Culture

1933-1945: ‘There is no such thing as labor relations’

The health care program now known as Kaiser Permanente began in the Mojave Desert when Dr. Sidney Garfield, fresh out of medical school, opened a clinic for 5,000 Colorado River Aqueduct workers in 1933. Dr. Garfield soon found his practice foundering because insurance companies were sending the most serious—and most profitable—cases to Los Angeles hospitals. He developed a prepaid plan with a focus on safety and illness prevention, and it worked. The hallmarks of what would become the Kaiser Permanente Health Plan—prepayment, prevention and group practice—were forged here, but it would be 12 years before members of the public could join.

In 1938, Henry J. Kaiser and his son Edgar persuaded Dr. Garfield to create a similar medical program for workers building the Grand Coulee Dam in Washington.

The resulting industrial health plan was so popular, the unions insisted dam workers’ families be included. That feature carried over when Dr. Garfield built the largest civilian medical care program on the World War II home front, covering almost 200,000 Kaiser workers in California, Oregon and Washington.

With the traditional labor pool—young, healthy white males—serving in the military, thousands of African Americans and other people of color migrated to the shipyards, securing good union jobs after the long hurt of the Great Depression. Women came out in force, too. The Permanente Foundation Health Plan, both the on-the-job care and the broad coverage of the 50-cent-a-week supplemental plan, was extremely successful.

For the first time in their lives, ordinary people could count on affordable medical care.
 

1946-1989: ‘If not for organized labor’

On July 21, 1945, with the war in Europe over and the shipyards beginning to close, the Permanente Foundation Health Plan opened to the general public. A year later, on Aug. 1, 1946, Dr. Garfield signed the Permanente Foundation’s first union contract, with the CIO-affiliated Nurses’ Guild. The contract, in a first for Alameda County hospitals, established a 40-hour workweek, down from 48 hours.

Key support for the Permanente health plan came from unions. Harry Bridges, president of the International Longshoremen and Warehousemen’s Union, was an early advocate. He defended the plan against attacks by professional medical associations, whose members called prepaid group practice unethical, and brought all 6,000 ILWU members on the West Coast into the plan. Almost 15,000 members of the Retail Clerks Union in Los Angeles, a large and prominent union led by Joe DeSilva, joined in 1951.

But by the mid-1960s, financial pressures began creating divisions. In 1966, registered nurses in Northern California, represented by the California Nurses Association, became the first nurses in the state to conduct a work action. Major strikes erupted in 1968 in both Northern and Southern California. The strife simmered, and in 1986, a seven-week strike by SEIU Local 250 had some 9,000 clerks, certified nursing assistants and technicians walking the picket line at 14 Kaiser Permanente facilities in California. The action didn’t prevent a two-tier wage restructuring plan, but there was one positive outcome: The first Joint Conference on Service Issues, a precursor to the Labor Management Partnership agreement.
 

I’ve had the privilege of working for Kaiser Permanente for more than 30 years, and it was clear to me from day one that there is something different about our organization and the people who work here.

We’re big, with more than 175,000 employees and 18,000 physicians who provide coverage and care for more than 10 million members. What makes us unique, though, is our mission—to provide high-quality and affordable health care and to improve the health of our members and the communities we serve—and the actions, behaviors and decisions we take to support our mission. We walk the talk.

Our success these past 70 years has been the result of a lot of tremendous work and effort, individually and collectively, by hundreds of thousands of people. Today, we are fortunate to have great people working in all parts of the organization who are well-informed, highly motivated and focused on fulfilling our mission. We have leaders at every level who are delivering better health for all.

Early in my career at Kaiser Permanente, I gained an appreciation for the important role labor has played throughout our history. In fact, labor plays a broader and very different role at Kaiser Permanente than it does in many companies across America. Part of the reason we have worked well with labor is that even when we’ve had disagreements, unions have demonstrated a lasting interest in the success of Kaiser Permanente and the employees they represent, especially during challenging times.

I also have a personal appreciation for the role of labor in our society. My father belonged to a carpenters union. Unions were a voice advocating for the American dream for my family—saying my father should get work, he should be fairly paid, he should be treated right. My father had the jobs he had and the job protection he had because of the unions stepping up and speaking out.

At Kaiser Permanente, we place a tremendous value on creating and maintaining an environment where people not only feel comfortable speaking out but are encouraged to do so—and the Labor Management Partnership unions are actively supporting this culture. We want everyone in this organization sharing their best thinking every day, so we can create the best experiences for our members and patients, no matter where, when or how they come in contact with Kaiser Permanente—which is the essence of One KP.

As we look to the future, we need to continue to bring our best thinking forward during a time of dramatic change in health care. We need to have the mindset that we are going to embrace this change and lead the industry in charting the course for 21st century health in this country, so we can carry on the legacy of Kaiser Permanente for many years to come.

Elizabeth Rollice, RN, always knew that the Intensive Care Unit at the Woodland Hills Medical Center in Southern California was a great place to work.

As a staff nurse there, she and her co-workers enjoy good teamwork and excellent communication, and they deliver high-quality care to the sickest patients.

Now they have proof of their success.

This spring, the unit received the Gold Beacon Award for Excellence from the American Association of Critical-Care Nurses, the world’s largest specialty nursing organization. The award recognizes hospital units that demonstrate exceptional care through improved outcomes and greater overall patient satisfaction.

The team will be honored at the National Teaching Institute & Critical Care Exposition in San Diego, May 18-21.

“I knew that we did a good job and that everyone worked well together,” says Rollice, a member of UNAC/UHCP and a representative on the department’s unit-based team. “This award validates the quality of our work and tells us, ‘Yes, we are doing a pretty good job.’ ”

What’s best for the patient

Superb communication and a culture of collaboration among all members of the care team are key to the team’s success, enabling the consistent practice of evidenced-based medicine that has improved the quality of care.

Daily multidisciplinary rounds, for example, involve everyone on the care team who touches the patient.

“It’s about working in partnership with physicians, nurses and other staff to deliver high-quality care based on the newest evidence,” said Lynne Scott, RN, a clinical nurse specialist for the Critical Care and the Definitive Observation Unit. “We’re constantly moving forward.”

Nurses say team rounding gives them an opportunity to speak up and influence care decisions that affect their patients.

“We’re able to talk together about what’s best for the patient,” said Erica Bruce, RN, a UNAC/UHCP member who is the team's union co-lead. “If I feel that something is inappropriate, then I get a chance to ask the doctor. Family members get to ask questions about their concerns, too.”

Multidisciplinary rounding has produced an unintended benefit—higher member satisfaction. “I started in the ICU in 2002. We didn’t have a big rounding team at the time. Families sometimes felt unsupported,” recalls Paramjeet Dhanoa, RN, a staff nurse and UNAC/UHCP member. “Now that we have a big team, our families are more satisfied, because they feel they are not alone in making decisions. They are more comfortable.”

Open communication

Communication is vital in a department where staff members work around the clock in rotating shifts. To ensure information is consistently shared from shift to shift, the team:

• practices Nurse Knowledge Exchange Plus (NKE Plus)
• holds monthly UBT meetings, with members of the representative team responsible for sharing information with individual staff members
• holds quarterly staff meetings; those who miss the meeting must review the staff meeting binder and sign a form indicating they’ve read it
• uses a bulletin board to post important news and activities

The bulletin board, sandwiched between the nurses’ station and the staff restroom, attracts passersby with colorful fliers and posters.

“Your eyes are drawn to that communication board,” Rollice says. “You pass by a wall full of fliers, notes and postings, you can’t help but stop and look. It’s in a prime location.”

Conducted at the patient’s bedside, NKE Plus provides nurses with a template for patient safety and communication.

“It helps promote open communication and it helps us understand what’s going on with the patient,” says Judy Stone, RN, a staff nurse and UNAC/UHCP member, of the structured, in-depth, face-to-face handoff between the outgoing and the incoming nurse.

Stone says an additional itemized checklist “forces us, as nurses, to have all the pieces of the puzzle ready in the morning for multidisciplinary rounding. It really focuses us on everything that is going on with the patient so that we can deliver the best care that we possibly can.”

Clinical successes

Building the culture of collaboration and openness has had a big payoff:

• No ICU patient has contracted VAP since the first quarter of 2011.
• There have been no central line-associated bloodstream infections since the fourth quarter of 2011.
• The unit achieved the 86th percentile on the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) patient satisfaction survey from January 2013 through August 2014.

“To consistently deliver the best patient outcomes, you must have the processes and structures in place,” says Kareem Younes, RN, nursing project coordinator for Woodland Hills. “It’s about doing the right thing at the right time, every time.”

Our Value Compass puts the patient at the center. But—which patient do we mean?

If you are, say, a registered nurse on a telemetry unit, do you mean just your specific patient? Or all the patients in your department? Or at your whole facility? In your region?

What would happen if you took the One KP strategy to heart and considered every patient at every Kaiser Permanente facility your patient?

In this issue of Hank, you’ll find ways to do just that. How? By sharing your own department’s successful practices—and by learning from your colleagues’ triumphs in improving care.

Let’s face it: As at every large organization, there are silos and turf at KP, with attendant rivalries among departments, facilities and regions. That sense of competition on everything from service scores to attendance to membership growth can make it seem like quality is a zero-sum game—that my improvement must come at your expense.

As at other institutions, there’s also a bias against anything “not invented here.” How many times have you heard, “But that won’t work here. We’re—different.” Really? Is the birth of a baby so different in Oakland than in Portland? Is filling a prescription for statins so different in Atlanta than in Denver? Or could the same approaches to improving service and quality work regardless of location?

As an antidote to “not invented here,” try “proudly found elsewhere.” Open your mind, eyes, heart and—yes—ego to improvements from outside your home base. When you view every KP patient as yours, you won’t hesitate to spread what you’ve learned to others and to learn from them in turn.