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By working in partnership and leveraging the power of Kaiser Permanente's electronic health records, this eye care team at Redwood City Medical Center helps patients get the cancer screenings they need.
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This short video shows how a unit-based team at Kaiser Permanente's Capitol Hill Medical Center in Washington, D.C. is adjusting to a big jump in membership—and improving patient care at the same time.
In June 2015, Kaiser Permanente wrapped up the largest private-sector labor contract of the year—a tentative agreement covering 105,000 health care workers. More than 150 union and management representatives sat next to each other to hash out differences and shared interests through interest-based bargaining.
We believe our experience can serve as a model for other organizations and unions looking for new and better ways to do business—not just at the bargaining table but in the workplace, where we partner with a coalition of 28 local unions.
Our national agreements (this is our fifth since 2000) go well beyond the scope of traditional collective bargaining agreements. They cover not only wages, benefits and working conditions but also workforce and community health, workforce planning and development, performance improvement, and union and organizational growth. And we negotiate in a highly compressed time frame—in this case, just four, three-day rounds of formal bargaining.
The bargaining process and its outcomes have been transformative. Linda Gonzalez, who helped facilitate our first National Agreement and is now director of mediation services for the Federal Mediation and Conciliation Service, Southwest Region, noted how impactful the interest-based approach can be:
At the table, everyone has an equal right to speak and explain their interest. There’s more open dialogue and sharing of information. … It’s taken Kaiser and the unions a lot of hard work to get where they are. [But] to resolve difficult issues in partnership is a strength.
We have leveraged that strength in many ways over the years. Our Labor Management Partnership has met the goals set forth in our agreements since the beginning: to “improve the quality of health care, make Kaiser Permanente a better place to work, enhance Kaiser Permanente’s competitive performance, provide employees with employment and income security and expand Kaiser Permanente’s membership."
Our National Agreements commit us to operating principles that you won’t find in most labor contracts:
The parties believe people take pride in their contributions, care about their jobs and each other, want to be involved in decisions about their work and want to share in the success of their efforts. Market-leading organizational performance can only be achieved when everyone places an emphasis on benefiting all of Kaiser Permanente. ... Employees throughout the organization must have the opportunity to make decisions and take actions to improve performance and better address patient needs.
Interest-based bargaining doesn’t guarantee success. It works for us because our partnership works.
The partnership between Kaiser Permanente and the Union Coalition came about in 1997, in a challenging environment. The company had a long and close history with the labor movement. But amid growing market pressures and labor unrest in the 1980s and ’90s, we were at a crossroads. Most of the local unions representing KP workers formed the Coalition of Kaiser Permanente Unions to launch a unified corporate campaign.
Facing what would have been a mutually destructive strike, the leaders of both parties took a chance on an alternative approach. They agreed to:
Today it is the largest, longest-running and most comprehensive such partnership in the country. It covers 80 percent of our represented workforce and includes 43 local contracts, in addition to the national agreement. It has delivered industry-leading contracts, and helped Kaiser Permanente achieve industry-leading quality, solid growth and a culture of collaboration.
In short, our partnership is more than a labor relations strategy, it’s an operational strategy that provides strength and stability for Kaiser Permanente and our workforce, and better care and service for our members, patients and customers. It provides an infrastructure for continuous performance improvement and a way to better resolve difficult issues.
For example, during the Ebola crisis of 2014, health care providers and members of the public were concerned about how to best control spread of the disease. Kaiser Permanente, our union partners and the Centers for Disease Control and Prevention stepped back from the fear and misinformation that prevailed elsewhere. We worked together to develop training processes, educate people and agree on steps to ensure the safety and compensation of employees involved in caring for patients with the Ebola virus. Two of our hospitals were among the first in the United States to be recognized as part of the nation’s Ebola preparedness and response plan.
Day-to-day partnership is most evident in more than 3,400 unit-based teams—our term for the natural work groups that deliver care and service. Team members are trained in performance improvement techniques to spot opportunities, conduct small tests of change, assess results and implement solutions. They provide a new level of learning and decision making about the quality of their work and how to do it better.
UBTs are co-led by a union member and the manager or supervisor. In clinical settings they include physicians. We track the performance quarterly of every team, based on jointly set measures of performance, and we set aggressive goals for the number of teams to reach high performance, measured on a 5-point scale.
Seventy percent of them are rated high performing. That’s important because our data show that high-performing UBTs get better outcomes on service, quality, safety, attendance, patient satisfaction and employee satisfaction.
Amy Edmondson, Novartis Professor of Leadership and Management at Harvard Business School, has studied Kaiser Permanente’s model of teaming and offered this assessment:
Unit-based teams are a way to be entrepreneurial and a way to build greater accountability by those on the front line. The teams push people to brainstorm, to be attentive to what they see and to put their own experience to good use. The teams have the opportunity to identify challenges and they have tools and skills with which to work, but it’s up to them to put them to good use to make a difference for patients.
Our teams now have more than 7,700 frontline improvement and innovation projects under way. To align local team efforts with the organization’s broader strategic goals, all projects are focused on one or more points of the Kaiser Permanente Value Compass – a guidepost that shows our four shared goals of best quality, best service, most affordability and best place to work, with our patients and members at the center of all we do.
About 35 percent of these projects are focused on reducing waste or improving affordability. And 267 of those projects, produced joint savings of $10 million in 18 months; potential savings are much more. Twenty-eight percent of projects are focused on service enhancement. Here’s a snapshot of improvement projects conducted at each point of the Value Compass:
We know our strategy is having an impact on organizational performance and the workplace experience. Our 2014 employee survey showed strong correlations between several measures of employee engagement and job performance.
Departments that scored high on an index of 18 measures of workforce effectiveness (including things like taking pride in the organization, information sharing, understanding of goals and being held accountable for performance) reported significantly better results in service, quality, workplace safety and attendance. For instance:
In addition, members of high-performing unit-based teams are far more likely to say they have influence in decisions affecting work, are comfortable voicing opinions, and feel co-workers are respected despite differences.
Higher job satisfaction also contributes to significantly lower employee turnover. In California, for instance, our turnover rate for all hospital-based employees ranges from 6 percent to 8 percent, depending on the job type – versus the 2014 industry average of 9.4 percent statewide reported by the California Hospital Association.
Union Coalition members and Kaiser Permanente also collaborate on many issues rarely open to union participation. For instance:
Workforce planning and development: We invest heavily in workforce training and development – and we develop and implement most of that work jointly. For instance, a union-management Jobs of the Future Committee in Southern California is identifying emerging technology, assessing the impact on workers, managers and physicians, and developing training plans and career paths. More such efforts and investments are under way.
Market growth: Bringing together union members and Kaiser Permanente sales and marketing teams, our joint growth campaign helped win, expand, win back or retain 33 accounts covering 125,000 Kaiser Permanente members in 2014.
Our partnership is not perfect. It can stretch us to engage and educate our many stakeholders, and find time to solve problems and improve work processes in the course of day-to-day operations.
But in my experience, the biggest challenge is spreading innovation – facilitating the exchange of ideas and the adoption of successful practices from one team, medical center or region to another. We know that new initiatives can take root faster and more consistently if they’re modeled on a proven concept – especially when they are championed by our own work teams. Variation can be a plus when you’re looking for new and better ways to do things; when you’ve found the best way, you need to make it a work standard.
We recognize and spread success by communicating with teams regularly in multiple formats; through peer consultants and sponsors in every facility; a system-wide database that tracks teams’ tests of change and outcomes; and UBT Fairs, where teams share their findings in person.
Our Labor Management Partnership is now in its 18th year, and we are still learning how to take it further. We continue to believe it can be a model for labor relations and health care delivery. Four factors in particular are essential to success:
Our union and organizational leaders know how to do business in traditional, more adversarial labor relations settings. We’ve done it. We choose to work in partnership – not because it feels better (though it does) or because it’s easier (it’s not). We do it because it gets results – for the organization, the unions and workers, and the members, patients and communities we serve.
It’s time to look beyond labor relations and find new ways to innovate and engage teams. Our leaders took a risk 18 years ago to listen, understand and work together. It proved to be better way to deliver health care and achieve our social mission.
This article was originally published in “Perspectives on Work,” the magazine of the Labor and Employment Relations Association (LERA), Volume 19. Reprinted with permission. For more information, visit LERAweb.org.
Also see a PDF of the original article, with additional information about Kaiser Permanente and the Labor Management Partnership.
Format:
PDF (color or black and white)
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8.5" x 11"
Intended audience:
UBT members
Best used:
The 2015 National Agreement calls for every team to have a health and safety champion. This flier explains the role and encourages team members to volunteer. Share this flier at meetings and leave some in break rooms to encourage UBT members to volunteer to be your team's health and safety champion.
Format:
PDF
Size:
8.5" x 11"
Intended audience:
Frontline workers, managers and physicians
Best used:
Unlock key words and phrases that describe factors that affect member outcomes.
On a warm fall afternoon, nearly 35 children are bouncing off the walls as they get ready to leave the classroom and head out to their elementary school’s garden. They’re all members of an after-school garden club and cooking class called Edible Olympic. It’s the brainchild of Maria Peyer, an oncology nurse and team co-lead at the Longview Kelso Medical Office in Kaiser Permanente’s Northwest region and her husband, elementary school teacher Michael Bixby.
The kids can barely contain their excitement as Bixby tries to calm them down so they can listen to the afternoon’s agenda.
“The sooner you settle down and be quiet, the quicker I can finish what I need to say and you can get outside,” he implores the class.
Quickly, the hubbub settles. Bixby goes over what needs to be done: plant blueberry bushes, dig a hole for a tree, and remove bamboo sticks. He also reviews the Garden Guidelines, which include listening with respect, walking (no running) in the garden, and asking for permission before picking anything. Then he asks, “Whose garden is it?” and gets a resounding and loud, “Ours!” as everyone heads outside to get to work.
The students attend Olympic Elementary School in Longview, Washington. They don’t have many advantages: More than 20 percent of the city’s population is below the federal poverty line, and 90 percent of the school’s students participate in the free or reduced-price lunch program. Many experience food insecurity regularly, not knowing if they’ll have enough—or any—food to eat.
There are well-documented health disparities related to low income, and these kids are at risk. Edible Olympic is helping address that vulnerability, teaching the kids about healthy food and how to prepare it, laying the foundation for good eating habits that last a lifetime. It’s an example of how partnership principles expand naturally and necessarily into the community; the new 2015 National Agreement includes commitments to jointly work on improving the health of the communities we serve.
The Longview project grew out of a Kaiser Permanente adult cooking class recommended for oncology patients, one that focuses on a plant-based diet. Peyer says that after moving to Longview, she and her husband were struck by the limited resources available to the children in the community.
“We wanted to affect change as directly as possible,” says Peyer, an OFNHP/ONA member. “So we dove headfirst into Edible Olympic. We didn’t want to spend time in meetings, we just wanted to get in the dirt and the kitchen—and that’s what we did.”
She sought support from Thriving Schools, one of Kaiser Permanente’s Community Benefit programs. She forged partnerships with the school’s Parent-Teacher Organization and the Lower Columbia School Gardens, a nonprofit that helps schools create garden programs. Local stores donated money. High school students from Longview and Portland also are participating.
“The kids, their parents and the greater community have embraced the efforts and confirmed that our hunches were right,” Peyer says. “Good, healthy, real food, prepared simply, with love and in community, can be life transforming.”
Members of the Oncology unit-based team are supporting the project, too, donating money and time; four KP employees help staff the cooking class.
“Volunteering in the community gives us at KP a chance to share our skills and our approach to supporting good health,” says Elizabeth Engberg, the Northwest’s Thriving Schools program manager. “It also helps us learn about our members—where they live, work, learn and play, because that’s a huge part of what affects their health. Schools are the best place to do this.”
The program has had overwhelming and unexpected participation.
“The idea was that this project would launch with eight to 10 kids. We had 60 kids come to the information session,” Peyer says, which prompted an instant expansion from one to two sessions. The kids work in the garden on Thursday afternoons, and on Fridays, they walk across the field to the middle school, where they are able to use the home economics classroom for cooking class. The sessions run for five weeks and end with a celebration where the kids cook a complete meal and share with their friends and family.
The first session got under way last spring. A grassy patch of the school’s property was selected as the site for the garden, and the children got seeds started indoors. As weather allowed, the ground was prepared. While they waited for their seedlings to be ready to plant, the kids were introduced to kitchen safety and how to prepare the food they were just beginning to grow.
In the cooking class, kids have a healthy snack, then work in small groups to prepare the dish of the week. When the cooking is done, they gather together and enjoy their meal. The kids leave with a bag of groceries so they can cook the meal at home.
“In some cases, this may be the healthiest meal the family may eat during the week,” Peyer says.
On that fall day out in the garden, the kids in the second session organized quickly after studying the garden map Bixby brought along for reference. They divided themselves into groups and got to work with shovels, buckets and plants to complete the day’s activities.
One of the choices they faced was whether to extend the blueberries to the fence or stop a few feet in to allow for a foot path. Several kids piped up with ideas. The decision got made after 11-year-old Christian Aguibar offered his opinion.
“We can grow more things if we don’t have a walkway,” Christian said, “so let’s not have one.”
When teen members first visit the Burke Behavioral Health Center in Virginia, they are all asked the same intake questions, ranging from “What do you do for recreation?” to “Does your family have a history of violence?” Their answers help determine the best course of care.
Now, because of a unit-based team project to standardize care for transgender and gender-questioning members, teens ages 14 and older also are asked where they fall on the gender spectrum.
“We included this in the standard behavioral health assessment to normalize it instead of pathologize it,” says Sulaiha Mastan, Ph.D., a licensed clinical psychologist and UFCW Local 400 member. Mastan, who works exclusively with children and adolescents and has about 20 transgender teens in her care, says the information is important for treatment purposes.
For instance, a parent may say a child is depressed and is refusing to go to school. If that child is gender-questioning, gender-nonconforming or transgender, the underlying reason may have to do with changing clothes in the locker room or using the school restroom.
“If I have a teen who says, ‘I have a female body, but I am a male,’ then I am aware,” Mastan says.
The stakes are high: A 2011 study found that 41 percent of transgender or gender-nonconforming people have attempted suicide sometime in their lives, nearly nine times the national average.
In another change, the unit’s front desk employees now check the electronic medical record to learn each member’s preferred name and pronoun, respecting that a member may, for example, appear male but identify as female.
“At the front desk, we are the first impression,” says Anthony Frizzell, a mental health assistant and member of OPEIU Local 2. “It is imperative that we relate to the patient in the way the patient wishes.”
The UBT also standardized the steps it takes when members are interested in hormone treatments; started a support group on transgender issues for parents; and is developing a brochure that will guide transgender adolescents through receiving care at Kaiser Permanente.
The policies it created follow national and KP guidelines, says Sand Chang, Ph.D., a psychologist and gender specialist in the Multi-Specialty Transitions department in Oakland.
“Although it is not routinely done, this is really falling in line with best practice—to give young people an option,” Chang says.
The project earned the team the R.J. Erickson Diversity and Inclusion Achievement Award at Kaiser Permanente’s 38th National Diversity and Inclusion Conference in October.
The team’s initiatives send the message that wherever a person is on the gender spectrum, it is part of being human, says Ted Eytan, MD, medical director of KP’s Center for Total Health in Washington, D.C.
“What the team is doing is making it very normal,” Dr. Eytan says. “It is something about you that we need to know, rather than something that needs to be extinguished.”
Early in her nursing career, Yvonne Roddy-Sturm, now the chief nursing executive at Ontario Medical Center in Southern California, saw that caregiver diversity—or lack of it—matters.
“I saw differences in how some providers cared for people,” she says. “It wasn’t just based on race—economic status, language, lots of things came into play. We all make assumptions about others.”
The consequences of such assumptions are serious, impacting the quality of care a patient receives and leading to a wide range of health disparities.
In the 30 years Roddy-Sturm has been with Kaiser Permanente, our member and patient population has become more diverse—as has our workforce. And that’s helped KP deliver high-quality, patient-centered care.
“Patients who can relate to their caregiver are more likely to follow their treatment regimen,” says Roddy-Sturm. “They’re more likely to ask questions of people who are more like them.”
The Labor Management Partnership plays a significant role in building the skills, cultural competence and work environment needed to serve KP’s diverse patient population.
For example:
And there’s more. Many departments, including Ontario’s nursing department, make their diverse teams part of the hiring process.
“We always start with the skills required to do the job,” says Roddy-Sturm. “Then our panel members bring their own insights and diversity to the discussion. They look for fit, flexibility, compassion and empathy, as well as skill. We try to live our values.”
Research shows that patients fare better when they receive care in their preferred language and providers demonstrate sensitivity and respect for their cultural beliefs and values.
Frontline teams across Kaiser Permanente are doing just that, and nowhere is this more apparent than in California, where 85 percent of KP’s Latino members live. The Northern and Southern California regions have developed language assistance programs that help eliminate health disparities and personalize the care experience for patients, including:
“When we show respect for our patients’ cultures and values, we are more likely to provide better care, because they trust us and are more likely to follow through on the instructions we give them,” says Andrea Rudominer, MD, senior physician for Pediatrics and chief of diversity for the San Jose Medical Center. “Culturally competent care leads to better health outcomes for all of our patients.”
Brandon Johnson was close to giving up on his dream of becoming an X-ray technician.
Born with sickle cell disease, a genetic blood disorder that primarily affects African-Americans, the 35-year-old Southern California man was forced to drop out of school for semesters at a time.
But thanks to the sickle cell care team at the Inglewood Medical Offices, Johnson is now on medication that reduces complications. Last fall, he was able to complete his studies, and he has started looking for a radiology job.
“They got me on a plan to keep me out of the hospital,” says Johnson, who drives 60 miles one way from his Riverside home to see his doctor in Inglewood, even though other providers are closer. “If I didn’t have my health, I wouldn’t be where I am today.”
Johnson’s success is not uncommon for the Level 5 unit-based team, a group of physicians, managers and employees that provides personalized care for nearly 500 sickle cell patients in Southern California. About 300 of the region’s adult patients are treated directly by the team. Its approach is working—only five of the 300 needed frequent hospitalization and emergency care in the past year.
“Our goal is to keep sickle cell patients out of the hospital by giving them the care they need,” says Pippa Stewart, Inglewood’s department administrator.
Nationwide, about 70,000 people have sickle cell disease, which can cause chronic anemia, acute pain, infections and stroke. Although most are African-American, the disease also affects people of Indian, Middle Eastern, Hispanic and Mediterranean heritage. Patients often get stigmatized as drug addicts when they ask for narcotics to deal with their pain.
The current UBT grew out of a team that was established in 1999; before that, there was no comprehensive treatment program for KP’s sickle cell patients.
“Ninety percent of patients were getting their primary care in the emergency room,” says Shirley Brown, RN, a UNAC/UHCP member and the team’s care manager. Patients saw as many as 17 doctors as they went from appointment to appointment.
Now, the 12-member UBT—which includes four physicians, two registered nurses, a physician assistant, a pharmacist and a social worker—helps patients control symptoms by offering pain management care, providing resources such as a case manager, and urging them to keep appointments, which help minimize visits to the emergency room and hospital.
Team members coordinate with and help train the KP providers who care for the region’s remaining 200 patients. Last fall, Brown helped lead a session for 70 registered nurses from around the region. Osbourne Blake, MD, an internist and the team’s lead physician, provides regular updates to fellow physicians. “We’re trying to get everyone on the same page,” says Dr. Blake. A recent test of change focused on reducing the number of patients who miss appointments. For three months, Brown and a co-worker called patients every day to remind them about upcoming visits. The calls helped. The team’s “no-show appointment” rate dropped from 20 percent in May 2015 to 14 percent in August 2015.
“They all know you personally,” says Ryan Hull, a 27-year-old TV production assistant and film student. A few short years ago, he suffered frequent crises that required immediate medical attention. After he and his physician co-created a pain management program, his health improved dramatically.
“They did everything they could to find out what regimen works for me,” Hull says of staff members, who greet him by first name and offer walk-in appointments to accommodate his sometimes unpredictable schedule. “They figured out the perfect way to treat me.”
For the past few years, unit-based teams have been driving a powerful transformation. It’s helping to control chronic diseases; assisting in the early detection of cancer; providing familiarity with a patient’s community; and enabling frontline employees to speak a patient’s language. It creates customized care for each of Kaiser Permanente’s more than 10 million members.
It isn’t a cool new gadget or something out of a sci-fi flick creating the change, but rather a modern care approach that takes into account the infinite number of ways KP members are unique—that emphasizes diversity and inclusion.
“All of us as individuals have all these different multicultural identities, and so do our patients,” says Ron Copeland, MD, senior vice president of National Diversity and Inclusion Strategy and Policy and chief diversity and inclusion officer. “We have to create high-performing teams that work together to deliver culturally responsive care that addresses those differences.”
Increasingly, the workers, managers and physicians working together in UBTs are considering the many facets of individual patients as they transform—in small and large ways—how they care for and serve those patients, using their knowledge and empathy to rethink how we deliver care.
As the stories in this issue of Hank illustrate, some of those changes are aimed at eliminating race- and gender-based health disparities. Other changes are taking place outside our medical facilities—working with school-age children, for example, to give them better food choices and teach them healthy habits that can last a lifetime.
By doing this, UBT members are ensuring that Kaiser Permanente members are the healthiest they can be no matter their background or beliefs, language or gender, disability or economic status, whether they live in a big city or on a farm.
“UBTs have always led on innovating care by putting patients at the center, listening to them and customizing care for them,” says Hal Ruddick, executive director of the Coalition of Kaiser Permanente Unions. “This work strengthens and deepens that high-quality care.” KP’s workforce is full of diversity, and UBTs are designed to draw on all employees’ perspectives in deciding how best to do the unit’s work. It’s a natural step to include our members’ and patients’ viewpoints as well. Understanding and considering the complexity of the patients and communities we serve directly affects quality of care and health outcomes.
“It’s about using our knowledge of differences as an advantage to better understand the patients we care for,” says Dr. Copeland. “Our goal is health care equity—so that all our patients achieve optimal health. For that to happen, it’s essential that we have approaches that account for our patients’ unique needs, preferences and living conditions.”
