Team levels

Angela Chandler and Nee Tang, Pharm.D., didn’t like what they were seeing.

The team co-leads for the West Los Angeles Ambulatory Care Pharmacy crouched beside Camille Wong, scrutinizing her posture as the pharmacist and UNAC/UHCP member sat typing at her computer.

After a quick huddle, the pair worked together to adjust Wong’s chair until she was sitting in the ideal position to protect her from pain—and a potential injury.

“I didn’t know I could adjust my chair this way. It feels good,” Wong said appreciatively, her feet resting flat on the floor and her legs bent at the appropriate 90-degree angle.

Shift in culture

Such peer safety rounds are one of the hallmarks of a dramatic shift in culture for the team, a shift that has built engagement and created a workplace where frontline workers feel confident speaking up. The department went 3½ years without injuries and earned a national workplace safety award earlier this year.

“We’re all in it together, and we’re all here for each other,” says Chakana Mayo, a pharmacy technician and UFCW Local 770 member who is the team’s workplace safety champion.  

But the situation was not always so bright.

In 2011 and 2012, the department experienced a spate of workplace injuries. Employees, who spend most of their time on phones and computers, were sometimes reluctant to report pain—including one who suffered a repetitive motion injury so severe that it required two surgeries and time off from work.

“It was really a wake-up call,” says Tang, a pharmacy supervisor and the team’s management co-lead. “We needed to make sure that everyone feels comfortable enough to speak up when they have a problem.”

As a union partnership representative (UPR) from UFCW Local 770, Annamarie Marin helps support 72 unit-based teams at the West Los Angeles Medical Center. Last year, she helped the Oncology team overcome low morale to move from Level 2 to Level 4—and it’s now on the cusp of achieving Level 5. Marin recently was interviewed about her role as a UPR by LMP Communications Manager Sherry Crosby.

Q. What experiences helped prepare you for your position?

A. I have been part of UBTs since 2005. I started as a co-lead and then became an executive sponsor. This experience helped me tremendously, because I can relate to the teams on a personal level. I have been in the exact same place, dealing with similar challenges.

Q. What is your approach to working with teams?

A. Some teams need team-building exercises, while others need to learn to trust one another and share information on projects. Starter teams don’t know how to create agendas or structure meetings, so I help facilitate their meetings. The most important thing is making sure I’m available and that teams have what they need to succeed.

Q. What early challenges did the Oncology team face?

A. They were struggling with membership involvement and morale was low. Nobody wanted to participate in meetings.

Q. How did you help the team succeed?

A. I helped staff members understand that the UBT is not there to add work to their plate. Eventually, we got a group to participate in team meetings.

We went through different trainings and started on small projects. First, they focused on staff morale. Staff members practiced expressing appreciation for each other until it became part of the team's culture. Then they moved to an affordability project. That was a pivotal point in that team’s development, because the idea came from a labor partner.

It shows team members are involved in decision making and contributing to the department’s success.

Q. What was key to the team’s success?

A. I helped the team members understand their work through a different lens—what the function of a UBT is, and their role in it. They realized they have a great department and an engaged manager. It was really about helping them understand their value to each other.

For San Jose Medical Center’s inpatient pharmacy, the road to becoming a high-performing team first required a step—actually a jump—backward.

When the unit-based team was launched in 2010, it quickly was rated at Level 4 on the Path to Performance, the scale for evaluating a team’s effectiveness. The highest level is 5.

“We took it seriously and followed the process,” says Anita Nguyen, inpatient pharmacy director.

Then, in 2012, Nguyen, along with the team’s management and union co-leads, met with UBT consultants to assess their team performance. As they ticked down the list of questions and started to contradict one another, it became painfully clear: They were not the high-performing team they had previously thought.

“As a team we couldn’t answer the questions,” Nguyen says. “It was embarrassing.”

They were knocked down to a Level 1—the most fundamental rating.

Today, the team is a true Level 5, a highly functioning team that recently completed a successful stockroom project to reduce how many drugs are wasted, which is saving more than $10,000 a year. The success is a direct result of opening the department’s budget to the team, which only came about after team members started speaking frankly with one another.

The team’s downgrading was a painful, humbling blow, but most members agree that the assessment was valuable in putting the team on track to do this work and to earning the highest performance rating.

“I was not aware of what a UBT could really do for staff and managers,” Nguyen says. “We recognized the failure and I said, ‘I need you. Let’s work together.’”

Transforming teams

Inpatient pharmacy was one of several teams that shared their transformation stories at an event in July at San Jose Medical Center for national Labor Management Partnership leaders. The meeting spotlighted the medical center’s innovative approach to evaluating UBTs and supporting them in delivering the best care possible to Kaiser Permanente members.

Every quarter, San Jose UBT union and management co-leads sit down with their union and management sponsors, and with UBT consultant Heather Williams and Union Partnership Representative Eric Abbott, who support UBTs for the service area. Together they compare the team’s development against the traits outlined in the Path to Performance, including communication among team members and the status of improvement projects. The group then develops a plan for closing gaps, removing barriers and advancing to the next level.

The power of the process is in asking the critical questions, says Joan Mah, the UBT consultant for the San Rafael Medical Center, which has adopted the assessment practice. “Can your team members talk about the metrics? Kinda, sorta? Well if they can’t, we need to connect them with the skills to learn how. The whole point of this is supporting and strengthening. It’s an honest conversation.”

The assessment requires time and commitment from all parties, but by many accounts it is well worth the investment. In addition to San Rafael, which is seeing teams transformed through the process, the approach is being piloted in the Diablo and the Central Valley service areas.

The leap forward

For San Jose inpatient pharmacy, as candid and rigorous as the evaluation process was, it was also invaluable.

“We had to talk about what we really wanted,” says union co-lead Gubatan, an SEIU-UHW steward. “We basically said, ‘Let’s be truthful now. Let’s really do the work.’ ”

The team dramatically improved communication, developed trust, and engaged its members in the journey toward improvement.

“Everyone is empowered to contribute to this process,” Nguyen says. “Before, nobody questioned. Now everyone is empowered to question. With that, people feel like they really belong to the process.”

Kaiser Permanente and the Coalition of Kaiser Permanente Unions set an ambitious goal in the 2012 National Agreement: to have 75 percent of all unit-based teams achieve high performance by year-end 2014—for good reason. As teams develop, they deliver better, more affordable care and a better work experience.

There’s work to be done. More than 60 percent of teams in Georgia, Hawaii and the Northwest are meeting the goal, but overall, just 52 percent of KP’s 3,500 UBTs program-wide were rated high performing as of June 30.

The good news is that nearly 1,800 teams across KP have hit their mark, built performance improvement into their everyday work, and are showing other teams how to do the same.

Modeling the way

The Perioperative UBT at Ontario Medical Center in Southern California is one of those teams.

“It’s about having everyone involved and engaged,” says Michelle Tolentino, RN, one of the Perioperative UBT’s union co-leads and a member of UNAC/UHCP. “We attended UBT training together, got results on our first project (safely reducing patient stay times) and kept rolling.”

The 11-member representative team, which covers more than 60 nurses, surgical techs, medical assistants and others, reached Level 5 on the five-point Path to Performance soon after forming in 2012. Like many other teams in the region, it saw its rating drop in 2013 after a labor dispute led union members to suspend their UBT involvement. When the issue was resolved, the team regrouped and quickly regained its Level 5 rating.

The secret sauce

The team does a few key things right that helped it achieve and now maintain its high performance. Those can be modeled by other teams aspiring to Levels 4 and 5 status:

• Performance improvement tools: “Using our performance improvement tools—process mappings; run charts; plan, do, study, act cycles—keeps us all sharp,” says Mary Rodriguez, assistant clinical director and UBT co-lead. “That’s been key for us: understand the process and use the tools.”
• Constant tests of change: The Perioperative team now has seven active tests of change, most focusing on improving affordability and workflow efficiency. “Our projects often build off of other projects,” says Rodriquez. For instance, a recently completed project helped reduce turnaround time in the OR from 28 minutes to 20 minutes in three months. In a parallel project, the number of patients receiving medication at least 30 minutes before surgery—the ideal time for most patients—increased from 70 percent to 85 percent. Such projects draw on the whole team’s skills and perspectives, she says.
• Physician involvement: Shawn Winnick, MD, an anesthesiologist, assistant clinical director and UBT member, points to another key to success: “Physician presence on a (clinical) UBT is extremely important,” he says. “It brings a different perspective to projects.”

Calling UBTs “the single most powerful vehicle we have at KP to empower employees and lead change,” he notes that physician leaders at the medical center have supported UBT development and helped overcome barriers.

“Staff and physicians need to have the time to consistently make it to UBT meetings,” he says. “Even if it means bringing in someone to cover part of a shift, that is more than paid back by the cost savings and organizational benefits that come out of UBTs.”

The benefits accrue to the workforce as well as patients.

“We have a say in our work process,” says Robert Kapadia, a certified registered nurse anesthetist and member of KPNAA. “I come to the table as an equal partner and advocate for others on the team, and for our patients. Our UBT is a way to solve problems and move forward, not just complain.”

Dr. Winnick adds: “There’s not a single member of our team who hasn’t contributed an idea or helped make us better. That’s a measure of a performance. We all have different skills and perspectives, and we bring all of that to our team.”

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.”

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.