About LMP

The July/August 2011 issue of the Harvard Business Review highlights Kaiser Permanente’s as a model collaborative community that fosters innovation, agility and efficiency. In the issue’s lead article, "Building a Collaborative Enterprise," the authors make the case that KP is among the leading organizations that are reaping rewards from operating as collective communities that "encourage people to continually apply their unique talents to group projects — and to become motivated by a collective mission."

The authors of "Building a Collaborative Enterprise" identify four organizational efforts that are keys to developing a collaborative community:

• Defining and building a shared purpose
• Cultivating an ethic of contribution
• Developing processes that enable people to work together in flexible but disciplined projects
• Creating an infrastructure in which collaboration is valued and rewarded

A shared purose

The authors use the KP Value Compass to illustrate their point about the importance of defining and building a shared purpose. The Value Compass features the patient/member at the center of the compass with four surrounding points: best quality, best service, most affordable and best place to work. It is included in the 2010 national agreement between KP and the 29 local unions that make up the Coalition of Kaiser Permanente Unions and informs work at every level of the organization. As the authors explain, the Value Compass "guides efforts at all levels of Kaiser: from top management’s business strategy, to joint planning by the company's unique labor-management partnership, right down to unit based teams' work on process improvement.

"We must recognize that old ways of doing things will not work in the new world of health care or business in general," says John August, executive director of the Coalition of Kaiser Permanente Unions. "At the KP Labor Management Partnership, we have devoted ourselves to transform our relationships throughout the organization, to collaborate and to learn in the interest of service to our patients, members and our communities. We are on the right path, and it’s fantastic that the Harvard Business Review has recognized our success."

Improving quality, reducing costs

The article also recognizes the accomplishments of a team at KP’s Irvine Medical Center that applied a collaborative approach — dubbed the Total Joint Dance — to reduce the turnaround time between total joint replacement surgeries. By involving nurses, surgeons, technicians and other employees in coming up with solutions, the team was able to devise changes that reduced the average turnaround time between procedures from 45 to 20 minutes, freeing up 188 hours of operating-room time a year at an average annual savings of $132,000 per OR.

The practices have since been adopted by general surgery, along with head and neck, urology, vascular and other specialties at Irvine, the article notes, and the approach has spread to other KP hospitals.

Collaboration as strategy

"This is a great example of how we’ve been able to use a collaborative approach to harness the knowledge of frontline employees, and then spread the effective practices that we develop with that knowledge," says Barb Grimm, senior vice president of the Office of Labor Management Partnership.

The authors conclude that the organizations that will become the household names of the future will be those with a strong collaborative culture. "Few would argue that today’s market imperative — to innovate fast enough to keep up with the competition and with customer needs while simultaneously improving cost and efficiency — can be met without the active engagement of employees in different functions and at multiple levels of responsibility. To undertake that endeavor, businesses need a lot more than minimal cooperation and mere compliance. They need everyone’s ideas on how to do things better and more cheaply. They need true collaboration."

This story was originally published on InsideKP

I am one of the chairs the LMP leadership team, along with a union colleague from UFCW and two management leaders. I’m also the co-lead of the Woodland Hills’ union coalition. In addition, I’m a full-time certified registered nurse anesthetist in the operating room. To be an effective labor co-lead takes three things: time, collaboration and planning.

Time

I have been doing partnership work at Woodland Hills for 10 years. People respect the time I’ve invested. You have to be on fire for this because it’s an enormous responsibility. It’s going to cost you time, angst and effort. And you can’t build relationships passing in the hall. You have to make the investment of face time. That means showing up at the LMP council meetings, monthly, from 8:00 a.m. to noon.

Planning Ahead

It is important to bring in and plan for new blood. At Woodland Hills, we rotate the labor co-chair in our leadership team every two years. I believe this allows everyone to have a say. It builds trust and experience. And it ensures buy-in from each union—and each segment of each union. We build-in mentorship. For three months, the new person sits in and the current co-lead shows that person the ropes.

We also did this in the Kaiser Permanente Nurse Anesthetist Association when I was president in 2006. I would go with new facility reps to meetings. 

Collaboration

We really foster union efforts at the medical center level. We’ve got a group of long-term union coalition people and our unions speak with a single, powerful voice. There have been issues between unions, and we had to work things out until cooler heads prevailed. People say ‘I’m sorry’ and move on.

Working with management is both easy and difficult. It’s easy because they are so partnership oriented and respectful of the unions, and they welcome input. They lead by influence—not by authority by virtue of where they are on the food chain—just like we do. It is difficult sometimes because it requires us to work hard as partners. Sometimes it would be easier to just go along with their recommendations, but then we wouldn’t really be doing our jobs as union leaders. At certain points, you have to say, ‘Well, let me think about that,’ and ask your constituents what they think.

Hospitals are traditionally very hierarchical. The partnership is such an opportunity to have a voice.

An Internal Medicine team in Ohio improved its workflow and increased from 62 percent to 74 percent the number of diabetes patients with cholesterol levels under control—surpassing the region’s goal—even while coping with a staff shortage.

A medical/surgical unit at Fontana Medical Center, in Southern California, went 23 consecutive months without an incidence of hospital-acquired pressure ulcers—after previously experiencing seven to 10 cases a year.

Colorado’s regional laboratory improved the accuracy of its transfer and tracking records from 90 percent to 98 percent, significantly reducing rework and speeding turnaround times for patients’ lab results.

These outcomes, and hundreds of others across Kaiser Permanente, were the result of performance-improvement projects undertaken by unit-based teams (UBTs)—Kaiser Permanente’s strategy for frontline engagement and collaboration.

Physician involvement in UBTs to date has varied, and generally remains limited. However, based on evidence from across Kaiser Permanente, we believe unit-based teams can help physicians achieve their clinical goals and improve their efficiency and deserve their broader involvement.

How UBTs work

Teams identify performance gaps and opportunities within their purview—issues they can address in the course of the day-to-day work, such as workflow or process improvement. By focusing on clear, agreed-upon goals, UBTs encourage greater accountability and allow team members to work up to their scope of practice or job description. Achieving agreed-upon goals, in turn, promotes continuous learning, productive interaction, and the capacity to lead further meaningful change.

As a strategy for process and quality improvement, UBTs draw on the study of “clinical microsystems” by Dartmouth-Hitchcock Medical Center and the Institute for Healthcare Improvement. “If we want to optimize a system, it's going to be around teams and teamwork, and it's going to cut across hierarchies and professional norms,” says Donald Berwick, MD, president and CEO of IHI and President’s Obama’s nominee to head the Centers for Medicare and Medicaid Services. “Unit-based teams and much better relationships between those who organize systems and those who work in the systems are going to be essential.”

Four kinds of benefits

The focused nature of UBT activities translates to four broad benefits to physicians and patients:

• Clinical benefits: Saving lives and improving health
• Operational benefits: Using resources wisely and improving efficiency
• Member/Patient benefits: Giving a great patient-care experience
• Physician/team benefits: Improving team performance and worklife

The example below, of a positive clinical outcome in one unit, shows how UBTs use practical, frontline perspective to solve problems.

Simple solutions get results

The Internal Medicine department at Hill Road Medical Offices in Ventura (SCAL) faced a practical challenge: Patients with an initial elevated blood pressure reading need to be retested after waiting at least two minutes—but they often left the office before the staff could do a second test. In fact, the staff was doing needed second checks only 26 percent of the time as of March 2008. 

The team’s simple solution: A bright yellow sign reading, “Caution: Second blood pressure reading is required on this patient,” which employees hang on the exam room door so the physician or staff would be sure to do the test.“The teams come up with good ideas about workflow because these are the folks in the trenches and they see the headaches,” says Prakash Patel, MD. “They share ideas and work out processes that help.”

In just one month, the department’s score on giving second blood pressure tests was 100 percent. Their score on the regional clinical goal of hypertension control went from 76 percent in August 2008 to 79.8 in May 2009, just below the regional goal of 80.1 percent.

"I strongly encourage all chiefs of service to champion the unit-based team in their department by either active participation or as a physician advisor, particularly regarding quality, service and access initiatives," says Virginia L Ambrosini, MD, assistant executive medical director, Permanente Human Resources.

UBTs are taking hold at the right moment for Kaiser Permanente. At a time when health care providers are under pressure to contain costs, maintain quality, and improve service, UBTs have the problem-solving tools to address those issues.

Read the full article, including principles of employee engagement and tips for selecting a performance improvement project.

How we bargain our National Agreements is as important as what we bargain. We use an interest-based problem-solving approach. This is a collaborative approach to solving problems that strives to meet the most critical needs of all parties. It also aims to preserve — and improve — workplace relationships and partnership. It’s not about “giving in,” but rather is a process to negotiate differences amicably and reach results that will be lasting and durable.

Traditional, adversarial bargaining usually begins with each side staking out its position. In contrast, interest-based bargaining begins with all parties discussing what their needs are. Both parties work on an issue together, explore options and find a solution that meets the key interests. That sense of shared ownership smoothes the way for successfully implementing the agreement. This approach also opens the door to collaborative problem solving — as opposed to competition or compromise — and leads to creative, mutually beneficial solutions.

Interest-based bargaining works best when both sides share information, focus on key issues, listen actively, are open to different options and trust one another. We’ve found that this approach addresses the needs of union members and helps the organization improve performance — which ultimately benefits our health plan members and the communities we serve.

Learn more about the 2015 Coalition National Agreement and the 2018 Alliance National Agreement.