Best Place to Work

Our National Agreements commit us to operating principles that you won’t find in most labor contracts:

Power of partnership

Interest-based bargaining doesn’t guarantee success. It works for us because our partnership works.

The partnership between Kaiser Permanente and the Union Coalition came about in 1997, in a challenging environment. The company had a long and close history with the labor movement. But amid growing market pressures and labor unrest in the 1980s and ’90s, we were at a crossroads. Most of the local unions representing KP workers formed the Coalition of Kaiser Permanente Unions to launch a unified corporate campaign.

Facing what would have been a mutually destructive strike, the leaders of both parties took a chance on an alternative approach. They agreed to:

• Work collaboratively to improve the quality and affordability of care for the patients and communities we serve
• Help Kaiser Permanente lead the market in health care
• Involve unions and individual workers in workplace decisions
• Provide job security and be the best place to work in the industry.

Solving tough issues

Today it is the largest, longest-running and most comprehensive such partnership in the country. It covers 80 percent of our represented workforce and includes 43 local contracts, in addition to the national agreement. It has delivered industry-leading contracts, and helped Kaiser Permanente achieve industry-leading quality, solid growth and a culture of collaboration.

In short, our partnership is more than a labor relations strategy, it’s an operational strategy that provides strength and stability for Kaiser Permanente and our workforce, and better care and service for our members, patients and customers. It provides an infrastructure for continuous performance improvement and a way to better resolve difficult issues.

For example, during the Ebola crisis of 2014, health care providers and members of the public were concerned about how to best control spread of the disease. Kaiser Permanente, our union partners and the Centers for Disease Control and Prevention stepped back from the fear and misinformation that prevailed elsewhere. We worked together to develop training processes, educate people and agree on steps to ensure the safety and compensation of employees involved in caring for patients with the Ebola virus. Two of our hospitals were among the first in the United States to be recognized as part of the nation’s Ebola preparedness and response plan.

Frontline teams lead change

Day-to-day partnership is most evident in more than 3,400 unit-based teams—our term for the natural work groups that deliver care and service. Team members are trained in performance improvement techniques to spot opportunities, conduct small tests of change, assess results and implement solutions. They provide a new level of learning and decision making about the quality of their work and how to do it better.

UBTs are co-led by a union member and the manager or supervisor. In clinical settings they include physicians. We track the performance quarterly of every team, based on jointly set measures of performance, and we set aggressive goals for the number of teams to reach high performance, measured on a 5-point scale.

Seventy percent of them are rated high performing. That’s important because our data show that high-performing UBTs get better outcomes on service, quality, safety, attendance, patient satisfaction and employee satisfaction.

New tools and skills

Amy Edmondson, Novartis Professor of Leadership and Management at Harvard Business School, has studied Kaiser Permanente’s model of teaming and offered this assessment:

Unit-based teams are a way to be entrepreneurial and a way to build greater accountability by those on the front line. The teams push people to brainstorm, to be attentive to what they see and to put their own experience to good use. The teams have the opportunity to identify challenges and they have tools and skills with which to work, but it’s up to them to put them to good use to make a difference for patients.

Our teams now have more than 7,700 frontline improvement and innovation projects under way. To align local team efforts with the organization’s broader strategic goals, all projects are focused on one or more points of the Kaiser Permanente Value Compass – a guidepost that shows our four shared goals of best quality, best service, most affordability and best place to work, with our patients and members at the center of all we do.

Kaiser Permanente Value Compass

About 35 percent of these projects are focused on reducing waste or improving affordability. And 267 of those projects, produced joint savings of $10 million in 18 months; potential savings are much more. Twenty-eight percent of projects are focused on service enhancement. Here’s a snapshot of improvement projects conducted at each point of the Value Compass:

• Best quality: A medical imaging team worked across departmental lines to ensure that patients who visited the medical office for a flu shot, and also were due for a mammogram, could get one promptly, many within 20 minutes.
• Best service: A cross-functional team of service center workers redesigned work processes to handle incoming calls in the wake of the Affordable Care Act. The team cut the number of customer handoffs by 60 percent and reduced mean processing time for members’ issues from 26 days to three days.
• Most affordable: An inpatient pharmacy team launched a cost-reduction effort that is saving more than $600,000 a year by better managing inventories, alerting physicians to less costly equivalent drugs and reducing drug wastage.
• Best place to work: As part of our voluntary workforce wellness program, 62 percent of eligible employees – more than 80,000 people – participated in a confidential health assessment to identify potential health risks. 

Getting measurable results

We know our strategy is having an impact on organizational performance and the workplace experience. Our 2014 employee survey showed strong correlations between several measures of employee engagement and job performance.

Departments that scored high on an index of 18 measures of workforce effectiveness (including things like taking pride in the organization, information sharing, understanding of goals and being held accountable for performance) reported significantly better results in service, quality, workplace safety and attendance. For instance:

• 9 percent higher patient satisfaction scores
• 18 percent fewer lost work days
• 41 percent fewer workplace injuries
• 91 percent fewer bloodstream infections in at-risk patients

In addition, members of high-performing unit-based teams are far more likely to say they have influence in decisions affecting work, are comfortable voicing opinions, and feel co-workers are respected despite differences.

Higher job satisfaction also contributes to significantly lower employee turnover. In California, for instance, our turnover rate for all hospital-based employees ranges from 6 percent to 8 percent, depending on the job type – versus the 2014 industry average of 9.4 percent statewide reported by the California Hospital Association.

Union Coalition members and Kaiser Permanente also collaborate on many issues rarely open to union participation. For instance:

Workforce planning and development: We invest heavily in workforce training and development – and we develop and implement most of that work jointly. For instance, a union-management Jobs of the Future Committee in Southern California is identifying emerging technology, assessing the impact on workers, managers and physicians, and developing training plans and career paths. More such efforts and investments are under way.

Market growth: Bringing together union members and Kaiser Permanente sales and marketing teams, our joint growth campaign helped win, expand, win back or retain 33 accounts covering 125,000 Kaiser Permanente members in 2014.

Meeting organizational challenges

Our partnership is not perfect. It can stretch us to engage and educate our many stakeholders, and find time to solve problems and improve work processes in the course of day-to-day operations.

But in my experience, the biggest challenge is spreading innovation – facilitating the exchange of ideas and the adoption of successful practices from one team, medical center or region to another. We know that new initiatives can take root faster and more consistently if they’re modeled on a proven concept – especially when they are championed by our own work teams. Variation can be a plus when you’re looking for new and better ways to do things; when you’ve found the best way, you need to make it a work standard.

We recognize and spread success by communicating with teams regularly in multiple formats; through peer consultants and sponsors in every facility; a system-wide database that tracks teams’ tests of change and outcomes; and UBT Fairs, where teams share their findings in person.

Keys to success

Our Labor Management Partnership is now in its 18^th year, and we are still learning how to take it further. We continue to believe it can be a model for labor relations and health care delivery. Four factors in particular are essential to success:

• Develop leadership at all levels: Since its founding, our partnership has thrived under three different Kaiser Permanente CEOs and three different Union Coalition executive directors. Change is not sustainable if it depends on one top leader. Frontline and mid-level leadership, on both the management and union side, is key. We train for partnership at all levels, and have found that interest-based problem solving and bargaining are powerful learning development tools for up and coming leaders.
• Build trust: To work together, partners must trust one another. That trust must be earned, and is established over time. It will be tested, but the building blocks are well known: Do what you say you will do. Honor your commitments. Treat others with respect and deliver results.
• Measure results and share data: We set goals and track performance for all our teams. We share business and financial data with our partnership unions in bargaining, and share departmental and unit-level results with teams working on performance improvement projects. Teams can’t succeed without good information upon which to set clear expectations.
• Create a shared framework: Our workforce is diverse in every way – demographic, geographic, professional and technical. We also have different (and sometimes competing) needs, interests and concerns. But we share a desire to make our members’ and patients’ lives better. The Value Compass – with the member and patient in the center – provides a common touch point that we use to set priorities and guide decision making.

Our union and organizational leaders know how to do business in traditional, more adversarial labor relations settings. We’ve done it. We choose to work in partnership – not because it feels better (though it does) or because it’s easier (it’s not). We do it because it gets results – for the organization, the unions and workers, and the members, patients and communities we serve.

It’s time to look beyond labor relations and find new ways to innovate and engage teams. Our leaders took a risk 18 years ago to listen, understand and work together. It proved to be better way to deliver health care and achieve our social mission.

This article was originally published in “Perspectives on Work,” the magazine of the Labor and Employment Relations Association (LERA), Volume 19. Reprinted with permission. For more information, visit LERAweb.org.

Also see a PDF of the original article, with additional information about Kaiser Permanente and the Labor Management Partnership.

On a warm fall afternoon, nearly 35 children are bouncing off the walls as they get ready to leave the classroom and head out to their elementary school’s garden. They’re all members of an after-school garden club and cooking class called Edible Olympic. It’s the brainchild of Maria Peyer, an oncology nurse and team co-lead at the Longview Kelso Medical Office in Kaiser Permanente’s Northwest region and her husband, elementary school teacher Michael Bixby.

The kids can barely contain their excitement as Bixby tries to calm them down so they can listen to the afternoon’s agenda.

“The sooner you settle down and be quiet, the quicker I can finish what I need to say and you can get outside,” he implores the class.

Quickly, the hubbub settles. Bixby goes over what needs to be done: plant blueberry bushes, dig a hole for a tree, and remove bamboo sticks. He also reviews the Garden Guidelines, which include listening with respect, walking (no running) in the garden, and asking for permission before picking anything. Then he asks, “Whose garden is it?” and gets a resounding and loud, “Ours!” as everyone heads outside to get to work.

The students attend Olympic Elementary School in Longview, Washington. They don’t have many advantages: More than 20 percent of the city’s population is below the federal poverty line, and 90 percent of the school’s students participate in the free or reduced-price lunch program. Many experience food insecurity regularly, not knowing if they’ll have enough—or any—food to eat.

Income-related health disparities

There are well-documented health disparities related to low income, and these kids are at risk. Edible Olympic is helping address that vulnerability, teaching the kids about healthy food and how to prepare it, laying the foundation for good eating habits that last a lifetime. It’s an example of how partnership principles expand naturally and necessarily into the community; the new 2015 National Agreement includes commitments to jointly work on improving the health of the communities we serve.

The Longview project grew out of a Kaiser Permanente adult cooking class recommended for oncology patients, one that focuses on a plant-based diet. Peyer says that after moving to Longview, she and her husband were struck by the limited resources available to the children in the community.

“We wanted to affect change as directly as possible,” says Peyer, an OFNHP/ONA member. “So we dove headfirst into Edible Olympic. We didn’t want to spend time in meetings, we just wanted to get in the dirt and the kitchen—and that’s what we did.”

She sought support from Thriving Schools, one of Kaiser Permanente’s Community Benefit programs. She forged partnerships with the school’s Parent-Teacher Organization and the Lower Columbia School Gardens, a nonprofit that helps schools create garden programs. Local stores donated money. High school students from Longview and Portland also are participating.

“The kids, their parents and the greater community have embraced the efforts and confirmed that our hunches were right,” Peyer says.  “Good, healthy, real food, prepared simply, with love and in community, can be life transforming.”

Members of the Oncology unit-based team are supporting the project, too, donating money and time; four KP employees help staff the cooking class.

“Volunteering in the community gives us at KP a chance to share our skills and our approach to supporting good health,” says Elizabeth Engberg, the Northwest’s Thriving Schools program manager. “It also helps us learn about our members—where they live, work, learn and play, because that’s a huge part of what affects their health. Schools are the best place to do this.”

Overwhelming participation

The program has had overwhelming and unexpected participation.

“The idea was that this project would launch with eight to 10 kids. We had 60 kids come to the information session,” Peyer says, which prompted an instant expansion from one to two sessions. The kids work in the garden on Thursday afternoons, and on Fridays, they walk across the field to the middle school, where they are able to use the home economics classroom for cooking class. The sessions run for five weeks and end with a celebration where the kids cook a complete meal and share with their friends and family.

The first session got under way last spring. A grassy patch of the school’s property was selected as the site for the garden, and the children got seeds started indoors. As weather allowed, the ground was prepared. While they waited for their seedlings to be ready to plant, the kids were introduced to kitchen safety and how to prepare the food they were just beginning to grow.

In the cooking class, kids have a healthy snack, then work in small groups to prepare the dish of the week. When the cooking is done, they gather together  and enjoy their meal. The kids leave with a bag of groceries so they can cook the meal at home.

“In some cases, this may be the healthiest meal the family may eat during the week,” Peyer says.

On that fall day out in the garden, the kids in the second session organized quickly after studying the garden map Bixby brought along for reference. They divided themselves into groups and got to work with shovels, buckets and plants to complete the day’s activities.

One of the choices they faced was whether to extend the blueberries to the fence or stop a few feet in to allow for a foot path. Several kids piped up with ideas. The decision got made after 11-year-old Christian Aguibar offered his opinion.

“We can grow more things if we don’t have a walkway,” Christian said, “so let’s not have one.”

When teen members first visit the Burke Behavioral Health Center in Virginia, they are all asked the same intake questions, ranging from “What do you do for recreation?” to “Does your family have a history of violence?” Their answers help determine the best course of care.

Now, because of a unit-based team project to standardize care for transgender and gender-questioning members, teens ages 14 and older also are asked where they fall on the gender spectrum.

“We included this in the standard behavioral health assessment to normalize it instead of pathologize it,” says Sulaiha Mastan, Ph.D., a licensed clinical psychologist and UFCW Local 400 member. Mastan, who works exclusively with children and adolescents and has about 20 transgender teens in her care, says the information is important for treatment purposes.

For instance, a parent may say a child is depressed and is refusing to go to school. If that child is gender-questioning, gender-nonconforming or transgender, the underlying reason may have to do with changing clothes in the locker room or using the school restroom.

“If I have a teen who says, ‘I have a female body, but I am a male,’ then I am aware,” Mastan says.

High suicide rate

The stakes are high: A 2011 study found that 41 percent of transgender or gender-nonconforming people have attempted suicide sometime in their lives, nearly nine times the national average.

In another change, the unit’s front desk employees now check the electronic medical record to learn each member’s preferred name and pronoun, respecting that a member may, for example, appear male but identify as female.

“At the front desk, we are the first impression,” says Anthony Frizzell, a mental health assistant and member of OPEIU Local 2. “It is imperative that we relate to the patient in the way the patient wishes.”

The UBT also standardized the steps it takes when members are interested in hormone treatments; started a support group on transgender issues for parents; and is developing a brochure that will guide transgender adolescents through receiving care at Kaiser Permanente.

The policies it created follow national and KP guidelines, says Sand Chang, Ph.D., a psychologist and gender specialist in the Multi-Specialty Transitions department in Oakland.

“Although it is not routinely done, this is really falling in line with best practice—to give young people an option,” Chang says.

The project earned the team the R.J. Erickson Diversity and Inclusion Achievement Award at Kaiser Permanente’s 38th National Diversity and Inclusion Conference in October.

The team’s initiatives send the message that wherever a person is on the gender spectrum, it is part of being human, says Ted Eytan, MD, medical director of KP’s Center for Total Health in Washington, D.C.

“What the team is doing is making it very normal,” Dr. Eytan says. “It is something about you that we need to know, rather than something that needs to be extinguished.”