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Format:
PDF (color and black and white)
Size:
8.5" x 11"
Intended Audience:
Frontline employees, managers and physicians
Best used:
This poster features a pediatrics team that increased vaccine rates in children by administering shots in the exam room rather than an injection clinic. Post on bulletin boards, in break rooms and other staff areas.
In health care, there is no such thing as “normal business hours.” Babies insist on being born at 3 a.m. A car crash or bursting appendix can land a patient in the Emergency Room at noon or midnight or 5 a.m. To prevent infections, the cleanliness of hospital rooms is just as important at 4 a.m. as at 4 p.m.
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.
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.
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.
“There was a lot of ‘back talk’ between the shifts,” says Aragones, a lab assistant II and member of SEIU UHW. “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.
Riverside EVS attendant Virginia Gonzalez, a United Steelworkers Local 7600 member.
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.”
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.
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.
The 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.”
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, performance 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 flipchart 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-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 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.”
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.”
After a false start, the diagnostic imaging department at Woodland Hills Medical Center has found its stride. Its results are impressive: By drawing on the wide experience of the team, it’s improving workflow and boosting attendance.
To get those results, the department created one large UBT with several subcommittees and involved a physician champion. Two radiology summits, which were held to set priorities, included the whole team:
At first, the team’s diverse skills and experience flummoxed the department-based team (the term Woodland Hills uses instead of unit-based team).
“We didn’t know the scope of our work,” says Selena Marchand, a lead sonographer and labor co-lead. “The old DBT got stalled talking about things like the doctors’ parking lot.”
Lessons for large teams
In addition, says Marchand, the representative group—which was working without a facilitator—didn’t communicate with its co-workers about the DBT’s projects. “They thought we were some sort of secret society,” says Marchand, a member of SEIU UHW.
The team restructured in October 2009, electing one delegate from each “modality,” as the areas of expertise are known, to the representative group.
“Pushing responsibility and accountability back to different modalities has been one of our successes,” says Mike Bruse, the department administrator and management co-lead. “We’re focused on things that we can control in our department.”
The co-leads convened two department-wide summits to focus on improving team performance and set priorities. Staff members brainstormed about what the challenging issues facing the department were and wrote them on flip chart pages on the wall. Then, each employee attached a sticky note to the issues that most concerned them. The team and managers set out to tackle the seven issues that received the most tags. As the work got under way, progress reports were posted in the employee break room to keep everyone on the team—not just the representatives—informed.
The department also improved the way it distributes film to radiologists, so that patients’ results get to primary care physicians faster. Before the change, technicians were forced to constantly interrupt doctors to read films. Now, there is a tally sheet on each radiologist’s door indicating how many films he or she is reading. This allows techs to know who is available to read a film—and allows radiologists to work undisturbed. An aide to the technologists tracks the process, acting as a traffic controller.
“It was a relatively simple thing that improved satisfaction and patient care a lot,” says Mark Schwartz, MD, who represents physicians on the UBT. “And it didn’t cost any money.”
The team also improved attendance, decreasing last-minute sick calls by 14 days from the end of 2009 to October 2010. They beat the Lab Department in a friendly competition two quarters in a row and were rewarded with a barbeque. To do this, team members simplified presentation of attendance data and posted up-to-the-minute metrics.
Beyond these gains, management co-lead Bruse says the most significant change is employees’ confidence in their own ability to make improvements.
“Our meetings used to be ‘complain to Mike,’ ” he said. “These days, when people see a problem, they take steps to solve it themselves.”
Format:
PDF
Size:
8.5” x 11”
Intended audience:
Frontline workers, managers and physicians
Best used:
Inspire your team with this piece that highlights the importance of colon cancer screening for patients.
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.
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.”
Format:
Word document
Size:
Six pages
Intended audience:
Senior leaders, facilitators and consultants, UBT co-leads
Best used: Use this checklist to assess whether your team’s successful practice is ready to disseminate across KP.
Format:
PDF
Size:
8.5” x 11”
Intended audience:
Physicians working in unit-based teams
Best Used:
At meetings and trainings and in one-on-one conversations to explain the roles doctors play on UBTs.
Format:
PDF
Size:
8.5” x 11”
Intended audience: Physician UBT co-leads, physicians
Description: This leaflet details why UBTs are valuable to physicians using frequently asked questions about UBTs. This is a companion piece to the leaflet asking why chiefs should support unit-based teams.
The folks at the Denver Regional Pharmacy found their unit-based team to be a major improvement over the steering committee it replaced.
Team members found the committee to be unwieldy, and felt it largely bred distrust and miscommunication between union and management.
So, they regrouped.
A major problem they had encountered was the time pharmacy technicians wasted researching prescriptions that weren’t properly "batched." Often missing was the required electronic stamp from a pharmacist that tracks and closes the prescription.
Technicians spent roughly 1-4 hours a day per pharmacy tracking down misbatched prescriptions. The team aimed to cut that time by 50 percent.
"The biggest thing is if you view your situation as a failure you'll never succeed," management co-lead Luanne Petricich says. "When something is not working that's where your opportunity is. Don't be afraid to change something if it's not working."
The team modified the way pharmacists attached their electronic signature. That saved technicians hours of research time and freed them to spend more time with patients. Almost immediately the team saw a drop in the number of prescriptions that needed to be researched.
In the two pharmacies where the team instituted new batching practices, they saw a 75 percent drop in the number of prescriptions requiring research. The new protocol was introduced to 20 pharmacies in the region, and 70 percent of those saw similar gains.
This collaborative effort produced positive results as their projects improved customer service and affordability. The new UBT also gained some hard-earned trust.
Since that success, the regional team has become a model and a sponsor for smaller, pharmacy-specific UBTs launched in the region.
"I like the focus on efficiencies and waste because it ends up translating to a better work environment for employees," Petricich says. "Especially with this project, we found the technicians were doing redundant work that did not provide job satisfaction. So taking that away allowed for more time with patients, which is what many would rather be doing."
