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No one does it like we do.

Our negotiations for a new National Agreement will be one of the largest private-sector contract talks in the United States this year. No one else brings together such a large and diverse group of representatives from labor and management—plus physicians—to arrive at a single contract for so many union locals nationwide.

We’re so accustomed to this being our norm, it’s easy to forget how revolutionary our Labor Management Partnership is—and how democratic our interest-based methods are.

“At the table, everyone has an equal right to speak and explain their interest,” says Linda Gonzales of the Federal Mediation and Conciliation Service, which helps facilitate the negotiations. “There’s more open dialogue and sharing of information.”

The tone set by interest-based bargaining carries over to the work of unit-based teams. UBTs were one of the outcomes of 2005 bargaining. Today, they are the engine for performance improvement at Kaiser Permanente. They are also the structure giving frontline workers a voice in making decisions. The work UBTs do to improve care for KP members wouldn’t be happening if partnership weren’t in place, and if each successive national agreement didn’t commit everyone to finding innovative ways to address common interests.

It’s not always smooth sailing. But the interest-based model grounds everyone in shared values.

“There are some hard issues, and bargaining still has to take place,” says Joel Cutcher-Gershenfeld, a professor at the Institute of Labor and Industrial Relations at the University of Illinois. “At the end of the day, you have to find the right balance.”

Kaiser Permanente is inviting patients and families into the boardroom to talk turkey. There’s no sugar-coating a bad experience or making excuses for less-than-stellar service. Listening to our patients has become a core value, and patient advisory councils are one of the ways KP is bringing the patient into the conversation to improve care.

“There are over 35 advisory councils and over 400 patient advisors throughout the organization,” says Hannah King, the director of service quality for unit-based teams.

In the Northwest, as in other regions, the work being done by the councils is affecting outcomes. Within six months of the formation of the Oncology Patient Advisory Council, for example, oncology patient satisfaction scores climbed 6.5 percent. One change prompted by patient feedback was a fresh look at a procedure that sometimes is used in the course of a surgical breast biopsy. After hearing from patients about the pain they were experiencing, physicians standardized the wire localization procedure to reduce pain.

One of the newest councils in the Northwest was created to help serve the region’s growing Hispanic population. Patients on the council have been involved in a video project that will be ready to share with staff by year-end. In the video, Latino patients talk directly to KP care teams about their culture, providing insights into how to build trust and develop good provider-patient relationships.

Patients who serve on the councils are not paid to participate. “These are people who are invested in helping us succeed,” says Jonathan Bullock, program manager for Patient and Family Centered Care Programs in the Northwest.

Given the complexity of an organization as big as Kaiser Permanente, there’s been a learning curve for patients as well. At a recent council meeting in the Northwest, patients expressed frustration that a suggestion to improve signage hadn’t happened. As it turned out, their idea had been incorporated into the master plan—but there’s a schedule for updating signage, and the clinic they were familiar with wasn’t due yet for a refresh.

The word “rapid” stopped Kathy Stafford, RN, and made her ask more questions.

Stafford, the UBT co-lead and charge nurse for the Regional Infusion Center in the Northwest, had been reading an email from a Colorado colleague. The colleague wondered whether the center was using a new protocol for Remicade, an infusion drug prescribed for such diseases as Crohn’s, rheumatoid arthritis and psoriatric arthritis. The Colorado infusion center was trying a new “rapid” Remicade delivery method and looking to see what the experience of others had been.

The Northwest still was using the standard method, and Stafford, a member of the Oregon Nurses Association, was instantly curious. A regular Remicade infusion takes 3½ hours—three hours for the delivery of the drug, and then, to be sure there are no adverse effects, the patient has to wait 30 minutes before being discharged. The new protocol reduces that to a total of 1½ hours.

The gift of time

“If there is anything we can do to speed up infusions for our patients,” Stafford says, “it would be a service to them and, at the same time, save the organization money.”

In short, Stafford was putting the patient at the center of her decision making, bringing the Value Compass to life. The rapid Remicade protocol improves the patient’s care experience and improves service, quality, affordability and staff satisfaction:

• Patients spend less time in the clinic, since both the drug administration time and post-infusion wait time are reduced.
• Because patients are spending less time in the clinic, more patients can be seen. Up to 16 hours of patient chair time could be opened up every day.
• Because the clinic can accommodate more patients, fewer patients will be redirected for treatment in the Emergency department or at the regional Oncology department, improving those departments’ ability to serve their primary patients.

“Any chance we have to be more effective is worth it, so we can spend more time with our patients,” Stafford says.

Making it happen

Following up on the initial email inquiry, Stafford learned the evidence-based practice already was being used in Colorado and the California regions. She and Greg Frazier, the assistant department administrator and UBT management co-lead, pushed ahead with getting the protocol approved for use in the Northwest, benefitting all the region’s eligible patients.

“There was no stopping Kathy,” Frazier says. “She knew who to talk to in the organization and how to move things along….

“Our team is always looking at how to do things better, and to take care of the patient the best we can,” Frazier continues. Noting that the infusion team is highly motivated and self-directed, he offered words of encouragement to those who see an opportunity they want to pursue.

“Don’t turn away from a challenge. Ask questions,” he says. “It may not work, but look into it first before you discount it.”

Stafford credits the team for getting the new protocol approved so quickly, despite a complex approval process that included meetings with both physicians and pharmacists.

“Without the enthusiasm and involvement of the infusion RN team, this would not have gone as smoothly,” she says. “We found out about the protocol in March and we began implementation in May. That’s pretty fast.”

 “I was almost devastated,” says Karen Cardosa, a grocery clerk in Albany, Oregon, “when UFCW told us they were no longer offering Kaiser Permanente as an insurance option.”

Cardosa and her family had been KP members for years through the union’s Local 555 Employers Health Trust. That changed in 2009 when a variety of issues resulted in KP losing the account, which covered many Local 555 members. The union continued to represent nearly 2,000 Kaiser Permanente pharmacy and radiology employees, who—as KP staff members—continued to have KP health care.

Today, it’s a new story. Thanks to a 36-month KP offering that was finalized in April, Kaiser Permanente is again an option for up to 15,000 UFCW members and dependents in the Northwest region who are covered by the health trust.

“Our work with LMP is probably some of the most important work done in Public Sector strategy in the last two years. Working with our union partners, we’ve been able to come to the table with customer solutions that meet everybody’s needs—including the unions that aren’t part of KP, who have tremendous influence in purchase decisions. We are unique in having a strong labor partnership in our own business, and we can speak that language.”

—Kate Kessler, a Member Sales and Service Administration director

“When I was hired four years ago, my manager told me my Number One job was to get UFCW back,” Ehren Cline, a KP Sales and Account manager. Cline, including Jeston Black, the region’s senior labor liaison, and other colleagues partnered with Dan Clay, president of Local 555, to do just that.

“KPNW brought us a package we couldn’t refuse,” Clay says. An affordable price, high quality, a new hospital, expanded clinics and a new billing system helped seal the deal.

Clay’s own union members pushed for the new commitment.

“I have not been to a union meeting in the last five years where someone didn’t ask, ‘When do we get to go back to Kaiser?’” Clay says.

But something else was also at play. Thanks to Labor Management Partnership, Kaiser Permanente enjoys a joint union-management approach to winning and keeping health plan members that is almost unheard elsewhere in this country.

Read on and learn how it all comes together.

How the LMP Growth Campaign Works

Click to enlarge.

For more than 10 years, Kaiser Permanente’s Child Health Program has been veiled in relative obscurity despite the extraordinary service it offers.

Even more unknown is the role KP enrollment processors in Northern California, who are represented by OPEIU Local 29, are playing in helping the charitable health program fulfill KP’s mission of serving our communities.

“I like to say that we’re the best-kept secret of KP,” says Sharlene Jones, an enrollment processor who screens applicants for eligibility and guides them through the sign-up process. The community benefit program provides comprehensive medical, dental and optical coverage at little or no cost to children ages 19 and younger whose family income falls below the federal poverty level and who have no other coverage options.

Since August, the Oakland-based enrollment processors have attended more than 40 health coverage enrollment or outreach events across Northern California, from informational sessions at small medical clinics to large events like the “We Connect Health Care” enrollment and resource fair in Fresno, which drew thousands of people. The processors answer any question thrown at them about the Child Health Program and help enroll those who qualify.

“Our processors are able to help families right on the spot,” says Sara Hurd, a former employee who until recently led outreach for the program. “They know what challenges are and how to work through them.”

Long-lasting value

The Child Health Program has a goal of enrolling 80,000 qualified children across Northern and Southern California. The work the Local 29 members are doing to help meet that goal fits within the framework of Labor Management Partnership efforts to grow the number of Kaiser Permanente members—and to establish positive member relationships that can last a lifetime.

As outreach coordinator, Hurd’s priority was getting the word out about the program and forging relationships with community organizations. She also served as the sole contact for prospective applicants at outreach events—but she didn’t have the detailed enrollment knowledge the Local 29 processors have.

Maury Rosas, manager of Charitable Health Coverage operations, reached out to enlist the processors’ help. Including them in the work, Hurd says, “has been invaluable”—and as of May 2014, more than 77,000 children were enrolled.

“We needed people who really understood what the applications are about and could help people with eligibility,” Rosas says. Before he requested their help in the field, the enrollment processors’ interactions with potential qualifying applicants were by phone or letter.

“We’re able to answer their questions,” Jones says. “It allows us to put a face on KP.”

Many of the processers who attend the events have bilingual certification and are skilled in walking applicants through enrollment in Spanish.

“It’s important to show (the public) that we’re not just sitting behind a desk, pushing papers,” says Miriam Garcia, an enrollment processor. “We’re the labor force behind it all….We’re here to work with the community and are proud of KP.”

Demonstrating a commitment

The effort has been an unqualified success, Rosas says, from community agencies asking for repeat visits to the response of the children’s parents.

“They took me by the hand and walked me through the process of completing the application and made me feel comfortable with the process,” says Rufina Garcia, speaking through a Spanish interpreter. Garcia enrolled her three children in the program at an outreach event in March. “This has been the first time when I could walk in and give my information and be signed up right there.”

Delivering on KP’s mission in partnership between labor and management also helps build relationships with potential union-oriented purchasers of health care, says Katy McKenzie, a consultant to LMP and its membership growth work.

“It goes a long way when you’re talking to unions that represent low-wage workers,” McKenzie says. “They see that we actually do care about caring for people and our communities. It’s not just about selling something to them.”

McKenzie and others involved in the growth work helped promote the Child Health Program to unions representing low-wage or part-time workers, such as laundry or home care workers—people who don’t get dependent health care coverage as part of their job benefits or who can’t afford what is offered to them.

 “It’s a great opportunity to see that management is working with labor as a team,” Miriam Garcia says. “We’re not only supporting KP, but we’re supporting our own labor force.  We’re showing that we can work together and make a change. We’re helping make a change that carries over into the community.”

That kind of caring makes an impression. Rufina Garcia, who only has catastrophic medical coverage for herself, says she would choose Kaiser Permanente for her whole family given the chance.

“It has been a wonderful experience,” she says. “The way they treat my children is incredible. (The doctors and nurses) are very caring—they have more patience and actually listen to the kids….I believe they take better care of my children.”

See your doctor without leaving home? The house call of the future may be via your smartphone.

A visiting home health care nurse may one day live-stream exam information via a wearable device like Google Glass, speeding up the treatment process.

Or maybe you’ll be dropping in for a check-up at the clinic in your local shopping mall.

No one can say for sure which ideas will take hold, how long before those ideas morph again and how jobs will be affected. The good news is, we’ve successfully managed widescale change before.

“Changes in health care mean there will be job losses and job growth,” says Jessica Butz, the Coalition of Kaiser Permanente Unions’ national program coordinator for Workforce Planning and Development. “But in the long run, the new skills needed are good for workers and for our patients and members. We have options and support to make the transition work for us, and we’ll have better, more secure jobs.”

Joyce Lee, a Steelworkers Local 7600 member and a former imaging transcriptionist at Fontana Medical Center in Southern California, can speak to the truth of that. Four years ago, a new voice-to-text technology made her job obsolete. She now works as a phlebotomist, a job she always wanted.

“One of the things I’ve always loved about Kaiser is that you can have many careers here, you can be as good as you can be,” Lee says. “I got great support from my union, my manager and my career counselor.”

In the mid-2000s, thousands of workers across the organization saw their work vanishing as KP HealthConnect® was introduced. Time and again, Labor Management Partnership resources and safeguards not only kept individuals employed, but led to new skills and jobs within Kaiser Permanente that paid as well or better.

As KP implements new care delivery models, having a workforce planning and development program that draws on the input and experience of the workforce will help ensure smoother transitions and keep costs down.

“We want individual workers, teams and the whole organization not merely to survive change, but to thrive on change. We used partnership to do just that with HealthConnect,” says Hal Ruddick, executive director of the union coalition. “We don’t need to reinvent the wheel—we just need to get rolling on joint planning and implementation.”

Early engagement required

What all the new care models will look like is still taking shape. Despite the uncertainties, leaders recognize the need to start thinking now about how changing technology will affect the workforce. It’s becoming clear people will need to be trained for team-based care, to work seamlessly across different care settings and be technologically skilled or able to learn those skills.

“We have an opportunity—both labor and management—to lead on the new care models and to get ahead of those changes and get it right,” says Zeth Ajemian, the director of Workforce Planning and Development for Southern California and Hawaii. “It requires early engagement and flexibility.”

Remembering what we’ve already learned will help. The implementation of both KP HealthConnect and the coding process known as ICD-10 provides valuable case studies.

In 2009, the U.S. Department of Health and Human Services announced a big change for health care providers: The International Classification of Diseases, 9th Edition, known as ICD-9, would be replaced by ICD-10, which contains about 144,000 diagnosis and procedure codes. The changeover, now scheduled for Oct. 1, has meant 166 applications—including billing and claims systems in each region—needed to be upgraded, replaced or retired.

In addition, some 1,400 coders and many others needed retraining. Union coalition members are covered by the Employment and Income Security Agreement, which provides for retraining, redeployment and at least one year’s protection from layoffs due to process improvements or restructuring.

“Our ability to work collaboratively in partnership—and recognize workforce issues as part of our strategy—is huge,” says Laura Long, the director of National Workforce Planning and Development. “We need to look at the impacts on the workforce and the skills sets needed for the future. We can’t just flip a switch.”

Identifying potential problems

So KP and the coalition took a page from the KP HealthConnect playbook, when Kaiser Permanente leadership reached out to the unions.

“We had conversations about why the change was important and what it would look like,” says Marie Hamilton, RN, who was the national labor coordinator for KP HealthConnect implementation and is now the labor partner for OFNHP at Westside Medical Center in the Northwest. “Part of the implementation was making sure people got the skills they needed.”

The process was not pain-free, but by engaging the workforce, she says, “Kaiser got buy-in from the people using the system and identified potential problems early on. It was the most impressive thing I’ve seen in 40 years at Kaiser—a model that demonstrates how working in partnership can effectively manage sustainable change.”

When that engagement is missing, the repercussions can be far-reaching. Last year, for example, a decision to reduce or redeploy nurses in Southern California led to a pull-back in union support for unit-based teams in the region. The dispute was resolved, but it illustrated the risk of going it alone.

“In times of change, it can be tempting for both sides to fall back on old habits and traditional approaches—and we know where that gets you,” says Dennis Dabney, the senior vice president of National Labor Relations and Office of Labor Management Partnership. “The test of any partnership is working your way through tough issues and getting better results. That's what we are committed to do."

The joint approach to ICD-10 has included national “communities of practice”—with representation from frontline workers—to design training and make policy and budgeting decisions. Regular updates keep affected employees informed and let them air concerns.

One very specific payoff to the approach: The labor-management team in Colorado found serious flaws in a claims and billing system being developed by outside vendors. KP switched vendors and avoided a potentially disastrous disruption.

The Imagining Care Anywhere exhibit, created by Kaiser Permanente’s Innovation and Advanced Technology team and the Garfield Innovation Center, illustrates how current and emerging technology makes it possible to bring health care directly to a patient’s home—or wherever a member may be—and can transform the way care is delivered at the doctor’s office and in the hospital. Dan Weberg is director of nursing innovation at the Garfield center and has been traveling to Kaiser Permanente facilities, conferences and union meetings to talk with people at all levels of the organization about the exhibit. He was interviewed by LMP Communications Director Andrea Buffa.

Q. As director of nursing innovation, what kind of work do you do?

A. I have a really great job. I’m supposed to help envision the future about three to five years from now and figure out what technologies, what trends, what changes in nursing practices and what changes in health care might occur. And then help guide pilot projects and strategy and brainstorming sessions to move the organization toward that future.

Q. What is the Imagining Care Anywhere exhibit about?

A. Imagining Care Anywhere is the start of a conversation with everyone at Kaiser Permanente to create a vision of what it might look like in the future as we engage members no matter where they are. How can we seamlessly integrate their home life, their school life, their work life and their health interactions with Kaiser all together? How can we help people have a more healthy lifestyle or healthy work-life balance? It’s a tour that’s supposed to provoke people to think about and imagine what that care will look like.

Q. How are emerging technologies changing the future of health care?

A. One example is the smartphone. Many of us use it for everything from tracking our fitness goals to shopping lists to emails to Facebook. But the data and the information behind that can be integrated in with goals for your health life. We’re working on a project now called Profile and Preferences. You might be able to set personal health goals and then use the data you collect already—whether it’s through a fitness app or diet tracking—and upload that into your kp.org profile so you can see how you’re moving along with your goals. And then, when you meet with your care team, we have a better picture of who you are as a person, and we can help you facilitate your goals. Remote diagnostics and remote monitoring are a big deal now, too.

Q. What do you think virtual visits will look like?

A. There are several organizations now that do tele-visits, including Kaiser. I think the future is going to hold more of these as our TVs and our cable providers get faster and faster internet and smarter devices. It may not be a full visit, but it may be a way to engage with a care provider—whether it’s a nurse, a physician, some sort of navigator or a health coach. Keeping people from having to drive into one of our facilities for simple things is going to be key.

Q. How are things going to be different when people are in the hospital?

A. In the exhibit, there’s a “journey home” board, which allows members to know exactly what has to happen before they get discharged. They don’t have to continue asking the nurse or the doctor or the care team by clicking the call light—they can see it right there and they’re able to access it.

The board is also about answering their questions conveniently and in a way they can understand. The exhibit has the idea of using an avatar. After a nurse or teacher comes in to do some kind of education, the member still has some questions. Instead of having to ask the same questions over and over and feeling a little uncomfortable, they’re able to use a virtual person to answer them.

Q. How can KP support its employees and help them advance their careers as these changes begin to take place?

A. I think as an institution we need to keep thinking about how we evolve our roles, what are the things we need to do differently. The technology is coming whether we want it or not, so it’s about continuing to imagine how specific roles might change and coming up with strategies to train our workforce to be able to evolve with the technology.

Q. What role are the labor unions that represent KP’s employees playing?

A. We’re really excited about the engagement with the unions. I think it’s great that they’re using Imagining Care Anywhere as a springboard to talk to their constituents about how the future of health care is going to evolve and also work to create that future with us.

The front line should be driving this because they know what’s broken. And they can help us address that early, before we get too far down the road with a solution that may not meet the real need.