Unit-based team concepts

Patient safety is about more than the hands-on care delivered in a hospital or clinic. It’s also about what caregivers do to close care gaps and be sure patients get the care they need.

To ensure this happens with every abnormal prostate, breast, pelvic, osteoporosis and fecal exam, the Georgia region established a centralized Outpatient Safety Net Program. Almost four years ago, borrowing techniques from Southern California’s successful safety net program, the Georgia region dedicated the equivalent of four full-time and one part-time nurse. Their jobs: to continue reaching out to patients who don’t respond to an initial contact regarding an abnormal test result.

The program is saving lives—and has earned KP’s 2014 David M. Lawrence Patient Safety Award in the transfer category, an award for a region that successfully implements a project from an earlier award winner. The Southern California safety net system had won a 2012 Lawrence award for its work.

“If you have an abnormal stool test, you should be seen in gastroenterology,” says Rahul Nayak, MD, who served as physician program director of patient safety for Georgia when the program launched. “It will raise a red flag in our system if that doesn’t happen in a certain amount of time. That’s why it’s called a safety net—it’s the net below the tightrope walker.”            

Making contact with patients

Sonja “Patrice” Evans, RN, is the manager of Georgia’s outreach effort and leads the group of nurses. She also steps in to convince members who initially say they don’t want to come in for further testing. “We can prevent something small from turning into something big,” she says.

The nurses receive a list of patients who have abnormal results. They make two attempts to reach them by phone and send a certified letter if the calls don’t work. “Our team tries to catch a small group of patients before they fall through the cracks,” Evans says.

So far, it’s working.

A systematic approach

In 2013, the most recent year for which data are available, 4,000 members were contacted about abnormal breast exam results. Of those, 93 percent were successfully scheduled for a follow-up appointment within the prescribed seven days. For abnormal pelvic exam results, 2,000 members were contacted, and 95 percent of those were scheduled within seven days.

Five hundred members—most of whom had declined or not responded to previous contacts—were reached within 100 days of abnormal prostate exam results; 87 percent scheduled a follow up. The team contacted 200 members with abnormal osteoporosis exam results, and more than 70 percent scheduled a follow up within 30 days, which exceeded the Medicare 5-Star guidelines.  

Dr. Nayak, UBT co-lead for gastroenterology at Southwood Medical Center, says one of his patients benefited from the program.

“Our safety net caught a positive (fecal occult blood test) that I had missed two months prior,” he said when accepting the Lawrence award on behalf of the team. “That patient had an advanced adenoma which was well on its way to malignancy. Without the safety net, there is no guarantee that we would have found this polyp” in time.

Now, Georgia’s program is expanding and will include other types of patient notifications.

A former KP administrator, Michael Belmont now works for Restructuring Associates Inc., the consulting firm that helped during the creation and initial implementation of the Labor Management Partnership and that now helps facilitate national bargaining. He sees interest-based bargaining as a way to solve the problems of the future, before they arise, instead of getting stuck dealing with the baggage of past grievances.

My time at Kaiser Permanente dates back to the late 1980s. I was assistant hospital administrator in Panorama City, dealing with several unions. We were facing so much discord. It was all-encompassing, and it took the focus off improvement issues. The move toward interest-based bargaining and [the] Labor Management Partnership allowed us to put the focus on improving the member experience instead of continually trying to resolve labor problems.

Partnership, especially interest-based bargaining, gives employees and their unions a chance to have an impact on things they might not otherwise. They have a say beyond wages, hours and working conditions. In 2012, there was a bargaining subgroup on growth, focusing both on growing Kaiser Permanente and the unions. In a traditional setting, that doesn’t happen. For employees and their unions, the other side of the interest-based process is responsibility and accountability to take on and help solve the problems of the organization.

When we do trainings on interest-based problem solving, people will say, “This is how I deal with relationships.” If you are going to be a good partner—and have a successful relationship with a partner, kids, friends—you have to have your partner’s interests in mind as well as your own. Making this connection helps people connect the strategy to their work lives.

After 2000 bargaining, the Southern California region was looking for a change in labor relations, away from traditional, toward partnership. We were trying to move labor relations away from being a wall between the unions and management and toward facilitating a productive relationship between unions and management. I saw a gradual transition toward more of a partnering role. I left KP in 2006. I could come back [with Restructuring Associates] as a neutral [party] in 2010 and 2012 because of the [nature of the previous] relationships with union and management officials.

Interest-based bargaining is focused on solving problems up front rather than on grievances. People have to unlearn a lot of habits and build a lot of trust. There was 50 years of baggage [when the partnership started]. A traditional approach leaves lots of scars. Traditional is the comfort zone for most organizations. Traditional approaches are backwards looking: They are about solving problems from the past that pile up and wait for bargaining. Interest-based bargaining is about solving problems and issues that may come up in the future. Using the interest-based approach in bargaining and in day-to-day work is a much more forward-looking way to solve problems—and so much more effective.

Inspired by the goals of the worldwide “Baby-Friendly Hospital” initiative, the Health Education UBT at the Manteca Medical Center in Northern California set out in early 2012 to increase the percentage of new mothers who exclusively breastfeed. At the time, the number stood at 70 percent.

Steps emphasized by the initiative, sponsored by UNICEF and the World Health Organization (WHO), include training health care staff to inform every pregnant woman of the benefits of breastfeeding and to help mothers begin breastfeeding within one hour of giving birth.

Closing care gaps

The challenge was that while Manteca health educators provided prenatal services to expectant mothers, the moms went to Modesto to deliver their babies. The Manteca employees didn’t always learn whether their patients ended up breastfeeding. In order to make sure their patients were getting full support for breastfeeding as they made the transition from prenatal care to labor and delivery and beyond, the members of the Manteca UBT reached out to their hospital colleagues.

“As a Health Education department, we provide breastfeeding education during their prenatal care, but we were not reaching 100 percent of…moms after they switched to hospital services,” says Maria Prieto de Milian, a health educator, lactation consultant and active SEIU-UHW representative on the Manteca UBT. “There was not a consistent breastfeeding message.

“Our moms were in need of a continuum of care for breastfeeding.”

Researching best practices

The Manteca team, which meets monthly, is linked to a larger Health Education UBT at Modesto. The larger team meets quarterly and includes Modesto employees as well as the employees from the smaller teams at Manteca, Tracy and Stockton.

After researching best practices in breastfeeding support and exploring what other Kaiser Permanente locations were doing, the Manteca team introduced two small tests of change:

• Working with the larger Modesto UBT and with full support from the Women’s Health department, the Manteca team set in motion a collaborative approach to breastfeeding support involving health educators, lactation consultants, physicians, pediatricians, medical assistants and nurses. This includes hospital employees encouraging observance of the “golden hour” immediately after birth, when a newborn is placed skin to skin on the mother’s chest to promote bonding and breastfeeding.
• The team worked with other employees to make sure mothers-to-be were asked about breastfeeding at the regular 28-week prenatal visit, and that their questions or concerns were directed to lactation educators for follow-up.

The results were dramatic. By the end of 2012, 92 percent of Manteca prenatal care patients who delivered at the Modesto hospital were exclusively breastfeeding.

The umbrella UBT decided to spread Manteca’s idea.

“We turned it into a service-area initiative. It started as a pilot just for Manteca, and then the group decided it was so beneficial we’d roll it out to the whole Central Valley,” says Jose Salcedo, the management co-lead for the larger UBT. “The results were really conducive to parents and moms having a great experience. It’s a whole pathway from the early stages of pregnancy to the delivery and then to the pediatricians.”

“The breastfeeding initiative is now regular workflow throughout the Central Valley,” Salcedo said.

Good results sustained

At the time the Manteca UBT started its effort to improve breastfeeding rates, the Modesto hospital was working to achieve the Baby Friendly designation from the UNICEF-WHO program. After making significant progress toward that goal, it switched its focus to implementing the Northern California region’s Breastfeeding Toolkit, a new program that encompasses the same goals.

It's now been almost two years since the small tests of change, and Prieto de Milian says the Manteca UBT no longer is tracking the rate for its moms, viewing the project as a continued success.

New ideas are continually being added to strengthen the process. These include the advice call center providing 24/7 breastfeeding support while also scheduling follow-ups to the calls with lactation educators. In addition, lactation consultants are available to assist pediatricians by phone or by email on KP HealthConnect® during patient appointments.

With everyone’s minds and hearts on one goal, Salcedo and Prieto de Milian say, teamwork was seamless.

“What I like about the UBT is it’s a joint effort,” Salcedo says. “We have really good lactation educators who think outside the box, search for best practices and apply them. They went ahead and ran with it and made the recommendations. Management supported them all the way.”