frontline news for kp workers, managers ......frontline news for kp workers, managers &...
TRANSCRIPT
FRONTLINE NEWS FOR KP WORKERS,
MANAGERS & PHYSICIANS
IN THIS ISSUEHenrietta on why bigger teams can be better teams
Colorado team finds new way to cut wait times
BACK COVER: Tear-off poster for KP Walk!
SPRING 11 | ISSUE No. 27
INSIDE! 2010 LMP Performance Report
7
2 www.lmpartnership.orgHank Spring 2011 | No. 27
Published by Kaiser Permanente and Coalition of Kaiser Permanente Unions
CommuniCations DireCtors
Maureen AndersonStacia Hill Levenfeld
eDitor
Tyra Ferlatte
Contributors
Kellie Applen, Cassandra Braun, Andrea Buffa, Paul Cohen, Paul Erskine, Jennifer Gladwell, Laureen Lazarovici, Julie Light, Shawn Masten, Anjetta McQueen, Gwen E. Scott, Beverly White
Worksite photos: Bob GumpertGraphic design: Stoller Design Group
ContaCt us
Email feedback and story ideas to [email protected].
3 LIKE NIGHT ANd dAYFull participation in a team’s performance improvement work from all members
on all shifts can send service and quality scores soaring, while shifts left out in the
cold can drag down a whole department. It’s hard enough ensuring all members
of a single shift are on board—so what’s a unit-based team to do?
6 WHY SIzE dOESN’T MATTERFrom the desk of Henrietta: When something grows more-than-ideally large,
perhaps the question should not be whether to downsize, but instead—how do
you make size work for you? Many outsized unit-based teams, it turns out,
are doing this with great success.
7 RETHINKING dIvISION OF LAbOR SLASHES PATIENT WAIT TIMESPlan, do, study, act: Find out how this Colorado team sliced wait times
almost in half.
CONTENTS
Secretly, most of us have part of ourselves that would
enjoy a return to the simpler idyll of childhood, where the
world, it seemed, revolved around me, myself and I.
If you are one of those, take heart: You can be the center of
the universe!
At least, that is, when the universe we’re talking about is the
universe of transformation. After all—guess where the most
important change starts. But it turns out it’s not quite as blissfully
self-centered as childhood was.
“You can’t transform an institution without transforming yourself,”
social activist Van Jones recently told a group of more than 600
delegates gathered at the 2011 Union Delegates Conference,
the annual meeting of the Coalition of Kaiser Permanente Unions.
The theme of the conference was “transformational leadership,”
so there was a lot of discussion about the nature of transformation
and what it takes to lead such change.
At Kaiser Permanente, Jones noted, change already is coming
from the top down, starting with Chairman and CEO George
Halvorson. It’s coming from the bottom up, with the thousands
of unit-based teams now in place.
But the hardest change, he cautioned, is the inside out.
“The individual inside-out is a paradigm shift—it’s figuring out
the emotional stuff that’s keeping you from changing,” he said.
“Often us rabble-rousers have a plan for everything and everyone
else to change—except us.”
But without that personal shift, said Jones, who started three
successful social justice nonprofits before serving as a green
adviser to President Obama, transformation never takes hold.
Without that personal shift, it’s easy to get caught up in finger-pointing.
Michael Aragones, the labor co-lead on a team featured in
this issue’s cover story, tells of a time when his department was
experiencing “a lot of ‘back talk’ between the shifts. People would
say, ‘How come they are doing this or that?’ and ‘How come
I have so much work?’”
Sound familiar? What Aragones and his colleagues did next was
transformational: They sat down, brought a larger perspective
to the problems they were having, and everyone was willing
to give up a bit of his or her own personal self-interest to arrive
at the solution.
To transform an institution, the leaders of the transformation
need to walk their talk. That means being honest about the gaps
between how you think people should be treated—and how you
actually treat others. And then having the courage to figure out
what needs to change to close the gap, and doing it.
It’s not child’s play.
Watch a video interview with Van Jones, shot at the Union
Delegates Conference, at LMPartnership.org/vanjones.
3
6
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.
eDITOR’S LETTER: Top down, bottom up, inside out
BACK COVER: Tear-off KP Walk! poster
Cover story
www.lmpartnership.org 3 Hank Spring 2011 | No. 27
(continues on page 4)
Like night and dayAt KP, health care is 24/7,and unit-based teams are finding ways to fix a longstanding weak link—the disconnect between shifts.
So what’s a unit-based team to do? Full participation in a team’s performance
improvement work from all members on all shifts can send service and quality scores
soaring—while shifts left out in the cold can drag down a whole department. It’s hard
enough ensuring all members of a single shift are on board.
But getting everyone onboard around the clock is a daunting challenge.
Shifts that pass in the night may be oblivious to the other’s particular challenges and
culture. They might not fully understand how their own work affects the other shift’s
workflow. Rivalries and finger-pointing can ensue.
NIGHT OWLS IN THE LAB
As the double doors swing open, cold night air blasts into the receiving bay at the
Regional Reference Laboratory in North Hollywood, California. Employees are ready,
bundled up in knit scarves and hoodies. It’s 11:30 p.m. on a mid-February night,
and couriers are delivering gray cooler bags filled with vials and tubes of specimens
from all over Southern California. Clinics from Kern County in the north to San Diego,
nearly 180 miles south, have closed for the evening. Now all of those blood tests and
urine samples have to be processed and analyzed so providers can detect disease
or spot the warning signs of a developing chronic condition.
At the specimen processing department, the graveyard shift is the busiest. “We’re like
the mailroom,” says Leland Chan, supervisor and management co-lead. More than
10,000 specimens go to the automated chemistry department during the graveyard
shift, compared with about 4,300 in the morning and nearly 9,000 at night.
Michael Aragones, the labor co-lead, likens the three shifts to gears all rotating
together and powering each other forward. But not so long ago, the gears were
getting jammed up.
Building resentments Something was going on: Staff members on each shift thought the workload wasn’t
being distributed equally—and they were getting the short end of the stick. Employees
with different duties on the same shift felt the same way about their peers.
‘What affects the night shift usually affects all of us.’
—Paula Cunningham, EVS attendant, Steelworkers Local 7600, Riverside Medical Center
eDITOR’S LETTER: Top down, bottom up, inside out
(continued from page 3)
“There was a lot of ‘back talk’ between
the shifts,” says Aragones, a clinical lab
scientist and member of UFCW Local 770.
“People would say, ‘How come they are
doing this or that?’ and ‘How come I have
so much work?’”
The unit-based team was the vehicle for
improving the workflow. Team members
from all shifts got involved collecting,
collating and analyzing data about the
specimen count, hour by hour.
The results revealed why employees
were feeling overworked: Between 2008
and 2010, the number of specimens going
to bacteriology, for instance, increased
from fewer than 4,000 to more than 5,000.
Moreover, the time of night that most
specimens arrived had changed. The lab
used to see a big spike around 9:30 p.m.;
now the rush came about 11 p.m. So the
team adjusted the start and end time of
the graveyard shift to match the flow of
work coming in.
“At first, there was a lot of resistance,”
Chan says, with employees worried about
child care arrangements and traffic.
The data, however, “gave us a better
understanding of the workflow,” which let
staff members see why they were being
asked to make changes. “It was the UBT
that helped solve that.”
“It wasn’t managers saying, ‘Well, you just
have to,’” Aragones says. “We have to look
at workflow for the whole department, not
just one shift. It’s like a spider web. You pull
one strand, and it affects the whole thing.”
Now that the work is flowing better, the UBT
is working on new initiatives.
“The UBT makes my life easier,” says Chan.
“It allows me to work more closely with
the crew because we are on equal terms.
Sometimes, as a manager, you don’t
have all the answers. They do the work.
They are the experts.”
For more information, contact
‘ We have to look at workflow for the whole department, not just one shift. It’s like a spider web.’
—Michael Aragones, clinical lab scientist, UFCW Local 770, Northern California Regional Reference Lab
NOT IN THE DARK:
The Riverside EVS team has made a point of
making sure that its night shift workers have
as much say in the running of the department
as their day shift counterparts. Team members
pictured include: Page 3, left to right, EVS
attendant Virginia Gonzalez, manager Angel
Pacheco and EVS attendant Robert Casillas;
this page, Casillas (above), Gonzalez, (above
right) and EVS attendant Paula Cunningham
(below right); pages 5 and 6, Cunningham.
Gonzalez, Casillas and Cunningham are
members of United Steelworkers Local 7600.
L I K E A N DN I G H T D A Y
4 www.lmpartnership.orgHank Spring 2011 | No. 27
COOKING UP CAMARADERIE
It is 7:15 p.m. in the kitchen of the Downey Medical Center. “Huddddlllle!” shouts
Francisco Vargas, a gentle giant of a man. The sound of his booming voice echoes off
the tile floors and stainless steel work surfaces. One of about 20 SEIU UHW members
working the night shift in the Food and Nutrition department, Vargas gathers the troops
before they begin to wash dinner trays and deliver late meals to patients.
Assistant Department Administrator Patricia Villareal and her union partner Amelia
Cervantes review new data on the team’s improvement projects, such as cooking less
soup on weekends so less is wasted, and give a reminder about clocking in accurately.
The huddle ends with a team cheer—“Work hard, stay positive!”—and with that,
food service kitchen worker Nancy Rudeas, an SEIU UHW member, and a colleague
scurry off to prepare two late dinner trays. They double-check to see that a patient’s
special request for green tea is being filled (it is).
“I love doing this,” Rudeas says, heading up on the elevator.
A few late tray deliveries have become a fact of life for the department, a consequence
of abandoning set meal times in favor of a “room service” model: Patients simply make
a phone call when they are ready for a meal, just like a hotel guest might.
Successful practices for round-the-clock unit-based teams Using one or all of these will help pull your team together
[ ✓ ] Huddles
[ ✓ ] Written communication: a one-page newsletter, bulletin board,
whiteboard or flip-chart paper posted where everyone can see it in the
normal course of their work
[ ✓ ] Verbal communication: assign employees to update specific co-workers,
eventually creating a culture of sharing information informally
[ ✓ ] Adjust schedules so employees from other shifts can attend UBT
meetings, or rotate meeting times to different shifts
[ ✓ ] Create a formal, deliberate process to solicit input from employees on all
shifts and take their feedback into consideration
[ ✓ ] When it’s time to choose new co-leads, consider cultivating leaders
from the night shift
This patient-centered innovation meant the workflow changed. Foreseeable peaks and
valleys in cooking and cleaning became a less predictable, variable demand. Tasks
that once had been the domain of one shift or the other “leaked” into the next shift.
Tensions rose among employees as the distribution of work was thrown into flux.
“Because we have a UBT, we could sit down together and ask, ‘How can we get
this resolved?’” says Villareal.
Together, the team experimented with adjusting start times for different jobs in the
department until it settled on a mix that’s working. “The morning picks up for the night
shift, and the night shift picks up for the morning,” she says.
From OK to greatThe department set out to improve its customer service scores in September 2008.
Though a respectable 86.7 percent of patients surveyed agreed with the statement
“the people serving my meals were polite and professional,” that was nonetheless
among the lowest scores in the Southern California region.
Together, the UBT members came up with a script that encourages food service
workers to introduce themselves by name, ask if they can open any containers,
and—most crucially—ask if there is anything else they can get for the patients.
By consistently using the script, by October 2010, the score shot up to 99 percent.
Night-shift workers like Rudeas have contributed to that success. The shifts share
information in huddles and bulletin boards.
“What goes on during the day, we know at night,” she says. “And what goes on
at night, they know during the day.”
For more information, contact Pat.F.Villareal @kp.org or [email protected].
CUSTOMER SERVICE SCORES
Percentage of patients surveyed who agreed
with the statement “the people serving my
meals were polite and professional.”
SEPT. 2008 } 86.7%
OCT. 2010 } 99%
www.lmpartnership.org 5 Hank Spring 2011 | No. 27
(continues on page 6)
A SWEEPING SUCCESS
The Environmental Services department at Riverside Medical Center is continuing its
winning streak: In 2010, it went 260 days without a workplace injury. The UBT received
a huge banner congratulating it on the achievement, and the co-leads thought it would
be nice if each team member signed it before hanging it up.
The banner remained out for a few days to make sure all staffers had a chance
to sign—including the workers who come in at 11 p.m. for the graveyard shift.
Only then was the banner hung up on the unit wall.
“This made a huge difference,” says Angel Pacheco, who will become the new
management co-lead in May and who himself works the night shift. “This actually
shows that everyone is involved and can take pride and ownership.” After all, per-
formance metrics are measured by department, not shift, and night shift workers
contributed to creating a safer workplace as much as their day shift counterparts.
The EVS team posts a flip-chart sheet after every monthly UBT meeting with three to
four important items of information to pass on to the rest of the staff. Each shift reviews
the sheet at a daily huddle held at the beginning of each shift. The quick review of
UBT business, including key performance metrics, follows the team’s stretching exercises
that have helped reduce workplace injuries and won it recognition throughout KP.
The sheet hangs on the door of the supply closet, where each staff member comes when
starting work to get carts, trash bags and keys to the offices they have to clean. This
strategic placement ensures workers from all shifts have access to the daily UBT updates.
Face time mattersFace-to-face communication augments written communication and helps build the
camaraderie that helps teams improve performance. For instance, Pacheco makes
a point of visiting the night workers in the outlying medical office buildings—he drives
an hour to Temecula to see one employee.
“It’s worth it,” he says. “I just take the time to reflect on things.”
Paula Cunningham, an EVS attendant and member of Steelworkers Local 7600, is one
of four union members on the 6 p.m. to 2 a.m. shift responsible for passing information
from the UBT’s representative group meeting to her shift colleagues.
“They trust us to deliver the information to them,” says Cunningham, whose work
schedule is adjusted so she can attend representative group meetings in the early
From the Desk of henrietta: Why Size doeSn’t matter
But when something grows more-than-
ideally large, perhaps the question should
not be whether to downsize, but instead—
how do you make size work for you?
Many outsized unit-based teams, it turns
out, are answering that question with
great success.
No doubt, larger teams face challenges
that smaller ones don’t. Teams with lots
of members can be unwieldy, slowing
down rapid improvement and mucking up
communication. But the reality is that many
big or multidisciplinary departments across
KP, such as radiology or primary care,
must rely on large or representative UBTs.
And despite their inherent challenges, many
of those larger teams have found ways of
working and communicating effectively.
Take, for instance, South San Francisco
Pediatrics. It began as a large team—
and intentionally grew even larger, adding
more members with an aim to improve its
performance improvement work. Blasphemy!
Reaching consensus or brainstorming
was cumbersome and drawn out with the
original 10-person representative UBT,
and it took them six to eight months to
complete one project, says Sue Sorensen,
the Pediatrics manager.
“It was hard to get anything done,” she
says. “We really struggled in the beginning
to try to find the meaningfulness in the work
and the team. And that’s why we went to
the bigger group. Once we got to a bigger-
size group, all of a sudden there was a
larger cross-section of people represented.”
Adding more members, and the right kind
of members—passionate, outspoken staff
and five physicians—brought a greater
range of opinions to the team, resulting in
better representation of their department.
But it didn’t stop there.
It’s true, bigger isn’t always better. Consider, for instance, zits, SUVs, the national debt.
afternoon. “We talk frequently and rely heavily
on huddles.” Other night shift workers also
rotate into the group’s meetings.
Because he’s an on-call employee, Robert
Casillas works all the shifts, so he has
insights into what makes each shift unique.
The morning shift is more hectic, he says.
The evening work is much calmer. More
people are cleaning sections solo, but they
pass one another in the hallways and share
information with each other then.
“We have our communications plan, which
we share with the other staff,” Casillas says.
“We don’t want anyone to think we’re
hiding stuff. And when the information
comes from us, it’s less like a demand from
management. It’s more about figuring out
ideas to help us do our work.”
6 www.lmpartnership.orgHank Spring 2011 | No. 27
The larger UBT breaks down into smaller
workgroups, each tackling a different issue.
The main UBT becomes the clearinghouse
for ideas and projects, while the sub-teams
can move quickly through brainstorming
and working out details.
“It keeps it a lot more dynamic because
it’s changing all the time,” Sorensen says.
“The previous UBT group worked on one
project at a time. People were getting tired
in that group….You need a hybrid because
you don’t want to lose that intimacy,
but you need to make it efficient.”
The new structure not only has allowed
them to get more done at one time—
the team has completed three projects in
two months—but it has greatly improved
relationships between physicians and staff,
Sorensen said.
Similarly and equally blasphemous, farther
south the San Diego Home Care clinical
UBT—which incorporates the Home Health,
Palliative and Hospice Care departments,
totaling 140 staff members—also grew its
representative UBT. They realized several
critical positions weren’t represented,
including social workers, home health aides
and IV nurses. So they grew to a current
total of 11 members.
But instead of dividing amoeba-like into
smaller groups, a la the Pediatrics team,
the Home Care team members found their
key to success in fine-tuning communication,
say manager Daniele Wilson and union
co-lead Lisa Tuckwell.
As team members developed new
workflows for their patient referral list
project, they realized they needed effective
ways to communicate those changes out to
staff. The new, efficient system would work
only with everyone’s involvement. So the
team created a communication tree—
‘At first we thought we had reached everyone. Then we realized we hadn’t….The communication tree was good. But it’s really how the person articulates the information.’
—Daniele Wilson, manager, Home Care, San Diego (shown here, left to right, with union co-lead Lisa Tuckwell)
Sometimes, seeing the hospital at the
end of the day as they do, it is night shift
employees who spur the entire department
into action.
The night workers noticed the hospital
was running low on privacy curtains. When
the ones soiled during the day were taken
down, there were not enough from the
laundry to replace them. Cunningham brought
the information to the representative group,
and the co-leads secured more curtains.
“What affects the night shift,” she says,
“usually affects all of us.”
For more information, contact
(continued from page 5)S T A R R I N G U B T s
From the Desk of henrietta: Why Size doeSn’t matter
SHARE YOUR BEST PRACTICE
Has your team successfully used the
PDSA steps to improve service, quality
or affordability? Email Hank about it at
Each issue, Hank features a team that has successfully
used the “plan, do, study, act” (PDSA) steps of the Rapid
Improvement Model (RIM). Find out about other teams’
best practices and learn more about how to use the PDSA
steps by visiting: LMPartnership.org/ubt.
www.lmpartnership.org 7 Hank Spring 2011 | No. 27
a diagram outlining which UBT member
represents which staff members.
The representative knows to whom he or
she is responsible for relaying information
from the UBT, and vice versa, staff members
are clear about whom to go to if they have
questions or suggestions. The communication
tree is posted throughout the main office
and emailed to staff. Additionally, meeting
minutes from every UBT meeting are emailed
to staff and posted throughout the office.
But as in life, nothing is perfect.
It recently became clear to the Home Care
team that staff members were receiving
slightly different messages from each
UBT representative.
“At first we thought we had reached
everyone,” Wilson says. “Then we realized
we hadn’t….The communication tree
was good. But it’s really how the person
articulates the information.”
To ensure everyone is receiving the same
information, the team designated a point
communication person from the UBT.
The team agrees on what information it
wants to communicate, and that person
then sends emails and voicemails with
the same message to each staff member.
“It’s a work in progress. You go back and
refine it,” Wilson said. “I think we’re finally
at the point where we reach everyone.”
Despite the challenges and fine-tuning
of ensuring that all 140 Home Care staff
members are on the same page, clearly the
team has something working for it. After
strong campaigning via their communica-
tion tree for staff members to participate in
People Pulse, the department went from
a 54 percent response rate in 2009 to a
whopping 93 percent in 2010.
Maybe big is the new small. It’s just what
you make of it.
Department: Internal Medicine, Hidden Lake Medical Office, Colorado
Value Compass: Service
Problem: Patients were waiting too long to have their vitals taken before seeing a doctor
Metric: Reduced wait time from check-in to taking vitals
Labor co-leads: Cindy Agan, SEIU Local 105; Tanya Ball, UFCW Local 7
Management co-lead: Shannon Martinez, nurse manager
Physician co-lead: Angie Martinez, MD
Small tests of change: The team discovered there's a lot of work the medical assistants
could do to lighten up the load of the licensed practical nurses (LPNs), who take patients’
vitals. This helped reduce patient wait time.
Result: The team went from an average wait time of 19 minutes to under 11 minutes.
Next step: The team members have agreed to monitor their data once a week for the next
year to ensure they’re sustaining their improvement.
Biggest challenge: The team change. It’s not easy to take a hard look at how you’re working
and ask if it makes sense.
“We had some pushback at first,” union co-lead Agan says. “But once they saw how the
change worked, they saw the benefit.”
What works: By huddling twice a day, the team is seeing an improvement in how the
department is running.
“We do a morning huddle and a late afternoon huddle, around 4 p.m. This helps us figure
out who’s going to cover what and ensure our patients are taken care of,” Martinez says.
Background: The Internal Medicine department at Hidden Lake is made up of four smaller
teams that function as one unit-based team using a representative model. The representational
team’s decision to take on patient wait times was quite an undertaking, with a goal of reducing
wait times by almost nine minutes.
Each smaller team came up with a process to reduce the wait time based on its specific
needs. Some of the changes included adjusting hours of the medical assistants and LPNs.
Team members also took a close look at the division of work, and then tackled the issue
of whether the right people were doing each task.
For additional information, contact the co-leads at [email protected], Tanya.M.Ball@
kp.org, Angie.N. [email protected] or [email protected].
Rethinking the division of labor slashes patient wait times
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