Last year, the outpatient procedure unit-based team at Capitol Hill Medical Center rewrote the instructions it sends to patients scheduled
for a colonoscopy. A patient who found the earlier directions confusing played a leading role in the process.

The new instructions helped reduce by 20 percent the number of colonoscopies that needed to be repeated. Involving the patient was “a transformational experience
for the team,” says Jennifer Walker, RN, lead UBT consultant and improvement advisor in the Mid-Atlantic States region.

It also showed the power of a new provision of the 2015 National Agreement. 

What if every organization and every union had a labor management partnership like ours?

It’s not as far-fetched as it sounds. On Aug. 16, more than 250 union, business and government leaders from all over the United States gathered in Chicago for Partnership Day, a meeting hosted by the Federal Mediation and Conciliation Service at its biennial conference—and offered a realistic look at the ups and downs that occur in partnerships and what it takes to launch and sustain them.

“We know partnership can make a difference,” Allison Beck, FMCS director, told the gathering. “This is not some fantasy that happens in a make-believe world.” She should know. As leader of the FMCS, the federal agency that mediates labor disputes across the United States, she’s seen firsthand how acrimonious relationships can ruin companies and unions—and how more open and respectful ones can help them both succeed.

The partnership between Kaiser Permanente and the Coalition of Kaiser Permanente Unions is the longest-lasting and strongest one in the nation, so conference participants asked many questions about how it operates.

A race to the top

Dennis Dabney, KP's senior vice president of National Labor Relations and Office of Labor Management Partnership, told the packed room he spends a lot of time on the phone with leaders from other companies interested in starting and strengthening partnerships.

“I've seen so many companies engaged in a race to the bottom,” Dabney said. “I'd like to see more engaged in a race to the top.” If he has any regrets about Kaiser Permanente’s partnership, he said, it's that we didn’t create unit-based teams sooner.

Colorado

Thanks to a diligent chart review process, the Medicare Risk Business Services unit captured an additional $10.3 million last year in Medicare reimbursements unclaimed in 2010. The hospitals Kaiser Permanente contracts with in the region were submitting documentation with incomplete physician signatures, which prevented KP from submitting the bills for reimbursement. The technical error causing the problem was corrected, but the team had to review 26,000 hospital inpatient notes for 2010. The total collected is more than three times what the team predicted when it began correcting the error.

Georgia

When staffers at the Cumberland Medical Office Building pharmacy in Atlanta open bottles of pills to dispense prescriptions, the bottle is supposed to be marked with a big X, a flag for reordering. But often, a pharmacist or pharmacy tech would find only a few pills left in unmarked, open bottles, not enough to fill a patient’s prescription. So the team brainstormed ways to ensure the bottles are properly marked, including posted reminders and giving everyone his or her own marker. The number of unmarked bottles fell from 30 to zero the first week; went back up the next week; then dropped back down and stayed down—lowering costs and improving service.

Hawaii

When the Honolulu clinic’s Obstetrics and Gynecology team members realized patients were waiting six minutes or more for routine injections, they decided to designate one nurse each week as the “shot nurse,” whose priority duty is giving shots, and one as a “floor nurse,” who helps direct patients to the shot nurse and pitches in when it’s busy. Whiteboards let staff know who is filling the roles. The team has dropped member wait times to an average of 3.2 minutes.

 Mid-Atlantic States

Unit-based team storyboards, a homemade “test of change” video shot by the Radiology UBT on its efforts to boost co-pay collections, and a roomful of enthusiasm and healthy snacks marked the inaugural UBT Expo in the Mid-Atlantic States region. A dozen teams at Largo Medical Center in Maryland—from Adult Medicine to Vision Essentials—exhibited projects on service, quality, best workplace and affordability. When attendees weren’t networking at the exhibits, they heard formal presentations from teams, who were introduced by their sponsors.

Northern California

The Redwood City Medical Center inpatient pharmacy is celebrating success after sustaining, for more than six months, a dramatic reduction in the rate of medications administered late (a half-hour past their scheduled time) in the medical-surgical wards. Previously, 26 percent were late; now, the range is 12 percent to 15 percent. Working with the med-surg nurse manager, the team began using color-coded bins to distinguish new medications from discontinued ones and delivering medications 15 minutes before the hour in which they are scheduled to be administered. These and other changes have improved communication and give nurses more information about where to retrieve the medications.

Northwest

By focusing on hospital quiet and Nurse Knowledge Exchange, the Women and Newborn Care arena at Sunnyside Medical Center has earned recognition as one of the best of its kind the throughout Kaiser Permanente, improving its HCAHPS Overall Hospital rating by 17.5 in 2011. The report rooms—where staff members congregate and talk—have doors that close automatically, and nurses try to respond to all call lights within three dings. “A patient does not belong to one nurse, but the whole department,” says Dory Schutte, RN, a member of OFNHP and one of the UBT’s co-leads. In addition, Nurse Knowledge Exchange at shift changes and having nurses join physicians and midwives on rounds has improved communication and patient satisfaction.

Ohio

Giving post-procedure snacks to patients is standard, but Ohio’s Gastroenterology department realized it was averaging $750 to $800 a month on snacks, well over budget. After Carol Zimmerman became manager, the UBT implemented small but key changes: Eliminating rarely eaten snacks, replacing more expensive items (Oreos) with less expensive choices (graham crackers), and removing temptation by keeping supplies locked out of sight. Zimmerman also began to regularly share the department’s budget and costs with staff. The team noticed an impact within two months, with hundreds of dollars saved in short order. Reviewing the budget is now a standing part of team meetings.

Southern California

Faced with the teams using linens inappropriately, Panorama City Medical Center’s Materials Management unit-based team set out to educate other hospital staff about the costs involved—reminding them not to use linens to mop up spills or as makeshift tablecloths and to refrain from overstocking linen in patient rooms. Managers and union leaders worked together to develop a storyboard and presentations and reviewed linen usage and stocking levels with individual departments. The result? The overall costs of linen for Maternal Child Health, one of the first departments targeted, were reduced by 6.8 percent, more than three times the original goal.

Colorado

The Regional Imaging teams in Colorado are lucky to have two effective sponsors: Joseph Gonzales, clinical operations for Regional Imaging, and Rebecca “Becky” Torres, a pharmacy technician and SEIU Local 105 member. Part of their success, the pair says, is the emphasis they have placed on sharing information—with each other and with their teams. The pair also figured out a way to spread effective practices. Using a PowerPoint template, the sponsors asked co-leads to explain what they’re working on, how it supports regional goals, whether it worked and the outcome. Then, the teams came together for a UBT Fair and shared their PowerPoints.

Georgia 

David Jones, MD, has a title unique at Kaiser Permanente: assistant to the medical director for unit-based teams. He mobilizes his fellow physicians in the Georgia region to get involved with UBTs and unleash the power of partnership to improve performance and grow membership. “The first thing I tell physicians about the UBTs is that it is about improving the work that we’re already doing,” he says. “It’s not about adding more work, it’s about looking at the work you're doing and figuring out how to do it better.” Read more from Jones—including how his experience with UBTs has transformed the way he delivers care to his patients.

Hawaii

A small region, Hawaii needed a novel approach to sponsorship: Branch out rather than always branch up. Initially, a five-member unit-based team committee tried to troubleshoot issues for the region’s fledgling teams. Often, those committee members, who also had roles as team co-leads or contract specialists, were trying to wear too many hats and got jammed. So the region, which now has more than 40 teams, has tapped 19 people to receive sponsorship training. The group includes middle managers, directors and other executives, frontline nurses who serve on the Kaiser Permanente board of the Hawaii Nurses Association, OPEIU Local 50, and former labor team members and co-leads.

Mid-Atlantic States

While the Mid-Atlantic States region’s clinical unit-based teams have management and labor co-sponsors, large teams such as lab and radiology are sponsored in a different way: A UBT leadership group made up of labor and management from these area performs sponsorship functions as a united body. “We generated a vision of our UBT sponsorship. We got very specific on how we would work together,” says Jane Lewis, executive director of health plan regional services and a member of the group that sponsors eight pharmacy UBTs. The UBTs report their projects and team dynamics at monthly meetings. The leadership group reviews People Pulse, service scores, quality results and other metrics, identifies struggling teams, and recognizes teams that excel.

Northern California

The region has been on a roll with its “A Leader’s Role as UBT Sponsor” training. Launched in the spring, the tutorial gives management and labor leaders an easy-to-understand yet in-depth look at providing effective support to unit-based teams and their performance improvement work. The short, online training covers everything from outlining a sponsor’s role and how a sponsor can model partnership to tips on developing strong UBT co-leads and high-performing teams. Several facilities have combined the training with in-person, interactive exercises, and early feedback suggests the blended approach is striking a chord with sponsors. The online training can be found at KP Learn.

Northwest

“My role as a senior sponsor is to bring the message of UBTs to physician leadership,” says Rasjad Lints, MD, the region’s executive sponsor of UBTs. Lints is especially interested in helping teams focus on outcome metrics—a measure of the final result of something, such as how many patients with hypertension have their blood pressure under control—and to help everyone on the team understand that improving on process metrics often drives improvement on outcomes. It can be difficult to see the value in participating in process metrics if team members don’t see how it relates to the outcome measures. “At the end of the day, physicians have to drive the care,” Lints says. While working in UBTs presents physicians with some unique challenges, he believes that “if the physicians aren’t engaged, it’s a lost opportunity.”

Ohio

In an effort to improve the quality of team project information in UBT Tracker, the regional LMP support team solicited the help of the people who support the work of teams—sponsors. In June, an improvement adviser met with Ohio’s 20-plus sponsors and asked them to work with their teams to boost the input of that data. To illustrate the value and role of quality data in UBT Tracker, they used the data in Tracker to brief the sponsors on their UBTs’ projects and status. Their approach made an impact: The region has reported an increase in sponsor engagement, and several teams have reported performance and relationship improvements. 

Southern California

The regional Labor Management Partnership department is launching a new sponsor training curriculum that covers the nuts and bolts of what sponsors do and how they do it. Topics include: the responsibilities of sponsoring bodies (such as helping define how the teams should be structured and guiding selection of co-leads); coaching skills to help develop UBT leaders; the similarities and differences between labor and management sponsorship; how managing in partnership differs from traditional management; and how the sponsor role differs from that of facilitators, project managers, trainers and consultants. Also included in the course are basics of the Labor Management Partnership and unit-based teams, such as the key elements for UBT success, the roles and responsibilities of UBT co-leads and members, and consensus decision making.

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.

Take, if you will, the humble cell phone.

Oh wait. The cell phone may be ubiquitous, but it’s far from humble. Today’s smarty-pants phones have more power than the computers on the Voyager 1, which was launched in 1977 and 36 years later departed our solar system. Its three computers can process about 8,000 instructions per second. A smartphone swallows more than 14 billion.

The articles in this issue of Hank—articles about how technology is transforming care delivery and about how individuals and Kaiser Permanente are meeting the challenges that presents—would have overwhelmed the Voyager computers’ memory.

For communicating across distances, the string with two tin cans is humble. Even the rotary phone, patented in 1892, seems modest in comparison with today’s devices, which are used more for all manner of modern information sharing than for something as quaint as talking to another human being.

A rapid tech-based transformation, akin to the makeover of the old-fashioned phone, is already sweeping through care delivery. It’s hard to fathom the many ways technology will allow us to decentralize the delivery of health care while improving our connection with our patients and members. The changes will require new skills.

And starting today, the mindset we bring to the workplace is just as important as our skills. Without a willingness to explore new ways of doing our work, we are (to mix a metaphor) like an ostrich dialing the operator for help on a rotary phone, patiently waiting the long seconds for the 0 to return to its starting place while the future creeps up from behind. We’ll never know what got us.

Be bold. Be willing to go where no one has gone before.