we started to see a dip in our service scores.”

Douglasville is a tiny clinic, so patients are supposed to check in with the pharmacist to confirm their prescription before heading to the lab for tests. But often, no one told them that—so when they did get to the pharmacy, they had to wait 10 or 15 minutes while the prescription was filled.

Not surprisingly, since members assumed their prescription would be ready when they were done with their lab work, complaints starting coming in.

“I would step out in the waiting room and talk them through the process,” Oraefo says. “I saw an opportunity to improve.”

The pharmacy began working with the nurses to make sure they explained the clinic’s routine to patients. The facility expanded on the work by holding open house events for new members.

“They were so much happier, especially when they were able to see me as their pharmacy manager,” Oraefo says. “It made a difference. People were thinking, ‘These people are taking the time to show us what’s going on.’”

Understanding KP’s offerings

One element of preparing for health care reform is becoming educated about the law and its provisions, so we can help members understand the changes, too.

Since 2010, Colorado’s patient registration associates (PRAs) have seen an increase in the number of patients with deductible health plans, which often have significant payments associated with them. More experienced with KP’s HMO plans, which feature the familiar copay arrangement, the PRAs didn’t feel confident talking to members about deductible plans.

Since the Health Insurance Marketplaces that open this fall are expected to bring even more members with those types of plans, the PRAs made a proactive decision to educate themselves.
 
“While there will be a number of different types of plans, the concepts don’t change,” says patient registration manager Jeffrey Clayman. “Improving their confidence in their ability to talk about these plans was a natural fit.”

The regional PRA UBT held a training that included actors playing the patients and members, so the staff could practice realistic encounters. The clerks gained experience in explaining the costs and how the plans work—and they also got practice in how to respond when someone gets upset at an unexpected bill.

“We tried to learn how to be more aware of how we communicate to patients,” says PRA Diana Wagner, a member of SEIU Local 105 and the regional UBT’s union co-lead. “I treat patients the way I would want to be treated—which is businesslike. But the service quality person made a point, that you need to treat patients the way they want to be treated.”

Tim Kieschnick, a Kaiser Permanente executive consultant who has been working to understand how our member demographics will be changing, says that currently, many members with deductible plans don’t realize they have a deductible.
 
“They’ll pay a $25 copay,” he says, “and then four months later, they get a bill for $1,300”—and they’re shocked.

 “The goal should be no surprises,” he says. “How you do that is something we’re all trying to figure out.”

Sustaining improvement

The other challenge, of course, is to sustain a successful change.

With the many demands of a busy Pediatrics department, co-leads Ramirez and Sandino admit it can be easy to forget to use the new member workflow. To keep the momentum going, Ramirez provides a reminder in the team’s morning huddle if a few days have passed without seeing a new patient.

And Sandino says she tries to “be like a cheerleader.”

“We need members to have our jobs,” Sandino says. “Health care reform is a reality—it’s beyond KP, and it’s beyond the unions. I was never a cheerleader, but I’m a cheerleader at Kaiser around this.”

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.”

With the increasing complexity and pace of change in health care, “soft skills” such as problem solving, collaboration, cultural competence and team leadership are becoming as important as technical skills. That’s why Kaiser Permanente and the unions in the Coalition of Kaiser Permanente Unions, through the Labor Management Partnership and its unit-based teams, engage the workforce in continuous learning, critical thinking and performance improvement.

Recognizing KP’s unique workplace strategy, the Journal of the American Academy of Physician Assistants invited LMP to submit an article for its July 2013 issue, “Building the right skills for the healthcare workforce of the future.” This link will get you to the journal’s website; scroll past the headline to read the full text of the article.

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.

Louise Dempsey is the business representative for UFCW Local 1996 in Atlanta. She spoke with LMP communications consultant Laureen Lazarovici about her experiences as a union activist in the South.

In the late ’60s and early ’70s, my mom worked for the Social Security Administration. She transferred often for her job, so we moved a lot. She was in the union, and she organized two of the offices she got transferred to in order to get better benefits. One was in the hills of Tennessee, where there were a lot of coal mines and a lot of poverty. She once worked for a group of attorneys and mobilized her co-workers to get better wages. There was a lot of disparity in pay in terms of gender and race. Sometimes, they didn’t exactly like her. She earned the reputation as the go-to person. People would say, “If anybody can get it done, it’s Mildred.”

Unions at Kaiser Permanente

And today, here we are in the South. It is not strong union territory. Because of Georgia’s so-called “right to work” law, employees can work for KP here whether they join the union or not [in contrast to KP regions in other states with stronger worker protection laws]. But people join because they know that the stronger we are, the more we can stand up for ourselves. We have to talk to folks about the benefits of working for a unionized company. I worked for KP as an LVN before there was a union. Our wages were all over the place and assignments were based on favoritism. We’ve had people come to work for KP because it’s unionized.

When they hear about the Labor Management Partnership, they say, “I’ll sign up.” They understand they have a voice, they can be part of a UBT, they can affect the direction their team is going, and say what they need and want and be heard. Sure, we have to educate managers, but we have to educate employees about unions, too. When I talk at new employee orientation, I tell them we are there as a mediator, facilitator, advisor. You are not by yourself anymore. I’ve got your back and your front and your side, too. With the Labor Management Partnership, KP is always offering opportunities for employees to learn, like the Ben Hudnall Memorial Trust. I have been in the medical field for 30 years, and folks are always thirsting for more knowledge.

Getting used to a new way of doing things

Folks in management come into Kaiser and they are not used to unions or the partnership. We have to educate them: We have a union, we have a contract, we have a partnership. We educate them about a union environment and also that we are not the traditional head-butting adversarial union.

Normally, when I go into a meeting at KP, there is not a whole bunch of posturing. People want to get to a solution. There is no name-calling, finger-pointing or yelling. It makes a difference. Partnership benefits the local because I have open access to the employees. I went to five facilities recently. I was not stopped once. It is always, “Hi, how are you, who do you need to see?” My co-workers at the local who represent employees at other companies don’t all have that. KP has not relegated me to a break room or to certain hours. I can have a bulletin board in the break room. I have the time to speak with new hires during orientation. They don’t censor the questions the employees ask or the ones I answer. That’s partnership.