The problem

The psychiatrists, psychologists, social workers, nurses and support staff of the Oakland Adult Psychiatry Service are a highly trained professional staff committed to their patients' wellbeing. Yet up until a year ago, they had heard the following again and again: "Ninety percent of new patients need to be seen within two weeks. Your new patients are waiting too long to get in to talk to someone."

Although different methods had been tried to ease the backlog, the access problem kept creeping back. Each time it did, staff morale dipped and frustration grew.

"We felt we were working harder, but getting further behind and hearing about it," recalls Maggie Schadler, PhD, a psychologist and also an SEIU UHW-West shop steward.

When Robert Fusco, MD, the new Psychiatry department chief, looked at the access data, he was concerned.

"I brought together the Adult Service team leaders, which included the shop stewards and asked what process we should use to explore how to improve the access," Dr. Fusco said.

"The advice came from the union representatives. They said take it to the whole team."

And that's what Dr. Fusco did.

The solution

At an Adult Service staff meeting, he approached the team, which includes physicians, and suggested they work together to find a solution. He talked about the basics of access supply and demand—the demand for appointments, the supply of appointments the department had, and what happens to access when too many staff were away from the clinic at the same time.

For the first time, the staff understood how access affected their department, their coworkers and ultimately, the patient.

The advice came from the union representatives. They said take it to the whole team.

Robert Fusco, MD

At brainstorming sessions, the staff came up with 100 ideas, which they later rated in an online survey. Although it took almost an hour to go through the survey, 79% of the department's employees completed it.

"An authentic structure of shared decision-making, shared accountability and the freedom to bluntly express views and interests mobilized the staff to problem solve. We felt there was a real possibility to do something," said Andris Skuja, PhD, a psychologist and the lead SEIU UHW-West steward.

In the meantime, the team was faced with one of its biggest challenges. Employees were leaving for summer vacation; there were a few staff vacancies, and one psychologist was out unexpectedly with an injury. The result? The backlog of patients jumped.

"This was a crisis. Our access had plummeted," said Dr. Fusco.

The results

On their own, the staff proposed solutions to work through the backlog by taking time normally scheduled for staff meetings and using it for patient intake. September was spent clearing up the backlog. By October, access had improved dramatically and in November, the department met their goal and saw 90% of new patients within the two weeks.

But the team wanted to do more than clear up the backlog. Working as a unit-based team, they are now looking at how to improve access throughout the year as well as a way to set up additional intake when needed.

The upward trend is continuing in 2008. Access to Oakland's Psychiatry department climbed past the 90% mark to 97% in February.