What happens when teams truly walk a mile in their patients’ shoes? They often discover their own actions are making that mile a rocky one for patients—and as a result make huge breakthroughs in the way they deliver care.

In the case of South San Francisco’s multidepartmental pre-admission team, observing their processes from the other side of the gurney spurred them to dramatically streamline the pre-surgery and admitting process for patients. With the member at the forefront of their thinking, the team members turned a two-inch-thick packet of confusing, redundant information into a streamlined, one-page checklist. And a funny thing happened—while redesigning the process to help patients, the team improved the way it works.

“Patients would often get confused and weren’t sure what the next step in the process was,” says Brian Tzeng, MD, the Peri-operative Medicine director. “We realized we didn’t have a clear path for the patient to follow.”

Other teams throughout Kaiser Permanente are making similar realizations, framing their performance improvement work by asking the question, “What’s best for the patient?” If a possible solution doesn’t work well for the member and patient, then there’s more brainstorming to be done. These teams are taking the Value Compass to heart—organizing their work not just around the four points but examining what they’re doing from the patient’s perspective.

What does that mean for frontline teams? At the San Diego Medical Center, the Emergency Department sees up to 300 patients every 24 hours. Physicians and staff members are always on the go, delivering on the ultimate bottom line—saved lives. What could be more important? Clinical quality is high; patients are seen in a timely manner and the rate of unscheduled return visits is good.

Yet the results of a recent patient satisfaction survey bothered the team. The department scored well overall, but their patients gave it only 63 percent approval on one question: While you were in the Emergency Department, were you kept informed about how long the treatment would take?

Managers newly charged with co-leading unit-based teams sometimes need to build team cohesion before diving into the nitty-gritty of setting goals and improving performance.

Brenda Johnson, optical site supervisor at the South Bay Medical Center in Southern California, has found a way to do just that—and improve her staff’s eating habits at the same time.

Inspired by a presentation at a regional leadership conference hosted by Jeffrey Weisz, MD, executive medical director of the Southern California Permanente Medical Group, she launched a healthy eating club in her department. Every week, staffers chip in $12 each—and get four healthy, fresh-cooked meals in return.

At the early spring meeting, Dr. Weisz discussed Kaiser Permanente’s Healthy Workforce initiative and distributed a booklet listing the calorie count of hundreds of food items.

Making change easier

“I looked at the book, and I thought, ‘Oh, my goodness,’” said Johnson, shocked at the number of calories in some of her favorite foods.

“I looked around at my employees,” she said. “Some have health issues. Some drink sodas by the 32-ounce cup every day.” The medical center is ringed by mini-malls with fast food restaurants. “We’ve been eating the same stuff for years,” she said. “The only question was who’s going to go pick it up.”

Gil Menendez admits he was one of the 32-ounce-cup soda drinkers—a habit he gave up when he joined the club. Menendez, an optical dispenser, SEIU UHW member and  labor co-lead of the UBT, was so motivated by the changes in his lunchtime habits that he also began a strict diet and exercise routine. He’s lost 20 pounds.

New ways to work together

Johnson cautions that the healthy eating club isn’t a diet club. She picks recipes out of a pamphlet produced by the California Department of Public Health, Champions for Change, and prepares the ingredients at home. Others sometimes prepare recipes from their families and cultures. She combines ingredients in the morning, steams them in a slow cooker the staff keeps at work, and a meal is ready by lunchtime.

“I have to cook for my family anyway,” says Johnson. At home, “We’ve changed our habits because of high blood pressure. I prepare this food with love because I’m preparing it for both of my families: my family at home and my family at work.” 

About 15 to 20 people participate in the club each week, up from 10 when it first began in May 2010. In addition to its health benefits, the club has helped her department be more productive and collegial, says Johnson.

“It’s going strong,” adds Mendez. “It brings us together.”

Looking for ways to make the Sand Canyon Surgicenter in Irvine more efficient, Albert Olmeda wound up learning a lot about blue wrap—like the fact that it makes up nearly 20 percent of the waste generated by hospital surgical services. 

The lead Central Services technician and SEIU UHW member also learned that this heavily used hospital product, an industrial strength plastic used to maintain the sterility of medical and surgical instruments until opened, is not biodegradable and persists in the environment. 

But recycled blue wrap can be sold as raw material for use in the production of other plastic products. Today, the surgicenter’s unit-based team has gone green with a blue wrap recycling project that is not only saving money and protecting the environment, but also aiding the community. 

“The biggest problem with the blue wrap is when we throw it in the landfill, it’s there forever,” says Olmeda. “That’s a big concern especially considering how much blue wrap we use.” 

How recycling works

About 600 pounds of blue wrap is collected every week from the center’s six operating rooms. It is picked up free of charge and sorted by Goodwill of Orange County, which sells it to a Houston recycling services company. The company reprocesses the plastic into beads that are used in various products, including railroad ties, pallets and artificial siding for decks, docks and houses. 

The surgicenter has been recycling its blue wrap and plastic bottles since September 2009, reducing the facility’s solid waste disposal fee by 10 percent annually. The savings amount to a modest $5,880—but there’s a greater payoff. Proceeds from the sale of blue wrap and other recyclable products enable Goodwill to provide education and training programs for developmentally and physically disabled adults, including a state-of-the-art fitness center. 

Peter Bares, business development manager for Goodwill of Orange County, says the relationship with Kaiser Permanente has gone beyond expectations. “It is kind of the perfect storm because of the nature of what we do and why we do it and the materials that the hospital generates,” he says. 

Getting buy-in

As the frontline staff person responsible for the surgery center’s blue wrap disposal, Olmeda—and his fellow UBT members—championed the recycling cause, educating the staff at weekly in-services and UBT huddles.  The team got the rest of the department on board by integrating the blue wrap recycling process without creating additional tasks. 

“We figured if we changed workflows, staff wouldn’t want to do it.” says UBT co-lead Nicole Etchegoyen, a surgery scheduler and SEIU UHW steward. “But if we asked them, ‘How would this work best for you?’ then everyone would get involved, and they did.” 

The team members designated a single container for blue wrap in each operating room. They also placed a larger bin for collecting multiple bags of discarded blue wrap near the soiled utility room, where the trash is taken on its way out of the surgery center. 

“It’s not a big deal,” EVS worker and SEIU UHW member George Sollars said, hoisting bags. “We just carry it over here on our way out this door. It’s one of the easiest jobs. And it’s for a really good cause.” 

No trash, just recycling 

The hardest part was making make sure that other trash didn’t make it into the blue wrap recycling containers accidentally. Labeling the containers with signs reading ‘Recycling Blue Wrap Only’ helped, as did regular reminders by UBT members. 

Now, everyone in the operating rooms—from doctors, nurses and surgical techs to nursing assistants and EVS workers—makes sure that the blue wrap containers aren’t contaminated with other trash, Etchegoyen says. 

Olmeda does periodic spot checks. “Everybody who plays a role in the operating room has to look out to make sure no trash is going inside the containers,” he says. “It’s a team-building thing.” 

“If it wasn’t for the UBT, this wouldn’t be happening,” said Ramin Zolfagar, MD, department head and UBT member. “We are helping the environment by ‘going blue,’ so to speak, and the end result is gym equipment for the disabled—which makes it all the more worthwhile.” 

After learning about the project at a recent Orange County UBT fair, other departments are thinking about emulating it. 

Visit the Goodwill of Orange County website to find out more about their work.

Hemaxi Khalashi isn’t afraid of strange smells. As a clinical lab scientist, her nose is in all kinds of odd odors. But the stench that filled her corner of the Northern California Regional Lab one recent morning put her and many of the other lab workers on edge.

“It was like a bad, old gassy smell, or something deteriorating,” Khalashi said. “I asked my supervisor to walk with me to that corner of the room and asked her what she smelled, and she said, ‘Something dead—rotten.’”

The lab employees quickly fingered the culprit—a new instrument that tests blood samples for Hepatitis B—but they needed a solution, and fast. Their first step: to huddle.

The 15-minute meeting gave lab workers the chance to air their concerns, and provided managers with the opportunity to let the team know the vendor already had been contacted and would be coming by that day. Khalashi spoke up and asked what could be done, right away, to help those who worked near the machine. The section manager suggested masks, which are always available for lab employees.

“Huddles are usually the starting point for getting something done,” said Larry Ratto, a lab assistant and SEIU UHW-West member whose desk is the rallying spot for such meetings. “They are really good for making immediate change—and they never last more than 15 minutes, tops.”

In short order that morning, an issue that might have caused an undercurrent of anxiety was aired and laid to rest. Lab employees and managers determined test results weren’t being compromised and that the odor, though unpleasant, was harmless—and thanks to the huddle, everyone knew it. They later decided to install an air purifier next to the instrument and developed new procedures for handling its waste. The two steps have mitigated the smell.

The lab workers’ instinct to huddle, which stemmed from a year’s worth of practice, is one shared by many high-performing teams throughout Kaiser Permanente. The most successful unit-based teams, those that improve performance and meet goals, are using huddles regularly and effectively—and not just when a major problem needs to be solved.

Huddles aren’t a substitute for the training and skill-building that members of unit-based teams need as they shift into new ways of working—training and skills that help create the learning environment where frontline workers are engaged in decision making and see the connection between their work and larger, strategic outcomes.

But those who study group dynamics say routine huddles can give teams the opportunity to get good at solving problems together when the stakes are low—practice that increases the odds of solving problems successfully when the stakes are high. Frequent, candid conversations, these experts say, create working environments conducive to improvement and change.

“I see it in our group,” said Denise Ja, microbiology section manager. “Huddles have improved our communication, our camaraderie and our teamwork.”

Amy Edmondson, a Harvard Business School professor whose research examines what factors foster outstanding performance in health care settings, says huddles are a way of building what sociologists call “social capital.” In other words, they build social connections that produce real value by increasing productivity.

“The more we know each other and…(have) exchanged our thinking, the more we’ve just connected as human beings—the better we do,” said Edmondson, who led two workshops at this spring’s Union Delegates Conference.  “If we’re friends, I will make that extra little cognitive effort to think, ‘Oh, I wonder why she thinks it’s that way?’ Or, ‘I wonder why she sees it that way?’”

The willingness to extend that extra effort can make a world of difference in solving problems, creating a healthy work environment—and improving patient outcomes.

Many shapes and sizes

In Northern and Southern California, 79 percent of high-performing UBTs were huddling as of November 2009. Just 30 percent of newly established teams were doing the same. Once a team has gotten trained in the Rapid Improvement Model and other fundamental techniques, huddles can be an addition that helps improve working relationships.

Huddles mean different things to different departments. Some teams meet daily; others do it weekly. Many departments convene at the same time and same place; others are more spontaneous. Most huddles are short.

Part of what makes huddles effective is that they create frequent, regular opportunities for all the members of the unit-based team—the people whose work naturally draws them together—to come together and contribute ideas.

And they have a casualness that makes even the most reticent team member comfortable speaking up.

“I think because we’re close together in physical proximity, people feel less inhibited,” Ja said. She finds that in more formal meetings, some team members hold back. But when the team huddles in the work area, she said, “It’s kind of a hustle-bustle, and people are anxious to put their two cents in.”

Ja’s team usually huddles every Friday. But during the height of the H1N1 epidemic, the number of specimens the lab handled skyrocketed from 30 to 900 per day, and the team resorted to meeting daily and sometimes even hourly.

As team members worked frantically to devise a new system for tracking samples, the huddles became the place to test new ideas. It was in a huddle that someone suggested a coding system using letters, but the team quickly ran through the alphabet. The team members huddled and re-huddled until they were using a combination of letters, dates and numbers.

Huddles helped the lab workers keep up with the onslaught of work, pulling off what had seemed impossible.

“Everyone contributed ideas,” said Mark Stanley, microbiology director. “We depended on everyone’s knowledge.”

Figurative huddle

Even teams whose members don’t all work in the same location find that huddling works.

Colorado’s asthma care coordinators are spread out across the region, and usually see each other only two or three times a month. But when the department of seven launched a big push to improve the refill rate of an asthma control medication among children, team members decided to huddle once a week over the phone.

During their phone chats, which usually ran 30 to 45 minutes, team members related their progress in reaching out to members ages 5 to 17 who had not refilled their prescription in four months. Developing a habit of sharing their best practices, successes and failures with colleagues made the team members more accountable, said Kristie Wuerker-Delange, RN, an asthma care coordinator and member of UFCW Local 7.

“It’s kind of an, ‘Uh oh, I have to get this done because we’re going to talk to everybody, and they are going to want to know what I’ve been doing for the week,’” she said.

During one huddle, for example, asthma care coordinator Cindy Lamb told the team she had found that promoting the convenience of the mail-order pharmacy, giving members the telephone number to the regular pharmacy, and providing the member’s prescription number helped patients get their refills faster.

Within eight months, the refill rate of inhaled corticosteroids leapt nearly 20 percentage points, from 43 percent in March 2009 to 60 percent in January 2010—a feat that would not have taken longer without their huddles, Wuerker-Delange said.

“They kept the team focused on the same goal,” said Lamb, a member of UFCW Local 7. 

While other teams have the benefit of simply moseying over to a colleague’s desk, meeting over the phone has its pluses.

“I feel like people open up a bit more,” Wuerker-Delange said. “They are more apt to say a certain thing if someone’s not looking at them.”

Morning ritual

For the Family Medicine department at the Culver Marina Medical Offices campus in Southern California, huddles are part of the morning routine, like brushing your teeth after breakfast.

At 8:25 a.m., Department Administrator Barbara Matthews pokes her head into team members’ offices, her cue that it’s time to convene in the hallway. Patients already are beginning to arrive, so huddles rarely last more than five or 10 minutes.

Doctors, nurses, medical assistants—everyone who is working that day—attend. Co-leads use the time to relay who is working, share a workplace safety message, offer service reminders and more.

“I am upset if I can’t make our morning huddles,” said Krystle Harris, a medical assistant and SEIU UHW-West member. “If I am screening a patient and have to miss it, then I’ll ask one of my co-workers, ‘Aw man, what was the huddle about?’”

Matthews said in the beginning it wasn’t easy getting everyone to huddle and some team members still might choose not to attend if given that option.

But she thinks it’s no coincidence that since the department started huddling a year ago, its hospitality scores have increased, from 83 percent in December 2008 to approximately 89 percent in December 2009.

Other shifts, more subtle but just as significant, are taking place as well. Gene Oppenheim, MD, the physician in charge of the Culver Marina Medical Offices, notes that employees who frequently used to arrive five or 10 minutes late are on time now. Matthews says team members like Harris, who used to say little during meetings, are doing a lot more talking.

That’s a clue that team members are confident their views are valued and they aren’t afraid they may get in trouble for sharing their thoughts—two key characteristics that research shows leads to high performance.

One day recently Harris overheard licensed vocational nurse Jolavette Pye, an SEIU UHW-West member, trying to schedule a specialist appointment for a patient.

The specialist was booked for quite some time, but Pye called back a week later and sure enough, there was a cancellation.

“I brought it to the huddle to congratulate her,” Harris said. “She went out of her way—and the patient was really happy.”

Harris said she thinks sharing with the team the praise she’s overheard co-workers receiving from a patient helps morale, so she does it whenever she can.

“I am shy and I don’t like to speak around a lot of people,” Harris said. “But I am beginning to speak up and discuss little things that are on my mind. I’m just more comfortable in the huddle setting.” 

Have questions about huddling you’d like to bounce off one of the team co-leads interviewed for this article? Email Denise.Ja [at] kp.org, Concepcion.Savoy [at] kp.org, Kristine.Wuerker-Delange [at] kp.org, Deana.L.Parker [at] kp.org or Barbara.J.Matthews [at] kp.org for their thoughts.

9 reasons to huddle

1. Resolves small problems before they become big problems.
2. Provides real-time collaboration.
3. Makes it easier for employees to speak up, due to informal nature.
4. Encourages people to raise questions and share ideas.
5. Increases the pool of ideas for addressing an issue.
6. Leads to better communication through frequent communication.
7. Improves staff morale.
8. Lays the foundation for taking on big problems by providing routine practice at solving small problems.
9. Keeps you warm on cold days.

New to huddling?

Here are some tips to help you get the most out of your huddles.

• Get the group’s attention. Set a positive tone. Use people’s names.
• Describe the plan or topic for discussion, including relevant background information and contingencies.
• Explicitly ask for input. Have a two-way conversation. Effective team leaders continuously invite others into the conversation.
• Encourage ongoing monitoring and cross-checking.
• Specifically ask people to speak up if they have questions or concerns.

Some ideas of what to discuss:

• Observed workplace safety issues that everyone can learn from.
• Other departments’ work that may impact the team’s work that day.
• Small tests of change to resolve identified issues and help improve performance.
• How everyone is doing and who may need extra support that day.
• New policies or procedures or other changes.

—From the Sponsor and Leader Resource Guide for UBTs.
 

‘Huddles have improved our communication, our camaraderie and our teamwork.’

Denise Ja, microbiology section manager, Northern California Regional Lab

Surgical checklists improve patient safety, strengthen team dynamics

In high-risk industries—including aviation and high-rise construction as well as health care—surgeon and best-selling author Atul Gawande has found that a good checklist not only specifies common sense safety measures, it also ensures “that people talk to one another about each case, at least just for a minute before starting,” he writes. “[It is] basically a strategy to foster teamwork—a kind of team huddle.”

A major theme of Gawande’s latest book, The Checklist Manifesto: How to Get Things Right, is that the best checklists are not just a top-down set of tasks for others to follow. They’re a tool for better team communication, coordination and inquiry. Read more about using checklists here.