FRONTLINE NEWS FOR KP WORKERS, MANAGERS ......Frontline workers, managers and physicians may not...

WINTER 11 | ISSUE No.26

FRONTLINE NEWS FOR KP WORKERS,

MANAGERS & PHYSICIANS

NOPE... BETTER... BUT STILL NO...

CLOSE, BUT NO CIGAR...

BY GEORGE, I THINK THEY,VE

GOT IT. SEE WHAT SMALL TESTS OF CHANGE CAN DO...

DAY 1

DAY 63 DAY 137

DAY 24

WHY TEAMS THAT TRY AND FAIL ARE BETTER THAN TEAMS THAT ALWAYS SUCCEED

IN THIS ISSUEGot members? Learn how to keep them, and get more

Talk about failure! (It leads to success)

Fremont doc says: Credit team for top osteoporosis screening rates

EDITOR’S LETTER: Falling down on the job

2 www.lmpartnErship.orgHank Winter 2011 | No. 26

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, Glenda Carroll, Paul Cohen, Paul Erskine, Tiffany Gardner, 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 AdAPT, AdOPT, AbANdON False starts can be frustrating—but they can be springboards to success.

From projects that changed direction after the data came in, to tests of change

that were tweaked or abandoned, frontline team members talk about their

flops—and how helpful those flops were.

6 MEMbERS dON’T GROW ON TREESFrontline workers, managers and physicians may not think they’re salespeople—

but as this story out of the Mid-Atlantic region shows, the care and service we

provide can make all the difference in retaining current members and attracting

new ones.

9 PLAN, dO, STudY, ACTLearn how this San Diego UBT has brought a halt to patient-handling injuries.

10 FROM THE dESK OF HENRIETTA Find out why talking about failure is a short cut to success.

11 PHYSICIANS ON PARTNERSHIP How did this physician chief’s department become one of the best at screening

patients for osteoporosis?

In the “Game Changer” story in the Fall 2010 issue, Lisa Manio-Bibat, RN,

the HAS/PACU assistant nurse manager at South San Francisco Medical Center,

was misidentified. Hank sincerely regrets the error.

CONTENTS

Learning can be a bumpy business. I watched a video clip the other day of my great-niece at her

first birthday party, at a park near her home. With her slightly tipsy

1-year-old’s walk, she crossed the playground area, a light grip

on her grandpa’s index finger. At the edge of the playground,

her foot didn’t quite clear an inch-or-so step up as the paving

changed. Down she sat—slightly surprised, judging from the

look on her face.

She got up, circled back, and took the baby step again. This time,

though she teetered for a moment or two when her foot hit the

step, she didn’t fall.

Unabashed—and apparently both unsatisfied and unashamed

of her less-than-“perfect” performance—she circled back again.

And now she took the step in stride, as if she’d been doing it for

five years instead of five minutes. Content with her new mastery,

she marched on down the path.

We tend to forget that trial and error is a key part of learning,

no matter how old we are. Sometimes we have to do something

more than once, adapting our process slightly each time, until we

decide we’ve gotten it right and we adopt it into our repertoire

of how we do things—or we decide it’s not getting us where we

want to go and we abandon it for another approach.

As Harvard Business School professor Amy Edmondson says in

“Adapt, adopt, abandon,” the story that begins on the opposite

page: “Somewhere along the line we get socialized and begin to

buy into the absurd notion that we should be perfect.”

The cover story of this issue of Hank is about teams that have

learned to get better by letting themselves get it wrong at first.

The next story, “Members don’t grow on trees,” is all about how

adapting to changing circumstances is key to our success.

When we look around, there’s plenty of evidence that the world,

inside and outside of Kaiser Permanente, is not yet perfect.

There are plenty of places where, metaphorically speaking,

we fall down on the job. Obviously, in health care, where a wrong

decision in some settings can mean death, there are places

where experimentation is anything but appropriate—but we all

lose when we lose the ability to experiment in other settings.

My great-niece didn’t think that falling down was OK, and she

ran her own small tests of change until she got it right. Rather

than letting our current knowledge become a boundary we can’t

venture beyond, we need to use what we know as a basis for

further experimentation.

What we already know helps us identify problems and propose

thoughtful, reasoned ways we might solve those problems—which

we can then test. Some ideas will work, and we can adopt them.

Some will fail and, unabashed, we can abandon them.

—TYRA FERLATTE, Hank editor

3

6

9

10

11

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.

Cover story

www.lmpartnErship.org 3 Hank Winter 2011 | No. 26

Asking questions, getting answers: The San Diego Nuclear Medicine team discovered that the premise of their first performance improvement project—high repeats of heart scans—was not the problem they initially suspected. Above, assistant technologist and labor co-lead Jessica Larson (left) and technologist Christine Cook (right) assist patient Robert Evans. Larson and Cook are members of OPEIU Local 30.

Adapt, adopt, abandonWhy teams that try and fail are better than teams that always succeed

WINTER 11 | ISSUE No.26

his is the story of a team that never failed a test

of change. No matter what the team members did, rapid improvement cycle after rapid improvement cycle, every small test tried was a better jewel than the one before. They received an A for their PDSAs.They were fearless—in their imaginations.

The only problem with the team’s brilliant

tests of change was that they never got

tested, never got to the stage where

stumbling or failed ideas might have real

consequences. There was no learning,

no innovation, no growth—just intriguing

ideas that remained bottled.

In health care, it’s still frowned upon to talk

about failures or things that don’t work out

perfectly for fear the information will be used

against the people involved. But even in a

high-stakes industry where the consequence

of some decisions means life or death, there

is plenty of room for improving performance

by learning from small failures.

Using small failures as learning opportunities

is the cornerstone of creating a learning

organization. Small failures are at the heart

of the Rapid Improvement Model and its

plan, do, study, act cycles.

“Despite the increased rate of failure that

accompanies deliberate experimentation,

organizations that experiment effectively…

are likely to be more innovative, productive

and successful,” writes Amy Edmondson,

a professor at Harvard Business School,

in a December 2004 article in the Quality

and Safety in Healthcare Journal.

This in fact is a story of false starts: the

story of unit-based teams and employees

throughout Kaiser Permanente already are

learning, developing and innovating from

missteps or downright unsuccessful small

tests of change.

From projects that changed direction

after data contradicted the original premise,

to tests of change that were tweaked or

abandoned all together, workers describe

how they tried a small improvement that

didn't turn out as expected and still gained

from the experience. And even, eventually,

found success.

(continues on page 4)

‘ Anyone who has never made a mistake has never tried anything new.’

— A L B E R T E I N S T E I N

Want to know what leaders can do? Find out with Donna Lynne, Colorado region president, and others.

(see page 5)

(continued from page 3)

Learning to failAt San Diego Medical Center’s Nuclear

Medicine department, the unit-based team

decided its first test of change project would

look at reducing the number of redundant

heart scans, which technologists were

certain were wasting time and resources.

In November 2009, team members began

to track the number of repeat scans to

establish a baseline. They figured repeats

would be at least 25 percent of the heart

scans. After a month of logging the scans,

however, they discovered something

quite different.

“The number of repeat heart scans was

actually between 7 to 10 percent,” says the

UBT’s labor co-lead, Jessica Larson, a tech

assistant and OPEIU Local 30 member.

The team’s hypothesis was amiss.

It switched gears.

Since several of the staff recommendations

for test of change projects related to heart

scans, the team focused next on the variation

in the instructions patients were given.

If team members gave identical instructions,

they might be able to all but eliminate repeat

heart scans.

“The test of change at that point was

to make sure everyone was following the

protocol,” says Randy Andres, a nuclear

medicine technologist and OPEIU Local

30 member.

The team created laminated handouts with

one set of clear instructions that technologists

and receptionists were to hand out to every

patient before a scan.

“We did that for a few weeks, and found

it was a lot more complicated than we

anticipated,” Larson says. “You had

inpatients, outpatients, observation-unit

patients….Forms were getting misplaced

because patients would leave them in the

waiting rooms or in their purse. Or people

weren’t even giving them out.”

During the same time, a supply shortage

meant the department had to switch the

type of injectable radioactive isotope it was

using. The change meant a whole new

set of protocols. Compounding it all, the

department’s longtime manager retired.

It was time to shelve the test of change.

But was it a waste of time? Not at all, say

Larson and Andres. Both say it provided

valuable information about the department’s

work flow—as well as practical knowledge

of how to conduct tests of change.

“This was a very good teaching experience

for us,” Andres says. “We didn’t even know

about tests of change before this. It’s not

simply a matter of just changing something.

You have to go through this process.”

Too much of a good thingFurther north at Redwood City Medical

Center, the Gastroenterology department

discovered you can have too much of a

good thing.

‘We had to think outside the box. This was a way to reach a lot of people.’

— J U L I E D A L C I N , director of Medicine, Redwood City Medical Center

The nature of learning: Like other teams, San Diego Medical Center’s Nuclear Medicine team has sometimes learned the most from tests of change that didn’t pan out. Above, technologist Ken Lukaszewski; opposite page, left to right: Several team members gather for a shot, including Lukaszewski; Suzanne St. Clair, assistant department administrator; technologist Gary Holowach; technologist Christine Cook (seated, left); clerk Debora Winslow (seated, right); and assistant technologist Jessica Larson (standing, right). All but St. Clair are members of OPEIU Local 30.

Adapt, adopt, abandon

4 Hank Winter 2011 | No. 26 www.lmpartnErship.org

onna Lynne, the Colorado region president, has climbed 36 mountains—some higher

than 14,000 feet, including Kilimanjaro. All after she was 55.

The native New Yorker says developing her mountain-climbing skills after moving to the

Rocky Mountain state “required a lot of learning and physical and mental stamina and ability

to accept failure, because sometimes you don’t make it to the top.”

“This wasn’t in my genes, so it was a challenge,” Lynne says.

Her approach to learning to climb isn’t very different from her approach to taking risks at

work, she says. And Lynne feels strongly that sharing her own risk-taking experiences helps

encourage teams to think outside the box, take risks and push themselves in their own work.

“If you don’t, as a leader, demonstrate that you’re willing to take a risk, people below you

feel the same way,” Lynne says.

It is this type of transparency and modeling at the top, says Amy Edmondson, a Harvard

Business School professor, that helps create a workplace environment of openness,

in which failed tests and unexpected outcomes can occur and be analyzed and learned

from without reprisal.

“They (leaders) can go first,” Edmondson explains. “And by go first, I mean they can

acknowledge their own vulnerability.”

Barbara Grimm, senior vice president of the Office of Labor Management Partnership,

concurs with Edmonson on that point—somewhat to her own chagrin.

WHAT CAN LEADERS DO? BE A GOOD MODEL.Grimm recalls a decision she made earlier in her career that she quickly regretted,

realizing it fell short of the model of partnership decision making to which she held

herself: “I thought I was inclusive, and I wasn’t inclusive enough,” she says.

But it already had been communicated widely to employees.

“When I look back, it mortifies me. It’s a little like, ‘Oh gosh, it nearly brings a post-

traumatic stress reaction.’”

So the following day, she sent a send-all voicemail to 5,000 people, apologizing

for “jumping the gun” and explained how she planned to follow up. In response,

she received an influx of positive emails and voicemails from people who appreciated her

acknowledgement of the lapse and were confident in the steps she outlined to remedy it.

“I remember my boss telling me, ‘I bet you never knew the shining moment of your

career was going to be the one that reveals you’re human,’” Grimm recalls.

John August, executive director of the Coalition of Kaiser Permanente Unions, shares a

different type of personal tale.

As a young union organizer, August had developed a successful system for organizing.

Then one day he met with organizers who had a lot more experience. They showed him

a way of organizing that was particularly effective for a much larger scale of campaigning.

Contracting with an Oregon company that

specializes in mass outreach calls, the

department began using automatic robocalls

to reach patients ages 50 to 75 who were

due or overdue for colorectal screenings.

“We had to think outside the box,” says

Julie Dalcin, director of medicine. “This was

a way to reach a lot of people.”

The first round of robocalls went out in

November 2009, with some 10,000 calls

made. They reached 97 percent of the

members who were due for the tests—

but there was a problem. The calls were

made within a span of three hours, and the

response overwhelmed the department and

the facility. The voicemail box the team had

set up in advance barely helped; it could

take only 50 messages.

“We got bombarded by calls from patients

calling back with questions or requests.

Our operator was inundated,” says manager

Isabel Uibel. “Physicians in other departments

were also bombarded with calls. People…

were like, ‘What’s going on?’”

Michele Coons, a medical assistant and

SEIU UHW member, was devoted to

returning the calls and to mailing “FIT kits,”

the at-home stool tests that help detect

early signs of colorectal cancer, to those

who had requested them.

“Many people had a lot of questions,”

Coons says. “‘Why did I get this call?’

‘What does a FIT kit test mean?’”

It took a week to figure out a system for

getting back to all the patients, she says.

“I think at the end of day you have to be

willing to try,” Uibel says. “And forgive

yourself for the time you put into something

that didn’t work. And don’t lose motivation.

But also know when…you’ve got to say,

‘We’re not going down the right path at all.’”

In some workplaces, what had happened

would be labeled a disaster. But not in

Redwood City. The essential idea was

sound. For the second round of calls,

the team addressed the overwhelming

response by having the calls made over

a two-week period.

“We didn’t think we needed to throw the

baby out with the bathwater,” Uibel says.

“We just had to keep tweaking to make the

system work for us.”

Too good to be true When it came to how quickly patient

messages are responded to, the Internal

Medicine department at the East Denver

Medical Office in Colorado was pretty

close to bottom—only 8 percent of patient

advice calls were answered within an

hour. The team members were open to

trying anything, and after several small tests

of change, they hit on something so ridicu-

lously simple that some people resisted it.

Nurses tape neon orange cards with the

patient message to the door of the exam

room where the doctor is working.

The doctor sees the message on the way

out of the room and goes back to his or

her office to respond.

Within the first three months of the test,

the department saw message turnaround

times soar to 30 percent answered

within the hour.

“You had some tangible symbol that you

were trying to make these numbers move.

It was a great motivator,” says

Christopher Hicks, MD, the team’s

physician co-lead. “It was different.

It wasn’t something that was

happening electronically.”

Then they hit a wall.


Why teams that try and fail are better than teams that always succeed

5 Hank Winter 2011 | No. 26


www.lmpartnErship.org


How the Mid-Atlantic States region brought new members into the KP fold by tapping into the power of the unions—and how frontline staff helped close the deal

MEMBERS DON’T GROW ON

TREES

he loyalty of a small group of SEIU janitorial workers

at American University in Washington, D.C., dem-

onstrates the power of KP’s front line to grow and retain

membership: They inspired their union to bring an even

larger group into the Kaiser Permanente fold.

When the New York-based Local 32BJ consolidated some

smaller units in its Mid-Atlantic States coverage area and

raised the possibility of changing health care providers,

the university’s janitorial workers balked at leaving KP.

Why? The care and service they receive from frontline workers,

managers and physicians in KP’s Mid-Atlantic States region.

“We were taken aback by their adamancy,” said Barbara

Caress, director of Strategic Policy and Planning for Local

32BJ, an SEIU union that uses its Taft-Hartley funds to pro-

vide health coverage for about 100,000 janitorial, security

and other workers in the northeastern United States. “It led

us to think about why they were so committed to Kaiser.

This was an atypical response.”

Front lines shine

That led 32BJ officials to seriously consider KP as an alterna-

tive for several thousand members who work for a variety of

employers in KP’s Mid-Atlantic States region. Most of them are

immigrants for whom Spanish is the sole or primary language.

Leaders from the Coalition of Kaiser Permanente Unions and

KP already were courting 32BJ—and other unions—for more

health plan members as part of a joint marketing venture. At

this opening, they leapt into action, giving KP’s front lines a

new opportunity to shine.

The Union Coalition and KP designed a special “Backstage

Pass”—a bilingual demo and facilities tour that gave potential

members from SEIU the opportunity to interact with care

providers and see how the Labor Management Partnership

sets KP apart from other health plans and systems.

“We needed to engage local leadership and rank and file,”

Caress said. “It was their call (whether they wanted to change

health plans), not ours.”

At one facility, the West End Medical Office Building in North-

west D.C., the 32BJ workers met Louise Casa, a KP nurse

practitioner and shop steward for UFCW Local 400. Casa

explained to the group how she, her partner and daughter all

receive KP care—and noted how she appreciates the conve-

nience of having the lab, pharmacy, and primary and specialty

care providers all in one location.

Collaborative marketing

Casa, who’s been with KP since 1997, also explained

how the Internal Medicine department employees work on

an interdisciplinary team that includes physicians, nurse

practitioners, nurses and nutritionists “who all believe that

the patient is the focus of our work.”

“I think the members of 32BJ were pleased to see a sister

union member,” said Casa. “I am proud to be part of a

company and a coalition of unions who have stepped into

uncharted waters to enhance our labor experience and

drive the success of our company.”



“I think it was very inspiring for them to see nurses working

in a very active labor environment,” said Michael Kapsa,

director of Business Strategy for the Coalition of Kaiser

Permanente Unions, who helped KP reach out to the union

leaders.

The tour tapped into the larger joint marketing strategy

that takes advantage of KP’s deep and largely positive

history with labor unions. In the Mid-Atlantic States region,

Kapsa has been working with the region’s sales team to

win accounts with unions that use their trust funds to offer

health coverage to their members.

“There is no way this would have happened without col-

laboration around growth,” Kapsa said. “They appreciated

the KP model, but needed more information.”

Kapsa and his partner, David R. Russell, the region’s

manager of Large Group Sales, landed the account and,

as of Oct. 1, about 3,200 additional 32BJ workers became

new KP members.

John August, executive director of the Union Coalition, said

KP stands to gain as the nation grows more diverse.

“Providing medical care that meets the cultural needs of all

patients is more than a diversity issue, it is a bottom-line

issue,” August said. “The partnership can and will play a

role in bringing the power of the Value Compass to the field

of culturally competent care”—care that takes into account

issues of race, language, age, gender, lifestyle, ethnicity, faith,

location and/or socioeconomic status that affect individual

decisions and attitudes about health and medical care.

‘ There is no way this would have happened without collaboration around (membership) growth. They appreciated the KP model but needed more information.’

— Michael Kapsa, director of Business Strategy, Coalition of Kaiser Permanente Unions


WHY DOES IT MATTER?Here are some examples of how culturally competent care can make a difference:

A Spanish-speaking patient may avoid an accidental overdose if care providers are alert to the fact the word

“once”—as in, “take this medication once a day”—can be mistaken for the Spanish word “once,” meaning the

number 11.

If a Latina with diabetes is advised on how to create an appropriate diet with foods that are familiar to her, instead

of being expected to eat a wide range of new foods, she may be more likely to manage her disease effectively.

A non-English-speaking patient with heart disease who receives help from an interpreter—and so gets a good

understanding of how exercise affects his health—may be more inclined to adhere to an exercise regimen.

If an elderly Chinese man with congestive heart failure feels his religious beliefs have been integrated into his treatment

plan, he may be better at taking his medication and be less likely to have to visit the emergency department.

Sources: Monica Villalta, Diversity director, Mid-Atlantic States; National Diversity Office; Nilda Chong, MD, Ph.D., MPH, “A Model for the Nation’s

Health Care Industry: Kaiser Permanente’s Institute for Culturally Competent Care,” The Permanente Journal, Summer 2002, Vol. 6, No. 3.

ne of the next frontiers in delivering excellent

health care—one that will come to the forefront as

health care reform extends coverage to a more diverse

population—will be mastering the art of culturally

competent care.

Understanding a patient’s cultural values not only shows

respect for the patient, it also is essential for gathering

necessary clinical information efficiently, said Monica Villalta,

the diversity director for the Mid-Atlantic States region.

Thus, providers are alert to a wide range of factors that can

influence a patient’s perspective.

Culturally competent care may lead to:

• decreased rates of hospitalization for preventable

causes for groups most at-risk.

• increased patient satisfaction.

• increased employee satisfaction due to better

communications with patients.

• containment of rising health care costs.

“Language is but one component of culturally competent

care,” Villalta said. “There are health decisions based

on beliefs, attitudes, and shared experiences. According

to KP’s National Diversity department, organizations

that provide culturally competent care acknowledge and


understand cultural diversity in the clinical setting, respect

members’ health beliefs and practices, and value

cross-cultural communication.

MEETING NEW MEMBERS’ NEEDS

Villalta and the Diversity department were “instrumental” in

helping the Mid-Atlantic States’ ensure that the new members’

needs were met, said Michael Kapsa, Director of Business

Strategy for the Coalition of Kaiser Permanente Unions.

“We need to do this effectively and not just piecemeal,” Villalta

said. “For health care organizations seeking to grow and retain

their patients, this is not a wish. This is a must.”

The challenges are many, including engaging new patients

in preventive care. For instance, members and patients may

come from a country or culture where the patient-doctor

relationship is strictly hierarchical and patients do not ask—

or answer—questions about their own care.

Villalta always underscores her point by posing this question

in her training courses: “If you are going to have the right

diagnosis and ensure the patient complies with instructions—

how can you do this if you don’t understand each other."

For more information, contact Monica Villalta at

[email protected]. Your team also can learn more and

find out about training in culturally competent care by visiting

the National Diversity website at Diversity.kp.org.

Beyond language: The challenge of delivering culturally competent care



“We were sitting around threshold or target

and then would drop back down,” explains

Olivia Wright, supervisor and management

co-lead. “We were just hovering around

20 to 30 percent.”

The team brainstormed about why it couldn’t

move the number above 30 percent.

Someone suggested one reason could

be that the call center opened at 7 a.m.

and most of the staff didn’t start until 8 a.m.

They were starting the day already behind

the curve with waiting messages. Two

nurses changed their schedule and started

coming in at 7:30 a.m. That seemed to

help: 52 percent of patient messages got

a reply within an hour.

“You’ve got to give something a shot,”

Wright says. “The first thing you come

out of the gate with isn’t necessarily going

to be the end-all be-all, but you’ve got to

start somewhere.”

One of the most surprising lessons for the

entire department was the fact that small

changes could have such a large impact.

“There was a sense of disbelief,” Wright

recalls. “We had to reassure the team that

the volume of work hadn’t gone down or

that it wasn’t because of the time of year.

We’ve sustained these results since May,

and it finally started to sink in that small,

subtle changes really are the reason for

these results.”

Failure is part of experimentationExperts who study organizations like health

care and the airline industry corroborate the

importance the process of experimentation

plays in organizational learning.

“Under conditions where there’s a lot of

uncertainty and constantly moving parts

and work is customized or unique, the only

way to make it work is to allow the right

level of leeway for teams…to experiment

thoughtfully,” Edmondson says. In the long

run, lasting success comes from a willing-

ness to try new things; but, if you try new

things, you're going to fail sometimes.

This isn’t license for projects based on

haphazard hypotheses, but it underscores

the fact that performance improvement

methods such as the Rapid Improvement

Model are made for small failures. Because

the process allows for quick experimentation,

with results evaluated within 30 to 60 days,

there is little to lose.

Barbara Grimm, senior vice president

of the Labor Management Partnership,

would have people ask themselves a few

questions that can help them weigh the

possibility of failure.

“Have you reasoned through the

consequences? That is key,” Grimm says.

“Do you have the patient’s interest

absolutely there? Do you have a plan if

it doesn’t go well?”

Edmondson argues there are two key

reasons health care organizations still resist

learning from small failures: The culture

often discourages questions, challenges,

or admissions of error, and a demanding

workload and pace force staff to rely on

quick fixes when something doesn’t work,

instead of systematic problem solving.

That is changing at Kaiser Permanente

with the commitment to providing frontline

staff with training and support to conduct

root cause analysis and problem solving

with RIM, RIM+ and other performance

improvement tools. And unit-based teams

give staff members the place and time

to do this work.

John August, executive director of the

Coalition of Kaiser Permanente Unions,

believes the true purpose of the Labor


Management Partnership is to recognize the

mission of KP and the mission of the unions

are at profound risk due to the economic,

competitive and public policy environment

in which we operate.

“We must continually remind everyone in

the organization that the why of what we do

in partnership is driven by this fundamental

recognition and agreement,” August says.

“We’ve got to begin there….If we don’t make

the effort to discuss the reasons why we’re

doing this, people will get the impression that

people are just being asked to do something.

And being asked to do something doesn’t

create an atmosphere of safety.”

Edmondson says the sense of safety will

further develop when we learn to accept

and work with our limitations.

“People need a sense of psychological

safety, and frankly a sense of humor about

our humanness,” Edmondson says.

“Somewhere along the line we get socialized

and begin to buy into the absurd notion

that we should be perfect.”


“It was a huge breakthrough for me,” August recalls. “I had to let go of what I thought

was working so well. And I did. And the new system worked even better. I had to get

over my own commitment to my own system. And I never forgot what a great feeling

it was, to allow these new ideas to create something much better.”

In addition to modeling the willingness to take risks and being transparent about

their own decisions and mistakes, leaders also can outline where the boundaries for

experimentation lie.

“It’s essentially saying, ‘There isn’t blame for these things, but there are things where

blame and action is needed,’” Edmonson explains. “Like failure to ask for help when

you’re in over your head. Failure to learn from prior experience is a problem.”

One of the biggest mistakes leaders—at all levels—can make is to say or simply

imply that winners are people who get it right all the time.

“Many times you can convey that without even meaning to,” Edmondson says.

“We get excited and our face lights up when we have success, and we groan when

something doesn’t work. It’s human nature, but we’ve got to do better.”

Grimm agrees.

“If you ask leaders, they say, ‘I absolutely want people to take risks,’” Grimm says.

“Where it falls down is...at the time of the mistake. Your reaction of disappointment,

your own discomfort that you weren’t supportive enough.”

For Lynne, when it comes to weighing a risk and its repercussions—good or bad—

she reminds herself of the alternative: “What’s the risk of not doing something?”

Not doing something, she says, “creates missed opportunities to learn from failures.

It creates a status quo mentality: “We’ve always done it this way; we’re comfortable

where we are. We’re not going to stretch.’”

WHAT CAN LEADERS DO? BE A GOOD MODEL.

Examining workflow: Several of San Diego Nuclear Medicine’s projects focused on the protocols for heart scans completed by technologists like Christine Cook (above). The technologists are represented by OPEIU Local 30.

‘The first thing you come out of the gate with isn’t necessarily going to be the end-all be-all, but you’ve got to start somewhere.’

— O L I V I A W R I G H T, supervisor and management co-lead, East Denver Medical Office





Dr. Robert Pearl, president and CEO of the MidAtlantic

Permanente Medical Group, noted that providing superior

quality and personalized service to all patients is the goal of

physicians, nurses and support staff across the region.

“Culturally competent care is essential for us to achieve

that goal,” he said. “Many of our new members did not

obtain the preventive screening and health care treatments

they needed in the past. By welcoming them into Kaiser

Permanente and meeting their language and cultural needs,

we have the opportunity to help them improve their health,

not just now, but in the future. Having spoken with some of

these new members, I know they are convinced they made

the right choice for themselves and their families when they

selected KP.”

Meeting cultural needs

The joint marketing collaboration continues in other regions,

too. Pre-planning with the coalition has helped identify other

accounts likely to lead to similar successes, Russell said.

The addition to the region’s roughly 500,000-member tally

was a coup, Russell said. Now the challenge is to ensure the

workers understand KP and understand how to access care.

With help from regional Diversity Director Monica Villalta,

bilingual tours were provided, along with membership

meetings in union halls. KP and the union also produced a

new member kit, which included a membership card holder

written in Spanish, explaining their rights—and avenues—to

having health care delivered in their native language.

Because of the new members’ limited English skills, frontline

workers will have an especially significant role to play in how

they experience Kaiser Permanente and influence whether

they want to stay with KP.

Caress, for example, was impressed that KP had bilingual

staff and many resources in Spanish.

“They seemed very sensitive to language issues,” she said. “It

is very hard to get that kind of service in a network of doctors.”

For more information, contact Michael Kapsa at

[email protected] or David Russell at

[email protected].

MEMBERS DON’T GROW ON TREES

Department: 2 North-South Medical-Surgical units, San Diego

Value Compass: Affordability, Best Place to Work

Problem: High number of injuries from turning patients. In 2009, the combined department

saw 16 patient-handling injuries; in 2008, that number was 18.

Metric: Patient-handling injuries

Labor co-leads: Tess Patiag-Limcuando, RN, UNAC/UHCP, and Jennifer Flores, RN,

UNAC/UHCP

Management co-lead: Erlinda Aquino, RN, nurse manager

Small tests of change:

• Regular safety observations. All staff members underwent safety observation

training and are required to conduct three safety observations per week on teams turning

patients. Previously, only charge nurses and managers conducted the observations.

Having everyone conduct regular observations expanded the number of observations—

one month, the team recorded 500 observations. The frequency of the observations keeps

proper patient-handling techniques constantly at the forefront of team members’ minds.

• Checklist. The UBT adapted a checklist of key things that should be done when turning

a patient, such as ensuring a patient’s bed rails have been lowered. Turn-team captains

refer to this checklist at every patient turning.

• Set and celebrate small goals. As a way to motivate and encourage staff members

to maintain safe patient-handling techniques, the UBT set small, attainable goals the

department could celebrate. The team had a pizza party when it reached the first

100 days without an injury, then again after accruing no injuries for the month of July,

which historically has been the units’ highest injury month. The next big celebration

will come when the team reaches 365 days without an injury.

Result: 327 days without a patient-handling injury as of mid-November

Download the team's checklists—one for safety observers, one for turn team captains—

by visiting LMPartnership.org/snapshots/san-diego-team-halts-injuries-vigilant-observation

Biggest challenge: “Making sure you communicate—and with some degree of consistency—

to everyone,” Aquino says. “And hard-wiring it so people understand it’s not just the flavor

of the month.”

Getting buy-in from staff members so it didn’t feel like they were being asked to do another

thing on top of their regular workload was another challenge.

Side benefits: Because patients are turned regularly every other hour, the incidences of

pressure ulcers also have dropped. Neither unit has had a patient with a hospital-acquired

pressure ulcer in three months as of mid-November.

For more information, contact manager Erlinda C. Aquino, RN, at (619) 528-5976 or

[email protected].

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.

San Diego team halts injuries with vigilant observation

SHARE YOUR BEST PRACTICE

Has your team successfully used the

PDSA steps to improve service, quality

or affordability? Email Hank about it at

[email protected].

Diversity by the numbers

KP members speak more than 80 different

languages.

In Southern California, 24 percent of KP’s

members are Latino and 12 percent are

African Americans.

In Georgia, 37.8 percent of members are

African American.

In Hawaii, 33 percent of members are Asian

and 21 percent are Hawaiian.

Ethnic minorities comprise 42 percent of KP’s

non-physician workforce.

Of the 10 Permanente Medical Groups, one is

led by an Asian-American woman and one is

led by an African-American man.

KP has twice as many Asian physicians as the

national average.

Female doctors make up 32 percent of KP

physicians, exceeding the national average by

10 percent.

‘It led us to think about why they were so committed to Kaiser.’—Barbara Caress, director of Strategic Policy and Planning, Local 32BJ


From the Desk of henrietta: Talk abouT failure!


One could spend hours and hours digging up quotes about taking risks and having the courage

to make mistakes. There’s the inspirational, the poetic, the simple, the blunt. Whichever idiom

speaks to you, the really good quote will articulate one basic principle—don’t be afraid to fail.

But I’d amend it to say, “Don’t be afraid to fail, and don’t be afraid to talk about that failure.”

When it comes to improving performance and providing the best care we can, I think all of

us at Kaiser Permanente could embrace the idea of an ongoing post-mortem, if you will.

OK, before the naysayers reach for their gavels and megaphones, hear me out. I’m not

suggesting that KP workers haphazardly hit the high wire of change sans netting, preparation

or proper tools. That would be reckless, not bold.

Instead, I’m suggesting, like many leaders and thinkers out there, that we should not

be afraid to take smart, well-reasoned risks in our performance improvement work.

And equally important, we should actively fight the urge to brush under the rug all evidence

of those well-reasoned risks that didn’t work out. Making mistakes is one of the best

ways we learn, after all—and especially when we’re working in teams, we can’t learn from

mistakes, or learn from others, if people aren’t willing to talk about what didn’t work.

I should know. Not just because I’ve read the papers by some of the best thinkers on orga-

nizational learning, who have found that greater learning and innovation occur in open work

environments that encourage experimentation and learning by trial and error. No, this risk-averse

girl gained this knowledge (and continues to realize it) the hard way, through lots of practice.

As a cub reporter, I was lucky enough to experience many failed attempts with various stories.

(And, more seasoned now—I still am.) Every time a story was rewritten, the blow to my ego was

as mortifying as if someone had dumped cake batter over my head and I was forced to walk

around the newsroom leaving a trail of dripping batter.

But I got over it pretty quickly. For one thing, there was simply no time to wallow in self-pity

on a daily deadline. For another, the dialogue I had with editors nearly always felt like a

collaboration, not a reprimand for a failed attempt. That environment let me appreciate the

valuable lessons I was learning with every edit.

The health care workforce, like those in other high-stakes industries, is trained in the pursuit of

excellence; mistakes often are treated like a cancer, to be avoided at all costs. But the inspiring

Barbara Grimm, senior vice president of the Office of Labor Management Partnership,

puts mistakes in a different light.

The trick, she says, is learning how to find a balance between the pursuit of excellence and

the pursuit of reasoned risk-taking—and to talk about “tests of change” that flop.

In the “What can leaders do? Be a good model” story in this issue of Hank, Grimm recalls

an episode from earlier in her career where she made a mistake and publicly acknowledged

and apologized for it.

Despite the risk of post-traumatic flashback, Grimm believes strongly in taking measured

risks and in being willing to openly discuss those risks that end in error.

Talking about it, she says, “reinforces that it’s OK to make a mistake if it was reasoned.”

In other words, if a person or a team thinks through the possible consequences of a

particular action and, before proceeding, takes steps to avoid any serious side effects and

prevent harm—then it’s all right if it doesn’t turn out as expected. The “failure” provides

valuable information that can help get it right in the end.

I think the regular discussions with my editors over what worked or didn’t work in a story—

and why—is the sort of open dialogue Grimm is advocating. I know it made it easier for me

to take risks and try new approaches, which, over time, improved my writing. My editors

provided a safety net: If my poetic take on traffic-snarling road construction didn’t work

for some reason, there was an opportunity to fix it before it was unveiled to thousands of

readers. And since I’d always put some thought into the attempt, it was rarely a total bust.

There was always something salvageable.

In the same way, I think unit-based teams and their sponsors create a safe haven to

provide feedback, varying perspectives and a sounding board for proposed small tests.

In the process of such dialogue, the team minimizes the risk as much as is possible.

Of course, going out on a limb—even a well-supported one—is still scary when you’re

facing a looming deadline, or, say, when your goal is to deliver the best care possible to

thousands of KP members. But it is always far more exhilarating, and I dare say,

more instructive, and in the end—brings the best results.

And you don’t need a quote to tell you that.


Back at the labIn San Diego, Larson thinks even if the tests of change didn’t work exactly as planned,

it gave the team something even more important—the beginning of a different work culture.

“Being able to work on small tests of change enabled us to get past what’s always been,”

Larson says. “There are people who have been here longer than I’ve been alive and so are

accustomed to the way it was always done. But trying something new can save us time,

and save the company money, and can be better for the patient. So I found it nice to look

at it like, ‘Let’s try just this little thing and it might just make it better.’”

Larson is certain the eventual reward will outweigh any frustrations in wrong hypotheses

or failed tests.

“Either you find you can fix something or you can’t, and you just move on,” Larson says.

“Just keep trying. Because ultimately, it’s going to be a success in the end.”

For more information about the teams featured in this article, contact: Jessica Larson,

tech assistant and labor co-lead at San Diego Nuclear Medicine, (619) 528-6524 or

[email protected]; Isabel Uibel, manager of Redwood City Gastroenterology,

(650) 299-2274 or [email protected]; Olivia Wright, management co-lead of Internal

Medicine, East Denver Medical Office, (303) 360-1508 or [email protected].


‘Never let the fear of striking out get in your way.’ —BABE RUTH


physiCians on PartnershiPFrom the Desk of henrietta: Talk abouT failure!

11 Hank Winter 2011 | No. 26www.lmpartnErship.org

When Kaiser Permanente researchers determined hip fractures could be reduced by 37 percent through proactive measures, the chief of Orthopedic Surgery, Podiatry and Sports Medicine at the Fremont Medical Center went straight to his department’s unit-based team.

It was a good move: As of August 2010,

the department had increased osteoporosis

screenings for at-risk patients to a stunning

71 percent, from less than 20 percent the

year before, becoming one of the highest

performers in Northern California.

When he approached the team, recalls

Eric Cain, MD, “we talked about the benefits

and the steps involved (to increase

screenings). We worked out the details,

the processes and the competencies—

and we agreed to do it.”

Teamwork, says Dr. Cain, is as critical in the

medical office as it is in the operating room.

NO MORE ‘I TELL, YOU DO’

“In a traditional office, the role of the

physician was, ‘I tell, you do.’ In today’s

world, where the focus is on providing

patient-centered care, it’s critically important

that everyone in the department have a

voice,” he says. “That may be uncomfortable

for some doctors—they don’t want to be

seen as weak. But being open to new ideas

is a much better place to be.”

The department’s unit-based team

members—and its patients—have benefited

from Dr. Cain’s open-mindedness.

“They know they can come to me with

anything, and that if a patient shows up

without an appointment, I’m happy to see

them,” he says.

And it’s a two-way street, he notes:

“We are mutually accountable. If I’m going

to be late, I let them know. If they come to

me with a problem, I’ll challenge them to be

the problem solvers rather than being the

only one solving problems.”

Collaborating with the department’s

unit-based team has been key to improving

patient care, Dr. Cain says.

“Whenever I have an idea, I take it to them

and we discuss it,” he says. “There’s an

openness, a two-way dialogue, and that’s

critical, because often the best solutions

come from the frontline staff.”

Working in partnership not only improves

morale but also patient care, Dr. Cain

says. “When your approach is patient-

centered, you need to have a team

of people providing patient care.

And it has to be driven by passion and

an almost religious fervor. Ultimately,

you have to ask yourself, ‘How would

I like to be treated? How do I want my

family members to be treated?’ ”

BETTER PATIENT CARE

The department was operating as a team

when Dr. Cain joined Kaiser Permanente

in 2002. Forming a unit-based team was

a natural progression that formalized

the department’s existing team-oriented

approach to patient care.

Particularly because he’s experienced

better patient care as one of the benefits

of partnership, Dr. Cain encourages

fellow physicians to work within their

unit-based teams.

“It’s absolutely critical that the staff is

empowered to speak up,” he says. “It’s a

change of focus for many docs, but they

can learn a lot….Unit-based teams are a

good way of working together. It’s a good

way of doing business. It’s good for the

patients and it’s good for the employees.”

Teamwork works, says this Northern California physician

71%>20%

OSTEOPOROSIS SCREENING RATES

FREMONT MEDICAL CENTER

AuGuST 2009 | AuGuST 2010

‘ There’s an openness, a two-way dialogue, and that’s critical, because often the best solutions come from the frontline staff.’

— Eric Cain, MD, chief of Orthopedic Surgery, Fremont Medical Center

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It Pays to Have Goals2011 Performance Sharing Program

What’s good for our patients is good for Kaiser Permanente. And what’s good for Kaiser Permanente is good for all of us.

The needle won’t move itself. Here are some things you can do to help reach our PSP goals:

• Understand your department’s PSP goals and how your current performance compares with the targets.

• Work with your unit-based team to develop ways to meet and exceed your PSP goals.

• Check out LMPartnership.org and UBT Tracker to see what other teams have done and get inspired by their ideas.

How does PSP work?

The program is simple: The union and management leaders in each region jointly identify goals and targets for the year in such areas as workplace safety, attendance and service. If the region meets certain economic goals and the facility meets or exceeds the PSP targets, employees at that facility who are represented by partnership unions get cash bonuses.

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