Improve service scores. Reduce waste. Retain members. Gain new members. Cut wait times. Work safer. Perfect patient safety. Innovate care.

Teams are juggling constantly, trying to meet their own objectives, move forward on initiatives related to facility, regional and national goals, and comply with regulatory requirements—all in a competitive economic environment.

When the curve ball comes sliding in, it can be one thing too many, derailing a strong team or keeping a struggling team at ground level. So a host of unit-based team supporters are turning their attention to strategies to help unit-based teams prioritize competing demands—from personalized mentoring to intensive workshops for co-leads.

“I see my role as taking away the noise and the chaos…to help them figure out, ‘Realistically, how many things can we work on at once?’” says Denise Johnson, San Jose Medical Center continuum of care administrator and a UBT sponsor. “I have to help them not be crazy, because we don’t want a lot of projects that don’t make a difference.”

Here are four strategies for helping teams.

Strategy #1: Planning pays off

Every year, labor and management sponsors at the San Jose Medical Center sit down with their UBT co-leads to develop an operating plan. The plan flows from Kaiser Permanente’s organizational goals as well as from regional goals, facility priorities, and the needs of the department. Each sit-down includes the service area’s UBT consultant and its union partnership representative. Projects emerge naturally from that plan, with teams turning to the Value Compass and a tool called a PICK chart to fine-tune their priorities.

“They have to figure out what’s in their sphere of influence,” says Eric Abbott, the area’s union partnership representative. “What are the things they can change, and of those things, how much time do they have?”

When Johnson became sponsor of one San Jose team, it was immediately clear to her the UBT had too much on its plate. She worked with the team to winnow eight projects down to two.

“In my experience, people get bogged down with the to-do list and sometimes don’t stop and think about what’s really on that list and what effort does it serve,” she says. “They thought I was crazy. They came from a mentality where ‘more is better.’”

Strategy #2: Urgency can be a tool

Two years ago, San Diego’s interventional anesthesia unit-based team was humming along in its performance improvement work when it got hit with the news that co-pays for patients who suffer from chronic pain would be increasing sharply.

The 14-member team responded with a new service project, a multiphase communication plan to help members understand the new co-pay and their options. And then the next wave broke: The team learned it had a matter of days to move into a new specialty services building. It suspended the co-pay project to plan for and complete the move.

One key performance improvement tool—a process map—proved instrumental. The team created a detailed map that laid out every piece of work that needed to be done in preparation for the transition, from changing procedures to adapting to a new phone system to altering workflows based on the new floor plan.

“They simply became a single-issue team,” says their UBT consultant, Sylvia Wallace, of the 2011 move.

With the process map in hand, the team spotted an opportunity to weave communication about the new co-pays together with communication about the move. As a result, it didn’t miss a beat in providing its members with critical information about available financial assistance.

The comprehensive plan helped the unit’s service scores hold steady through the transition—and then increase at the new facility. The moving plan became a template for other departments, which are still moving into the Garfield Specialty Center.

“Everyone participated. All types of ideas were solicited and implemented,” says Grace Francisco, the assistant department administrator and the management co-lead at the time. “Everyone has a role and accountability for each step.”

Strategy #3: Take time to train

Teams stand a better chance of weathering competing demands when they have a solid understanding of partnership principles and processes as well as performance improvement tools and methods.

In Colorado, the UBT consultants used LMP Innovation grant funds to host a two-day workshop centered on two regional priorities. Co-lead pairs from throughout the region learned how best to serve new members and improve the affordability of KP care by reducing waste and inefficient practices. They walked away with a variety of team improvement tools and resources.

“We are trying to set the teams up to be successful by giving them the time to focus on topics that could have a huge impact in the region in the next few years,” says Linda Focht, a UBT consultant and UFCW Local 7 member.

In San Diego, regular UBT summits bring co-leads together for intensive sessions on given topics. Service area and local union leaders play a major role in structuring the agenda, so the team development matches up with high-level strategy. The joint planning creates a full picture, one that resonates better at the front line and sets up teams to work on projects that make a difference to KP’s reputation.

“Leaders see a lot more than what we see,” says Jenny Button, director of Business Strategy and Performance Improvement in San Diego. “Leaders see what is going on with the competition. They see across all of the different metrics we are working toward. They see at a broad level where our biggest gaps are.”

Strategy #4: One-on-one attention counts

At San Jose Medical Center, sponsors like Johnson and Hollie Parker-Winzenread, an assistant medical group administrator, are coaching UBTs one on one in performance improvement tools to help them set priorities.

 “Teams like to jump to the solution,” says Parker-Winzenread. “But they struggle with the process….The gain falls apart, because the process is not strong.”

San Jose’s clinical laboratory UBT is a success story, jumping from a Level 1 to a Level 4 in less than a year after new co-leads worked together to reach joint agreement on the department’s priorities. The team started with tests of change that made strides in attendance. Today, it has moved on to complex projects that require shifting schedules to accommodate demands for getting lab results earlier in the day.

Guidance from their sponsors has helped keep team members on track.

“We’d come up with all of these ideas and projects, and they made suggestions and really helped prioritize what we worked on so we didn’t bite off more than we could chew,” says Antoinette Sandez, a phlebotomist, the team’s union co-lead and an SEIU UHW member.

“You have to help teams to believe in the process,” Johnson says. “As a sponsor I can’t rush the process and say harder, faster, move, move, move. That won’t get us what we want in the long run. Because we’re looking for sustainability.”

See what other teams are doing to find success in Total Health.

Richmond Medical Center Pediatrics knew that “pretty good” wasn’t good enough in 2012. The department’s service scores hovered stubbornly around 88 percent. Its unit-based team members knew they could do better and distinguish themselves from competitors.

“We wanted to give KP members that ‘wow’ experience,” says manager Cynthia Ramirez—to make them glad they chose Kaiser Permanente and to give them reasons to stay with us.

So the UBT, knowing the system can be frustrating when you’re unfamiliar with it, created a project that would take the mystery out of the process. In doing so, the team also hoped to debunk any idea that KP is an impersonal health care factory. 

“We need to not just look at our work as a job all the time,” says union co-lead Jill Sandino, a medical assistant and SEIU UHW member. “It’s kindness from the gate.”

Time for our A game

With major elements of the Affordable Care Act going into effect this fall, focusing on a member’s total experience with KP has never been more important. After years of preparation, how we respond to the challenges and opportunities will make a big difference for our organization and for our members. And every UBT can get ready by figuring out where its processes aren’t the best—or are merely OK—and getting to work on improving them.

“For the first time in our history, how well we do fundamental business operations—billing, copayment collection, customer service—has the potential to overshadow the health care we deliver in driving overall member satisfaction,” especially because more members will have plans with deductibles, says Larry Sirowy, KP’s executive director for market research. Sirowy and others have been working to figure out the characteristics of the people who will become members through health care reform—and what we need to do to be able to provide all our members, new and old, with the care they need.

Without a crystal ball, no one can say exactly how Kaiser Permanente will be affected. But one thing everyone is anticipating is an influx of new members—and we know that if new members stay with us after the first year, we’re likely to keep them as members in future years. So in the months ahead, we need our A game, and we need to bring it to every aspect of our work.

The good news is UBTs are already working—and seeing results—on a variety of projects that will improve our ability to provide new members with excellent service and care as well as reaffirm current members’ decision to choose KP.

Richmond’s "wow" experience

To ensure new patients have a topnotch visit, for example, the Richmond Pediatrics UBT created a workflow that involves everyone. It starts with the receptionist spotting the new member flag in KP HealthConnect and giving the person a customized welcome. In the exam room, the medical assistant provides a welcome packet—offered in Spanish or English—with basic department information, critical phone numbers and instructions on how to sign up for kp.org. Department manager Ramirez comes by to introduce herself and share her business card.

The physician caps it off by welcoming the patient to his or her practice and touting the great teamwork in the department.

“This reinforces that they’re in good hands, and we’re a family and know everyone by name,” Ramirez says.

The new workflow is making a difference: The department’s service scores increased from 88.3 percent satisfaction at year-end 2012 to 95.1 percent in the first quarter of 2013.

“Starting with a small Rapid Improvement Model project has made a big impact,” Ramirez says. “It gives us the momentum to be ready for whatever comes next.”

Unexpected consequences

In January, Georgia’s Douglasville Medical Office got a dress rehearsal in receiving a flood of new patients when the local city government signed on with KP.

“I hadn’t realized how large this group was,” says pharmacist manager Adaora Oraefo, until, at the end of 2012, “we started to see a dip in our service scores.”

Douglasville is a tiny clinic, so patients are supposed to check in with the pharmacist to confirm their prescription before heading to the lab for tests. But often, no one told them that—so when they did get to the pharmacy, they had to wait 10 or 15 minutes while the prescription was filled.

Not surprisingly, since members assumed their prescription would be ready when they were done with their lab work, complaints starting coming in.

“I would step out in the waiting room and talk them through the process,” Oraefo says. “I saw an opportunity to improve.”

The pharmacy began working with the nurses to make sure they explained the clinic’s routine to patients. The facility expanded on the work by holding open house events for new members.

“They were so much happier, especially when they were able to see me as their pharmacy manager,” Oraefo says. “It made a difference. People were thinking, ‘These people are taking the time to show us what’s going on.’”

Understanding KP’s offerings

One element of preparing for health care reform is becoming educated about the law and its provisions, so we can help members understand the changes, too.

Since 2010, Colorado’s patient registration associates (PRAs) have seen an increase in the number of patients with deductible health plans, which often have significant payments associated with them. More experienced with KP’s HMO plans, which feature the familiar copay arrangement, the PRAs didn’t feel confident talking to members about deductible plans.

Since the Health Insurance Marketplaces that open this fall are expected to bring even more members with those types of plans, the PRAs made a proactive decision to educate themselves.
 
“While there will be a number of different types of plans, the concepts don’t change,” says patient registration manager Jeffrey Clayman. “Improving their confidence in their ability to talk about these plans was a natural fit.”

The regional PRA UBT held a training that included actors playing the patients and members, so the staff could practice realistic encounters. The clerks gained experience in explaining the costs and how the plans work—and they also got practice in how to respond when someone gets upset at an unexpected bill.

“We tried to learn how to be more aware of how we communicate to patients,” says PRA Diana Wagner, a member of SEIU Local 105 and the regional UBT’s union co-lead. “I treat patients the way I would want to be treated—which is businesslike. But the service quality person made a point, that you need to treat patients the way they want to be treated.”

Tim Kieschnick, a Kaiser Permanente executive consultant who has been working to understand how our member demographics will be changing, says that currently, many members with deductible plans don’t realize they have a deductible.
 
“They’ll pay a $25 copay,” he says, “and then four months later, they get a bill for $1,300”—and they’re shocked.

 “The goal should be no surprises,” he says. “How you do that is something we’re all trying to figure out.”

Sustaining improvement

The other challenge, of course, is to sustain a successful change.

With the many demands of a busy Pediatrics department, co-leads Ramirez and Sandino admit it can be easy to forget to use the new member workflow. To keep the momentum going, Ramirez provides a reminder in the team’s morning huddle if a few days have passed without seeing a new patient.

And Sandino says she tries to “be like a cheerleader.”

“We need members to have our jobs,” Sandino says. “Health care reform is a reality—it’s beyond KP, and it’s beyond the unions. I was never a cheerleader, but I’m a cheerleader at Kaiser around this.”

A few months ago, a patient walked from the outpatient clinic to the operating suites at San Francisco Medical Center. He had an infection in his knee that needed to be drained. Paul Preston, MD, was at work and evaluated the man. His condition wasn’t urgent, and he got a bed to wait in.

What happened next is a cautionary tale. The patient’s condition changed—quickly and unexpectedly.

Dr. Preston, who was in charge that day, had moved on and was artfully multitasking on several other matters.

A nurse popped around the corner and interrupted him.

“Dr. Preston, this guy is sick,” she said.

Rapidly changing situations are a part of life in hospitals and clinics. But how they are handled varies wildly, depending largely on whether there is a culture of psychological safety—one where employees can speak up freely and offer suggestions, raise concerns and point out mistakes without fear of negative personal consequences.

Despite volumes of findings linking psychologically unsafe work cultures with poor patient outcomes—up to and including death—the health care industry, including Kaiser Permanente, continues to struggle with creating the culture of open communication that is a key component of safety.

Fortunately, this nurse worked with a physician and in an environment where speaking up is welcomed.

“Boy, was she right,” Dr. Preston recalls. “The patient had become septic in the short time he was there. I was obviously preoccupied, but what she had to say was far more important.”

The need for culture change

Positive exchanges like the one that day don’t yet happen reliably enough.

“I think there is a culture of fear around speaking up,” says Doug Bonacum, KP’s vice president of quality, safety and resource management. “We have indication (of that) from People Pulse scores.” In the patient safety world, Bonacum says, it’s still too common to hear of events with adverse outcomes where someone knew something wasn’t right—but didn’t speak up.

Studies have shown that poor communication among surgical team members contributes to a significant increase in patient complications or death (up to four times as many adverse events). Poor communication is also to blame in more than 60 percent of medication errors nationwide.  

“If I had a magic wand and could change one thing about the health care culture and the way we work together in order to improve patient care, it would be around our ability to speak up and people's willingness to listen and act,” Bonacum says. “I think it’s mission critical for worker and patient safety.”

Unit-based teams, by addressing issues of status and power, instinctive fear of retaliation and more, are helping build a culture where people are able to speak up. Leaders play a critical role in that transformation by actively developing rapport with employees and/or explicitly admitting mistakes and “disavowing perfection.”

“The definition of leadership is creating the condition to allow your team to succeed,” says Dr. Preston, who is the physician safety educator for The Permanente Medical Group. He notes that in aviation, senior pilots are strongly encouraged to tell those working with them, “If you see anything wrong, please let me know as soon as possible.”

Building new habits

A modified version of that practice, a pre-surgery briefing, now takes place in most Kaiser Permanente operating rooms.

“We don’t really want to say in front of the patient, ‘Hey, if I screw up, let me know,’” Dr. Preston says. “So we go around and say our names and what we’re going to do, and it builds confidence.”

The briefing, he explains, “is a conversation to build the group’s knowledge of what they're supposed to be doing, what to expect and watch out for. It sets the expectation that everyone needs to speak up.”

Dr. Preston says holding a briefing is the single most important thing a surgical team can do for patient safety. And debriefing afterward is critical, too, he says: “It's a chance for teams to consolidate what they learn. . . and get more and more reliable.”  

Leaders—physicians, managers, union co-leads and stewards—should model the behavior of speaking up around errors. Creating a blame-free environment, Dr. Preston says, “involves the willingness of leaders to go first in displaying vulnerability. . . by talking about mistakes they made when they wish someone had spoken up.”

Structured conversations help

Putting in place mechanisms that encourage employees to speak up is another way to foster open communication around errors and performance improvement. Such systems also provide a forum where people learn how to express themselves clearly and non-emotionally—and help to reconnect them with the value and purpose of their work.

South San Francisco Radiology’s unit-based team, for example, has created a structured communication system where radiologic technologists are asked to speak up in the moment and “stop the line” when they encounter anything that deviates from the agreed-upon workflow or is a potential patient safety risk. Afterward, they fill out a brief report that captures the event. 

“We made it an obligation for people to speak up,” says radiologic technologist Donna Haynes, the department’s UBT union co-lead and a member of SEIU UHW. “We wanted to empower employees.”

Since implementing the program in April 2012, more than 250 Stop the Line forms have been submitted. As a result, the department has prevented a number of small events from reaching the patient—and has seen a 50 percent reduction of “significant events” from the previous year, incidents in which a patient is incorrectly irradiated, whether it be a wrong body part or a scan is repeated unnecessarily.

The Stop the Line forms are simple and easily accessed in work areas and radiation rooms. They’re not used for punitive purposes; they’re used to track workflow issues that then are addressed by the UBT.

“For us it was a big rush, really trying to empower people to take the time to do what’s right,” says Ann Allen, the medical center’s Radiology director. “Also having trust in the fact that ‘I can submit real data and it will actually implement change.’ ”

Continuous learning

Allen’s comment speaks to another huge benefit to creating an environment where people feel free to voice their ideas and concerns: It makes the difference between an organization that is continuously learning and improving performance and one that is stifling innovation and stagnating.

The link between higher-performing unit-based teams and the ability to speak up is clear.

The People Pulse survey has a set of 12 questions that get at a department’s culture and comprise the Work Unit Index. One typical question is, “In my department or work unit, I am encouraged to speak up about errors and mistakes.” In 2011, the survey found that departments where Work Unit Index scores were highest had better HCAHPs scores, more satisfied patients, fewer workplace injuries, lower absenteeism, and fewer hospital-acquired infections and pressure ulcers. Departments whose Work Unit Index scores were in the bottom quartile consistently had poorer performance in those same areas.

“High-performing teams are clear on the goal…and hold each other mutually accountable for outcomes,” Bonacum says. “That level of accountability to each other is what differentiates them and enables people to say something that lower-performing teams can’t and won’t.”

Once you get to a tipping point, Dr. Preston says, people will look out of place if they aren’t speaking up.

“There's no such thing as a perfect day,” Dr. Preston says. Even good surgeons make errors—routinely—and no system, he says, can eliminate human error entirely. “But the earlier the team can recognize what is called an ‘undesired state’ and trap it, the less severe it is. And this is a huge thing for labor and managers, because we’re all there (in the room). Everybody has eyes and ears. The person who’s engaged has a huge role.”

An open, supportive environment is one aspect of a workplace where workers can point out problems when they see them.

But to ensure the support doesn’t evaporate in the stress of a busy day, there needs to be more than the expectation that people will do the right thing. There needs to be a solid system in place that formalizes the commitment to speak up.

A Radiation Oncology team in Northern California knows this firsthand. From the time the South San Francisco Cancer Treatment Center opened in May 2009, its leaders worked to establish a culture that encouraged staff members to speak up when they saw something wrong and to provide input on process improvements. The center didn’t have a clear-cut mechanism for doing this, however; it was fostered through leaders’ encouragement and role modeling.

Then in 2010, a mistake was made—relatively small, but a HIPAA violation: A patient was accidentally given a printout with the personal information of another patient. The member returned the paper to the receptionist, and no lasting harm was done. But it highlighted the fact that staff members needed a way to record process failures, empowering them to address issues large and small, says Marcy A. Kaufman, the center’s Radiation Oncology administrator.

A protocol that calls for submitting a Responsible Report form was already in place for those times when an error reaches the patient. “But we wanted to create something where everyone can give input at all parts of the process,” Kaufman says.

Stop the Line

So the unit-based team created what its members call Stop the Line. If a radiation therapist or anyone else in the department encounters anything that deviates from the workflow or compromises care, he or she first acts to ensure patient safety, if such action is needed—and then fills out the Stop the Line form to document the incident. The focus is not on individual error but on what can be done to improve the system to prevent similar mistakes in the future.

“It’s a chance to look at the system to see if it is doing its job—are the checks and balances working? Or do we need to bring to the UBT and come up with a different workflow?” Kaufman says.

At monthly staff meetings, the team pulls out a binder with the Stop the Line reports and discusses the incidents and any follow-up actions taken. That discussion is important not only as a way to close the loop but also because it demonstrates to staff members that their voices were heard. The forms don’t drop into a black hole never to be heard of again.

“You have to constantly be talking about this to keep the momentum going,” Kaufman says.

The process applies to all staff, including physicians.

“In the field of medicine where, in general, it is quite hierarchical, it’s even more imperative we have a system like this to encourage every member of the department to speak up, regardless of title, to make sure we’re giving the best patient care,” says Amy Gillis, MD, the center’s chief of Radiation Oncology.

Dr. Gillis recalled the wrong-patient information episode. The initial assumption was that one of the medical assistants, who normally handle such paperwork, had made the mistake. This time, however, the culprit was a physician.

Staff members hesitated, Dr. Gillis says, wondering, “ ‘Should I really write up a physician?’ ” As she notes, however, “We all need to have a greater awareness.”

“It really does take everyone’s buy-in to make it happen and be successful,” she says. In this case, what it took to convince staff was input from the physicians themselves, with the doctors saying, “Yes, please write that up.”

Successful practice spreads

Stop the Line has been so popular that the cancer center’s four sister centers in Northern California have adopted the practice.

South San Francisco Radiology also adopted the Stop the Line form and process, adapting it to meet its specific needs. The department does hundreds of thousands of scans a year, from mammograms to basic X-rays to CT scans. With such high volume, radiologic technologists often feel pressure to keep patients moving through in a steady flow.

“We needed to give technicians permission to do the right thing,” says radiologic technologist Donna Hayes, the department’s UBT union co-lead and an SEIU UHW member. “We wanted them to know it’s OK to stop the process for this. I think it helped that it also came from management.”

As at the cancer center, the process is not used in a punitive way. Instead, it’s used as a way to highlight and address glitches in the workflow—not only within the department, but also in other departments.

“We’ve been able to take the data back to the orthopedics chief or take ED-related issues back to ED,” says Ann Allen, the Radiology director. “We funnel back to those departments that are partners so they can help us make changes.”