Path to Performance

Sometimes the best way to spread effective practices is to spread experienced people. That’s what happened when the Alpharetta Ob-Gyn UBT in Georgia zoomed from Level 1 to Level 4 in just 10 months after two nurses from two different high-performing UBTs transferred there at the same time.

Jane Baxter and Ingrid Baillie had been UBT co-leads at two different clinics when they each got a new job with the Alpharetta Ob-Gyn department. They both drew on their experiences to guide their new team when they became co-leads at Alpharetta. “We knew the steps in the process and what to expect,” says Baxter, the department’s charge nurse.

Fledgling teams should begin with small performance improvement projects, they say. “We started with the low-hanging fruit,” says Baillie, RN, a member of UFCW Local 1996. “You don’t need to reach for the stars right out of the box.”

Pick your projects wisely

And, says Baillie, there’s no need to look any further than Kaiser Permanente’s organization-wide and regional priorities to find plenty of ideas for performance improvement projects—and a wealth of data that is being collected regularly.

“KP makes no secret about what is important to it,” says Baillie. “From that alone, you have all the data you need.”

For instance, the Alpharetta team’s first efforts were to improve clinic start time and get a second blood pressure test for patients with high initial readings. “These are important to KP, and they helped us gel as a team,” says Baillie.

“Small wins help develop confidence,” says Baxter. Now the team is taking on more complex cross-departmental initiatives, such as trying to make available online the big packet of paperwork patients need to complete before a first Ob-Gyn visit.

Getting physicians involved also has been part of this UBT’s success. You won’t find doctors who think UBTs are just for clinic staff on this team, says Baxter.

“Our providers are very invested,” she says. “They take minutes at meetings. We are all on an equal playing field.”

Improve service scores. Reduce waste. Retain members. Gain new members. Cut wait times. Work safer. Perfect patient safety. Innovate care.

Teams are juggling constantly, trying to meet their own objectives, move forward on initiatives related to facility, regional and national goals, and comply with regulatory requirements—all in a competitive economic environment.

When the curve ball comes sliding in, it can be one thing too many, derailing a strong team or keeping a struggling team at ground level. So a host of unit-based team supporters are turning their attention to strategies to help unit-based teams prioritize competing demands—from personalized mentoring to intensive workshops for co-leads.

“I see my role as taking away the noise and the chaos…to help them figure out, ‘Realistically, how many things can we work on at once?’” says Denise Johnson, San Jose Medical Center continuum of care administrator and a UBT sponsor. “I have to help them not be crazy, because we don’t want a lot of projects that don’t make a difference.”

Here are four strategies for helping teams.

Strategy #1: Planning pays off

Every year, labor and management sponsors at the San Jose Medical Center sit down with their UBT co-leads to develop an operating plan. The plan flows from Kaiser Permanente’s organizational goals as well as from regional goals, facility priorities, and the needs of the department. Each sit-down includes the service area’s UBT consultant and its union partnership representative. Projects emerge naturally from that plan, with teams turning to the Value Compass and a tool called a PICK chart to fine-tune their priorities.

“They have to figure out what’s in their sphere of influence,” says Eric Abbott, the area’s union partnership representative. “What are the things they can change, and of those things, how much time do they have?”

When Johnson became sponsor of one San Jose team, it was immediately clear to her the UBT had too much on its plate. She worked with the team to winnow eight projects down to two.

“In my experience, people get bogged down with the to-do list and sometimes don’t stop and think about what’s really on that list and what effort does it serve,” she says. “They thought I was crazy. They came from a mentality where ‘more is better.’”

Strategy #2: Urgency can be a tool

Two years ago, San Diego’s interventional anesthesia unit-based team was humming along in its performance improvement work when it got hit with the news that co-pays for patients who suffer from chronic pain would be increasing sharply.

The 14-member team responded with a new service project, a multiphase communication plan to help members understand the new co-pay and their options. And then the next wave broke: The team learned it had a matter of days to move into a new specialty services building. It suspended the co-pay project to plan for and complete the move.

One key performance improvement tool—a process map—proved instrumental. The team created a detailed map that laid out every piece of work that needed to be done in preparation for the transition, from changing procedures to adapting to a new phone system to altering workflows based on the new floor plan.

“They simply became a single-issue team,” says their UBT consultant, Sylvia Wallace, of the 2011 move.

With the process map in hand, the team spotted an opportunity to weave communication about the new co-pays together with communication about the move. As a result, it didn’t miss a beat in providing its members with critical information about available financial assistance.

The comprehensive plan helped the unit’s service scores hold steady through the transition—and then increase at the new facility. The moving plan became a template for other departments, which are still moving into the Garfield Specialty Center.

“Everyone participated. All types of ideas were solicited and implemented,” says Grace Francisco, the assistant department administrator and the management co-lead at the time. “Everyone has a role and accountability for each step.”

Strategy #3: Take time to train

Teams stand a better chance of weathering competing demands when they have a solid understanding of partnership principles and processes as well as performance improvement tools and methods.

In Colorado, the UBT consultants used LMP Innovation grant funds to host a two-day workshop centered on two regional priorities. Co-lead pairs from throughout the region learned how best to serve new members and improve the affordability of KP care by reducing waste and inefficient practices. They walked away with a variety of team improvement tools and resources.

“We are trying to set the teams up to be successful by giving them the time to focus on topics that could have a huge impact in the region in the next few years,” says Linda Focht, a UBT consultant and UFCW Local 7 member.

In San Diego, regular UBT summits bring co-leads together for intensive sessions on given topics. Service area and local union leaders play a major role in structuring the agenda, so the team development matches up with high-level strategy. The joint planning creates a full picture, one that resonates better at the front line and sets up teams to work on projects that make a difference to KP’s reputation.

“Leaders see a lot more than what we see,” says Jenny Button, director of Business Strategy and Performance Improvement in San Diego. “Leaders see what is going on with the competition. They see across all of the different metrics we are working toward. They see at a broad level where our biggest gaps are.”

Strategy #4: One-on-one attention counts

At San Jose Medical Center, sponsors like Johnson and Hollie Parker-Winzenread, an assistant medical group administrator, are coaching UBTs one on one in performance improvement tools to help them set priorities.

 “Teams like to jump to the solution,” says Parker-Winzenread. “But they struggle with the process….The gain falls apart, because the process is not strong.”

San Jose’s clinical laboratory UBT is a success story, jumping from a Level 1 to a Level 4 in less than a year after new co-leads worked together to reach joint agreement on the department’s priorities. The team started with tests of change that made strides in attendance. Today, it has moved on to complex projects that require shifting schedules to accommodate demands for getting lab results earlier in the day.

Guidance from their sponsors has helped keep team members on track.

“We’d come up with all of these ideas and projects, and they made suggestions and really helped prioritize what we worked on so we didn’t bite off more than we could chew,” says Antoinette Sandez, a phlebotomist, the team’s union co-lead and an SEIU UHW member.

“You have to help teams to believe in the process,” Johnson says. “As a sponsor I can’t rush the process and say harder, faster, move, move, move. That won’t get us what we want in the long run. Because we’re looking for sustainability.”

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.