Value Compass Concepts

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!

Colorado

When the Minor Procedures department at the Franklin Medical Office added three surgeons to its staff, the impact was positive: Access improved—patients got in faster. But staff members noticed the new surgeons were using $20 to $30 more in dressings and drapes than surgeons who had been in the department longer. The physicians responded positively when shown the information and, while allowing for medically justified exceptions, have standardized their usage of soft goods so it is more cost effective.

Georgia

The Oncology/Infectious Disease staff at the Cumberland Medical Office Building embarked on a medication reconciliation project to keep patients safe and avoid unnecessary hospital admissions. A manual cleanup of patient records came first. To check the accuracy of the records, medical assistants and licensed practical nurses, all members of UFCW Local 1996, called patients and asked them to bring their medications (or a list) to their next appointment. Providers deleted duplicates and worked across clinical disciplines and with pharmacy colleagues to sustain and improve the process. In just three months in 2011, the percent of duplicate medications fell to 15 percent, which translates to $90,000 saved by reducing hospital admissions.

Hawaii

The nurses in the 23-bed Mother/Baby unit at Moanalua Medical Center learned a lesson in human nature when they placed life-saving emergency airway kits—essential for keeping a weak infant's airways unobstructed—at each bedside. Individual parts of the kits come in handy in other procedures and regularly turned up missing. Keeping everything in zippered plastic bags with a “do not remove” sign didn’t do the trick. But after the team started re-purposing breast pump kit bags--which are sturdier and have labels with room to list the kit’s contents, whether an item has been used and if it’s been replaced—the team went from 75 percent of beds with fully stocked kits to 100 percent in four months.

Mid-Atlantic States

The Adult Primary Care UBT in Falls Church, Va., is using the New Member Identifier tool in KP HealthConnect as the basis for targeted welcome letters and phone calls to set up appointments with primary care physicians and help refill prescriptions. And, when a new member comes in, he or she is provided with a new member kit and offered a one-on-one facility tour. Patient satisfaction percentile scores have risen from 84.6 in the first quarter to 87.4 in the third quarter. Cassandra Hodziewich, MD, a family practice physician, says more new members “are getting needed labs (and) screenings."I think it’s made a difference in the quality of their care."

Northern California

Santa Clara Medical Center showcased its performance improvement work in October to eight UBTs from five regions as part of a two-day LMP learning lab. Visiting the Cardiovascular ICU, the delegation learned how the team uses visual boards to share improvement ideas and track projects. The Pharmacy department explained how it used Six Sigma to reduce workplace hazards, and the Women’s Clinic department outlined its use of process mapping to reduce lab errors. On returning home, the visitors were tasked with finding ways to implement some of what they learned.

Northwest

The Primary Care Team B staff at the North Lancaster Medical Office feels especially strongly about the importance of detecting colorectal cancer early, when it’s highly treatable, since some of their own providers have suffered from the disease. The team, which presented a poster at the Institute for Healthcare Improvement conference in December, tracks who’s eligible for a Fecal Immunochemical Test (FIT) kit, makes sure those members get one, and follows up if the kit isn’t returned. And staff members tell patients how early detection made the difference for their co-workers. The return rate is now 85 percent, up from 50 percent. “We add a personal touch by telling our story,” says labor co-lead Bill Waters, a medical assistant and SEIU Local 49 member, “and people respond.”

Ohio

The Parma Internal Medicine UBT has had a host of successes in its journey to becoming a high-performing team. In addition to improving meetings by defining roles and responsibilities, it has ensured sponsor support and increased staff engagement by creating sub-committees to work on projects. One of its innovative tests of change? Team members decided that while continuing to reduce actual wait times, they would work on the perception of time that patients experience while waiting—and created a slide presentation. The slideshow plays on computers in exam rooms and features health information on chronic diseases.

Southern California

The Bonita Primary Care unit-based team in San Diego, which was included in a poster presentation at the annual Institute for Healthcare Improvement conference, set out on a four-month blitz to reduce its supply expenses by 10 percent, or about $4,750. The team agreed to decreased minimum levels of stock and made diagrams of shelves with new quantities. Staff labeled bins and removed, combined and organized the excess stock, and then used the excess as the primary source for exam room restock over the next four months. As a result, fewer supplies were stocked in exam rooms, fewer supplies were ordered and less stock expired (which would have needed to be replaced). In five months, the team saved nearly $24,700.

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.

Colorado

When people go to school to learn how to perform X-rays or take blood pressure, they don’t generally expect they’ll be bonding with colleagues while getting their commercial driver’s licenses or that putting on snow chains will be part of their job. But members of the “mobile coach” unit-based team, who travel to clinics that do not offer mammograms on site and who are in charge of every aspect of running a mammography lab on wheels, took these tasks on and more. Their unusual assignment is improving the quality of care—they screen an average of 15 patients a day and performed 2,584 exams in 2012, finding 12 cancers.

Georgia

The Pharmacy team at the Cumberland Medical Offices cut labeling costs by more than 50 percent by improving accuracy in printing prescription labels. Techs now take a medication off the shelf before typing in the prescription or passing it off to a pharmacist. This helps them select the right code from the National Drug Code database—reducing the need to reprint labels and the associated medication information sheets that are given to patients. Within three months of the change, the number of incorrect codes on labels went from 13 a week to zero. Spending on labels dropped from $1,355 in November 2011 to $569 in March 2012, and monthly shredding costs dropped from $90 to $30. 

Hawaii

The Gerontology specialty team at the Honolulu clinic uses a distinctive combination of red and blue tape to keep its nursing staff free of accidental syringe needle sticks, which can lead to serious disease. More than a year ago, the team set a goal to have no more than three sticks a year—the number of incidents in the previous year. But telling busy caregivers not to rush was not enough. Today, a designated area blocked off by the tape signals to other staff that a nurse needs to concentrate fully on preparing an injection or disposing a needle. The UBT reinforces the warning with signs and a monthly safety message. There have been no needle sticks since October 2012.

Mid-Atlantic States

When busy patients kept canceling appointments, the Baltimore Behavioral Health unit-based team had to find a way to address the no-shows, which were having a negative impact on the clinic’s workflow. In June 2012, 32.7 percent of open slots for new referrals went unused. Then the team stepped in with personal reminder calls and letters, as well as in-person coaching during the after-visit summary review about—yes—how to cancel an appointment. Once patients learned how easy it is to use kp.org to cancel an appointment and understood how other members benefit from the newly opened slots, the no-show rate dropped to 25 percent in February 2013.

Northern California

When parcels arrive at the Fremont Medical Center, they are placed onto a conveyor that rolls them into a warehouse, where they are processed and staged for delivery. Before the conveyor was installed—a suggestion made by UBT member Pablo Raygoza, a storekeeper and SEIU UHW member—workers had to do a lot of bending and lifting to pick boxes up, handling each one multiple times. The improvement was part of a three-year effort to increase worker safety by redesigning and streamlining work processes. As of March 2013, the effort had kept the Supply Chain department injury free for more than 660 days and earned it this year’s regional President’s Workplace Safety Award.

Northwest

The Northwest welcomed 2013 with a recommitment to the region’s hospital’s unit-based teams at a three-day Value Compass Refresh meeting, attended by more than 300 UBT co-leads, subject matter experts and regional leaders. Groups explored subjects like overtime, process improvement and patient flow. In the end, hundreds of potential projects were identified by co-leads and subject matter experts to take back to their UBTs for discussion and next steps. Representatives from the Operating Room UBT discussed opportunities to improve communication with surgeons. On hand was Imelda Dacones, MD, the chief medical officer of the Westside Medical Center (slated to open this summer). She listened with an eager ear and asked questions of the teams to help understand the challenges. “All the physicians who have privileges at the new hospital,” she says, “will go through the Patient Safety University training.”

Ohio

Members regularly complained about long waits for prescriptions at the Parma Pharmacy, so the unit-based team decided to map the prescription-filling process using a spaghetti diagram. The tangled web of lines captured in the drawing told the story and pointed to the root cause of the problem: Pharmacists did a lot of unnecessary walking and backtracking. The primary culprit was walking to and from the technicians, who are located in the front of the pharmacy, to deliver prescriptions. The team decided to move pharmacists closer to the techs—a small change that gives pharmacists more time to dedicate to filling prescriptions and shaved wait times by 84 seconds, or 14 percent.

Southern California

The eight-person nephrology unit at the Stockdale Medical Offices has always exceeded regional goals for its discipline and prided itself on the care it provides its kidney transplant patients—but it got a rude awakening in January 2012, when it saw fresh data from the regional renal business group. The team was merely average. Team members got busy, analyzing the metrics and scouring patient records. To help flag the care each patient needs, they turned to the Proactive Office Encounter functions in KP HealthConnect™. They hosted a special short-term clinic just for transplant patients. Nurses made outreach calls. And the percent of patients getting five key services shot up—flu shots (up 50 percentage points), dermatology appointments (up 32 points), renal ultrasounds (up 22 points), annual follow-up visits (up 25.5 points) and lab work (up 26 points).

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.

An imaginary friend of mine smokes, is decidedly chunky, and has high blood pressure and high cholesterol. His kids nag him about the cigarettes and weight; his wife worries more about the hidden conditions.

This fellow could be any one of many of us, and if he wanted to track his efforts to improve his health, he could use the “cloverleaf” graphic introduced in this issue of Hank—a visual summary of the four measures of health at the heart of the new Total Health Incentive Plan.

The cloverleaf has a lot in common with the Value Compass, which illustrates the interconnectedness of service, quality, affordability and the workplace environment. The Value Compass reminds us that improving in one area at the expense of another isn’t progress—and that improving in one area frequently leads to improvements in other areas.

So it is with health. If I take up smoking and have a cigarette each time I’m tempted to eat something sweet, I may improve my Body Mass Index, or BMI—but I won’t have improved my health. If my imaginary friend starts to make better food choices and ups his exercise, however, he’s likely to see improvement across the spectrum of health issues he’s facing. By measuring improvement in several areas, the new incentive plan puts the emphasis on bringing the whole person into better balance.

And by putting the focus on collective improvement, the plan recognizes that all of us are making decisions as individuals in a social system—a system that can make it harder, or easier, to make better choices. Losing the dougnuts at a breakfast meeting may seem like a small gesture, but many such gestures add up to powerful change.