Patient safety is about more than the hands-on care delivered in a hospital or clinic. It’s also about what caregivers do to close care gaps and be sure patients get the care they need.

To ensure this happens with every abnormal prostate, breast, pelvic, osteoporosis and fecal exam, the Georgia region established a centralized Outpatient Safety Net Program. Almost four years ago, borrowing techniques from Southern California’s successful safety net program, the Georgia region dedicated the equivalent of four full-time and one part-time nurse. Their jobs: to continue reaching out to patients who don’t respond to an initial contact regarding an abnormal test result.

The program is saving lives—and has earned KP’s 2014 David M. Lawrence Patient Safety Award in the transfer category, an award for a region that successfully implements a project from an earlier award winner. The Southern California safety net system had won a 2012 Lawrence award for its work.

“If you have an abnormal stool test, you should be seen in gastroenterology,” says Rahul Nayak, MD, who served as physician program director of patient safety for Georgia when the program launched. “It will raise a red flag in our system if that doesn’t happen in a certain amount of time. That’s why it’s called a safety net—it’s the net below the tightrope walker.”            

Making contact with patients

Sonja “Patrice” Evans, RN, is the manager of Georgia’s outreach effort and leads the group of nurses. She also steps in to convince members who initially say they don’t want to come in for further testing. “We can prevent something small from turning into something big,” she says.

The nurses receive a list of patients who have abnormal results. They make two attempts to reach them by phone and send a certified letter if the calls don’t work. “Our team tries to catch a small group of patients before they fall through the cracks,” Evans says.

So far, it’s working.

A systematic approach

In 2013, the most recent year for which data are available, 4,000 members were contacted about abnormal breast exam results. Of those, 93 percent were successfully scheduled for a follow-up appointment within the prescribed seven days. For abnormal pelvic exam results, 2,000 members were contacted, and 95 percent of those were scheduled within seven days.

Five hundred members—most of whom had declined or not responded to previous contacts—were reached within 100 days of abnormal prostate exam results; 87 percent scheduled a follow up. The team contacted 200 members with abnormal osteoporosis exam results, and more than 70 percent scheduled a follow up within 30 days, which exceeded the Medicare 5-Star guidelines.  

Dr. Nayak, UBT co-lead for gastroenterology at Southwood Medical Center, says one of his patients benefited from the program.

“Our safety net caught a positive (fecal occult blood test) that I had missed two months prior,” he said when accepting the Lawrence award on behalf of the team. “That patient had an advanced adenoma which was well on its way to malignancy. Without the safety net, there is no guarantee that we would have found this polyp” in time.

Now, Georgia’s program is expanding and will include other types of patient notifications.

The Molecular and Cytology Lab unit-based teams in Stapleton, Colorado, were facing a challenging trifecta. Increased membership, changes in guidelines from the Centers for Disease Control and Prevention (CDC) and slow work processes made it tough to quickly process two widely used tests.

Membership in the Colorado region has grown by more than 60,000 members since 2013 in part because of the Affordable Care Act. Total membership in the region is now at its highest ever, with more than 600,000 members. The influx of new members is a strain on the system, and teams are digging in deeply to meet those members’ needs, from the first point of contact in the medical office to the last encounter as they pick up their prescriptions on the way out.

The lab teams are feeling the pressure, too—especially since they also process samples for the Georgia region, which is expected to grow, and they still do some work for facilities in the former Ohio region, which was sold to another health plan last year.

“We knew there would be an increase in the number of tests we would be doing. We also knew that our process was very labor intensive,” says Roxanne Whitesides, the Molecular and Specialty Testing manager. “Already this year, we’ve increased our workload 10 percent because of an increase in membership.”

Preventive care approach

The screens in question are for the human papillomavirus (HPV) and the Papanicolaou (Pap) test. Both detect disease at an early stage when treatment is highly effective, and so are central to Kaiser Permanente’s preventive care approach. As of June this year, the Molecular and Cytology teams—each of which has a role in processing the screens—already had processed 23,300 Pap screens and 16,800 HPV screens.

Meanwhile, CDC guidelines on HPV were revised in recent years and now recommend that women age 30 to 64 have an HPV screening and that girls as young as 11 receive the vaccine. The agency says HPV is the most common sexually transmitted infection in the United States. Some strains can cause cancer, and the CDC says about 21,000 of the HPV-related cancers each year could be prevented by the vaccine.

Because of the changed recommendations, even before the enrollment jump, the labs were seeing an increase in the number of HPV screens they processed. In 2012, the labs processed 650 HPV screens a month. By this spring, the monthly average had more than quadrupled: the average for March, April and May 2014 was 2,800 per month. In May alone, 3,354 samples were processed.

Labor-intensive processes

The final hurdle the teams faced was that their processes were labor intensive, requiring significant hands-on time from the technician. There was frequent back and forth between the Cytology and Molecular departments, which caused delays and interruptions. The complex work processes added to the pressure of the growing workload and caused frustration and tension.

The teams began an intensive study of what other labs were doing, including researching the latest technology. They visited other sites and vendors and decided to go with a cutting-edge Roche instrument. The pathologists—who work closely with the labs—supported getting the new equipment, and the lease was fast-tracked for installation. The instrument was in place within two months.

At that point, the teams set to work to figure out how their processes would change with the new equipment.

Cross-training provides insights

“We trained each other on the new equipment and on the processes within the two departments,” said Luann Martin, a cytology technologist, UFCW Local 7 member and co-lead of the Cytology unit-based team. “I could appreciate things going on in both departments.”

The collaboration between the Molecular and Cytology departments enabled them to improve their work processes and interactions—and ensured that as one problem was fixed, another wasn’t created.

“It’s important to keep talking. People have different expectations and comfort levels,” says Beth Fisher, a medical technologist, UFCW Local 7 member and co-lead of the Molecular UBT. “Be patient with one another,” says Melissa Baca, a cytologist lab assistant, SEIU Local 105 member and union co-lead of the Cytology UBT.

Most important, Fisher says, the new equipment is enabling the teams to meet the growing demand.

“The big payoff is that we're able to process all those HPV samples in less than half the time it used to take, so we've been able to absorb the workload increase with no new staff,” she says. “And we're able to identify the HPV strains that are most linked with cervical cancer as part of the initial screening. That saves money, because we don't have to send out all the positives for additional testing.”

South San Francisco allergy team’s specialty may be allergens and hay fever, but that didn’t prevent it from helping to improve patients’ screening rates for cancer, too.

It didn’t happen all at once—some staff members were skeptical at first. Scheduling a screening appointment for a wheezing patient didn’t seem right.

“At first people would say things like, ‘You know, I really don’t feel comfortable saying to a patient, “Oh, you’re due for mammography” when they’re sneezing and congested and here for allergies,’” says Alva Marie Aguilera, the department’s supervisor and management co-lead for the unit-based team.

Screenings as strategy

But part of delivering on Kaiser Permanente’s Total Health promise is to identify health risks and signs of disease as early as possible. Regular screenings for such diseases as high blood pressure, diabetes, and colorectal, cervical and breast cancers are an important part of our strategy.

That means caregivers and employees in seemingly unrelated departments—not just those in, say, internal medicine—have a role to play, and KP HealthConnect® provides them with a powerful tool.

Any time a patient is seen, a “proactive office encounter” message pops up in the member’s electronic record if he or she is due for a health screening or if important health data needs to be updated. It doesn’t matter what the reason is for the current visit or which department the patient is being seen in. 

The members of South San Francisco allergy department took the important work of taking the next step to heart: Following up on the prompt and offering to schedule the patient for the screening or asking the necessary questions to fill in missing information.

Scripts and reminders

To help make sure those things happened consistently, the team tried some small tests of change:

• It created a general script to help broach the questions with patients and posted laminated cards on computers to serve as reminders.
• Aguilera reports the weekly screening numbers so staff members know how they are doing and where they missed opportunities to follow through on the HealthConnect® prompts.

The small changes had a big impact. Before the team started the project in February 2012, it followed through on the prompts 80 percent of the time. In the first two months of the project, that jumped to 90 percent. By early 2013, the prompts were being followed up on 95 percent of the time and held steady at that rate for the rest of the year.

It wasn’t just staff members who were uncertain of the practice in the early days.

“At first it was kind of surprising to patients,” says medical assistant Lidia Vanegas-Casino, a member of SEIU UHW and the UBT’s union co-lead. “So we had to explain to them: ‘It’s a way to help you, and to keep up with the things you need done. It’s a proactive approach to keeping you healthy.’”

Positive example

It was one of KP’s own commercials that convinced team members of their important role in keeping patients healthy. Aguilera showed the ad that features KP member Mary Gonzalez, who had gone in—fittingly—for an allergy appointment when the receptionist noticed she was due for a mammogram and booked an appointment for her. The screening picked up a mass, and Gonzalez subsequently learned she had breast cancer. The early detection helped ensure a positive result.

It wasn’t a primary care or OB-GYN department that got her that screening. It was allergy.

“It really hit home for people,” Aguilera says. “If it wasn’t for the allergy receptionist who took that time, we don’t know what would have happened. That was a big encouragement.”

On one level, the pediatric clinic at Georgia’s Panola Medical Center Offices is like any other pediatric clinic. Babies squawking and squealing are part of the soundtrack—and under that, there’s the murmur of parents and nurses cooing to get the little ones to stop crying.

But the Panola clinic’s unit-based team stands out. Its members work at one of the several pediatric clinics in KP’s Georgia region that have significantly improved preventive care and screenings for their young patients, who range in age from newborn up through their teens.

The pediatric teams have achieved these goals in the midst of competing demands by staying laser-focused on a handful of quality measures in the Healthcare Effectiveness Data and Information Set, or HEDIS.

“Our projects are usually HEDIS-related,” says Panola’s labor co-lead, Sheryl Boyd, a licensed practical nurse and member of UFCW Local 1996. “HEDIS is so measurable.”

The work is a good example of how, instead of driving an agenda from the top down, achieving a goal can be inspired by engaging frontline teams in understanding how they contribute to KP’s brand promise of total health.

“The teams are not ‘being told what to do,’ but rather they see the big picture and see what they can do to affect it,” says David Jones, MD, Georgia’s physician co-lead for UBTs. Dr. Jones says he and his labor and management LMP counterparts stay abreast of Georgia’s regional goals and priorities, then work with UBT consultants to communicate those to frontline teams.

“We incorporate UBTs as a lever to execute our clinical goals,” says Dr. Jones, creating a vital loop of communication and support.

Collaboration pays off

One of the Panola UBT’s successes has been to increase the number of girls getting the human papillomavirus vaccine (HPV) by their 13th birthday. The vaccine can help prevent a virus that increases the risk of cervical cancer.

The project kicked off in October 2011. At the time, the team wasn’t tracking how many of the girls in the target population had received the vaccination, which is delivered in a series of three shots over six months. The team’s initial goal was to get 5 percent of the girls eligible for the shot vaccinated. In the first six months, the team succeeded in getting 10 percent of the target population started on the series—and by October 2013, nearly 20 percent had gotten the complete series, a significant achievement. While it has yet to reach the national HEDIS average for the vaccination, the team is steadily closing the gap.

Team members achieved these results by working with the clinic’s information technology staff to get a list of patients—11- and 12-year old girls—who needed the vaccine. They contacted parents and made appointments. In the exam room, nurses discussed HPV and the importance of the vaccine with patients and their parents.

And they worked with their IT colleagues again, modifying the computer system so they could book appointments six months in advance. That allowed them to act on a crucial step—scheduling visits for the two follow-up booster shots right then and there.

The parent education was extremely important, says Erica Reynolds, the charge nurse and management co-lead.

“Some parents think we want people to come back in for appointments because we want the co-payments,” she says—but in fact, if the shots aren’t completed in the proper time period and the immunization series needs to be started all over, it requires even more visits. To avoid that, she says, “Scheduling a nurse visit for the second and third vaccines has become a part of our workflow.”

Hard-wiring success

That kind of hard-wiring of successful practices is the holy grail of performance improvement.

As labor co-lead Boyd puts it, “Our projects are not ‘projects.’ They are ongoing.”

In addition, Dr. Jones says, the integration of partnership and performance is taking place at all levels in the region.

For example, he says, physician leaders “integrate the Labor Management Partnership and performance improvement into existing meetings so it is not viewed as outside those discussions.”

As a result, when Georgia earned a five-star Medicare rating in fall 2013 for the first time—bringing all of KP’s regions into that rarified club of health care excellence—Rob Schreiner, MD, the region’s executive medical director, specifically credited UBTs and the culture of continuous improvement for the achievement.

Driven by those two engines, says Schreiner, “We’ll improve quality, service and affordability at a tempo that exceeds that of our competitors.”