LMP Focus Areas

It's a simple set of five letters, but it can pay big dividends when you're interacting with patients.

Let's spell it out and communicate our best.

Acknowledge—The first letter of the AIDET acronym reminds each staff member or care provider along the patient’s path to acknowledge his or her presence. Making eye contact with a patient or giving the member a smile is all that’s needed.

Introduce—When you identify yourself by name, you change the patient’s visit from an anonymous interaction into a personalized experience.

Duration—A little information goes a long way. Letting patients know how long a visit is expected to take lets them know their time is valued. If a doctor is running late or the lab is behind, letting patients know about the delay and keeping them updated shows respect.

Explanation—Whose body is it? No one likes it when a caregiver starts doing something without telling a patient what they’re doing and why.

Thank you—The last step wraps up the visit by thanking the patient for coming in or for providing the information needed to provide them with excellent care.

For the second year in a row, the Northwest region experienced the fewest workplace injuries of any hospital-based region in Kaiser Permanente. The Northwest ended the 2011 reporting year with a 15 percent improvement over injury rates in 2010. (The two California regions, Hawaii and the Northwest operate hospitals, while Colorado, Georgia, the Mid-Atlantic States and Ohio do not.)

Workplace Safety Committee co-leads Marilyn Terhaar and Susan McGovern Kinard attribute the region’s success to several factors:

• Real-time information. Terhaar sends safety alert emails to managers, stewards, UBT co-leads and safety champions. The alerts list the injuries for the prior week and offer safety tips and resources.
• Goals at the frontline. Keeping injury rates low is a regional goal and a PSP goal. Unit-based teams are encouraged to work on these workplace safety issues prior to tackling other goals.
• Culture change. Safety conversations have become part of the workplace culture. If an employee sees someone not working safely or a hazard in the work area, she or he speaks up, knowing the problem will be addressed.
• Investigation. The approach to safety is proactive. The Employee Health and Safety department investigates the root cause of an accident and tries to make sure the accident does not happen again.

High cost to both employees and KP

Employee injuries are significant in several ways. An injured employee may lose pay and time at work, and a department may have to work short, which may impact patient care. And there’s a financial impact on the organization—which eventually could affect member premiums.

 “The cost to open a workers’ compensation claim is about $1,200 on average,” says Terhaar. “Once you start adding in medical and surgical costs, the expenses can soar.”

Indemnity claims—those claims that cover employees with more serious injuries that require a longer time off—average $21,000.

 “That’s one of the reasons we have such a laser focus on safe patient handling. The risk to the employee for injury is so great,” explains McGovern Kinard.

Prevention

The Northwest region employs a well-constructed safe patient handling program. New employees are trained on safe patient handling, and more than 1,000 employees were retrained in 2011. Hospital and clinic policies require staff to move patients using safe handling techniques and equipment.

 “We have mobile lifts and overhead lifts at Kaiser Sunnyside Medical Center and will have the same equipment at our new hospital opening next year,” says Paulette Hawkins, RN, a workplace safety consultant. “In addition, all medical and dental clinics have mobile lifts and receive annual hands-on refresher training on request.”

Members of the workplace safety committee aren’t resting on their laurels. This year, they plan to bring the focus of safety to the UBT level.

“Most teams can solve their own issues,” say McGovern Kinard. “There’s been an increase in awareness that’s been growing steadily over the last five years. Our numbers say it all.”

Our bodies metabolize the excessive sugar in processed foods just as it processes alcohol and other toxins, causing damage to our liver and other organs.

Sugar makes us more likely to develop a variety of risk factors that lead to serious illness, while making us crave sweet even more.

In fact, sugar causes a cycle of addiction in the brain in much the same way as drugs and alcohol—and cigarettes. When it comes to addictiveness, nicotine takes the, um, cake.

Physicians at the University of California at San Francisco (UCSF), led by outspoken pediatric endocrinologist Robert Lustig, MD, published a paper in February in the journal Nature showing that like alcohol and tobacco, sugar is a toxic, addictive substance. They argue that it should, therefore, be closely regulated, with taxes, laws on where and to whom it can be advertised and age-restricted sales. The researchers said that increased global consumption of sugar is primarily responsible for a whole range of chronic diseases that are reaching epidemic levels around the world.

Is sugar—so pervasive in processed foods, soda and junk food in general—the new tobacco? Let’s see.                                    

It can kill you.

If Lustig and his colleagues—and many other independent researchers—are even half right, sugar and junk food have been responsible for millions of preventable deaths. According to journalist Eric Schlosser, author of “Fast Food Nation” and the children’s book “Chew on This,” poor diet and lack of exercise may soon surpass smoking as the No. 1 cause of preventable death.

People make huge amounts of money by selling it.

Remember how long the tobacco industry denied the link between tobacco, advertising, and lung cancer and heart disease? We are hearing the same protestations from the processed food industry today. Don’t buy it!

Schlosser, a keynote speaker at the 2012 Union Delegates Conference, recounts how McDonald’s was built. Founder Ray Kroc discovered that profits were higher when kids ate out with their parents. So he lured children in with lollipops. Later, he added a clown. Today, fast food chains hire child psychologists, hold focus groups for toddlers and put 5-year-olds in MRI machines to see which part of their brain is responsible for brand loyalty.

“Think about the profit margin in a soda,” Schlosser says. The raw materials are water, food coloring, sugar and a paper cup. Nutritional value: less than zero. Cost to produce: pennies. Now there’s a profit margin!

It’s not hard to figure out why people are hesitant to speak up at work. Offering a suggestion for improvement or pointing out when you think something isn’t right exposes a person to any number of possible responses—many of them unpleasant.

There’s the sarcastic retort. There’s the deafening silence. There’s the reply, pointing out exactly why you’re wrong, delivered in the nicest of tones but carrying an unmistakable edge of one-upsmanship. Who needs it? Who wants to create waves and risk a good job?

But when we don’t speak up, we put health and happiness at risk. As Doug Bonacum, Kaiser Permanente’s vice president of quality, safety and resource management, says in this issue’s cover story, speaking up “is mission critical for worker and patient safety.”

In addition to the moral imperative of protecting people from injury, there’s a strong economic incentive for speaking up. Improvement doesn’t typically come from a single person’s great idea—it comes from people sharing ideas. And we at KP have to keep improving, finding ways to deliver care as good as or better than we deliver now with fewer dollars per member. Our future depends on it.  

Since we get good at what we practice, we each have to practice speaking up. Practice means starting with lots of baby steps—don’t tackle the high-stakes stuff first! And let’s practice being good listeners, too, providing the space that lets others speak up safely.

The Labor Management Partnership and unit-based teams provide the framework for transforming what Bonacum calls a “culture of fear” around speaking up. But with that framework in place, it’s still up to each and every one of us to find the courage to address the immediate, particular obstacles that keep us silent.

An imaginary friend of mine smokes, is decidedly chunky, and has high blood pressure and high cholesterol. His kids nag him about the cigarettes and weight; his wife worries more about the hidden conditions.

This fellow could be any one of many of us, and if he wanted to track his efforts to improve his health, he could use the “cloverleaf” graphic introduced in this issue of Hank—a visual summary of the four measures of health at the heart of the new Total Health Incentive Plan.

The cloverleaf has a lot in common with the Value Compass, which illustrates the interconnectedness of service, quality, affordability and the workplace environment. The Value Compass reminds us that improving in one area at the expense of another isn’t progress—and that improving in one area frequently leads to improvements in other areas.

So it is with health. If I take up smoking and have a cigarette each time I’m tempted to eat something sweet, I may improve my Body Mass Index, or BMI—but I won’t have improved my health. If my imaginary friend starts to make better food choices and ups his exercise, however, he’s likely to see improvement across the spectrum of health issues he’s facing. By measuring improvement in several areas, the new incentive plan puts the emphasis on bringing the whole person into better balance.

And by putting the focus on collective improvement, the plan recognizes that all of us are making decisions as individuals in a social system—a system that can make it harder, or easier, to make better choices. Losing the dougnuts at a breakfast meeting may seem like a small gesture, but many such gestures add up to powerful change.

Colorado

The new Lone Tree Specialty Care Medical Office, a 25-acre campus, boasts outdoor patios, picturesque mountain views and a walkway around the perimeter of the building. The facility, which opened in December 2013, was awarded a LEED (Leadership in Energy and Environmental Design) Silver certification by the United States Green Building Council. Lone Tree, which is near a light rail line, used recycled materials, water-wise fixtures and shading devices for balancing solar heat to win the LEED designation. The facility has nearly 350 employees and 45 physicians to take care of the 3,000 ambulatory surgeries and 3,000 minor procedures expected per year.

Georgia

What happens when two nurses from two different high-performing UBTs transfer to the same brand-new Level 1 team? That team zooms to a Level 4 in only 10 months. Jane Baxter and Ingrid Baillie, both RNs, had been UBT co-leads at the Crescent and Cumberland medical centers, respectively, and then joined the Ob/Gyn staff at Alpharetta. Drawing on their experience—at different times, they each have been UFCW Local 1996 members and members of management—they helped their new UBT move up through the Path to Performance. “We knew the steps in the process and what to expect,” says Baxter. Their advice to fledging teams: Start with small performance improvement projects in areas that clearly are Kaiser Permanente priorities and that already have lots of data collected.

Hawaii

Nurses on the 1-West Medical-Surgical unit-based team at Moanalua Medical Center vastly improved how well they educate patients about medications, moving from about 40 percent of surveyed patients saying they understood side effects and other aspects of their prescriptions to 96 percent reporting this awareness. Between April and December 2013, the RNs, who are members of the Hawaii Nurses’ Association (HNA), made notations on patient room whiteboards, rounded hourly and did daily teach-backs on every shift. The team members designed a three-day survey for a sampling of patients to report what they understood about side effects of their medicine. The survey provided speedier feedback than waiting more than three months for HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores.

Mid-Atlantic States

A Nephrology team at Tysons Corner Medical Center in Virginia helped patients prevent or manage chronic kidney disease by getting them into the classroom. Just 70 percent of the unit’s patients at risk of renal failure were enrolling in KP disease management classes in February 2013. But several successful tests of change boosted at-risk patient enrollment in March to 100 percent, where it has remained since. The team noted on individual patient charts if the member suffered chronic kidney disease, developed scripting for in-person coaching, mailed class invitations to patients’ homes and handed out class agendas with after-visit summaries.

Northern California

The Modesto Pediatrics UBT improved wait times for immunizations—and not only increased service scores but also reduced overtime costs, an example of how a change can affect an entire system. The team reduced patient waits for immunizations from 45 minutes to 15 minutes between June and August 2013 and maintained the improvement through the rest of the year. A workflow change was key to the dramatic reduction. When a patient is ready for an injection, physicians now copy the orders to a nursing in-box instead of searching for a licensed vocational nurse to give the shot. The half-hour reduction in wait times—which is credited with improving service scores from 86 percent to 95 percent—also reduced the need for LVN overtime by an hour a day, resulting in savings of more than $16,600 over six months. 

Northwest

The regional Employee Health and Safety department won KP’s “Engaging the Frontline” National Workplace Safety Award. Through the Northwest’s Safety Committee Challenge, facilities had to complete a rigorous set of tasks, including regularly scheduled safety meetings, joint planning with NW Permanente and Permanente Dental Associates, safety conversation training, awareness plans and a safety promotion event during the year. Of the 16 facilities that rose to the challenge, nine met all of the qualifications. The region ended the year with a 4 percent reduction in accepted claims compared with 2013. Leonard Hayes, regional EVS manager, won the individual award for his work, which contributed to the East service area’s EVS team going injury-free for the last four years.

Southern California

The regional LMP council has set a 2014 Performance Sharing Program (PSP) goal to power up unit-based teams’ achievements on improving affordability. When at least 50 percent of a medical center’s UBTs complete a project that saves money or improves revenue capture—and if the region meets its financial goals—eligible employees and managers there will get a boost in their bonus. “Imagine how powerful it will be to have a majority of unit-based teams achieving measurable cost-savings and revenue-capture improvements,” says Josh Rutkoff, a national coordinator for the Coalition of Kaiser Permanente Unions. “The idea is to take all the strong work on affordability at the front line to a whole new level.”