LMP Focus Area

David Jones, MD, works in the Georgia region with the Southeast Permanente Medical Group. He has been with the medical group for more than 11 years, and currently works in the Panola Medical Office. He spoke with LMP senior communications consultant Julie Light.

Q. What is your partnership role?

A. My role with the Labor Management Partnership in Georgia is assistant to the medical director for unit-based teams. I serve as the physician regional co-lead for all the UBTs for the region. I’m excited about this role and how it can help engage our physicians.In this role, I work closely with all of the teams, with a particular focus around supporting the physicians and helping them understand the value of UBTs and how UBTs really can improve what we do day to day in the offices and how they can improve the care for patients. It also means removing any potential barriers that the physicians may face, or anticipate, to allow them to be more engaged with the UBT process.  Another part of my role is working with our unit-based team’s resource team. In that capacity, I bring more of a clinical perspective to UBTs.

Q. How do teams improve care?

A. A project I had personal involvement with was the pediatric team at our Panola office, which addressed ADHD (Attention Deficit Hyperactivity Disorder) medication management. Before our UBT project, we were meeting the goal of having a follow-up visit within 30 days approximately 25 percent of the time. Through our UBT work, we increased those results to reaching and sustaining a rate above 90 percent after three months.

Q. Why haven’t more physicians embraced partnership?

A. The first thing I tell physicians about the UBTs is that it is about improving the work that we’re already doing. It’s not about adding more work, it’s about looking at the work that you're doing and figuring out how to do it better.

I think one of the barriers physicians face has been just lack of understanding. It wasn’t clear to physicians the value that UBTs can bring to the team. So it’s taking the UBT process and putting that into terms that are meaningful to physicians. Time is always a barrier for most people, and particularly for physicians. That’s why it’s important to have them understand that it’s not about doing more or working harder, it’s about working better. This is a very new way of thinking about teamwork. It’s about the physician being engaged and involved and still having a leadership role, but also embracing the value and the input, perspectives, talents and skills of the whole team, and understanding how everybody can share the same goal and work together and improve the accountability across the board.

What it really takes is physicians and teams going through the process. I can talk with them all I want, and tell them how it is in theory, but once they start to go through the process and see the results, and see how morale and efficiency improves—that’s when they become believers.

At 10:30 a.m. sharp, South Bay Medical Center appointment clerk Carolina Meza removes her telephone headset. She fires up what looks like the world’s tiniest iPod, attached to a portable speaker that’s not much bigger. She gathers four of her co-workers in a patch of open space near the coffee room. They do some neck rolls, march in place and then do a move Meza calls “the incredible hulk”—a shoulder stretch that brings welcome relief to those facing a computer screen for most of their day.

“When we go back to our stations, we feel refreshed,” says Meza, a member of SEIU UHW.

It’s called Instant Recess, and it’s the brainchild of Toni Yancey, MD, co-director of the UCLA Kaiser Permanente Center for Health Equity. It involves a quick, daily group exercise and is aimed at incorporating physical activity into a normal workday. It comes at a time when research is showing that workplace fitness initiatives targeting individual behavior (such as counseling and gym memberships) aren’t working. An organization’s whole infrastructure needs to be addressed, says Yancey. 

That’s what makes Instant Recess so appealing. It demonstrates KP’s commitment to Total Health—including for a healthy and safe work life for KP employees as well as the members and communities we serve. It’s consistent with KP’s Healthy Workforce push, and also seems to help reduce workplace injuries and improve attendance.

At the South Bay call center, for instance, annualized sick days fell almost one full day per full-time equivalent between 2010 and 2011, when the department began Instant Recess. The number of ergonomic injuries went from three to zero.  

Overcoming obstacles

While they are seeing results now, team members were wary when senior leaders at their medical center approached them about trying Instant Recess. “I was very skeptical,” says Darlene Zelaya, operations manager. “We can’t prevent the calls from coming in.” In fact, hold times for patients did go up when the team first implemented Instant Recess.

The unit-based team worked together with project manager Tiffany Creighton to adapt Instant Recess to their members’ needs. For instance, before calling a recess, team members check the reader board to assess how many agents can be off the phones at one time. They hold many small exercise bursts throughout the day instead of one or two longer ones. And they keep the music turned down low to avoid disturbing agents on the phone with patients.

Making it work locally

In the South Bay lab, Instant Recess looks and sounds totally different—but is getting similarly promising results. That department blasts a boom box for 10 full minutes during the Instant Recesses it incorporates into its huddles at shift change twice a day. Clinical lab scientist Nora Soriano steps away from her microscope to join in. She’s lost 43 pounds recently, and she partly credits Instant Recess. Soriano, a member of UFCW Local 770, says the initiative inspired her to exercise more at home. “My son got me an Xbox,” she says. “I don’t stop for half an hour, sometimes 45 minutes.”

Not all of Soriano’s co-workers were so enthused when they first heard about Instant Recess. “I was kind of negative,” admits Julia Ann Scrivens, a lab assistant and UHW member. “I thought, ‘I am so busy. You want me to do what?’ ” Area lab manager Dennis Edora says, “It was a shock. No one knew what to expect.” But the lab’s staff had just been through some stressful changes—including getting new equipment and moving to a new floor—and team members were hungry for something that would help rebuild morale.

“We collaborated with all the different job codes,” says Edora. “Everyone added their different flavor,” she says, noting that employees rotate as a leader, some choosing Hawaiian dance moves, others yoga-inspired stretches. “Instant Recess really got us together. It wasn’t just exercise.” Moreover, it was helping reduce injuries: the lab reported only one repetitive motion injury in 2011, after beginning Instant Recess in April. There were five such injuries in 2010.   

And Scrivens is sold as well. “It is fun,” she says. “It makes me happy.”

“Team” is a noun. “Teaming” is a verb, defined by the woman who coined it as teamwork on the fly, coordinating and collaborating across boundaries, without the luxury of stable team structures.

That woman, Harvard Business School Professor Amy Edmondson, talked to the 2012 Union Delegates Conference about why teaming is such a crucial skill, especially for those in health care settings where work is complex and unpredictable.

“In health care, many times people are interacting with each other in an emergency room, for instance, now, for five minutes, but they don’t know each other,” says Edmondson. “The catch is we have to act as if we trust each other…because we often don’t have the luxury of having a lot of time to get to know each other.”

A “team” is a static, stable entity. But, says Edmondson, “In health care, if we wait until we have the perfectly designed ‘team,’ the moment has passed. We have to get together quickly, do what needs to be done, and then disband and do other things.”

In the absence of long-term work relationships, Edmondson says allegiance to an organization with a compelling vision can be the glue that holds these teams-on-the-fly together. “There is the pride in working for KP,” for instance, she says. “That is a real bond.”

Looking at the performance improvement work of unit-based teams at Kaiser Permanente, the principles of teaming still apply. While not as fluid as an emergency room, UBTs still see plenty of flux. Just think about the manager that gets promoted or retires, or the labor co-lead who rotates out of that role. The team has to be able to keep focused on improving performance even as the cast of characters changes.

UBTs can be stable teams that do great work. They are a very powerful tool,” Edmondson says. “And yet, I also want people to be able to quickly get up to speed, do what needs to be done with other people in the absence of those stable structures.”

A UBT needs to be a scaffold that is strong enough to withstand the flux, says Edmondson.

“If there is clarity about what the structure looks like—independent of the people who are in that structure—you are better off,” says Edmondson, a point explored in research she’s conducted with Harvard colleague Melissa Valentine. “We won’t always have the same human beings in those roles, but the roles are reasonably static.”

Amy Edmondson says innovation depends on a culture of focused chaos.

Those words sound like opposites. They are. Don’t worry. It’s not a mistake.

In fact, innovation depends on four pairs of seeming opposites. As unit-based teams ramp up, involving frontline managers, physicians and employees in finding new ways to improve performance and transform health care, they can benefit from creating a culture of innovation. This is how Edmonson, a professor at Harvard Business School, defines the four cultural contradictions of innovation:

• Chaotic/focused
• Playful/disciplined
• Deep expertise/broad thinking
• Promotes high standards/tolerates failure

Let's take a more detailed look.

Chaotic/focused

“An innovation culture is focused,” says Edmondson. “It is really intent on improving a process or inventing a new business model or coming up with a new product.” At the same time, it is chaotic. “Any idea is welcome and possible—at least until we sort it out. No idea is a bad idea—at least early in the process.”Chaos, says Edmondson, “is about welcoming all ideas, even ‘wacky’ ideas.” Only in a psychologically safe learning environment will employees feel open enough to offer these “wacky” ideas, she adds.

Playful/disciplined

The Labor Management Partnership offers a disciplined process for innovation in the form of the Rapid Improvement Model (RIM) and the plan, do, study, act cycle. But, Edmondson emphasizes, teams use these tools “without knowing in advance what the answer is.” There is a careful and well-managed process, but the content of the conversations about improving performance must be open and inclusive. As teams begin a performance improvement project, UBT leaders need to be very clear about what aspect of performance they are trying to address—not on how the team is going to do it.

Deep expertise/broad thinking

An innovative team is one that values those who bring deep expertise (in a specific topic, subject area or clinical specialty, for instance) and people who are broad, general thinkers who span boundaries. “Both of those skill sets are absolutely essential at the same time,” says Edmondson.

Promotes high standards/tolerates failure

In an innovative work culture, “We hold very high standards but we are also very tolerant of failure,” says Edmondson. “That sounds ‘wrong,’ at first,” she admits, “but it is essential because, in innovation, you will never get it right the first time. You try something, test it out, it’s not going to work quite right and then you either tweak it or throw it out altogether and try something else.”

Spreading new ideas that get results throughout a large organization such as Kaiser Permanente, says Edmondson, requires finding ways to “shine a very quiet spotlight”—another seeming contradiction!—on innovators so others become aware of what they are doing and are drawn to try it too. 

“In today’s world, there are two ways to get the word out,” she says. The first is face-to-face communication, “positive buzz that starts locally and spreads.” The other is internal online social networks as “a way to listen, motivate and share practices that are potentially better.”

“It can catch on,” says Edmondson. “When there are pockets of effectiveness, other people see them, and they want to play too.”

The theme of the 2012 Union Delegates Conference was “You Gotta Move”—and Amy Edmondson’s advice for the delegates was “you gotta learn.”

The Harvard Business School professor studies what she calls “learning environments.” To support innovation and teamwork, it’s essential the Labor Management Partnership and unit-based teams foster learning environments throughout Kaiser Permanente.

Imagine the ideal learning environment: People feel free to take risks. They feel psychologically safe. They believe they won’t be punished or humiliated for speaking up with ideas, questions, concerns or mistakes. “Without that kind of psychological safety, it’s very hard for an organization to learn,” says Edmondson.

Now imagine the opposite of a learning environment, one where no one speaks up. “Nobody ever got fired for being silent,” says Edmondson. “And yet many bad things happen as a result of silence. Silence is a strategy for individuals to stay safe, but not necessarily for patients to stay safe or for organizations to stay vibrant.”

Creating a learning environment is up to leaders—to those people with influence, whether or not they have a formal leadership role.

“Leaders have to go first,” Edmondson says. They “have to be willing to ask questions themselves, invite participation, acknowledge their own fallibility, and to explicitly state we don’t know everything yet.” These behaviors help an environment where others can take the risks of learning.

But, she cautions, “The learning environment doesn’t live at the ‘organization’ level. For the most part, there are pockets of learning environments.…In a large, complex system, answers don’t come from central headquarters or the CEO. The answers come from the people at the front line doing the work.”

A labor management partnership like the one at Kaiser Permanente “is an important foundation” for building a learning environment, says Edmondson. “A true partnership is completely consistent with the context for mutual learning.”

Both management and union UBT co-leads can help create a learning environment by articulating the unit’s or department’s purpose and goals “in a meaningful way that touches hearts and minds, that motivates and encourages,” she says.

They can—and must—also reduce the fear people experience that makes them reluctant to speak up. The LMP helps develop and support people, helping them be their best and most courageous, Edmondson says.

When Helen Bevan told her National Health Services colleagues in the United Kingdom she would be speaking at a conference of Kaiser Permanente union employees, they were surprised.

“What could they possibly learn from us?” they asked.

A lot, she says.

“Kaiser is a role model for us,” explains Bevan, chief of service transformation at the NHS Institute for Innovation and Improvement, part of the largest government-sponsored health care system in the world.“We look at and learn a lot from Kaiser in terms of innovations, efficiencies, use of new technology and its approach to patient care.”

We have much to learn from them as well—especially when it comes to large-scale change.

How to move forward

“To move forward in health care, leaders must tell their story, make it personal, create a sense of ‘us’ and include a call for action,” says Bevan, one of the plenary speakers at this year’s Union Delegates Conference in Hollywood. “The way to build and sustain health care reform is to learn the lessons of social movement leaders.”

Bevan’s point is on the mark. The 700 delegates attending the conference, themed “You Gotta Move,” were called to act on improving their own health and the health of their communities. They took that message to the streets of Hollywood, distributing fliers with tips on easy steps to take to improve health. Some also gathered for a flash mob in front of Hollywood’s Grauman’s Chinese Theatre, dancing to Beyonce’s “Move Your Body”—a song made for Michelle Obama’s “Let’s Move” campaign to end childhood obesity.

“It’s such a great experience to see the extent to which union members are stepping up to be a part of the change process,” Bevan says.

Building commitment and energy

The actions at the delegates conference—and beyond—are precisely what’s needed to reform health care in America and the world, she says, adding: “We can only create large-scale change if we build a platform of commitment and energy.” 

Because unit-based teams, KP’s platform for improvement, engage frontline workers, managers and physicians, they “already have that commitment and energy,” Bevan says. UBTs “create a sense of coming together around a common cause and achieving the same outcomes.”

But UBTs alone can’t bring about the large-scale change needed to meet the unprecedented challenges to improve quality and reduce costs.

Engage and inspire

“Transformation needs to occur at all levels of the organization in order for it to be sustainable,” Bevan says. “Senior leaders need to stop being pacesetters and start engaging, inspiring and emotionally connecting with employees. The passion is there. We just have to tap into it.”

As the task of delivering health and health care becomes more complex and the scale of change increases, “We need to think widely and innovatively about how we define the role of senior leaders,” Bevan says.

That’s where social movement thinking comes in. “Successful movements often have charismatic leaders—think Martin Luther King or Nelson Mandela—but what ultimately guides and mobilizes the movement are leaders at multiple levels.” The key, she says, is to depend less on reorganizing structures and processes as the catalyst for change and more on unleashing emotional and spiritual energy for change.

“People are much more likely to embrace change if it builds on the passion, the sense of a calling that got them into health care in the first place,” Bevan says. By connecting to that shared passion through storytelling, “We can create an unstoppable force for change.”

What happens when things change in your job and you have to rethink what’s always worked in the past?

For me, that moment came two years ago when I moved into a management role. I had spent 24 years as a frontline nurse, union steward and labor partner to hospital administration before my job transition.

Frankly, I wasn’t sure what to expect going in, but having been a steward and a labor partner helped me become a better manager. Kaiser Permanente has given me opportunities to grow as a leader that I don’t believe I would have had elsewhere. Along the way I learned six lessons that I think can help others lead in a collaborative team environment:

• Speak well and connect. As a labor partner, I developed my speaking and presentation skills—skills that most don’t learn in nursing school. My confidence grew with each presentation and I now feel a connection with my colleagues that helps us all gain value from our conversations.
• Give and get respect. As a nurse, I was respected at the bedside by physicians, managers and other nurses. I don’t think I would have been as respected as a manager if I hadn’t been respected at the bedside first. My clinical experience helped give me credibility.
• Understand operations. As a labor partner I learned valuable lessons about hospital operations. That allowed me to build on my experience as a caregiver and begin to see the bigger picture—how things are intertwined and why certain decisions are made.
• Listen and hear. You have to be a great listener and actually hear what people are saying. You have to be able to take things in and think about how to respond. As a steward, I always mulled things over before reacting, and I try to do that still.
• Know your contract. Most union leaders know their contract inside out—certainly I did when I was president of the RN bargaining unit. Managers should, too. The National Agreement gives us many tools that can help both sides stay on track.
• Stay flexible, be practical. Nurses are very solution-oriented. The solution to a problem has to make sense. I learned over the years that different people might get to the same outcome, but there are many ways to approach the problem. You need to be willing to try a different route to get to the solution so that everyone feels they have a voice in the process.

As a labor leader, I learned to believe in people and know that there’s always another side to any story. My staff understands they can come to me any time. And our unit-based team helps us draw on everyone’s knowledge and allows everyone to be heard.

In the end, it wasn’t that hard to make the transition from labor leader to manager. In both roles you have to consider diverse points of view, and sometimes you have to step back and ask, “Does it make sense?” You’re not always popular, but I’m OK with that.

We may not always agree. But there is no “we” or “them,” we are all one—because we always put our patients first.

I can’t get that old Springsteen song “My Hometown” out of my head: “Foreman says these jobs are going, boys, and they ain’t coming back….” That was a hit back in the early ’80s, when auto, rubber and steel factories started closing in the Midwest.

Looking back from the ditch we’re stuck in today, you can see that economic steamroller of devastation flattening industries and states.

Despite a few bubbles here and there, people keep losing their houses and their jobs, and let’s face it—they ain’t coming back anytime soon. Since 2000, the median income for ordinary Americans dropped by $2,197 per year. Most of us who are working feel fortunate to have any job at all. Those of us who have meaningful jobs—like keeping people healthy and caring for them when they are sick—we’re really lucky.

At Kaiser Permanente, we’ve got more than good fortune on our side. Not only do we have good jobs, with industry-leading wages and benefits, but we’ve got a strategy to make them great: We take value creation to heart.

That’s the point of the Value Compass—creating value.

As we work in our unit-based teams to improve service, quality and affordability and create the best place to work, we create more value for our members and patients, which will protect and improve our good jobs.

The Value Compass is not an initiative, a symbol or a checklist. It’s a shared vision.

It reminds us the sum of team collaboration produces value greater than our individual efforts alone. It reminds us how important our contributions are—and why we work so hard at improvement. It acknowledges that work has meaning not just for the “leaders” but for everyone.

Three years ago, when Joann Horton learned her job might be eliminated when HealthConnect™ came online, her first response was fear.

A medical clerk at the Hayward Medical Center in Northern California, Horton needed the income, but she also loved her job. “I was terrified,” she says.

Joyce Lee, an imaging transcriptionist at the Fontana Medical Center in Southern California, found herself in the same boat last year. With KP shifting to a new voice-to-text technology for transcribing radiology results, Lee’s skills were becoming obsolete.

“All of us were figuring out how we were going to do the transition,” she says.

Both of these “changing workplace” stories could have ended badly, especially in today’s shaky economy.

But now, Horton and Lee are fans of the job counseling and retraining provided to partnership union employees through the Employment and Income Security Agreement that allowed them to stay with KP.

Successful retraining 

The two women received one-on-one guidance from career counselors who helped them identify and train for in-demand positions.

Horton, who is now the department secretary for Home Health in Hayward, says career counselor Martha Edwards “gave me what I needed to build my skills up, but she also gave me a lot of emotional support.” Edwards works for the Ben Hudnall Memorial Trust, established under the 2005 National Agreement to provide career counseling and job training to members in 12 of the unions that are part of the Labor Management Partnership.

Lee, who now works as a phlebotomist at the Fontana Medical Center in Southern California, also received services through the Ben Hudnall trust. She says counselor Michele DeRosa “has a gift for networking; for figuring out all the pieces of the puzzle, for being the encourager.”

Ongoing outreach

The partnership’s career counseling benefits have benefited thousands of employees in a short amount of time. From its inception in 2007 through March 2011, roughly 10,000 employees had seen career counselors through the Ben Hudnall Trust, with many more attending workshops or promotional events.

The SEIU UHW-West & Joint Employer Education Fund offers similar services to SEIU-represented employees in the Northern California, Southern California, Colorado and Northwest regions. Since 2006, almost 16,000 KP employees have enrolled in training through the program and 6,885 have received counseling and referral services. 

Those who have used the programs’ services are enthusiastic proponents; however, ongoing outreach is required, Edwards says, especially since the concept of career counseling is new to many employees. 

“I think there’s a lot of mystery around the words ‘career counselor,’ ” she says, “and perhaps some intimidation and confusion.”

Obstacles to career counseling include a fear of being seen as vulnerable or needy, difficulty finding the time for training while working and concern that some managers might not appreciate an employee who is seeking to advance from their current position, Edwards says.

It’s an important part of the counselor’s work to help employees get over these hurdles so the program works best for their needs, she says.

Many employees first learn of the services when facing a major challenge, like Horton and Lee.

However, the programs are designed to offer help in many situations, from employees seeking to change careers to those wanting to gain skills in their field; from those struggling with a manger or co-worker to those struggling with work-family balance.

All services are confidential.

“Our goal is to have something for everyone,” says Lucy Runkel, director of the SEIU UHW fund. “We reach many employees, but we always want more.”

Managers are educational partners

Data from the programs show most employees learn of career counseling through word of mouth. Information also is available at events and online.

Both programs have started boosting educational outreach to managers, whom they view as key allies in spreading the word about the services.

“With a manager, we get more bang for our buck, because they can educate all of their staff,” says Runkel. 

Both Kaiser Permanente and its union-represented employees stand to gain, she says. “We think people who are better trained, happier, and have greater longevity on the job are going to provide better care than someone who is new, or unhappy or poorly trained.”

Career counselor Edwards put it this way: “It helps with Kaiser’s ‘best place to work’; seeing employees vital, motivated, moving and growing is a plus for the whole team.”

The Moanalua Medical Center in Honolulu is saving the planet, one unit-based team at a time.

The Ambulatory Surgery Recovery UBT started collecting small bags of recyclables on its own in March. But team members resorted to some “trash talking,” and now the entire medical center collects about 30 pounds of recyclables each week.

“The original goal was to help our aina (land) thrive,” says Avis Yasumura, RN, the team’s union co-lead and member of the Hawaii Nurses Association, OPEIU Local 50. “Being on an island, there are limited space and resources.”

The region estimates that since October 2010, the recycling has diverted 7.1 tons from the landfill and saved several hundred dollars in recycling fees.

The ASR team started by identifying items on its unit that a local vendor was willing to collect and recycle: irrigation bags, wrappers for intravenous tubing and operating room “peel packs” (sterile wraps for drapes, instruments, gowns and gloves). The team used tests of change to successfully gather and segregate the items.

ASR shared its effective practices in several ways, including:

• a PowerPoint presentation on products that can be recycled
• “Going Green” editions of its UBT newsletter and fliers with pictures of recyclables
• helping other units order blue recycle containers and arranging for pick up with the EVS department

The team also promoted the project at Hawaii’s first UBT fair, with a colorful storyboard display, complete with examples of recyclable products.

“It was the talk of the UBT fair,” says ASR co-lead Janet Lundberg, nurse manager of procedural sedation. “This recognition inspires all UBTs to take risks.”

More than 10 teams at the 300-bed center are recycling now.

Where did the ASR unit get the recycling bug in the first place? Carolyn Sandison, an HNA nurse, was inspired by an LMP bulletin board poster in her break room about the blue-wrap recycling project at Sand Canyon Surgicenter in Southern California.