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Many of the several hundred health care workers who gathered at the Manhattan Beach Marriott on May 10 are used to working through the night—it goes with their jobs. But they aren’t used to waiting. By midnight, some were napping on the couches in the lobby. Others milled about in small groups, talking quietly. And some retired to their rooms and asked friends to call them if and when anything happened.

Finally, around 2 a.m., the news came: A subgroup had ironed out the final details. By 3 a.m., the hotel’s central ballroom was filled with cheering, hugging workers—and supervisors, middle managers and senior vice presidents. The 140 management and union negotiators who formed the Common Issues Committee (CIC) gave their unanimous thumbs-up to a new National Agreement that will guide the work of some 130,000 workers, managers and physicians in the nation’s largest private health system.

“It was like we had just won the World Series,” says Alan Kroll, director of the Clinical Contact Center in Colorado and a first-time member of the CIC. “We’d had our ups and downs as a team, but in the end, we all came through as a team. The energy and camaraderie was tremendous.”

R-E-S-P-E-C-T

“The energy of the room was not because we liked each other. It was because of the respect that partnership had brought,” says Ashwin Deo, an orthopedic technician in Sacramento and SEIU UHW member who served on the CIC.

The agreement, reached in the course of five three-day sessions from March to May, is the largest private-sector labor agreement negotiated in the United States this year. Like previous National Agreements, it covers not only wages and benefits but also goals related to service, quality, affordability, workforce and community health, and more. 

Yet how the CIC reached the agreement is even more remarkable than the agreement itself. Rather than engage in a power struggle, the negotiators used interest-based bargaining to solve problems. That process allowed it to focus on solutions to the biggest issue facing health care today—that it costs too much, and too few Americans can afford it—while maintaining Kaiser Permanente’s industry-leading wages and benefits.

Rather than chopping care or benefits to control costs, says John August, executive director of the Coalition of Kaiser Permanente Unions, the agreement “provides union members with the tools to tackle cost by improving care and efficiency. Improved care and efficiency, delivered by workers at the front line, are the key to extending quality care to every person in our country.”

“Our national bargaining is unique,” says Dennis Dabney, the senior vice president of National Labor Relations and the lead management negotiator. “There is not only a group of labor negotiators at the table, but a broad cross-section of our employees providing recommendations on how to better deliver high-quality, affordable care and ensure Kaiser Permanente is a great place to work well into the future.”

Moreover, the outcome is a testament to the interest-based approach to partnership, not just interest-based bargaining.

“As our facilitators told us, economic issues are tough to resolve in interest-based bargaining,” says Adam Nemer, care delivery finance officer in the Northwest and a member of the bargaining subgroup that focused on benefits. “In the end, we met both management and labor's key interests. But I suspect that was not just because of what happened at the benefits table. It was also the result of an open and honest dialogue on benefits between senior labor and management leaders over the past few years. It was about trust and transparency. In my view, we didn’t reach a solution just because of interest-based bargaining—but we couldn’t have gotten there without it.”

Revolutionary healthy workforce plan

As part of the solution to controlling costs, the agreement includes a revolutionary plan to create the healthiest workforce in the health care industry. Beginning in 2013, the agreement will reward the collective workforce achievement of reduced health risk factors, measured by body mass index (BMI), cholesterol levels, blood pressure levels, smoking rates and workplace injury rates.

“Unions and management agreed that health improvement is an essential strategy for reducing chronic conditions—one of the leading drivers of rising, unsustainable cost,” says SEIU UHW President Dave Regan. “This is a high-road, long-term strategy for the common good.”

Those involved in the process say it’s unlikely that the high road would have been taken had these been traditional, adversarial negotiations. As Joan Mah, an optometrist at San Rafael Medical Center in Northern California and a first-time observer representing her ESC-IFPTE Local 20 colleagues, put it: “Traditional bargaining is really about what I want and not about what is right….When you take the time to allow management and labor to surface their interests, it’s really looking for a global solution.”

“At times it was frustrating, but it was also interesting to see how the interest-based process led us to options we could work with,” says Jean Melnikoff, a senior director of human resources for Southern California, one of the management co-chairs of the workforce of the future subgroup.

Opening doors—and minds

Her sentiment was echoed by members of every subgroup. But that is not to say the process is easy.

“When things get difficult, you need to regroup and work your way through it,” says Arlene Peasnall, senior vice president of human resources in Southern California. “But you end up with better results and stronger relationships.”

“The people who’d done it before said, ‘It’s OK, it can be done,’” says orthopedic technician Deo. “Don’t be afraid of the tension in the room. Don’t be afraid of emotions, because that’s what gets creativity out….When labor and management are at the table, talking to each other as equals, and the ideas are valued equally—I think that opened a lot of doors. And minds, too.”

It's a simple set of five letters, but it can pay big dividends when you're interacting with patients.

Let's spell it out and communicate our best.

Acknowledge—The first letter of the AIDET acronym reminds each staff member or care provider along the patient’s path to acknowledge his or her presence. Making eye contact with a patient or giving the member a smile is all that’s needed.

Introduce—When you identify yourself by name, you change the patient’s visit from an anonymous interaction into a personalized experience.

Duration—A little information goes a long way. Letting patients know how long a visit is expected to take lets them know their time is valued. If a doctor is running late or the lab is behind, letting patients know about the delay and keeping them updated shows respect.

Explanation—Whose body is it? No one likes it when a caregiver starts doing something without telling a patient what they’re doing and why.

Thank you—The last step wraps up the visit by thanking the patient for coming in or for providing the information needed to provide them with excellent care.

Our bodies metabolize the excessive sugar in processed foods just as it processes alcohol and other toxins, causing damage to our liver and other organs.

Sugar makes us more likely to develop a variety of risk factors that lead to serious illness, while making us crave sweet even more.

In fact, sugar causes a cycle of addiction in the brain in much the same way as drugs and alcohol—and cigarettes. When it comes to addictiveness, nicotine takes the, um, cake.

Physicians at the University of California at San Francisco (UCSF), led by outspoken pediatric endocrinologist Robert Lustig, MD, published a paper in February in the journal Nature showing that like alcohol and tobacco, sugar is a toxic, addictive substance. They argue that it should, therefore, be closely regulated, with taxes, laws on where and to whom it can be advertised and age-restricted sales. The researchers said that increased global consumption of sugar is primarily responsible for a whole range of chronic diseases that are reaching epidemic levels around the world.

Is sugar—so pervasive in processed foods, soda and junk food in general—the new tobacco? Let’s see.                                    

It can kill you.

If Lustig and his colleagues—and many other independent researchers—are even half right, sugar and junk food have been responsible for millions of preventable deaths. According to journalist Eric Schlosser, author of “Fast Food Nation” and the children’s book “Chew on This,” poor diet and lack of exercise may soon surpass smoking as the No. 1 cause of preventable death.

People make huge amounts of money by selling it.

Remember how long the tobacco industry denied the link between tobacco, advertising, and lung cancer and heart disease? We are hearing the same protestations from the processed food industry today. Don’t buy it!

Schlosser, a keynote speaker at the 2012 Union Delegates Conference, recounts how McDonald’s was built. Founder Ray Kroc discovered that profits were higher when kids ate out with their parents. So he lured children in with lollipops. Later, he added a clown. Today, fast food chains hire child psychologists, hold focus groups for toddlers and put 5-year-olds in MRI machines to see which part of their brain is responsible for brand loyalty.

“Think about the profit margin in a soda,” Schlosser says. The raw materials are water, food coloring, sugar and a paper cup. Nutritional value: less than zero. Cost to produce: pennies. Now there’s a profit margin!

A few months ago, a patient walked from the outpatient clinic to the operating suites at San Francisco Medical Center. He had an infection in his knee that needed to be drained. Paul Preston, MD, was at work and evaluated the man. His condition wasn’t urgent, and he got a bed to wait in.

What happened next is a cautionary tale. The patient’s condition changed—quickly and unexpectedly.

Dr. Preston, who was in charge that day, had moved on and was artfully multitasking on several other matters.

A nurse popped around the corner and interrupted him.

“Dr. Preston, this guy is sick,” she said.

Rapidly changing situations are a part of life in hospitals and clinics. But how they are handled varies wildly, depending largely on whether there is a culture of psychological safety—one where employees can speak up freely and offer suggestions, raise concerns and point out mistakes without fear of negative personal consequences.

Despite volumes of findings linking psychologically unsafe work cultures with poor patient outcomes—up to and including death—the health care industry, including Kaiser Permanente, continues to struggle with creating the culture of open communication that is a key component of safety.

Fortunately, this nurse worked with a physician and in an environment where speaking up is welcomed.

“Boy, was she right,” Dr. Preston recalls. “The patient had become septic in the short time he was there. I was obviously preoccupied, but what she had to say was far more important.”

The need for culture change

Positive exchanges like the one that day don’t yet happen reliably enough.

“I think there is a culture of fear around speaking up,” says Doug Bonacum, KP’s vice president of quality, safety and resource management. “We have indication (of that) from People Pulse scores.” In the patient safety world, Bonacum says, it’s still too common to hear of events with adverse outcomes where someone knew something wasn’t right—but didn’t speak up.

Studies have shown that poor communication among surgical team members contributes to a significant increase in patient complications or death (up to four times as many adverse events). Poor communication is also to blame in more than 60 percent of medication errors nationwide.  

“If I had a magic wand and could change one thing about the health care culture and the way we work together in order to improve patient care, it would be around our ability to speak up and people's willingness to listen and act,” Bonacum says. “I think it’s mission critical for worker and patient safety.”

Unit-based teams, by addressing issues of status and power, instinctive fear of retaliation and more, are helping build a culture where people are able to speak up. Leaders play a critical role in that transformation by actively developing rapport with employees and/or explicitly admitting mistakes and “disavowing perfection.”

“The definition of leadership is creating the condition to allow your team to succeed,” says Dr. Preston, who is the physician safety educator for The Permanente Medical Group. He notes that in aviation, senior pilots are strongly encouraged to tell those working with them, “If you see anything wrong, please let me know as soon as possible.”

Building new habits

A modified version of that practice, a pre-surgery briefing, now takes place in most Kaiser Permanente operating rooms.

“We don’t really want to say in front of the patient, ‘Hey, if I screw up, let me know,’” Dr. Preston says. “So we go around and say our names and what we’re going to do, and it builds confidence.”

The briefing, he explains, “is a conversation to build the group’s knowledge of what they're supposed to be doing, what to expect and watch out for. It sets the expectation that everyone needs to speak up.”

Dr. Preston says holding a briefing is the single most important thing a surgical team can do for patient safety. And debriefing afterward is critical, too, he says: “It's a chance for teams to consolidate what they learn. . . and get more and more reliable.”  

Leaders—physicians, managers, union co-leads and stewards—should model the behavior of speaking up around errors. Creating a blame-free environment, Dr. Preston says, “involves the willingness of leaders to go first in displaying vulnerability. . . by talking about mistakes they made when they wish someone had spoken up.”

Structured conversations help

Putting in place mechanisms that encourage employees to speak up is another way to foster open communication around errors and performance improvement. Such systems also provide a forum where people learn how to express themselves clearly and non-emotionally—and help to reconnect them with the value and purpose of their work.

South San Francisco Radiology’s unit-based team, for example, has created a structured communication system where radiologic technologists are asked to speak up in the moment and “stop the line” when they encounter anything that deviates from the agreed-upon workflow or is a potential patient safety risk. Afterward, they fill out a brief report that captures the event. 

“We made it an obligation for people to speak up,” says radiologic technologist Donna Haynes, the department’s UBT union co-lead and a member of SEIU UHW. “We wanted to empower employees.”

Since implementing the program in April 2012, more than 250 Stop the Line forms have been submitted. As a result, the department has prevented a number of small events from reaching the patient—and has seen a 50 percent reduction of “significant events” from the previous year, incidents in which a patient is incorrectly irradiated, whether it be a wrong body part or a scan is repeated unnecessarily.

The Stop the Line forms are simple and easily accessed in work areas and radiation rooms. They’re not used for punitive purposes; they’re used to track workflow issues that then are addressed by the UBT.

“For us it was a big rush, really trying to empower people to take the time to do what’s right,” says Ann Allen, the medical center’s Radiology director. “Also having trust in the fact that ‘I can submit real data and it will actually implement change.’ ”

Continuous learning

Allen’s comment speaks to another huge benefit to creating an environment where people feel free to voice their ideas and concerns: It makes the difference between an organization that is continuously learning and improving performance and one that is stifling innovation and stagnating.

The link between higher-performing unit-based teams and the ability to speak up is clear.

The People Pulse survey has a set of 12 questions that get at a department’s culture and comprise the Work Unit Index. One typical question is, “In my department or work unit, I am encouraged to speak up about errors and mistakes.” In 2011, the survey found that departments where Work Unit Index scores were highest had better HCAHPs scores, more satisfied patients, fewer workplace injuries, lower absenteeism, and fewer hospital-acquired infections and pressure ulcers. Departments whose Work Unit Index scores were in the bottom quartile consistently had poorer performance in those same areas.

“High-performing teams are clear on the goal…and hold each other mutually accountable for outcomes,” Bonacum says. “That level of accountability to each other is what differentiates them and enables people to say something that lower-performing teams can’t and won’t.”

Once you get to a tipping point, Dr. Preston says, people will look out of place if they aren’t speaking up.

“There's no such thing as a perfect day,” Dr. Preston says. Even good surgeons make errors—routinely—and no system, he says, can eliminate human error entirely. “But the earlier the team can recognize what is called an ‘undesired state’ and trap it, the less severe it is. And this is a huge thing for labor and managers, because we’re all there (in the room). Everybody has eyes and ears. The person who’s engaged has a huge role.”

An open, supportive environment is one aspect of a workplace where workers can point out problems when they see them.

But to ensure the support doesn’t evaporate in the stress of a busy day, there needs to be more than the expectation that people will do the right thing. There needs to be a solid system in place that formalizes the commitment to speak up.

A Radiation Oncology team in Northern California knows this firsthand. From the time the South San Francisco Cancer Treatment Center opened in May 2009, its leaders worked to establish a culture that encouraged staff members to speak up when they saw something wrong and to provide input on process improvements. The center didn’t have a clear-cut mechanism for doing this, however; it was fostered through leaders’ encouragement and role modeling.

Then in 2010, a mistake was made—relatively small, but a HIPAA violation: A patient was accidentally given a printout with the personal information of another patient. The member returned the paper to the receptionist, and no lasting harm was done. But it highlighted the fact that staff members needed a way to record process failures, empowering them to address issues large and small, says Marcy A. Kaufman, the center’s Radiation Oncology administrator.

A protocol that calls for submitting a Responsible Report form was already in place for those times when an error reaches the patient. “But we wanted to create something where everyone can give input at all parts of the process,” Kaufman says.

Stop the Line

So the unit-based team created what its members call Stop the Line. If a radiation therapist or anyone else in the department encounters anything that deviates from the workflow or compromises care, he or she first acts to ensure patient safety, if such action is needed—and then fills out the Stop the Line form to document the incident. The focus is not on individual error but on what can be done to improve the system to prevent similar mistakes in the future.

“It’s a chance to look at the system to see if it is doing its job—are the checks and balances working? Or do we need to bring to the UBT and come up with a different workflow?” Kaufman says.

At monthly staff meetings, the team pulls out a binder with the Stop the Line reports and discusses the incidents and any follow-up actions taken. That discussion is important not only as a way to close the loop but also because it demonstrates to staff members that their voices were heard. The forms don’t drop into a black hole never to be heard of again.

“You have to constantly be talking about this to keep the momentum going,” Kaufman says.

The process applies to all staff, including physicians.

“In the field of medicine where, in general, it is quite hierarchical, it’s even more imperative we have a system like this to encourage every member of the department to speak up, regardless of title, to make sure we’re giving the best patient care,” says Amy Gillis, MD, the center’s chief of Radiation Oncology.

Dr. Gillis recalled the wrong-patient information episode. The initial assumption was that one of the medical assistants, who normally handle such paperwork, had made the mistake. This time, however, the culprit was a physician.

Staff members hesitated, Dr. Gillis says, wondering, “ ‘Should I really write up a physician?’ ” As she notes, however, “We all need to have a greater awareness.”

“It really does take everyone’s buy-in to make it happen and be successful,” she says. In this case, what it took to convince staff was input from the physicians themselves, with the doctors saying, “Yes, please write that up.”

Successful practice spreads

Stop the Line has been so popular that the cancer center’s four sister centers in Northern California have adopted the practice.

South San Francisco Radiology also adopted the Stop the Line form and process, adapting it to meet its specific needs. The department does hundreds of thousands of scans a year, from mammograms to basic X-rays to CT scans. With such high volume, radiologic technologists often feel pressure to keep patients moving through in a steady flow.

“We needed to give technicians permission to do the right thing,” says radiologic technologist Donna Hayes, the department’s UBT union co-lead and an SEIU UHW member. “We wanted them to know it’s OK to stop the process for this. I think it helped that it also came from management.”

As at the cancer center, the process is not used in a punitive way. Instead, it’s used as a way to highlight and address glitches in the workflow—not only within the department, but also in other departments.

“We’ve been able to take the data back to the orthopedics chief or take ED-related issues back to ED,” says Ann Allen, the Radiology director. “We funnel back to those departments that are partners so they can help us make changes.”

Fremont’s Operating Room team loved taking the first parts of Northern California’s business literacy training—so much so, it immediately requested the last two sessions, when teams pull out their budgets to review line-item expenses for the department. The review of payroll and non-payroll budgets has caused controversy and concern in some quarters, but the Fremont OR team not only took it in stride, it rode the momentum of the training by developing several performance improvement projects to reduce waste. One of those, streamlining its ready-made surgical supply packs, is projected to save roughly $34,000 a year. The Northern California training began rolling out in 2011. The first three sessions are a tutorial on the basics of Kaiser Permanente business, explaining such things as our integrated business model (how the various KP entities do business together), key sources of revenue, and business concepts like margin goals. The rubber meets the road in the final two sessions, with their look at the department’s financial realities. Team co-leads Yolanda Gho, Operating Room nurse manager, and Gus Garcia, a surgical technologist and SEIU UHW steward, talked with communications consultant Cassandra Braun about the training, its benefits and how it inspired their team to do better.

Q & A

Q. Were you concerned about sharing the department’s payroll and non-payroll budget with staff?

Gho: Not really. I thought, “Why don’t we highlight the areas where we have opportunities to improve, like sutures—ones we can improve on and have control over.” With payroll, my one concern was showing someone’s salary. But it was explained that they didn’t show individuals’ salaries. So I was totally on board.

Q. What was the staff’s reaction to the training?

Gho: The response was quite eye-opening. There was an audible gasp. When they saw [the red lines], they were like, “Oooh, I thought we were doing great. Why do we have all that red on the screen?” What’s great about this group is their minds immediately started running, thinking about what they could do.

Garcia: To me, it’s like: We can fix that, or come up with ideas (for fixing it). That is what melds it all together.

Q. Talk about your project to streamline surgical packs and how it was influenced by the business literacy training.

Garcia: Surgical packs have draping and supplies for each particular procedure. They’re ready-made. So you always had to add things or throw away things that you didn’t want, depending on the procedure. I was trying to see what we need or don’t need. I worked with the supplier and our teams, like general surgery, and I asked their opinion—“What do you need in this thing and what do you not need?” We streamlined the packs to have the bare minimum. So everyone uses everything in the pack.

Gho: After the training, Garcia wanted to revisit this issue, because he had brought this up before.

Garcia: The wheels were turning in my head. If we’re not using it, we’re wasting money.

Q. You also started work on reducing waste of sutures and other supplies?

Gho: Yeah, it was a culture change. In the past, as a nurse or tech, you were trained to always be ready. You were trained that the surgeons shouldn’t have to ask for something. Some people think that if they’re able to do that, they’re seen as efficient and anticipating the needs. But the world is different, the economy is different. Now we have to ask ourselves, “Do we need to have this open to look good or just in case a surgeon asks for it? Or is it OK not to open it, but to have it in the room and ready?” Before, we were all trained that way—anticipate, anticipate, anticipate. We now give ourselves a centering moment before we open sutures or supplies that are not needed immediately for a case.

Q. What advice would you give to other teams thinking about taking business literacy training?

Gho: My advice is to help educate your staff members by being transparent about information that affects them and the team. As a manager, I want to create awareness and understanding of the issues with my staff. It bridges the information and knowledge gap. The more we’re armed with information, the better decisions we make.

Garcia: If it was up to me, I’d have everyone take the class. I think it just gives you a different perspective. It breaks it down and gives you an overall view that staff members don’t get to see all the time. It keeps them informed.

Gho: People tend to complain about things but do nothing about it. In our UBT, you bring solutions. We’re doers. It’s our chance to do something.