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FRONTLINE NEWS FOR KP WORKERS,

MANAGERS & PHYSICIANS

SUMMER 09 | ISSUE No.19

IN THIS ISSUEPeer support easing KP HealthConnect go-lives

Tightening OR procedures saves $50,000 a year

Doctors laud unit-based team for clinical successes

When MINUTES COUNT How the frontline is saving the day

2 www.lmpartnership.orgHank Summer 2009 | No. 19

Published by Kaiser Permanente and Coalition of Kaiser Permanente Unions

CommuniCations DireCtors

Maureen AndersonStacia Hill Levenfeld

eDitor Tyra Mead

Contributors

Patty Allison, Kellie Applen, Cassandra Braun, Glenda Carroll, Janet Coffman, Paul Cohen, Paul Erskine, Jennifer Gladwell, Laureen Lazarovici, Julie Light, Anjetta McQueen, Gwen E. Scott

Worksite photos: Bob GumpertGraphic design: Stoller Design Group

ContaCt us

Email feedback and story ideas to [email protected]

3 WHEN MINuTES COuNT The only road to be on is the road to performance improvement. Where are you?

6 TAKING THE TECH OuT OF TECHNOLOGY A perhaps unusual collaboration between the Northwest and Southern California

demonstrates the value of a KP HealthConnect best practice.

8 WASTE NOT, WANT NOT See how an Ohio operating room used the “plan, do, study, act” steps to save

about $50,000 a year just by keeping better track of their records.

10 BLuE MOON Henrietta dives into depression—and comes up with information about what

can be done.

10 LETTERS TO THE EdITOR

11 dOCTORS PRAISE TEAM FOR dOING WHAT NO dOCTOR ALONE COuLd dO When a Mid-Atlantic team focused on care for high-risk diabetic patients, clinical

outcomes got dramatically better—changing one doctor’s view of her role.

CONTENTS

It’s jargon, frankly—“performance improvement.”

The problem with the phrase is that it doesn’t say anything

about what we do day to day.

Most of us who work at Kaiser Permanente don’t come to

work to do “performance,” with the exception perhaps of the

members of our Educational Theater troupe. We come to

work to help care for our patients and members—registering

them for their appointments, checking them in, collecting their

co-pays, taking their blood pressure and other vitals, asking

about their symptoms, giving them a diagnosis, working out a

treatment plan, performing surgery, prescribing medication,

filling prescriptions, cleaning the rooms where they’re treated

and cared for, preparing meals for those who are hospitalized,

and on and on. Those who aren’t involved in direct patient care

are doing work that supports those who do the direct care.

There are thousands of jobs at KP, and millions of tasks to be

done. It’s all those millions of things—not “performance”—

that we want to be better at doing. A million small changes

can add up to one pretty huge overall change.

So break it down for yourself. Think about what you do every

day and how you can do it better. Be specific. If you can make

the change all on your own, do it! If the wrinkles need to get

ironed out with one or more colleagues—make it happen.

Don’t wait for someone else to get the ball rolling.

“To be a great leader of change, we have to make a profound

connection with what’s in people’s hearts,” says Helen Bevan,

the chief of service transformation for Great Britain’s National

Health Service, who spoke at the Union Delegates Conference

this spring.

To do your specific job better, start by connecting with what’s

in your heart. Remember what drew you to Kaiser Permanente.

And go from there. Help lead the way.

That’s what lies behind the success of both the unit-based

teams and the cross-functional teams that are the subject of this

issue’s cover story, “When minutes count,” and that’s what lies

behind the success of every department, team and individual

mentioned in this issue of Hank.

eDITOR’S LETTER

Making a connection

3

6

8

10

11

Why teamwork and performance improvement matter now more than ever

What is Hank?Hank is an award-winning journal named in honor of Kaiser Permanente’s visionary co-founder and innovator, Henry J. Kaiser.

Hank’s mission: Highlight the successes and struggles of Kaiser Permanente’s Labor Management Partnership, which has been recognized as a model oper-ating strategy for health care. Hank is published quarterly for the Partnership’s 120,000 workers, managers, physicians and dentists. All of them are working to make KP the best place to receive care and the best place to work—and in the process are making health care history. That’s what Henry Kaiser had in mind from the start.

For information about the manage-ment and union co-leads advancing partnership in your region, please visit LMPartnership.org/about/contacts/regional.html.

Cover story

www.lmpartnership.org 3 Hank Summer 2009 | No. 19

MINUTESWhen

COUNTWhy teamwork and performance improvement matter now more than ever

Record unemployment rates and crashes in the stock and housing markets make working in partnership more relevant than ever before—and more urgent.

One way to respond to the economic crisis would be to run faster,

jump higher, pray harder. But there’s a far more reliable way to stave

off disaster, one that thousands of Kaiser Permanente workers,

managers and physicians already are doing: creating lasting

solutions to issues that previously were “solved” with short-term

workarounds that never fixed the underlying problems.

That approach means engaging with your colleagues to find ways

to do things better together—which is the essence of partnership.

The results blow people away.

“To have something you’ve implemented with your peers, and

actually have it work? You never see this,” said Sharon Rudometkin,

a ward clerk in the intensive care unit at the Orange County Medical

Center in Southern California.

CROSSING DEPARTMENT LINES

Rudometkin, an SEIU UHW-West member, is a member of a

“cross-functional” team that came together as part of the Perfor-

mance Improvement (PI) system that has been introduced over

the last two years. The system was developed by an inter-regional

leadership team with the intention of creating a consistent, coherent

performance improvement methodology that leverages the best of

other systems yet is tailored to KP’s specific needs. It includes a

network of more than 100 improvement advisers, who work with

facility operations teams to redesign processes from the patient’s

point of view.

“This is KP’s improvement system. It integrates some of the tools

from Lean, some of the tools in Six Sigma,” says Lisa Schilling,

RN, the vice president of Health Care Performance Improvement,

referring to other performance improvement methods. The advisers

and a number of other key players—from frontline workers to top

executives—get specialized training through the Improvement

Institute, which is led by the national Department of Care and

Service Quality.

What matters most, Schilling said, is that “we focus not on the tool

but on the performance we want to achieve—on capability and

results. The focus is on being the best health care delivery system

in order to meet our members’ and patients’ needs.”

“I’ve been here 28 years, so I’ve seen lots of ideas and lots of

programs,” Rudometkin said. “But this is the first one I’ve seen

that’s been successful, and actually changed things.”

(continues on page 4)

‘ This is the way we should do business. Everything we do, it should be called performance improvement, with the Value Compass in the middle.’

—Marianne Giordano, LMP co-chair and OPEIU Local 30 president

Adalio Carino (above), an RN and UNAC/ UHCP member, is the labor co-lead for the patient flow team at the Orange County Medical Center in Anaheim, which discovered that the time it took to discharge patients from the hospital was creating a ripple effect that backed up transfer times out of the emergency department; Myrna Lehmus (above, near right), lead EVS attendant, and ward clerk Sharon Rudometkin (above, far right) are also on the team.

WhenMINUTES COUNT (continued from page 3)


The more than 1,000 unit-based teams (UBTs), which the 2005

National Agreement lays out as KP’s fundamental workplace unit,

and the improvement advisers and cross-functional teams share

a common goal: To create a work environment in which a

commitment to being the best and to continuous improvement

is the norm.

“Right now we’re trying to understand how the interactions

(between cross-functional teams and UBTs) are supposed to work.

We’re hiring UBT consultants who are working with frontline teams.

There are different levels of UBT involvement,” said Maria Lee, an

improvement mentor in Southern California. “There’s a will to make

sure we put these things together, and make it work.”

SHARED APPROACH TO PROBLEM SOLVING

By design, the cross-functional teams and the UBTs share a

common approach to problem solving: Both rely on the plan,

do, study, act—or PDSA—cycle of the Rapid Improvement

Method, which also is known as RIM. And both are getting solid,

measurable results—the kind of results that are essential for

Kaiser Permanente not only to survive the current national and

international economic crisis but to live up to its potential as the

model for the future of health care in the United States.

“It’s a bottom-up and top-down approach to performance

improvement that starts with an understanding that the key is

engaging the staff in the redesign and in finding the solutions—

so the bottom-up is all about the UBT, really testing changes that

will lead to better outcomes,” Schilling says. The top-down aspect

includes working with leaders to hone their ability to determine the

vital few goals that set direction for the frontline teams.

For now, the improvement advisers and the cross-functional teams

working with them are focused primarily on tackling issues that only

can get resolved if several departments work together to see how

they’re affecting one another’s business. The frontline UBTs, on the

other hand, have tended to form around individual departments.

At the Orange County Medical Center in Anaheim, for example,

the “patient flow” team includes both labor and management

members from the various departments—EVS, transportation,

emergency department, ICU, medical-surgical—that are looking at

how to reduce the amount of time it takes to transfer patients from

the intensive care unit to the medical-surgical floors.

In the long run, the goal is to move patients faster out of the

emergency department, where the wait to transfer a patient to

the ICU has sometimes dragged on for hours. The team first

thought the problem was in the ICU, because it was taking an

average of 79 minutes to transfer a patient from ICU to the

med-surg departments.

UNEXPECTED ‘ROOT CAUSE’

But as the team got a wider view of the problem, it became clear

the bottleneck was being created by the amount of time it took to

discharge med-surg patients from the hospital and by inefficient

procedures. Keeping the beds occupied longer in med-surg was

creating a ripple effect that was impacting the ICU and creating

the backlog in the ED.

As a result of the team’s work, transfer times out of the ICU have

dropped from 79 minutes in May 2008 to an average of 44 minutes

in January 2009. In May, only 24 percent of ICU transfers took



JAN. 2009

44 min.

Transfer times out of the ICU

[ Orange County Medical Center ]

Co-pay collections for elective surgery

[ San Diego Medical Center ]

$ 14%YEAR-END 2007

$ 45%

YEAR-END 2008

to

Lining up the dominoes

By working in partnership and looking past departmental boundaries, performance improvement

teams have been able to address systemic deficiencies. The changes are helping to keep costs

down and improve quality and service.

place within an hour of the order; by January, that had soared to

82 percent. And two new teams are working in tandem with the

original team, one looking at the time it takes to discharge patients

from med-surg and the other to work on the transfers into the

hospital from the ED.

“We work together as a team now,” said Adalia Carino, RN,

a member of UNAC/UHCP and the labor co-lead for the patient

flow team. “It used to be that ED got mad at us (for the backup),

but there were no beds to give them.”

The implementation of the cross-functional teams hasn’t been

without controversy, however. The PI system has been rolled out in

three waves to seven regions—the final wave starting in June—

and there was criticism that union partners weren’t always engaged

when the teams were selected and priorities set.

PARTNERSHIP EQUALS PERFORMANCE

In the San Diego service area, a big push is afoot to integrate the

performance improvement initiatives with the work being done by

unit-based teams. Labor and management leaders alike think it

makes sense for the two to work together.

San Diego LMP co-chair and OPEIU Local 30 President Marianne

Giordano says she didn’t learn about the PI system until the second

phase of the rollout.

“When I learned about the performance improvement stuff,

I thought, ‘What’s going on here? This is parallel work,’” Giordano

said. “Performance improvement is the work of unit-based

teams. The UBT is the vehicle to make this performance

improvement happen.”

Concerned that the PI system would be seen as an entirely

separate program from the UBT work, Giordano joined Finance

Administrator Lorna Curtis in attending the intensive Improvement

Institute training.

“This is the way we should do business. Everything we do, it should

be called performance improvement, with the Value Compass in the

middle,” Giordano said. “That’s how we need people to start thinking.”

If the approaches don’t converge, she continued, “I don’t think

we’ll succeed. The tools Lisa Schilling is providing are the tools to

achieve Kaiser’s mission and the Value Compass.”

The way things unfolded at the San Diego Medical Center

helps explain why UBTs haven’t always been integrated into the

PI system: The departments that have been part of the cross-

functional teams often don’t yet have a UBT. As the number of UBTs

increase across the program—the goal is 100 percent of teams

working in UBTs by 2010—frontline observers say a natural

integration is occurring.

“It all started in parallel and now we’re all aligned,” Curtis said.

“Now, we’re very united.”

INVOLVING THE PEOPLE WHO DO THE WORK

Even before an official PI system project was launched in the region

last year, Curtis had gotten nearly a dozen people trained in Lean

and Six Sigma methodologies, with the intent of using the tools to

address inefficiencies in hospital billing processes. San Diego had

ranked last in the region when it came to collecting co-pays at the

time of service.

MOSTAFFORDABLE

BESTSERVICE

BEST QUALITY

BEST PLACE TO WORK

PATIENTAND

MEMBERFOCUS

MAY 2008

60 min. 19 min.

Switching to electronic medical records provokes

plenty of anxiety—but peer-to-peer collaborations

during inpatient ‘go-lives’ have given birth to a new

best practice

TAKING THE TECH OUT OF TECHNOLOGY


The “go-live”: Thuy Truong, RN, and computer expert An Do (opposite page, left to right) and emergency department unit secretary Ann Coleman and lab supervisor George Shawn (above right, left to right) work through the new screens during the launch of the inpatient component of KP HealthConnect in the North-west; Troy Seagondollar (above, at right), RN, the national coordinator of KP HealthConnect benefit realization, helped steer the project to success.



An “impending sense of doom” is how one

nurse felt coming to work after the latest

phase of KP HealthConnect was imple-

mented at Sunnyside Medical Center.

Gracy Abraham, a 25-year Kaiser Perma-

nente nurse in the Northwest, had a lot of

apprehension walking into the oncology

department that morning last fall after the

“go-live” of the inpatient component of KP’s

electronic medical record system. She had

attended department trainings, taken extra

computer classes, done online tutorials

and practiced in the “sandbox”—a mock

environment that challenged employees

with simulated real-life situations.

Despite her preparation, she still was

nervous about “learning new things and

how to adapt to the system…without

compromising patient care.”

LEARNING FROM EXPERIENCE

There was similar apprehension throughout

KP’s only hospital in the Northwest.

A project as massive as KP HealthConnect,

the electronic medical record system for

more than 8 million members in eight

different regions, is overwhelming, even

when it’s phased in gradually. The inpatient

medical record, the latest component to be

introduced, brings a variety of benefits to

hospital care, with numerous features that

help improve patient care and safety.

Being ahead of the curve on electronic

medical records is one of many factors that

distinguishes KP’s quality of care—and the

way they were introduced in the Northwest

last fall underscores other attributes that

set KP apart from the crowd: a spirit of

teamwork and collaboration, and a willing-

ness to learn from experience.

What kept Abraham and her colleagues

going strong throughout the difficult weeks

of learning came from a perhaps unlikely

source. Taking an innovative approach, KP

management in the Northwest and South-

ern California regions and union leaders

from UNAC/UHCP and OFNHP teamed up

to ensure the Northwest’s go-live was as

successful as possible.

“This ‘took a village’ to make it work,”

from the staff who volunteered, to HR, to

payroll, to managers approving release time

and more, said Troy Seagondollar, RN, the

national coordinator of KP HealthConnect

benefit realization.

More than 40 nurses from Southern

California, who fondly became known as

the “travelers,” left their jobs and families for

as long as three weeks to come and work

side by side with their peers as they learned

the new system.

“When I saw the notice go up in our break

room, I was so excited for the Northwest,”

said Jennifer Werner, an RN at Riverside

Medical Center in Southern California who

was one of the travelers. “I wish we had had

that kind of support. It was chaotic when

we went live, and I felt like I was drowning.”

The Northwest benefited from a variety of

lessons learned during the Southern Califor-

nia rollout. Initially, Seagondollar said, while

the IT support staff “understood the system

very well, they didn’t have the expertise…

to integrate it into the coordination of care.”

QUESTIONS FROM PROVIDERS

What had begged for more attention,

Seagondollar said, were the questions

from the health care providers: “How do

I integrate this tool into giving better care?

How will this assist me in taking better care

of the patient?”

Those unanswered questions raised

everyone’s stress levels. Nurses speak a

different language than IT experts. Frontline

care, the needs of the patient, understand-

ing medical processes—the clinical users

needed to understand how the new system

would work for them, not how they would

work for it.

Seagondollar had advocated that KP

embark on peer-to-peer training.

He partnered with with Georgian Garcia, RN,

the director of nursing services at Baldwin

Park Medical Center, and for that go-live

nurse preceptors became experts in using

the system beforehand. They worked on the

nursing floors to answer specific questions

that addressed patients’ specific needs.

It didn’t take long for the approach to be

expanded throughout Southern California.

Instead of relying on IT staff to provide

support during a go-live, a complement of

clinicians from all the disciplines using the

electronic system to manage patient care

learned the system thoroughly—and then

helped their colleagues through the launch.

A MODEL FOR BEST PRACTICE

When it came time to plan for the North-

west, the opportunity to have peer-to-peer

training was embraced by management

and unions, and the idea of having Southern

California assist the smaller region was born.

Sheryl Miller, the labor technology coordi-

nator in the Northwest for the Coalition of

Kaiser Permanente Unions, worked with

Seagondollar to recruit nurses and affiliated

clinicians, while Northwest Permanente

partners recruited physicians. “It was a

team effort larger than any we’ve seen

before,” Miller said.

In all, 45 UNAC/UHCP members from

Southern California—including registered

nurses and physician assistants—signed

on, as well as a licensed vocational nurse

from SEIU UHW-West and 18 physicians.

They worked on the floors with the frontline

staff in the Northwest helping care for

patients, taking only a few days off.

When the Northwest staff members had

questions or issues with the new program,

the California providers were there to assist.

They’d wade through the new screens with

them, the new shortcuts, the new “dot

phrases”—all to make care for the patients

as seamless as possible.

Users needed to understand how the new system would work for them, not how they would work for it.


New technology benefits patients and staff Patient safety tops the list of benefits the KP

HealthConnect inpatient medical record brings to the

hospital setting. Some of the key elements include:

+ Outpatient information is readily available on the

inpatient side, reducing the chance of confusion

+ Illegible handwriting is no longer an issue

+ Unavailable charts are a thing of the past

+ Barcode labels for patient wristbands, medications

and lab specimens help prevent errors

+ Drug dosing is automatically double-checked, which

helps ensure factors such as weight, interactions with

diet, allergies and possible conflict with other medica-

tions have been correctly considered

+ Built-in checkpoints help ensure decisions are based

on a particular patient’s condition

+ When a physician overrides an alert, it still is viewable

by nursing staff, providing an additional safety check

+ Better documentation of services will help ensure

appropriate billing; in the first four months after go-live,

average daily revenue captured increased 53 percent

Each issue, Hank features a team that has successfully used the “plan, do, study, act” (PDSA) steps of the Rapid Improvement Model. Read more about this team’s challenges, find out about other teams’ best practices and learn more about how to use the PDSA steps by visiting LMPartnership.org/ubt/pdsa/.

Waste not, want not Departments: Operating room, central sterilization,

decontamination room, instrument room and environmen-

tal services at KP Ohio Ambulatory Surgery Center

Value Compass: Best quality, affordability, best place

to work

Problem: Surgical instrument trays often were incomplete

and instruments were being discarded accidentally or lost

during handoffs between the operating, decontamination,

instrument and sterilization rooms, resulting in a significant

financial loss

Metric: Instrument replacement costs

Labor co-leads: Ruby Pugh, certified nurse, operating

room, and Victoria Vogan, RN, staff nurse, operating

room, Teamsters Local 244; George Greiner, certified

surgical technologist, Criscelda Ford, certified sterile

processing technician, and Shadiye Jackson, certified

sterile processing technician, OPEIU Local 17

Management co-leads: Kerry Dease, regional patient

safety lead, and Anita Thomas, OR manager

Physician co-lead: John Wood, MD, associate medical

director, surgical specialties

First small test: The team took the top five utilized

instrument trays and required employees to sign off

that they had received the right instruments from every

handoff, starting and ending in the instrument room. If an

instrument was lost, it now was easy to find out who was

responsible. Employees were held accountable for the

instruments they were using.

Result: Instrument replacement costs from January to

June 2008 were $24,286. By changing how instruments

were distributed and handed off, the team was looking

to reduce costs by 25 percent. Instead, costs dropped

about 97 percent from June to December 2008,

to just $706.

Next step: The team continued to perform small tests of

change, streamlining the process, before rolling out to all

of the instrument trays.

Biggest challenge: Because the EVS staff needed to

clean the operating rooms after every surgery, if an instru-

ment had been discarded accidentally, it usually was too

late to recover it by the time the error was caught by the

decontamination room. Now EVS keeps track of which

trash comes from which room, and double-checks that

instruments have been accounted for before discarding

the bag.

Advice to other teams: “There was no finger-pointing

or blame assigned,” Dease says. “By involving employees

from all of the areas the process touched, everyone had

input into the new process.”

Value of engagement: “Our team felt engaged and

involved in implementing needed changes, rather than

having a process handed down to us by management.

By assessing the big picture, we were able to realize…

precise accountability,” Vogan said.

In the on-deck cIrcle

Hawaii is next on the schedule, with the inpatient

medical record implementation slated for this summer,

and discussions are under way about how to support

Hawaii. One piece already is in place: Mindful of the

value of sharing best practices, Greg Strongosky, MD,

from the emergency department at the Moanalua

Medical Center in Honolulu (pictured at left with unit

specialist Stephanie Sylvia), was on hand in the

Sunnyside emergency department in the first days

after implementation, absorbing the process so he

could help prepare his colleagues. “The hands-on

experience with Sunnyside’s successes will be an

invaluable tool that will benefit the go-live in Hawaii,”

he says.

TAKING THE TECH OUT OF TECHNOLOGY (continued from page 7)

“Our Northwest nurses will never forget the help

colleagues from Southern California provided. Many

have made lifetime friendships,” Miller said. “This is a

story that will live in many as ‘nurses helping nurses.’

The Southern California employees were vital to our

hospital support team and staff.”

GOING FORWARD

“This has been a big learning challenge,” said Patricia

Arionus, RN, a 22-year KP employee. For many nurses,

she said, “When we went to school, everything was

done on paper.”

The younger nurses, more familiar with computers,

“have really helped us out,” said Susan Shepard, RN,

the charge nurse in the oncology unit. “We all learn in

different ways and at different paces.”

There were other challenges, too: Some staff missed

the training, and delays between training and the go-live

meant some of the lessons had been forgotten.

Planning for the change was intense. There was a

moratorium on meetings, and performance improvement

projects launched by unit-based teams in the hospital

temporarily were suspended so everyone could focus

on learning the new system.

“We’re learning,” Arionus said a few months after the

implementation. “We share tips with each other. Once

the support from the visiting nurses was gone, we’ve

taught each other ways to remember things, other ways

to do things.”

As demanding as the implementation has been, it’s also

provided some surprising benefits. “Some of the learning

I can apply outside of work,” Shepard said.

For example?

“I now know what it means to right-click!”

SHARE YOUR BEST PRACTICE

Has your team successfully used the PDSA

steps to improve service, quality or affordability?

Email Hank about it at [email protected].


Round-robin successes

Every region that’s engaged so far in the PI work has had good results to report. Among the success stories:

‘ To have something you’ve implemented with your peers, and actually have it work? You never see this.’

— Sharon Rudometkin, ward clerk

UP AND WALKING AFTER SURGERY

IN SANTA CLARA

In just a few months’ time, a team at the Santa Clara

Medical Center (Northern California) dramatically improved

the number of patients up and walking sooner after admis-

sion, going from meeting its goal only 10 percent to 20

percent of the time to hitting it nearly 80 percent of the time.

“Each day that a patient is in the hospital and not

ambulating can reduce their muscle mass by 2 percent,”

said Kasey Spears, the patient mobility manager and a

team member. “So it’s really, really important we don’t lose

a day—and get them up and their circulation going.”

The cross-functional team achieved the dramatic results

by making simple changes that standardized and simplified

the ambulation process, and it also improved communica-

tion between staff and patients.

Renee De Santiago, a patient mobility technician 2 and

member of SEIU UHW-West, said the improved communi-

cation—with patients and between staff—is what has really

improved the ambulation process.

“The doctors, nurses and patient mobility department—

we’ve really become a team,” Santiago said. “We are all

equal…and we are all here for the benefit of the patients.”

OUT OF EMERGENCY

Like Orange County, San Jose Medical Center in Northern

California is looking to move patients out of the emergency

department faster. Small changes, like having a five-minute

time limit in which certain follow-up phone calls must be

placed, improved the transfer time by 7 percentage points

in just three months.

The team’s goal is to move 50 percent of patients who

are being admitted from the emergency department into a

hospital bed within 60 minutes. When team members began

their first test of change in November, about a quarter of ED

patients were transported to a bed within an hour. By the

end of February, that number had climbed to 32 percent.

“We want to place the patient in the most appropriate

level of care,” said Sommer Kehrli, director of performance

improvement. “ED staff is trained to be working on emergent

issues. If a patient is stable, it’s more appropriate to have

them on the nursing floor, where that care is delivered.”

MID-ATLANTIC MAMMOGRAPHY SCREENING

RATES GO UP

The internal medicine team at the Fair Oaks Medical

Center in Northern Virginia has been working on increas-

ing mammography screenings through “in-reach”—if a

patient is in the office or on the phone and she is due for

the breast-cancer screening test, an alert pops up.

One of the keys to success was to work with mam-

mography technicians and get an OK to send two walk-in

patients a day for mammograms.

After beginning its work in November with advisers Janet

Shearer and Mary Jo Breslin, the team quickly exceeded

its goal of screening 81 percent of women between the

ages of 52 and 70 who come in for appointments, by

March 2009. By the end of December, some 82 percent

of patients in the target group were being screened, an

increase of 2.3 percent within five weeks.

Team members noted the PI work is naturally influencing

UBT work. Working in tandem with the MAS quality folks,

UBT members and the performance improvement team

members participated together in Improvement Institute

training to gain expanded tools for problem solving and

identifying opportunities for improvement.

“We’re trying to figure out a way to blend,” said Janice

Nelson-Drake, the Mid-Atlantic improvement specialist.

“Already, the training has had an impact on how we do

our work with the UBTs….We’re using more tools like

process mapping.

“It’s like everyone’s coming together,” she said. “Everyone

is working on improvement projects at the front line.”

For more information about the work of these teams and

others, please visit LMPartnership.org/news.

Frontline staff, managers and physicians: Working together to conduct small tests of change to

create continuous performance improvement. Whether in UBTs or cross-functional teams, they are working on local

issues they know need to be resolved as well as on goals that roll up to facility and to regional goals.

UBT implementation consultants: Funded by the LMP Trust, these team-based improvement experts—

sometimes referred to as “UBTics”—are working in the two California regions to help UBTs get started and to help

established teams become high performing. Total number: 20

Improvement advisers: Working at the medical center level and funded at that level or at the regional

level, these experts work with leaders on how to set a few priorities that also leverage improvement, as well as

coaching the cross-functional teams on their initiatives. Number: 120

Mentors: Also funded by the LMP Trust, the mentors are experts in specific performance improvement methods

and in managing change. They support the improvement advisers and leadership teams to achieve improvement

across entire systems. Number: 12

Improvement Institute: Intensive fellowship program attended by operations managers, UBT implementation

consultants and improvement advisers to develop improvement skills and apply them at the operations level.

Two-day program available for executives.

Each work group had frontline union and management

representatives. As Giordano says, “You can’t do these

projects unless you involve the people doing the work.”

The first two projects—completed before the PI system

came to San Diego—saw dramatic results: In 2007,

co-pay collections for elective surgery were increased

during the admitting process, from 14 percent to 45

percent. Another project, focused on collecting co-pays

during the discharge process, saw a 6 percent increase

in 2008.

The third endeavor, in labor and delivery, currently is being

worked on by a cross-functional team. Already, the team

has seen collections grow from 14 percent collected at

time of service to 50 percent.

While Curtis thinks some elements of the work have been

“top down,” she said that the cross-functional teams and

the unit-based teams are using the same tools, “just in

different-colored tool boxes.”

My goal,” she said, “is to blur the lines” between the two

types of teams, and keep all eyes focused on the prize:

performance improvement.

When minutes count (continued from page 5)

BELOW: Robbin Guiterrez at the Orange County Medical Center WHO’S WHO & WHAT’S WHAT?

From the Desk of henrietta:


HARD TALKS ARE GOOD TALKS

I could not agree more with the author of

“The Power of Breakthrough Conversations”

(Hank, Fall 08). Fatemeh Bani-Taba, health

care ombudsman mediator at Santa Rosa

Medical Center, and I were asked by Santa

Rosa Medical Center leaders to become

certified trainers for an intensive two-day

workshop, “Crucial Conversations,” which

has been used with high success in the

medical field. Managers at the Santa

Rosa Medical Center are required to take

the training, and the goal is to have this

rolled out to all physicians and staff at our

facility. Having the ability to have a difficult

conversation, and doing it well, is crucial to

our success as an organization, has a direct

impact on patient care, and is crucial to

our success as a world-class health

care organization.

—SHERYL R. GRAY

Employee and labor relations consultant

Santa Rosa Medical Center

ADVOCATING FOR INNOVATION

I was pleased to see your article about

“Disruptive Innovation” (Hank, July 08). As a

longtime Kaiser employee, I have become

concerned about GM-style “group think”

creating a vulnerability for Kaiser in the

shifting landscape of health care delivery.

Small clinics in strip malls are exactly where

we need to be running pilot projects. Issues

of accessibility, reduced travel time, easier

parking and better access to public transit

need to be considered in Kaiser’s long-term

strategic planning if we are to compete

over time. I hope the decision makers are

reading Hank.

—JOSEPH CUTLER

Behavioral medicine specialist

Santa Rosa Medical Center

Letters to Hank Hank welcomes your comments and perspectives about the Partnership and about stories in Hank:

Email: [email protected] | Fax: (510) 267-2154

lETTERS TO THE EDITOR

A larger proportion of Kaiser Permanente staff and physicians are very blue when compared with its members.

We’re not talking blue like the blue that

strikes you after two solid weeks of rain,

when your favorite team loses a game,

when the stock market tanks at 50

percent of its previous value or even when

your boyfriend walks out the door—

although the last two might lead to the

kind of blue we’re talking about.

YOU SAW ME STANDING ALONE

A short-term reaction of sadness and

depression to these events is, well,

normal, expected and appropriate.

We’re talking about the shade of blue that

leads to changes in our appetite, energy

and interests. The deep blue that impacts

how we do our job, maintain our relation-

ships or carry out other responsibilities.

WITHOUT A DREAM IN MY HEART

Almost 10 percent of KP staff members

across the system, or 15,000 individuals,

experience depression ranging from a

low-grade mood problem to down-and-

out despondency that may put them at

risk for self-harm. It impacts employees’

lives and affects KP services. Providing

the necessary assistance costs more

than $132 million annually, according to

data compiled in 2008 at the request of

the Healthy Workforce, an interregional

effort that grew from the 2005

National Agreement.

That’s why Healthy Workforce is launching

a campaign to educate staff and physicians

about depression and the remedies

available through Kaiser Permanente.

Why are so many of us depressed?

“I think part of it is that we are a population

of caregivers,” says Jerry O’Keefe, director

of the national Employee Assistance Pro-

gram (EAP) and a member of the Healthy

Workforce regional advisory committee.

“People who are caregivers give so much

they tend to think of themselves last when

it comes to self care.”

WITHOUT A LOVE OF MY OWN

At Kaiser Permanente, EAP staff psychol-

ogists and other professionals can help

you look for symptoms that may impair

daily activities, and they check to see that

the symptoms aren’t disabling. They can

assist with short-term problem solving.

They consider an organic cause for

depression and recommend medication

and more specialized help, if necessary.

Work environments can help prevent

depression or can lift us out of it, especially

if they nurture problem-solving capabilities,

expand our decision-making capacity and

acknowledge our contributions.

BLUE MOON, YOU KNEW JUST WHAT

I WAS THERE FOR

That’s one reason why unit-based teams

(UBTs)—which at their best improve health

care quality because they are committed to

problem solving, and encourage informed

and participatory decision making and

collaboration—are so compelling and

promise to distinguish our workplaces.

UBTs can distinguish us, too.

“I think the issue of choice, determination,

the say-so in our experience…does most

certainly play into the process of somebody

feeling like they can affect a change,”

says O’Keefe. “It’s an amazing thing how

an environment that changes a person

from feeling like an isolated cog into an

integrated member of a team will lift them.”

To receive confidential assessment and

treatment options, call the behavioral

health care member line at 800-900-3277;

for more information about depression, go

to kp.org/depression. See the back cover

for contact information for your region.

Blue MoonThere’s blue. And then there’s very blue.


When the Mid-Atlantic region’s Woodlawn

internal medicine department was tapped

to form a unit-based team focused on

improving clinical quality, physician Nara Um

welcomed the opportunity—and discovered

the team offered more to her success as a

doctor than simply meeting clinical goals.

“I thought, ‘OK, this is my chance to get

things done,’ ” Dr. Um said. “It actually

turned out to be a pretty rewarding and

interesting journey.”

For Um and other caregivers in the depart-

ment, the unit-based team (UBT) has been

a critical tool in tackling the health issues

of “non-compliant” patients with diabetes,

historically a hard-to-reach population.

Non-compliance carries a heavy price:

Those older than 55 who don’t take the

prescribed preventive medications or adopt

healthier lifestyles have been shown to

develop serious and costly complications.

‘WE NEEDED SOMETHING LIKE THIS’

“I was already saying, ‘We need something,

a support structure.’ And this came along,”

Um said. “We needed something like this

very badly. It would have been very difficult

to do this (work) without this structure.”

Through an aggressive education campaign

led largely by clinical assistants and nurses,

the percentage of Woodlawn’s diabetic

patients older than 55 who are taking

aspirin, one of the standard preventive drugs,

more than doubled. In the first quarter of

2008, 34.8 percent of Woodlawn’s diabetic

patients older than 55 were actively taking

aspirin. By the end of 2008 (the most recent

numbers available), that percentage had

jumped to 70.1 percent. If sustained,

this improvement will translate to better

health outcomes for those patients in the

years ahead.

Dr. Um, who recently stepped down as

physician co-lead, says the project has

been rewarding not only for the clinical

improvement, but because it demonstrated

the potential of working in partnership,

expanding the way she practices medicine.

“Intention and knowledge are there,

but (physicians) are short on time,” Dr. Um

explained. “We really don’t have time to

get over the psychological barrier, to get

patients to take the medications they need.”

ACTIVE ‘IN-REACH’

That’s where clinical assistants and

nurses step in, providing active “in-reach.”

When a patient visits or phones the office,

nurses and clinical assistants typically have

more opportunities to help the individual

understand why it’s important to take each

medication or make lifestyle modifications,

and to connect that member with KP’s

educational resources.

“I think we physicians sometimes get

hung up on the physician view of things….

We think, ‘You need this medication. Why

don’t you take this?’ ” Dr. Um said. “Then I

started thinking as if I was not the physician.

If I was the nurse bridging the gap, what

could I do? It was a huge learning experience

for me. It was great having different levels of

perspective—what they see as the problem

and basis for improvements.”

On-the-fly brainstorming in team huddles

has been key to working through tests of

change and integrating feedback, Dr. Um

said. “Every time we met, people would

come up with ideas I would never have

thought about. It was great because CAs

had a closer patient perspective.”

LEVERAGING TEAM ADVANTAGES

The UBT’s new physician co-lead, Arthur S.

Harrow, MD, has been equally impressed by

using a team-based approach to improving

clinical quality.

“I was in solo practice for many years,”

he said. “And it’s very, very difficult to take

care of diabetics. It’s a big project and big

time commitment….The idea of having a

group of change agents to find what works

at that particular place is brilliant.”

Both physicians see the potential in using

UBTs to improve the quality of care for other

chronic diseases. The department has been

toying with the idea of using a similar model

for its smoking cessation program.

“I hear a lot of the physicians grumble and

groan, ‘Oh, they want me to do this and do

that on top of seeing patients,’ ” Harrow

said. “What we need to do is engage more

people. Show that it can enhance your

satisfaction as a provider if you’re doing

something more than seeing the 30th

patient….The hardest part is convincing

people that something new can work.”

Read more about the Woodlawn UBT at

LMPartnership.org/news.

physiCians on PartnershiP

FOR DOING WHAT NO DOCTOR ALONE COULD DO Doctors Praise Team

34.8%

Q1 2008

70.1%

Q4 2008

Who’s taking their aspirin?

Team approach raises percent of

diabetic patients actively taking aspirin,

which will translate to better health

outcomes in the years ahead.

High-risk patients with diabetes who aren’t following

advice are a tough population. This Mid-Atlantic team

found a way to connect—and to expand one doctor’s

understanding of her practice.

Nara Um, MD, pictured in the photos above with a patient and other members of the Woodlawn internal medicine unit-based team, says the team came up with solutions that wouldn’t have occurred to her.

UBT

www. LmPartnership.com

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Broccoli. Pilates. Dental floss. The treadmill, elliptical and bicycle. Seat belts. Physical therapy. Psychotherapy. Laughter. Music and dance. Total health. We act on our belief that quality health care is a right for all by trying to improve our performance everyday. We believe in equilibrium. In life as an offsetting weight for work as well as a balancing act in itself. We pledge allegiance to many, to each other, with an abiding faith in partnership. All hail to the unit-based team, informed and collaborative decision making. We have never met a mutual interest we weren’t willing to work with. We believe there is an art to partnership as well as the daily hum of its practice. May you live in just times, make a difference and achieve the respect and good will of your community.

We stand for

healthyworkforceF

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!Healthy Workforce grew out of the 2005 National Agreement negotiations between Kaiser Permanente and the Coalition of Kaiser Permanente Unions. Check out these programs at kp.org/healthylifestyles or kp.org/healthy living. Find help with the Employee Assistance Program (EAP): Free and confidential consultation, short term problem solving, referrals for additional help—for all employees, physicians, and dependent family members

Colorado: www.minesandassociates.com 1-800-873-7138 Georgia: www.eapconsultants.com/index.php 1-800-869-0276 Hawaii: 808-432-4922 Mid-Atlantic States: www.mhn.com/home.do 1-800-227-1060 Northern California: xnet.kp.org/hr/ca/eap/index.htm Call your local EAP Services or Human Resources department

Northwest: xnet.kp.org/hr/ca/eap/index.htm, 503-813-4703 Ohio: www.easeatwork.com, 1-800-521-3273 Program Offices: kpnet.kp.org/pohr/eeprograms/eap.htm Contact the EAP provider in any convenient region/location Southern California: xnet.kp.org/hr/ca/eap/index.htm Call your local EAP Services or Human Resources department.

www.LMPartnership.org

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