Performance improvement

The word “rapid” stopped Kathy Stafford, RN, and made her ask more questions.

Stafford, the UBT co-lead and charge nurse for the Regional Infusion Center in the Northwest, had been reading an email from a Colorado colleague. The colleague wondered whether the center was using a new protocol for Remicade, an infusion drug prescribed for such diseases as Crohn’s, rheumatoid arthritis and psoriatric arthritis. The Colorado infusion center was trying a new “rapid” Remicade delivery method and looking to see what the experience of others had been.

The Northwest still was using the standard method, and Stafford, a member of the Oregon Nurses Association, was instantly curious. A regular Remicade infusion takes 3½ hours—three hours for the delivery of the drug, and then, to be sure there are no adverse effects, the patient has to wait 30 minutes before being discharged. The new protocol reduces that to a total of 1½ hours.

The gift of time

“If there is anything we can do to speed up infusions for our patients,” Stafford says, “it would be a service to them and, at the same time, save the organization money.”

In short, Stafford was putting the patient at the center of her decision making, bringing the Value Compass to life. The rapid Remicade protocol improves the patient’s care experience and improves service, quality, affordability and staff satisfaction:

• Patients spend less time in the clinic, since both the drug administration time and post-infusion wait time are reduced.
• Because patients are spending less time in the clinic, more patients can be seen. Up to 16 hours of patient chair time could be opened up every day.
• Because the clinic can accommodate more patients, fewer patients will be redirected for treatment in the Emergency department or at the regional Oncology department, improving those departments’ ability to serve their primary patients.

“Any chance we have to be more effective is worth it, so we can spend more time with our patients,” Stafford says.

Making it happen

Following up on the initial email inquiry, Stafford learned the evidence-based practice already was being used in Colorado and the California regions. She and Greg Frazier, the assistant department administrator and UBT management co-lead, pushed ahead with getting the protocol approved for use in the Northwest, benefitting all the region’s eligible patients.

“There was no stopping Kathy,” Frazier says. “She knew who to talk to in the organization and how to move things along….

“Our team is always looking at how to do things better, and to take care of the patient the best we can,” Frazier continues. Noting that the infusion team is highly motivated and self-directed, he offered words of encouragement to those who see an opportunity they want to pursue.

“Don’t turn away from a challenge. Ask questions,” he says. “It may not work, but look into it first before you discount it.”

Stafford credits the team for getting the new protocol approved so quickly, despite a complex approval process that included meetings with both physicians and pharmacists.

“Without the enthusiasm and involvement of the infusion RN team, this would not have gone as smoothly,” she says. “We found out about the protocol in March and we began implementation in May. That’s pretty fast.”

Summer interns often are put to work fetching coffee or making copies. But last year, UBT consultant Geoffrey Gamble wanted to create a more valuable experience for the teens of KP’s Summer Youth Employment Program at the Modesto Medical Center. So he trained a small army of performance improvement consultants to help support unit-based teams.

Despite initial skepticism from some team members and managers, the results were stunning. By the end of the summer, 12 of the 13 teams supported by the interns advanced at least one level on the Path to Performance. What’s more, four of the 19 projects carried out by the UBTs yielded savings or cost avoidance totaling $400,000. The program was such a success, it has returned to Modesto this summer and has spread to the Sacramento and San Jose medical centers. And in the process, the interns are gaining on-the-job training that translates to their studies and to the work world.

“I went in thinking we were going to do grunt work, but in reality it was like, ‘Wow, I’m actually doing something I can apply,’” says Nate Aguirre, who interned in Modesto’s Emergency Department last year. “It was a life-changing experience.”

The Community Benefit program has offered training and work experience to teenagers in underserved communities since 1968. In the past, that experience included clerical work or coaching on speaking in front of a large group. When Modesto’s internship coordinator retired in 2013, Gamble agreed to oversee the program as long as it supported his work developing UBTs.

Overcoming doubt with results

“When I first proposed the idea, directors were very skeptical,” Gamble recalls. “People would say, We’re struggling to do this with professionals—how do you expect to get momentum from a 16-year-old?’”

But Gamble saw the opportunity to offer teams a fresh perspective and the daily support many need to get started. He also wanted to show team members that performance improvement didn’t have to be complicated and could be incorporated in their daily work.

“I told managers that I was going to treat (interns) like adults and give them the skills I would give employees,” Gamble says. “If you hold them to that expectation, they will rise to the occasion.”

In the first few days of the eight-week program, Gamble trained the 16-year-old interns in basic performance improvement tools, including the Rapid Improvement Model, process mapping and Labor Management Partnership basics. By the second week, the youth were assigned to Level 1, 2 and 3 unit-based teams and started helping the teams launch projects and enter data into UBT Tracker.  

Rosemary Sanchez, Modesto’s Emergency Department supervisor, was one of the loudest doubters.

“At first I was like, ‘Ugh, one more thing to do.’ But then I thought, ‘OK, this could work and help us accomplish our goals and share our knowledge.’” 

Intern Nate Aguirre was crucial in helping the team on its project to streamline and standardize supplies in the treatment rooms.

“Nate was awesome,” Sanchez says. “He was so enthusiastic collecting data.”  

Getting the ball rolling

Aguirre also spent time talking to employees in the department to learn about their jobs and the challenges they face in their work.

Meghan Baker, an Emergency Department clerk and union co-lead for the UBT, says that sparked interest and support from UBT members—a shift from before, when they had struggled to get employees involved.

“People were into having their voice heard by someone,” says Baker, who's a member of SEIU-UHW. “Now people are talking and getting the ball rolling on things. And we’re making it known that people are being heard.”

At the start of the program, the Emergency Department UBT was ranked at Level 3. The team advanced to Level 4 after completing the work.

Michelle Smith, manager of Specialty Surgery Reception, appreciated the new perspective and support her team received from its intern for its project to reduce surgery no-shows and last-minute cancellations.

“It was nice to have someone get our project going,” she says, “because we were at a standstill.”

The team’s intern walked the UBT members through mapping out their process. New workflows emerged that included calling patients ahead of scheduled surgeries, which reduced no-shows and increased service scores.

When the teams were asked what they thought helped them advance, many said it was because of the interns coming to the departments every day to help push and support the work. 

“We would have eventually worked on the project, but having her come in and start us off in a positive way was great,” Smith says. “She taught us how to be a team, because we realized we all had to be part of the work.”

Want a safer workplace served up on a silver platter?

Then stop by the operating room at Kaiser Permanente’s West Los Angeles Medical Center in Southern California. Surgeons and the other health care workers there pass sharp instruments to one another on silver trays—rather than passing them hand to hand—which reduced injuries related to handling sharp instruments during procedures by 34 percent between September 2013 and May 2014.

“We can see the results,” says Lisa Duff, a surgical tech and workplace safety champion at the facility. This success is part of a new emphasis at the facility on task standardization—analyzing each step of an activity, identifying the potentially hazardous steps, coming up with a safer way of doing things and then ensuring everyone follows the new process the same way, every time.

How to reduce risk

“Injuries occur when there is not consistency,” says Tracy Fietz, chief administrative officer for Southern California Permanente Medical Group at West L.A.  “If you break [a task] apart on a fishbone diagram, you can identify where the risks are. It is about removing variation.”  

Standardizing practices also has helped several departments reduce—and in some cases eliminate—sharps-related injuries for up to 17 consecutive months. It’s also helped reduce injuries to EVS workers by 75 percent when they clean floors.

Another practice that is improving safety at West L.A. Medical Center is regular monthly meetings between senior leaders,  including Fietz, and the labor and management safety leaders of targeted departments. Departments that have special line-of-sight safety goals (see below) in the region’s Performance Sharing Program get special attention. The gatherings are a space to analyze processes, see what’s working—and what isn’t—and collect information to share with others.

How partnership helps

“I work with managers and the workplace safety champions, because it’s a partnership,” says Nor Jemjemian, the chief administrative officer for Kaiser Permanente Hospital/Health Plan at West L.A., who also leads those meetings. “I want the employees doing the tasks to be part of the solutions.”

Union-represented employees, for their part, appreciate the crystal-clear message top leadership is sending.

“You need management to back you up when you speak up,” says Duff, a member of SEIU-UHW. “Employees know that our managers will back them up 200 percent.”

Open communication, trust and partnership processes are the foundation of a safer workplace, says Jemjemian.

“When I was an employee, there were [hazardous] tasks I did that my manager didn’t know about,” he says. Today, in contrast, “UBTs create a venue and a forum to discuss the everyday work.”  

The Transportation department in the Northwest is coming out of a tumultuous time. A lack of trust between managers and employees created a barrier that affected morale—and made it difficult to focus on improving routes and processes.

The department uses a robust but complex process for optimizing its routes. For maximum efficiency, it has to integrate a variety of work streams and figure out where there are redundancies that can be eliminated. Because of the complexity of the process, however, it had been more than 15 years since the criteria and requirements for the transportation system from the customer’s point of view had been reviewed.

Eventually, the UBT worked out a thorough route-modernization plan based on data-driven service requirements and metrics that established parameters on how to revise and design its routes.

But before it got there, it had to fix its communication, which broke down so badly the team entered into an issue resolution. In the Northwest, the LMP Education and Training department is responsible for facilitating issue resolutions.

Blame-free solutions

“There was a lot of tension in the department, and people were nervous about losing their jobs as a result of our work around revamping routes. Poor communication was a problem,” says Greg Hardy, sponsor and manager of the department.

The issue resolution process uses interest-based problem solving, and that helped the team focus on a common goal: Serving its customers was the top priority and improving communication was a necessity. From there, other agreements came more easily, and the department was able to maintain staffing levels and improve processes as a result of its efforts.

Improved communication improves service

As a result of the improved communication, the team was able to improve service levels and achieve the efficiency and cost savings it had strived for.

“We have a group of dedicated workers who want things done the right way,” says logistics supervisor Chris Dirksen, the team’s management co-lead.

When it came to improving communication, the team members’ first step was to get a baseline measurement of what they were trying to improve. They created a survey that would measure not only communication but also morale and UBT effectiveness. Once they had that information, they created a SMART goal: to improve employee perception of communication, morale and UBT effectiveness by 15 percent within three months, raising the overall survey score from 2.55 to 2.93 by February 2014.

As the team began to investigate the issues, it discovered email was not a good form of communication. Fewer than 20 percent of the team members knew how to log on and use Lotus Notes. The team brainstormed ways get employees to use Lotus Notes email and frontline staffers began to instruct and coach one another.

Three months later, the team sent the survey out again and found it had met its goal. Perception of communication improved 48 percent, morale improved by 56 percent and UBT effectiveness improved by 21 percent. The team scored 3.4 on its survey, exceeding its stretch goal of 2.93, and anecdotal reports are that the communication success is continuing now that the team has successfully completely the issue resolution.

New ways to communicate

Team members use several means now for communicating with one another, including email. A communication board has been set up in the department’s headquarters, near dispatch, that includes information about the projects the team is working on, notes from UBT meetings and a copy of the department’s weekly e-newsletter, “Heads Up.”

In addition, the team has gone from a representative UBT to a general membership UBT and now has regularly scheduled meetings throughout the region, so that all employees are able to participate. “This has been our biggest success to share information,” says UBT union co-lead Nickolas Platt, a courier driver and member of SEIU Local 49.

“It’s cool to watch from meeting to meeting how more people show up each time,” Hardy says. “The engagement of the team has increased as we began to see improvement, and people could see change.”

Hundreds of Kaiser Permanente health plan members live in the rural communities of Kern County. Faced with driving yawning distances through winding, sometimes snow-covered mountain passes, many find it daunting to come to clinics for medical care. So in March 2012, KP leaders in the service area started to bring care to these members via a mobile health vehicle.

Great idea, right? But first, they had to figure out the details. How many providers and staff members could fit in the van? Who was going to do which tasks? Could medical office assistants collect co-payments and schedule appointments? Or would they be too tied up giving shots, checking HealthConnect for care gaps and performing other duties? And what would the van drivers do when they weren’t driving?

Rewriting the playbook

The old-fashioned playbook would call for the union to insist that KP hire a receptionist for the van and for the employer to exercise its prerogative to do whatever it wanted. But the Labor Management Partnership is strong in Kern County, so union and KP leaders worked out a solution that transforms care delivery and provides a model for how jobs of the future can be flexible, innovative and satisfying. On Kern’s two mobile health vans, the drivers take on reception tasks, such as collecting co-payments and booking appointments.

“I love member service,” says driver Alfredo Alvarez, a UFCW Local 770 member. “We are in contact with doctors, nurses and members.” He and fellow driver Javier Gonzalez spent several weeks receiving additional training in clinics and a call center. “I am getting paid, so why not stay busy and learn new things?” says Alvarez. Today, the clinic on wheels provides more than 500 doctor and nurse visits a month.

Keeping up with change

Holly Davenport, a UFCW Local 770 union representative who helped negotiate the innovative work agreement, says she sometimes hears resistance from union activists who wonder if this type of arrangement will lead to job losses. “We have to keep up with the way health care is changing,” says Davenport. “We did this in partnership. I heard what management had to say, they heard what I had to say, and we worked it out.” 

Davenport gives credit for the successful solution to her strong, trust-based relationship with Candace Kielty, an assistant medical group administrator in Kern. Says Kielty: “My role as a manager is to paint the big picture. We want to serve an underserved population, and we want to meet people where they are.”

However, Kielty says creative problem solving cannot rely solely on individual relationships, but must be built into the structure and culture of Kaiser Permanente through the Labor Management Partnership.  

“When I hire department administrators, in the orientation and mentoring, I talk about developing trust,” says Kielty. “It's an expectation.”