Clinical Outcomes

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Process Curbs VAP and Central Line Infections

Deck: 
Teamwork helps fight potentially harmful conditions

Like ICUs around the country, the Woodland Hills team struggled to protect patients from contracting ventilator-associated pneumonia (VAP) and central line-associated bloodstream infections.

Both conditions, among the most common hospital-acquired infections, can lengthen hospital stays, complicate recovery and even cause death.

But care improved dramatically after the team took steps that focused on patient safety and quality, and they credited a culture of collaboration as the key component to their success.

“It’s about working in partnership with physicians, nurses and other staff to deliver high-quality care based on the newest evidence,” says Lynne Scott, RN, a clinical nurse specialist for the Critical Care and the Definitive Observation Unit. “We’re constantly moving forward.”

They had their nurses place patients at the optimal angle of 30 degrees to ensure that fluids didn’t collect in their lungs, and also made sure that patients received routine oral care.

For greater oversight, two nurses changed the dressing 24 hours after the line was placed and were responsible for changing it weekly. The charge nurses were also involved, checking the dressing, IV tubing and injection ports twice a day.

And in further support, ICU employees held daily multidisciplinary rounds. This involved everyone on the care team who touched the patient, including physicians, nurses, dietitians, pharmacists, medical social workers and family members.

As of this writing, the results were nearly immediate with no patients contracting VAP or central line-associated bloodstream infections since late 2011.

Their efforts netted the team the 2015 Gold Beacon Award for Excellence from the American Association of Critical-Care Nurses, the world’s largest specialty nursing organization. The award recognizes hospital units that demonstrate exceptional care through improved outcomes and greater overall patient satisfaction.

Read more about what the team did to improve communication and collaboration.

Early Detection: Encourage Patients to Get Screened

Deck: 
Team improves rate of needed cancer tests

The staff at the Radiation Oncology department at the Los Angeles Medical Center knew well the importance of identifying cancer early.

It was part of their clinical routine, and when necessary, they knew patients could begin treatment and slow the spread of the disease.

“We see what happens when you don’t screen regularly,” says Sandra Miller, the department administrator and the UBT’s management co-lead.

So, the UBT was determined to deliver on Kaiser Permanente’s promise of preventive care and leverage the Proactive Office Encounter to increase the percentage of regularly scheduled mammograms, colorectal and Pap screenings by December 2013. 

“With Proactive Office Encounter, we are treating the whole member,” says Maria Caceres, an assistant department administrator who was involved with the improvement project.

But the team also had to overcome resistance from patients.

“I think most of our patients that come to us do not want to deal with [one more test],” says union co-lead and medical assistant Monica Villanueva, SEIU UHW. “However, the more we reinforce the importance of having it done, they are more willing.”

Electronic reminders on KP HealthConnect helped ensure patients were getting their screenings, but the team also used a process map to examine its own workflow.

They put color-coded sheets on providers’ keyboards in exam rooms as visual alerts to indicate a patient is due for a screening (pink for mammogram, orange for colorectal test, green for Pap test) and created a pending order in KP HealthConnect.

Medical assistants checked the Proactive Office Encounter before each appointment to alert physicians when screenings were needed, and to check results and make reminder calls to patients.

They gave staff access to the radiology department’s appointment system so appointments could be made for patients while they were in the office, and provided training by laboratory colleagues on how to instruct patients on using the Fecal Immunochemical Test (FIT) kits.

“We had to sit down and break down every step,” Miller says. “We would ask, ‘Where were we not taking advantage of an opportunity to communicate with the doctor or the patient?’ Our process really changed after that.”

As a result colorectal screenings improved by 25 percentage points, Pap smears got a 12-point bump and mammograms increased by 46 points.

And when results for two patients showed they had additional health issues, the physicians, employees and managers were convinced.

“They could see the value and the impact of their hard work,” Caceres says.

For more ideas to share with your team and spark performance improvement ideas, download a poster, a tip sheet or read what an allergy unit did.

 

Workflow Helps Patients Control Blood Pressure

Deck: 
Team went "all-hands" to keep hypertension in check

Story body part 1: 

The Largo Medical facility had 11,400 members with uncontrolled blood pressure, which represented the highest percentage in the Mid-Atlantic States region.

Largo’s Adult Primary Care department, with its diverse team of nurses, physicians, certified nursing assistants, nurse practitioners, pharmacists and receptionists, wanted to see who was slipping through the cracks in terms of blood-pressure management—and why.

And for good reason.

National studies show that for every 36 patients with hypertension whose blood pressure is brought under control, one life is saved from a heart attack or stroke.

The team decided to take action against the care gaps by following up machine blood pressure readings with manual readings. They sent the patients with repeat high blood pressure readings to a nurse practitioner or pharmacist for further treatment or counseling.

For the CNAs, they provided tips on better techniques for taking blood pressure to get accurate readings. To reach more patients with chronic hypertension, the team increased outreach calls for each receptionist to an average of 20 names each week.

But they also added reward to the work and posted weekly certificates acknowledging staff members who were the highest performing or most improved in number of outreach calls and number of blood pressure checks.

“Our approach is to address every elevated blood pressure at the point of contact in all clinical areas,” says management co-lead Cynthia K. Fields, RN, clinical operations manager. “The all-hands-on-deck approach is the key to our success.”

In four months, the team exceeded its goal with 73.6 percent of hypertensive patients with blood pressure under control.

“The providers and staff know that they work hard every day,” says Cynthia O’Brien, nurse practitioner, labor co-lead and union shop steward. “But transparent data showing improvements week by week allowed them to see the fruits of their labor.”

The team also began spreading successful practices to the specialty departments within the Largo Medical Offices so when patients have appointments there, they will get their blood pressure checked and managed.

As part of their efforts, the team ensured no patient with a repeat high-blood pressure reading left the facility without a plan of care based upon individual needs. The improved workflow also improved communications and morale. 

For more about this team's work to share with your team and spark performance improvement ideas, download a PowerPoint.

 

Bolder Communication Helps Diagnose Malnutrition

Deck: 
Dietitians play a key advocacy role for at-risk patients

After Northern California began a regional push in 2009 to improve the identification and diagnosis of malnourished patients, the Roseville Medical Center sought to put the plan to action.

The clinical nutrition team was partifcularly concerned because diet plays a key role in the body’s recovery.

This can be especially true for the elderly and patients with diabetes —two groups at the highest risk for malnutrition. Mary Hart, director of clinical nutrition for Roseville and Sacramento medical centers, says a lack of proper proteins and vitamins affects their ability to recover and heal.

And short hospital stays can be particularly challenging because most patients don’t stay in the hospital very long.

After sifting through the electronic charts of all admitted patients, the dietitians must spot patients “at risk” for malnourishment and reach them in time for a full evaluation and treatment—all before the patient is discharged.

While physicians are the only ones who can make an official diagnosis, they rely on clinical dietitians to assess the patient and alert the physician.

“We keep track of the number of patients who have met the criteria for clinical malnutrition, communicate that to the physician and follow up to see if (the patient) has actually been diagnosed,” Hart says.

The dietitians at Rockville put their assessments and recommendations into a patient’s electronic chart, but everyone did so a little differently.

So they standardized their process and language, which included bolding notes to doctors and speaking directly to them about potentially malnourished patients. Those simple steps made it easier for physicians to know what to look for, and diagnose accordingly.

“It helps because we can see them sooner and start nutritional management sooner and figure out how to refer them to outpatient care after they are discharged,” says labor co-lead and registered dietitian, SEIU UHW, Jennifer Amirali.

The team also piloted a KP HealthConnect tool that made it easier and quicker for clinical dietitians to identify at-risk patients. It pulls data from electronic medical records, and color-codes assessments, recommendations and final diagnoses between dietitians and physicians.

“There was more recognition (among physicians) of what a dietitian does other than just ‘serve food,’” Amirali says.

Hart agreed.

“(Physicians and administration) now see the important role of dietitians in the care team and what we can contribute to the organization and the health of the patient.”

For more about this team's work to share with your team and spark performance improvement ideas, download a poster or powerpoint.

TOOLS

Case Study of Partnership Success

Format:
PDF

Size:
Five pages, 8.5" x 11" 

Intended audience:
Frontline teams, managers, senior leaders and physicians, and health care leaders and policy makers

Best used:
Share this Cornell study with teams, colleagues and all parties interested in new approaches to health care delivery and workplace effectiveness—and in learning about the benefits of labor-management partnerships.

 

Related tools:

UBT Sends Message on Colon Cancer Screening

Deck: 
Union City team effort helps save lives

Various interventions have been implemented to increase the rate of colon cancer screenings, including at-home Fecal-Immunochemical Tests or FIT kits. These kits are mailed or handed to patients identified as age- or risk-appropriate and can be completed in the privacy of the member’s own home.

The FIT kit doesn’t require a doctor’s appointment and is returned directly to the lab in a prepaid envelope. Patients who have positive FIT kit results for occult blood are referred for further testing.

“A long time ago, there was no way to track these people,” Kari Russitano, medical assistant, SEIU UHW, says. “Kaiser has done a lot to improve cancer screenings.”

But getting members to take and return the test remains a problem.

In 2009, the Union City Medical Center fell short of its 71 percent return rate goal for colorectal screenings. Kaiser Permanente routinely mass mails the kits to members identified through the electronic medical records database. But many members either don’t return the tests or the ones they return aren’t legible.

“Thirty percent were thrown away because we couldn’t read their name or the medical record number,” Deborah Hennings-Cook, RN, manager, Internal Medicine, says.

Clinical coordinator, Vimi Chand, Department of Internal Medicine, adds, “Obviously mailing alone wasn’t working, so we decided to contact members by phone or secure email. And it worked.”

Of the 1,754 members contacted, more than 63 were referred for further screening. 

Having the medical assistants and receptionists make the calls was a hard sell at first, but their peers in the unit-based team stressed the preventive nature of the test.

“It didn’t seem like extra work, because we collaborated together and educated each other to think of it as if ‘this could be your family member,’” Sophia Opfermann, receptionist, OPEIU Local 29, says. “A lot of staff didn’t know what the FIT kits were for, so we educated them about that, too.” 

Then frontline staff came up with the idea for the note cards—bright fluorescent notes that read: “This test detects early signs of COLON CANCER.”

“Knowing that many people don’t understand the importance of the test, they made the verbiage strong about ‘saving lives’ and ‘help us help you,’" Hennings-Cook says. "It was something they wanted to do, and it worked.”

One challenge was adding the phone calls and emails to the medical assistants’ existing workload. Lists of patients who hadn’t responded were provided to medical assistants but some had more than others.

“We heard a little bit of flak when the lists first came out and some MAs had huge lists, but they helped each other and just did it,” Chand says. 

In the end, the bottom line was helping patients.

“By collaborating together and educating each other, we are helping to saving lives,” Opfermann says.

Secondary Blood Pressure Screenings Rise, Improve Care

Deck: 
Department explains the "why" behind the tests

The team in the Head and Neck Surgery/Audiology department at the South Bay Medical Center had been compiling monthly reports about missed second blood pressure checks.

And this can be a critical point for a patient’s care because high blood pressure is often called “the silent killer.” Those who have it often don’t exhibit symptoms until it’s extremely high, and untreated hypertension can lead to heart disease, stroke and kidney problems.

But the team reviewed the numbers without a follow-up plan.

So, they decided to have morning huddles several days a week to explain the screenings and follow with plans of action.

“We discuss why this is important and what it means to our members, that it can save lives, especially for those who haven’t been diagnosed,” says Kathy Malovich, the department administrator. 

UBT leaders provided team members with their individual performance scores on administering needed second blood pressure tests. They customized training and other follow-up plans, including coaching the team on procedures for Proactive Office Encounters (a process that takes advantage of a member’s visit to ensure the member gets any needed tests or appointments).

At huddles, they discussed the importance of controlling high blood pressure for patients. They emphasized that not only was it a strategic clinical goal but a Performance Sharing Program (PSP) goal for the medical center.  

“People think they’ve done the second test because they know they should have,” says Leroy Foster, who was the department administrator when the test of change began. “Maybe they got distracted by any number of things.” Foster said the hard data helped motivate the team. 

With a low of 35 percent for second blood tests, each team member jumped to 92 percent or better in a year. Four of the six team members hit 100 percent. In 10 months, team scores for second blood tests went up from 84.8 to 92.1 percent.

Huddling was also a key to success.

“I used to think, ‘you guys have way too many meetings,’” Jennell Jones, the union co-lead, says. “But now I see how meeting keeps people connected.”

The Case for Unit-Based Teams

Deck: 
A model for frontline engagement and performance improvement

Story body part 1: 

An Internal Medicine team in Ohio improved its workflow and increased from 62 percent to 74 percent the number of diabetes patients with cholesterol levels under control—surpassing the region’s goal—even while coping with a staff shortage.

A medical/surgical unit at Fontana Medical Center, in Southern California, went 23 consecutive months without an incidence of hospital-acquired pressure ulcers—after previously experiencing seven to 10 cases a year.

Colorado’s regional laboratory improved the accuracy of its transfer and tracking records from 90 percent to 98 percent, significantly reducing rework and speeding turnaround times for patients’ lab results.

These outcomes, and hundreds of others across Kaiser Permanente, were the result of performance-improvement projects undertaken by unit-based teams (UBTs)—Kaiser Permanente’s strategy for frontline engagement and collaboration.

Physician involvement in UBTs to date has varied, and generally remains limited. However, based on evidence from across Kaiser Permanente, we believe unit-based teams can help physicians achieve their clinical goals and improve their efficiency and deserve their broader involvement.

How UBTs work

Teams identify performance gaps and opportunities within their purview—issues they can address in the course of the day-to-day work, such as workflow or process improvement. By focusing on clear, agreed-upon goals, UBTs encourage greater accountability and allow team members to work up to their scope of practice or job description. Achieving agreed-upon goals, in turn, promotes continuous learning, productive interaction, and the capacity to lead further meaningful change.

As a strategy for process and quality improvement, UBTs draw on the study of “clinical microsystems” by Dartmouth-Hitchcock Medical Center and the Institute for Healthcare Improvement. “If we want to optimize a system, it's going to be around teams and teamwork, and it's going to cut across hierarchies and professional norms,” says Donald Berwick, MD, president and CEO of IHI and President’s Obama’s nominee to head the Centers for Medicare and Medicaid Services. “Unit-based teams and much better relationships between those who organize systems and those who work in the systems are going to be essential.”

Four kinds of benefits

The focused nature of UBT activities translates to four broad benefits to physicians and patients:

  • Clinical benefits: Saving lives and improving health
  • Operational benefits: Using resources wisely and improving efficiency
  • Member/Patient benefits: Giving a great patient-care experience
  • Physician/team benefits: Improving team performance and worklife

The example below, of a positive clinical outcome in one unit, shows how UBTs use practical, frontline perspective to solve problems.

Simple solutions get results

The Internal Medicine department at Hill Road Medical Offices in Ventura (SCAL) faced a practical challenge: Patients with an initial elevated blood pressure reading need to be retested after waiting at least two minutes—but they often left the office before the staff could do a second test. In fact, the staff was doing needed second checks only 26 percent of the time as of March 2008. 

The team’s simple solution: A bright yellow sign reading, “Caution: Second blood pressure reading is required on this patient,” which employees hang on the exam room door so the physician or staff would be sure to do the test.“The teams come up with good ideas about workflow because these are the folks in the trenches and they see the headaches,” says Prakash Patel, MD. “They share ideas and work out processes that help.”

In just one month, the department’s score on giving second blood pressure tests was 100 percent. Their score on the regional clinical goal of hypertension control went from 76 percent in August 2008 to 79.8 in May 2009, just below the regional goal of 80.1 percent.

"I strongly encourage all chiefs of service to champion the unit-based team in their department by either active participation or as a physician advisor, particularly regarding quality, service and access initiatives," says Virginia L Ambrosini, MD, assistant executive medical director, Permanente Human Resources.

UBTs are taking hold at the right moment for Kaiser Permanente. At a time when health care providers are under pressure to contain costs, maintain quality, and improve service, UBTs have the problem-solving tools to address those issues.

Read the full article, including principles of employee engagement and tips for selecting a performance improvement project.

 

 

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