For more than a year, the service scores at the Moreno Valley Optometry department zigged and zagged in no discernable pattern. Asked whether receptionists were helpful and courteous, 100 percent of patients answering the Ambulatory Service Questionnaire gave the highest score one month.

But two months later, only 78 percent of respondents were that enthusiastic. Two months after that, scores were back up into the 90s. The huge swings were discovered in May 2011 by Stephanie Valencia, the department’s new manager, who excavated two years’ worth of data.

“We had never looked at it before,” she says. “There was no trend. The scores were inconsistent.” Worse, says Valencia, the feedback from the most recent months was headed “on a downhill streak.”

Working with labor co-lead Gina Hitt, an optician and a member of Teamsters Local 166, Valencia and the unit-based team gathered information and set a baseline. For two days in September, the medical assistants asked all patients whether they found the receptionists to be helpful and then tallied the results.

The team used these to measure the effectiveness of a rapid string of small tests of change. These included adding a smile, positive tone of voice and eye contact on successive days. Each of those days, Hitt and her colleagues asked patients whether their receptionist was courteous and helpful. With each successive effort, the chorus of “yes” got louder and more effusive.

The act of simply examining the service scores seemed to set the team on an upward trajectory: The April 2011 score of 79.55 percent jumped to 89.09 percent in September and then 92.73 percent in October.

 “It is so neat to see how involved people are,” Valencia says. “Everyone is in sync.”

So, that’s a happily-ever-after story, right? Once upon a time, there was an optometry team in Southern California that never looked at its service scores. Suddenly, team members learned their scores were inconsistent and heading in the wrong direction. They focused on key data and tried out small tests of change. Their new practices boosted the score. Everyone lived happily ever after.

This happens every day with every UBT throughout all of Kaiser Permanente.

Right?

Maybe not.

Some UBTs are adept at using data to guide their attempts to improve performance, whether it be raising service scores, reducing infections, creating a safer workplace or boosting attendance. But for others, fear and anxiety about data and numbers are a significant obstacle on teams’ path to high performance.

In order to qualify as a Level 4 team on the Path to Performance, the team has to collect its own data and review it to see whether changes are helping improve performance. To ascend to Level 5, teams must be measuring their progress using annotated run charts.

But what if you break out in a cold sweat and experience shortness of breath at the sight of anything vaguely resembling math or numbers? Do you simply resign yourself (and your team) to being roadkill on the Path to Performance?

No. Read on.

1) Realize you are plenty smart enough.  

Kaiser Permanente, like all large health care organizations, collects and stores vast amounts of data in a variety of complex databases and websites. It employs people with a huge variation in their knowledge of and comfort with data. Just because you’re not at ease with numbers now doesn’t mean you never can be.

Even Bob Lloyd, the executive director of performance improvement at the Institute for Healthcare Improvement, an independent nonprofit in Massachusetts, jokingly refers to statistics as “sadistics.”

Luckily, the data you will need to turbocharge your team’s efforts to improve performance is probably a lot less complex than you fear.

 “It’s not really ‘math’ with formulas, statistics and calculations,” says Michael Mertens, a Kaiser Permanente performance improvement mentor in Southern California. “It’s mostly about before and after, addition and subtraction.”

2) Whether you acknowledge it or not, you collect data every day.  

 “My role in the tests of change has been soliciting feedback from the patients,” says Hitt, the Moreno Valley optician. She didn’t need a computer program or spreadsheet. A piece of paper and pencil did the trick. 

 “We are all data collectors,” proclaims Stacy Dietz, the UBT consultant for regional operations in Southern California. “And every day, we alter our behavior based on data.” For instance, we ask, “What is the temperature outside?” Then we decide whether to wear a wool turtleneck or tank top. We ask, “What is the length of my commute?” Then we decide whether it makes more sense to drive or take the train.

If you can collect and analyze data to determine your wardrobe, you can also do it to improve the performance of your team.

3) Before diving into the numbers, focus on the “why.”

As the new Kaiser Permanente ads challenge viewers, “Find your motivation.” For unit-based teams, the Value Compass offers a handy cheat sheet on motivation: The patient is at the center. Every data point on every chart represents the impact—positive or negative—that a Kaiser Permanente team had on a patient.

IHI’s Bob Lloyd explains there are three distinct reasons in health care for collecting and examining data:

• For research, such as KP’s recent study that found women in their late 60s who break a bone are five times more likely to die within a year than women that age who do not break a bone.
• For judgment, a category that would include the federal government’s recent rankings of Medicare insurance plans on quality and service (several KP plans got five out of five stars). This category also includes scores that determine whether or not a medical center or department earns its Performance Sharing Program (PSP) bonus.
• For improvement.

This last is the reason UBTs should be collecting and examining data.

 “The purpose of measurement in quality improvement work is for learning, not judgment,” Lloyd says. 

Data answers questions like, “How are we doing right now?” “Over time, are we getting better? Or getting worse?” “Is our small test of change making a difference? Or not?” In the absence of data, we have a tendency to fall back on relying on guesses, gut instinct, anecdotes—and to blame or give credit to specific individuals, justifiably or not.

 “You need data. Otherwise, you don’t have any solid information,” Hitt says. “You just have word of mouth.”

4) Only gather the data you actually need.

The holy grail of data for UBTs is the run chart. Don’t let the name throw you. It’s simply a chart that tracks some number (say, a service score, or number of last-minute sick calls) over time (day, week, month, quarter).

 “The most crucial question to ask is, ‘What are the few, vital pieces of information that are important?’ ” says Dennis Benton, executive director of the Panorama City Medical Center in Southern California. Any graph or data set that requires its intended audience to get special training to read is probably too complex for the task at hand, he says.

 “You can do a quick, just-in-time training at a UBT meeting,” says Benton. “We do it in leadership rounds. I point to the graphs and talk about them.” 

Run charts make it clear at a glance how your team's tests of change are working. Use this tool to walk through how to make one.

4 1/2) But, get the data often enough to support your improvement efforts.

For most teams’ small tests of change, data that can be collected daily, weekly or—at most—monthly will be most useful. Waiting for quarterly reports is generally not going to cut it. The Moreno Valley Optometry department did not wait for the Ambulatory Service Questionnaire results—which are posted monthly—to come in. It’s called the Rapid Improvement Model, folks. Not the Slow-as-Molasses Improvement Model.

Bottom line: The data should be useful for the team and be determined by the team.

5) Think art class, not math class.

 “I hate numbers,” admits Jenny Yang, a receptionist at the Moreno Valley Optometry department and a member of the UBT’s representative group. When the notion of using service scores to guide improvement first came up, Yang says she told her teammates, “I’m not going to do it. Make someone else do it.”

To help others like Yang, Benton says, when it comes to data, “Make a picture out of it. I am a big believer in graphs. With a graph, you can say, ‘We dipped here. What is the reason? What can we do about it?’ You can look at a trend relative to the goal.”

 “Graphs are visual,” Valencia adds. UBT members have a variety of learning styles and preferences: “Everyone learns differently.”  

And think in terms of moving video, not still photographs that capture single moments in time. IHI’s Lloyd asks, would nurses measure an ICU patient’s vital signs only when the patient arrived and when she left the unit? Or would they monitor vitals constantly via a telemetry machine? The second option is better, so caregivers can intervene in real time to help the patient’s recovery.  

6) You didn’t like art class? How about creative writing?

Numbers can tell a story. “There is narrative in data,” says Nancy Duarte, the author of “Slide:ology” and “Resonate,” two popular books about how to give compelling and memorable presentations. “What makes the numbers go up and down? How big are the numbers? How do the numbers contrast with other information?”

Yang agrees. Graphs with data “give you key points, high points and low points and trends,” she says. As a member of the representative UBT, Yang—a member of Steelworkers Local 7600—sees herself as a storyteller: “My audience is the UBT. The graphs help UBT members make sense of everything.”

Hey, if you liked math class, more power to you. “I love math,” says Hitt. “I am a number cruncher. But for me, charts and graphs? Not so much.”

7) It’s OK to ask for help.

So that graph you pored over in your UBT meeting is still making you break out into a cold sweat?

 “It’s OK to find a safe place to say, ‘I don’t get this,’ ” says UBT consultant Stacy Dietz. That might not be in a big group, but it could be one on one with a trusted peer.

Mertens, the Southern California performance improvement mentor, says the best way to learn to use data is to try it out. At the request of Susie Bulf, a UBT consultant, Mertens led a training for UBT co-leads in Fontana on how to create a run chart. He led an in-class exercise using sample data—and then another exercise where each team used its own data.

 “You get over the anxiety by doing it the first time,” Mertens says.

Each KP region boasts a roster of experienced performance improvement mentors. In addition, most UBT consultants have had some training in performance improvement strategies.

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.

NIGHT OWLS IN THE LAB

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.

Building resentments

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.”

COOKING UP CAMARADERIE

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.

From OK to great

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.”

A SWEEPING SUCCESS

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 time matters

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.”