After a false start, the diagnostic imaging department at Woodland Hills Medical Center has found its stride. Its results are impressive: By drawing on the wide experience of the team, it’s improving workflow and boosting attendance.

To get those results, the department created one large UBT with several subcommittees and involved a physician champion. Two radiology summits, which were held to set priorities, included the whole team: 

• More than 160 employees and physicians who see a quarter-million patients a year.
• Staff in eight far-flung clinics as well as throughout the medical center. They range in age from late teens to 40-year veterans of Kaiser Permanente.
• Team members in eight areas of expertise, including ultrasound, MRI, CAT scan, nuclear medicine, mammography, general x-ray, and special procedures.  

From confusion to clarity

At first, the team’s diverse skills and experience flummoxed the department-based team (the term Woodland Hills uses instead of unit-based team).  

“We didn’t know the scope of our work,” says Selena Marchand, a lead sonographer and labor co-lead. “The old DBT got stalled talking about things like the doctors’ parking lot.”

A secret society?

In addition, says Marchand, the representative group—which was working without a facilitator—didn’t communicate with its co-workers about the DBT’s projects. “They thought we were some sort of secret society,” says Marchand, a member of SEIU UHW. 

The team restructured in October 2009, electing one delegate from each “modality,” as the areas of expertise are known, to the representative group.

“Pushing responsibility and accountability back to different modalities has been one of our successes,” says Mike Bruse, the department administrator and management co-lead. “We’re focused on things that we can control in our department.”

Summits get everyone involved

The co-leads convened two department-wide summits to focus on improving team performance and set priorities. Staff members brainstormed about what the challenging issues facing the department were and wrote them on flip chart pages on the wall. Then, each employee attached a sticky note to the issues that most concerned them. The team and managers set out to tackle the seven issues that received the most tags. As the work got under way, progress reports were posted in the employee break room to keep everyone on the team—not just the representatives—informed.

Better workflow

The department also improved the way it distributes film to radiologists, so that patients’ results get to primary care physicians faster. Before the change, technicians were forced to constantly interrupt doctors to read films. Now, there is a tally sheet on each radiologist’s door indicating how many films he or she is reading. This allows techs to know who is available to read a film—and allows radiologists to work undisturbed. An aide to the technologists tracks the process, acting as a traffic controller.

“It was a relatively simple thing that improved satisfaction and patient care a lot,” says Mark Schwartz, MD, who represents physicians on the UBT. “And it didn’t cost any money.”

Better attendance

The team also improved attendance, decreasing last-minute sick calls by 14 days from the end of 2009 to October 2010. They beat the Lab Department in a friendly competition two quarters in a row and were rewarded with a barbeque. To do this, team members simplified presentation of attendance data and posted up-to-the-minute metrics.  

Beyond these gains, management co-lead Bruse says the most significant change is employees’ confidence in their own ability to make improvements.

“Our meetings used to be ‘complain to Mike,’ ” he said. “These days, when people see a problem, they take steps to solve it themselves.”

"Anyone who has never made a mistake has never tried anything new."

—Albert Einstein

This is the story of a team that never failed a test of change. No matter what the team members did, rapid improvement cycle after rapid improvement cycle, every small test tried was a better jewel than the one before. They received an A for their PDSAs.

They were fearless—in their imaginations. The only problem with the team’s brilliant tests of change was that they never got tested, never got to the stage where stumbling or failed ideas might have real consequences. There was no learning, no innovation, no growth—just intriguing ideas that remained bottled.

In health care, it’s still frowned upon to talk about failures or things that don’t work out perfectly for fear the information will be used against the people involved. But even in a high-stakes industry where the consequence of some decisions means life or death, there is plenty of room for improving performance by learning from small failures.

Using small failures as learning opportunities is the cornerstone of creating a learning organization. Small failures are at the heart of the Rapid Improvement Model and its plan, do, study, act cycles.

“Despite the increased rate of failure that accompanies deliberate experimentation, organizations that experiment effectively…are likely to be more innovative, productive and successful,” writes Amy Edmondson, a professor at Harvard Business School, in a December 2004 article in the Quality and Safety in Healthcare Journal.

This in fact is a story of false starts: the story of unit-based teams and employees throughout Kaiser Permanente who already are learning, developing and innovating from missteps or downright unsuccessful small tests of change.

From projects that changed direction after data contradicted the original premise, to tests of change that were tweaked or abandoned all together, workers describe how they tried a small improvement that didn't turn out as expected and still gained from the experience. And even, eventually, found success.

Learning to fail

At San Diego Medical Center’s Nuclear Medicine department, the unit-based team decided its first test of change project would look at reducing the number of redundant heart scans, which technologists were certain were wasting time and resources.

In November 2009, team members began to track the number of repeat scans to establish a baseline. They figured repeats would be at least 25 percent of the heart scans. After a month of logging the scans, however, they discovered something quite different.

“The number of repeat heart scans was actually between 7 to 10 percent,” says the UBT’s labor co-lead, Jessica Larson, a tech assistant and OPEIU Local 30 member.

The team’s hypothesis was amiss. It switched gears.

Since several of the staff recommendations for test of change projects related to heart scans, the team focused next on the variation in the instructions patients were given. If team members gave identical instructions, they might be able to all but eliminate repeat heart scans.

“The test of change at that point was to make sure everyone was following the protocol,” says Randy Andres, a nuclear medicine technologist and OPEIU Local 30 member.

The team created laminated handouts with one set of clear instructions that technologists and receptionists were to hand out to every patient before a scan.

“We did that for a few weeks, and found it was a lot more complicated than we anticipated,” Larson says. “You had inpatients, outpatients, observation-unit patients….Forms were getting misplaced because patients would leave them in the waiting rooms or in their purse. Or people weren’t even giving them out.”

During the same time, a supply shortage meant the department had to switch the type of injectable radioactive isotope it was using. The change meant a whole new set of protocols. Compounding it all, the department’s longtime manager retired.

It was time to shelve the test of change.

But was it a waste of time? Not at all, say Larson and Andres. Both say it provided valuable information about the department’s work flow—as well as practical knowledge of how to conduct tests of change.

“This was a very good teaching experience for us,” Andres says. “We didn’t even know about tests of change before this. It’s not simply a matter of just changing something. You have to go through this process.”

Too much of a good thing

Further north at Redwood City Medical Center, the Gastroenterology department discovered you can have too much of a good thing.

Contracting with an Oregon company that specializes in mass outreach calls, the department began using automatic robocalls to reach patients ages 50 to 75 who were due or overdue for colorectal screenings.

“We had to think outside the box,” says Julie Dalcin, director of medicine. “This was a way to reach a lot of people.”

The first round of robocalls went out in November 2009, with some 10,000 calls made. They reached 97 percent of the members who were due for the tests—but there was a problem. The calls were made within a span of three hours, and the response overwhelmed the department and the facility. The voicemail box the team had set up in advance barely helped; it could take only 50 messages.

“We got bombarded by calls from patients calling back with questions or requests. Our operator was inundated,” says manager Isabel Uibel. “Physicians in other departments were also bombarded with calls. People…were like, ‘What’s going on?’”

Michele Coons, a medical assistant and SEIU UHW member, was devoted to returning the calls and to mailing “FIT kits,” the at-home stool tests that help detect early signs of colorectal cancer, to those who had requested them.

“Many people had a lot of questions,” Coons says. “‘Why did I get this call?’ ‘What does a FIT kit test mean?’”

It took a week to figure out a system for getting back to all the patients, she says.

“I think at the end of day you have to be willing to try,” Uibel says. “And forgive yourself for the time you put into something that didn’t work. And don’t lose motivation. But also know when…you’ve got to say, ‘We’re not going down the right path at all.’”

In some workplaces, what had happened would be labeled a disaster. But not in Redwood City. The essential idea was sound. For the second round of calls, the team addressed the overwhelming response by having the calls made over a two-week period.

“We didn’t think we needed to throw the baby out with the bathwater,” Uibel says. “We just had to keep tweaking to make the system work for us.”

Too good to be true

When it came to how quickly patient messages are responded to, the Internal Medicine at the East Denver Medical Office in Colorado was pretty close to bottom—only 8 percent of patient advice calls were answered within an hour. The team members were open to trying anything, and after several small tests of change, they hit on something so ridiculously simple that some people resisted it.

Nurses tape neon orange cards with the patient message to the door of the exam room where the doctor is working. The doctor sees the message on the way out of the room and goes back to his or her office to respond.

Within the first three months of the test, the department saw message turnaround times soar to 30 percent answered within the hour.

“You had some tangible symbol that you were trying to make these numbers move. It was a great motivator,” says Christopher Hicks, MD, the team’s physician co-lead. “It was different. It wasn’t something that was happening electronically.”

Then they hit a wall.

“We were sitting around threshold or target and then would drop back down,” explains Olivia Wright, supervisor and management co-lead. “We were just hovering around 20 to 30 percent.”

The team brainstormed about why it couldn’t move the number above 30 percent.

Someone suggested one reason could be that the call center opened at 7 a.m. and most of the staff didn’t start until 8 a.m. They were starting the day already behind the curve with waiting messages. Two nurses changed their schedule and started coming in at 7:30 a.m. That seemed to help: 52 percent of patient messages got a reply within an hour.

“You’ve got to give something a shot,” Wright says. “The first thing you come out of the gate with isn’t necessarily going to be the end-all be-all, but you’ve got to start somewhere.”

One of the most surprising lessons for the entire department was the fact that small changes could have such a large impact.

“There was a sense of disbelief,” Wright recalls. “We had to reassure the team that the volume of work hadn’t gone down or that it wasn’t because of the time of year. We’ve sustained these results since May, and it finally started to sink in that small, subtle changes really are the reason for these results.”

Failure is part of experimentation

Experts who study organizations like health care and the airline industry corroborate the importance the process of experimentation plays in organizational learning.

“Under conditions where there’s a lot of uncertainty and constantly moving parts and work is customized or unique, the only way to make it work is to allow the right level of leeway for teams…to experiment thoughtfully,” Edmondson says. In the long run, lasting success comes from a willingness to try new things; but, if you try new things, you're going to fail sometimes.

This isn’t license for projects based on haphazard hypotheses, but it underscores the fact that performance improvement methods such as the Rapid Improvement Model are made for small failures. Because the process allows for quick experimentation, with results evaluated within 30 to 60 days, there is little to lose.

Barbara Grimm, senior vice president of the Labor Management Partnership, would have people ask themselves a few questions that can help them weigh the possibility of failure.

“Have you reasoned through the consequences? That is key,” Grimm says. “Do you have the patient’s interest absolutely there? Do you have a plan if it doesn’t go well?”

Edmondson argues there are two key reasons health care organizations still resist learning from small failures: The culture often discourages questions, challenges, or admissions of error, and a demanding workload and pace force staff to rely on quick fixes when something doesn’t work, instead of systematic problem solving.

That is changing at Kaiser Permanente with the commitment to providing frontline staff with training and support to conduct root cause analysis and problem solving with RIM, RIM+ and other performance improvement tools. And unit-based teams give staff members the place and time to do this work.

John August, executive director of the Coalition of Kaiser Permanente Unions, believes the

true purpose of the Labor Management Partnership is to recognize the mission of KP and the mission of the unions are at profound risk due to the economic, competitive and public policy environment in which we operate.

“We must continually remind everyone in the organization that the why of what we do in partnership is driven by this fundamental recognition and agreement,” August says. “If we don’t make the effort to discuss the reasons why we’re doing this, people will get the impression that people are just being asked to do something. And being asked to do something doesn’t create an atmosphere of safety.”

Edmondson says the sense of safety will further develop when we learn to accept and work with our limitations.

“People need a sense of psychological safety, and frankly a sense of humor about our humanness,” Edmondson says. “Somewhere along the line we get socialized and begin to buy into the absurd notion that we should be perfect.”

Back at the lab

In San Diego, Larson thinks even if the tests of change didn’t work exactly as planned, it gave the team something even more important—the beginning of a different work culture.

“Being able to work on small tests of change enabled us to get past what’s always been,” Larson says. “There are people who have been here longer than I’ve been alive and so are accustomed to the way it was always done. But trying something new can save us time, and save the company money, and can be better for the patient. So I found it nice to look at it like, ‘Let’s try just this little thing and it might just make it better.’”

Larson is certain the eventual reward will outweigh any frustrations in wrong hypotheses or failed tests.

“Either you find you can fix something or you can’t, and you just move on,” Larson says. “Just keep trying. Because ultimately, it’s going to be a success in the end.”

I am one of the chairs the LMP leadership team, along with a union colleague from UFCW and two management leaders. I’m also the co-lead of the Woodland Hills’ union coalition. In addition, I’m a full-time certified registered nurse anesthetist in the operating room. To be an effective labor co-lead takes three things: time, collaboration and planning.

Time

I have been doing partnership work at Woodland Hills for 10 years. People respect the time I’ve invested. You have to be on fire for this because it’s an enormous responsibility. It’s going to cost you time, angst and effort. And you can’t build relationships passing in the hall. You have to make the investment of face time. That means showing up at the LMP council meetings, monthly, from 8:00 a.m. to noon.

Planning Ahead

It is important to bring in and plan for new blood. At Woodland Hills, we rotate the labor co-chair in our leadership team every two years. I believe this allows everyone to have a say. It builds trust and experience. And it ensures buy-in from each union—and each segment of each union. We build-in mentorship. For three months, the new person sits in and the current co-lead shows that person the ropes.

We also did this in the Kaiser Permanente Nurse Anesthetist Association when I was president in 2006. I would go with new facility reps to meetings. 

Collaboration

We really foster union efforts at the medical center level. We’ve got a group of long-term union coalition people and our unions speak with a single, powerful voice. There have been issues between unions, and we had to work things out until cooler heads prevailed. People say ‘I’m sorry’ and move on.

Working with management is both easy and difficult. It’s easy because they are so partnership oriented and respectful of the unions, and they welcome input. They lead by influence—not by authority by virtue of where they are on the food chain—just like we do. It is difficult sometimes because it requires us to work hard as partners. Sometimes it would be easier to just go along with their recommendations, but then we wouldn’t really be doing our jobs as union leaders. At certain points, you have to say, ‘Well, let me think about that,’ and ask your constituents what they think.

Hospitals are traditionally very hierarchical. The partnership is such an opportunity to have a voice.

Imagine developing a severe cough and teeth-chattering chills. You want to be seen by a doctor but no one really understands you: Not the call center operator with whom you try to make an appointment; not the receptionist who checks you in; not the medical assistant who takes your temperature and blood pressure. Not even the doctor who speaks quickly and uses complicated medical terms.

“When you come in for medical care, it’s already like a foreign land,” says Kathleen Kearney, the manager and the UBT co-lead for the Obstetrics and Gynecology department at San Jose Medical Center.  “If you don’t speak English, it can be downright frightening.”

Giving patients better access

Kaiser Permanente has long been committed to providing language access in the form of interpretive services for its non-English speaking members. The Ob/Gyn unit-based team in San Jose has taken the additional step of creating a Spanish-speaking module, a sort of one-stop shop for Spanish-speaking patients.

The idea for the module came from Joseph Derrough, MD, who recognized that good patient care involves more than just the patient and the physician in the exam room. It includes each interaction, from making an appointment to checking in and being assigned a room.

“I realized that we had a significant percentage of patients who only spoke Spanish, and we could do better service to them by providing linguistic and culturally competent care,” Dr. Derrough says. “We had staff that spoke Spanish, but they weren’t all in the same place. My vision was that we could create a clinic module where, from registration to examination, the patient was spoken to in her own language.”

Making it happen

The unit-based team made it happen.

“From the time they walk in the door, every patient should receive the same level of care regardless of the language they speak,” says Glenda Morrison, a medical assistant, SEIU UHW chief shop steward and the UBT co-lead.

But in the beginning, the frontline staff members, including Morrison, were skeptical.

“Since we were already serving Spanish-speaking patients in our clinic, the question we were asking was, ‘Why is this needed?’ ” Morrison says.

But a visit to the Spanish-speaking Medicine module at the Santa Clara campus made them believers. That module has been in place for five years.

“When I saw it in action, a light went off—and I realized that by not speaking to our Spanish-speaking members in their own language, we weren’t providing them with the same care as we were our English-speaking members,” Morrison says.

Overcoming obstacles

Once the team decided to take on the project, it faced some challenges. Offices had to be moved and medical assistants had to be reassigned.

“We had a lot of meetings and a lot of nervous people,” Morrison says.

But again, the Santa Clara example eased fears: “Once they saw how it worked in Santa Clara, we got by-in from the staff and it was easier,” Kearney says.

The module, which opened Sept. 29, includes signage and literature in Spanish. The staff members, from the receptionists and medical assistants to the doctors, are fluent Spanish speakers.  Word about the new module went out through Spanish-speaking television news and newspaper reports. And there was a grand opening.

It’s going well so far, Kearny says, noting that “we have three Spanish-speaking providers each day, and they have appointment capacity for about 20 patients.”

Next steps

Now, the team is looking for ways to quantify the benefits of the new module. It’s hoping to be able to collect patient satisfaction data specifically from Spanish-speaking members to assess the impact, Kearney says.

“If it shows success, we’ll pass the idea on to other teams,” she says.

Meanwhile, the unit is looking at how it can provide culturally competent care for its other monolingual patients.

“We don’t what a certain group to feel singled out,” Morrison says. “We just want them to feel comfortable.”

When you get to the leadership level it’s easy to become disconnected and to forget that where the rubber meets the road is at the front line. Sponsoring a unit-based team helps me stay connected—and that helps me be a better manager.

Staying connected

As a sponsor for the Medical Secretaries and Scanning Center, I help the teams see where they fit in the bigger picture—and they help me see the challenges that teams face every day.

I check in with the teams and their co-leaders regularly, make sure they’re accomplishing their goals and doing work that meets regional and national goals. They have their own ideas for improving department operations and doing their own small tests of change. I help them think strategically about how they can impact the region and Kaiser Permanente as a whole.  

There will always be the manager-employee relationship, but when you walk into a UBT meeting, you leave the hierarchy at the door. To build credibility, everyone on the UBT must have an equal voice at the table. I believe in the partnership and, yes, there are a few times when a manager shoulders the responsibility and has to make decisions about regulatory compliance issues, regional strategic direction and planning, scope of practice discussions about licensures and policies, and personnel management. But there are a lot of other decisions that staff can be a part of making in a group setting, and getting buy-in from the folks who do the work makes all the difference in the world.

Removing obstacles

Because I’m in a leadership role, it is important that I help the teams overcome barriers. If they need help understanding a goal, metric or budget, I can gather the information and package it in a way that is most helpful to the team.  When I started working with these teams in 2007, they were already doing good work despite some major obstacles. The chartroom transitioned to the scanning center, and the medical secretaries had a lot of manager and staff turnover, and had difficulty meeting performance metrics. Now both teams are high functioning. They have accomplished so much in the last two years.

So to other sponsors I say, don’t be afraid to jump in. It’s so rewarding to see your teams grow. If we are going to improve performance, we’ll need engagement at all levels of the organization, and the UBT process allows that to happen.