Quality

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!

I am reminded of the old joke about the holiday ham:

A young bride is preparing her first holiday ham as her adoring husband watches. She slices off one end of the ham and sets it aside and puts the remainder in her roasting pan. “Darling,” her husband asks, “why did you lop off the end of the ham?”

“Why—I don’t know. My mother always did,” she replies. Curious, they call her mother, but her answer echoes her daughter’s: “My mother always did.”  When grandma is called, she has the same answer.

Happily, great-grandma is still on the scene. Her answer to the question is quick: “Why,” great-grandma says, “so it will fit in the pan!”

The obvious point being that sometimes we need to question whether old routines still serve us well. A more subtle point for anyone involved in improving performance is to recognize a workaround for what it is. The more than 3,500 unit-based teams at Kaiser Permanente have daily opportunities to question “the way we’ve always done it.” And as team members become skilled at problem solving and create a culture where asking questions is encouraged, they can create systemic solutions to recurring problems.

In these and other ways, they will create more efficient, cost-effective and safer ways to deliver quality health care. It is essential work, as the cover story of this issue, “Affordable Health Care for All,” makes clear. And the work already is well under way: Every story in the Winter 2013 issue if Hank highlights a different way that teams are improving quality while working to keep Kaiser Permanente affordable.

Kaiser Permanente is the model for the future of health care. Check out this issue's stories and be inspired.

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.

Colorado

The nurses in the Primary Care department at the Englewood Medical Office were short-staffed due to medical leaves and feeling overwhelmed. Messages from patients were piling up in the electronic inbox in KP HealthConnect. So the team brainstormed ideas, and the physicians offered to help clear the backlog. After testing a couple of time blocks, the doctors began setting aside 30 minutes every morning and afternoon to triage messages and call patients back directly without involving the nurses. As a result, the team consistently closes encounters within an hour more than 40 percent of the time—and, with more problems resolved by phone, access for patients needing in-person appointments has improved. Morale in the department is up, too—and the team recently won the region’s quarterly “Value Compass” award.

Georgia

At the Crescent Centre Medical Office Building in Tucker, the Adult Medicine unit-based team is closing care gaps, managing chronic conditions better and improving screening rates for colon cancer—all key elements that differentiate Kaiser Permanente from its competitors. For example, the team increased the percentage of patients with diabetes getting the recommended blood sugar control and cholesterol tests by enlisting licensed practical nurses who help review, print and process pending test orders. To increase colon cancer screening rates, the team began tracking the number of take-home screening kits handed out by providers and made outreach calls to patients who didn’t return them. Starting from scratch, the team ramped up rapidly and handed out 173 kits between September and December 2012 and achieved an impressive return rate of more than 76 percent.

Hawaii

At the Moanalua Medical Center’s 1 East unit, patients are learning more about their medications,  thanks to a successful test of change by the medical-surgical nurses. Two significant steps helped the Honolulu unit-based team achieve its goal of increasing patients’ medication awareness: Nurses took the time to review a single prescription and its common side effects with each patient, and then they reinforced the information at subsequent office visits. A follow-up survey showed that the percentage of patients saying they understood their medications and the possible side effects increased from 36 percent to 50 percent in just three weeks in May.

Mid-Atlantic States

Several UBTs have joined the region-wide Member Demographic Data Collection Initiative, gathering crucial information about race, ethnicity and language preference. The data is needed to fulfill accreditation and contractual requirements—and, even more importantly, to eliminate health disparities and provide culturally competent care. In Springfield, Va., the Pediatrics team increased data collection from 46.8 percent of patients to 95 percent in less than two months by changing its workflow. In addition to nurses surveying patients in exam rooms, the team’s receptionists start data collection at check-in. Using laminated cards to describe ethnicity choices helped the Reston, Va., Pediatrics team improve by 10 percentage points. Region-wide rates improved 31 percentage points since May 2011, says Tracy S. Vang, the region’s senior diversity consultant.

Northern California

The benefits of performance improvement work aren’t just in the results. Sometimes the work helps teams discover the crucial role they play in providing quality care. That’s what happened when the Richmond Medical Center’s patient care technician team set out to improve its workflow. The technicians, who help hospital patients get up and moving, had been meeting only 45 percent of physicians’ mobility orders. Their goal was to reach 75 percent by October 2012. By September, the team was fulfilling 95 percent of daily mobility orders. Communication with nurses and physicians improved, and the work had an added benefit: By helping patients get up more regularly, hospital stays were shortened, which is estimated to have avoided $600,000 in costs over five months.

Northwest

By eliminating variation and wasted time, the regional lab’s Histology unit-based team improved slide turnaround time by 11.8 percentage points from its starting point in 2011 to April 2013. The team has reduced delays by tracking its slide volumes every hour, implementing huddles and adding additional equipment to minimize downtime due to lack of equipment. These improvements also helped improve employee morale: People Pulse scores for the department Work Unit Index increased by 30 points from 2011 to 2012.

Ohio

The Labor Management Partnership is supporting frontline employees as the region transitions to become part of Catholic Health Partners. Once the process is complete, employees, physicians and operations and administrative personnel who are currently part of the Ohio Permanente Medical Group and Kaiser Foundation Health Plan-Ohio will become part of Catholic Health Partners. They will continue to work in the existing medical offices in Northeast Ohio.

Southern California

Being accurate 98.9 percent of the time sounds pretty great. But the Central Processing department at the West Los Angeles Medical Center sterilizes almost 4,000 trays a month, so even a tiny drop in accuracy can disturb Operating Room efficiency. But with managers and employees working together to analyze the department’s data, the unit-based team was able to reach its goal of 99 percent accuracy between June and August 2012. It continues to maintain that level of precision by using a buddy system to audit instrument trays, involving lead techs in quality assurance spot-checks, posting tray accuracy reports in break rooms and holding weekly meetings with the Operating Room department administrator.

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.”

Colorado

More than 60 trained champions are helping to motivate co-workers in their facilities to live a healthy lifestyle. Employees, managers and physicians are taking part in health fairs, 5Ks, healthy potlucks and Instant Recess™ sessions throughout the region. The region is also participating in the Spring Into Summer Challenge, a program-wide, team-based KP Walk activity to encourage walking during the longer daylight hours. Teams are forming with people of all fitness levels, especially employees who aren’t normally active. “Any change toward a healthy lifestyle is a success,” says Susan Mindoro, Total Health labor liaison for UFCW Local 7.

Georgia

The Southwood Specialties gastrointestinal UBT in Georgia increased efficiency and saved money by scheduling contract physicians, patients and nurses more strategically. The department handles both anesthesia cases (which require a physician to perform) and also sedations (which can be done by nurses). This Level 4 team figured out how to schedule contract physicians for four days a week instead of five by tracking which patients needed what level of care—making the most efficient use of a very expensive resource. The project required agreement, communication and coordination between the GI providers and teams at four KP clinics in Georgia to schedule their cases accordingly. The project saved $113,000 between April 2013 and January 2014.

Hawaii

After the nurses at Hawaii’s Ambulatory Surgery and Recovery unit created a brochure that standardized the information given to members during their visits, patients have a better understanding of wait times, department hours, visiting hours, where to get parking validated and the location of key departments. The team surveyed selected patients three times from October 2012 to April 2014. Team members tweaked information in the brochure based on feedback, says Maria Scheidt, an RN and member of the Hawaii Nurses Association, OPEIU Local 50. After the first survey, 70 percent of patients reported they received and understood the brochure. After the second survey, 90 percent said they understood it. By the third survey, the nurses had successfully educated 95 percent of patients.

Mid-Atlantic States

From Virginia to Maryland to Washington, D.C., nutritionists in UBTs identified children at risk for obesity and recruited them for Kaiser Permanente’s Healthy Living for Kids and Families course. Piloted in Northern Virginia, the project tracks the success of 11- to 14-year-old patients in establishing healthy eating habits, increasing daily activity and bolstering self-esteem. By drinking less soda or juice, exercising each day and curbing television viewing, a third of participating children at one medical center lost an average of 5.8 pounds in three months. Team members credit their partnership with pediatricians and the families for the results. 

Northern California

The region’s new Real-Time Attendance Estimator does what no other tool has done before: It projects into the future. The tool lets a cost center see how sick day use is affecting its ability to meet its year-end attendance goal by calculating the number of sick days that could be taken in an upcoming pay period without derailing progress toward that goal. If the number of sick days being taken needs to be reduced to meet the goal, the estimator shows that, too. The information is shown as a signal light—easy to print out and post.

Northwest

Fifty-eight percent of staff members in the Northwest who are eligible for the Total Health Incentive have taken the Total Health Assessment—one of the highest participation rates program-wide. Members of unit-based teams are finding ways to help cover each other so they have time to take the assessment. Managers are backing the effort, which is a key step in earning the incentive. “Since the UBT agreed that the THA would be a project, I supported folks completing the assessment during work time since it is work- and goal-related,” says Jason Curl, department administrator for Primary Care at Tualatin Medical Office. 

Southern California

The region’s Jobs of the Future Committee has assigned four subgroups to identify trends in technology and innovative care delivery methods. The subgroups are inpatient nursing, ambulatory nursing/primary care, laboratory and diagnostic imaging. Each is led by labor and management partners. The groups are researching the impact of innovations on today’s jobs and making recommendations regarding training and recruitment of the workforce of the future to best support these initiatives. Work already is starting, for instance, at the South Bay Medical Center, which is exploring new staffing models as part of its plan to open a mini-medical office building—which is in turn part of the larger Reimagining Ambulatory Design initiative. In Kern County, UFCW has collaborated with management on a mobile health van project to optimize staffing for this creative way to deliver care.

It took a whack on the head—literally—for Tedros Tecle to learn the importance of speaking up.

Tecle is a rad tech at our Santa Rosa Medical Center. Because of a less-than-ideal setup, he banged his head on a mobile X-ray machine. He wasn’t hurt, just really embarrassed. Enough so that he didn’t say anything.

You can guess what happened next: Another tech did the same thing and was injured. The experience motivated Tecle to become a facility workplace safety tri-chair and a champion for speaking up.

Keeping employees, managers, physicians and patients free from injury requires a #FreeToSpeak culture, one where halting work to address a safety concern is a cause for gratitude, not—as in some workplaces—scorn.

In fact, a #FreeToSpeak culture is the foundation for being able to do what we value most at Kaiser Permanente and in the Coalition of Kaiser Permanente Unions: providing high-quality care and service at an affordable price and the best place to work for our employees.

To do that, everyone on our unit-based teams—no matter their role or job title—must feel free to chime in with suggestions about how to make things better, no matter how wacky or inconvenient their ideas might seem. That’s not yet the case; responses to KP’s annual People Pulse survey show the need for improvement.

Creating a speaking-up culture takes time. In this issue of Hank, you’ll find tips and tools to get started and keep going, whether you’re a frontline manager or a union-represented employee. And you’ll hear from the Humans of Partnership who are, more and more, #FreeToSpeak.