Culture

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.

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.”

Early in her nursing career, Yvonne Roddy-Sturm, now the chief nursing executive at Ontario Medical Center in Southern California, saw that caregiver diversity—or lack of it—matters.

“I saw differences in how some providers cared for people,” she says. “It wasn’t just based on race—economic status, language, lots of things came into play. We all make assumptions about others.”

The consequences of such assumptions are serious, impacting the quality of care a patient receives and leading to a wide range of health disparities.

In the 30 years Roddy-Sturm has been with Kaiser Permanente, our member and patient population has become more diverse—as has our workforce. And that’s helped KP deliver high-quality, patient-centered care.

“Patients who can relate to their caregiver are more likely to follow their treatment regimen,” says Roddy-Sturm. “They’re more likely to ask questions of people who are more like them.”

The Labor Management Partnership plays a significant role in building the skills, cultural competence and work environment needed to serve KP’s diverse patient population.

For example:

• Unit-based teams provide a more inclusive workplace and give staff members a safe place to speak up.
• Two LMP-sponsored educational trusts provide tuition assistance, paid time off and career counseling to help employees move up the career ladder.

And there’s more. Many departments, including Ontario’s nursing department, make their diverse teams part of the hiring process.

“We always start with the skills required to do the job,” says Roddy-Sturm. “Then our panel members bring their own insights and diversity to the discussion. They look for fit, flexibility, compassion and empathy, as well as skill. We try to live our values.”

Brandon Johnson was close to giving up on his dream of becoming an X-ray technician.

Born with sickle cell disease, a genetic blood disorder that primarily affects African-Americans, the 35-year-old Southern California man was forced to drop out of school for semesters at a time.

But thanks to the sickle cell care team at the Inglewood Medical Offices, Johnson is now on medication that reduces complications. Last fall, he was able to complete his studies, and he has started looking for a radiology job.

“They got me on a plan to keep me out of the hospital,” says Johnson, who drives 60 miles one way from his Riverside home to see his doctor in Inglewood, even though other providers are closer. “If I didn’t have my health, I wouldn’t be where I am today.”

Johnson’s success is not uncommon for the Level 5 unit-based team, a group of physicians, managers and employees that provides personalized care for nearly 500 sickle cell patients in Southern California. About 300 of the region’s adult patients are treated directly by the team. Its approach is working—only five of the 300 needed frequent hospitalization and emergency care in the past year.

“Our goal is to keep sickle cell patients out of the hospital by giving them the care they need,” says Pippa Stewart, Inglewood’s department administrator.

Stigmatized as drug addicts

Nationwide, about 70,000 people have sickle cell disease, which can cause chronic anemia, acute pain, infections and stroke. Although most are African-American, the disease also affects people of Indian, Middle Eastern, Hispanic and Mediterranean heritage. Patients often get stigmatized as drug addicts when they ask for narcotics to deal with their pain.

The current UBT grew out of a team that was established in 1999; before that, there was no comprehensive treatment program for KP’s sickle cell patients.

“Ninety percent of patients were getting their primary care in the emergency room,” says Shirley Brown, RN, a UNAC/UHCP member and the team’s care manager. Patients saw as many as 17 doctors as they went from appointment to appointment.

Now, the 12-member UBT—which includes four physicians, two registered nurses, a physician assistant, a pharmacist and a social worker—helps patients control symptoms by offering pain management care, providing resources such as a case manager, and urging them to keep appointments, which help minimize visits to the emergency room and hospital.

Team members coordinate with and help train the KP providers who care for the region’s remaining 200 patients. Last fall, Brown helped lead a session for 70 registered nurses from around the region. Osbourne Blake, MD, an internist and the team’s lead physician, provides regular updates to fellow physicians. “We’re trying to get everyone on the same page,” says Dr. Blake. A recent test of change focused on reducing the number of patients who miss appointments. For three months, Brown and a co-worker called patients every day to remind them about upcoming visits. The calls helped. The team’s “no-show appointment” rate dropped from 20 percent in May 2015 to 14 percent in August 2015.

Dramatic improvement

“They all know you personally,” says Ryan Hull, a 27-year-old TV production assistant and film student. A few short years ago, he suffered frequent crises that required immediate medical attention. After he and his physician co-created a pain management program, his health improved dramatically.

“They did everything they could to find out what regimen works for me,” Hull says of staff members, who greet him by first name and offer walk-in appointments to accommodate his sometimes unpredictable schedule. “They figured out the perfect way to treat me.”

For the past few years, unit-based teams have been driving a powerful transformation. It’s helping to control chronic diseases; assisting in the early detection of cancer; providing familiarity with a patient’s community; and enabling frontline employees to speak a patient’s language. It creates customized care for each of Kaiser Permanente’s more than 10 million members.

It isn’t a cool new gadget or something out of a sci-fi flick creating the change, but rather a modern care approach that takes into account the infinite number of ways KP members are unique—that emphasizes diversity and inclusion.

“All of us as individuals have all these different multicultural identities, and so do our patients,” says Ron Copeland, MD, senior vice president of National Diversity and Inclusion Strategy and Policy and chief diversity and inclusion officer. “We have to create high-performing teams that work together to deliver culturally responsive care that addresses those differences.”

Increasingly, the workers, managers and physicians working together in UBTs are considering the many facets of individual patients as they transform—in small and large ways—how they care for and serve those patients, using their knowledge and empathy to rethink how we deliver care.

As the stories in this issue of Hank illustrate, some of those changes are aimed at eliminating race- and gender-based health disparities. Other changes are taking place outside our medical facilities—working with school-age children, for example, to give them better food choices and teach them healthy habits that can last a lifetime. 

By doing this, UBT members are ensuring that Kaiser Permanente members are the healthiest they can be no matter their background or beliefs, language or gender, disability or economic status, whether they live in a big city or on a farm.

“UBTs have always led on innovating care by putting patients at the center, listening to them and customizing care for them,” says Hal Ruddick, executive director of the Coalition of Kaiser Permanente Unions. “This work strengthens and deepens that high-quality care.”  KP’s workforce is full of diversity, and UBTs are designed to draw on all employees’ perspectives in deciding how best to do the unit’s work. It’s a natural step to include our members’ and patients’ viewpoints as well. Understanding and considering the complexity of the patients and communities we serve directly affects quality of care and health outcomes.

“It’s about using our knowledge of differences as an advantage to better understand the patients we care for,” says Dr. Copeland. “Our goal is health care equity—so that all our patients achieve optimal health. For that to happen, it’s essential that we have approaches that account for our patients’ unique needs, preferences and living conditions.”

Colorado

The Colorado region is improving patient care and saving millions by providing high-risk patients extra attention after discharge, leading to a reduction in readmission rates. In the Post Acute Care Transitions (PACT) program, nurse practitioners visit patients in their homes after discharge from a hospital or skilled nursing facility, giving them a chance to alter the patient’s care plan if needed. The PACT team has visited approximately 4,200 high-risk patients since the program began in January 2013. At that time, 22 percent of high-risk patients were readmitted within 30 days, at a cost of $11.7 million. The PACT team has reduced readmission rates by 50 percent, saving Kaiser Permanente approximately $6 million since the program began.

Georgia

To make sure no good deed goes uncopied, the Georgia region launched a Spread and Sustain system to move best practices throughout the region—and showed off the results to KP’s board of directors at a UBT fair early last summer. Georgia took a spread blueprint from the Southern California region and fine-tuned it to meet its needs. Now its unit-based teams, sponsors and regional leaders identify projects with good spread potential, determine other locations where the new process could work, share the practice and check back to see how they’re being sustained. Several projects have been successfully spread region-wide—addressing such issues as hypertension, HPV vaccinations and lab specimen collection.

Hawaii

Hawaii is a beautiful place to live, but Kaiser Permanente members who live on the less-populated islands sometimes find it challenging to get the care they need. To address that, KP offers a special benefit called Travel Concierge Service. If health plan members need medical care that isn’t available on their island, KP assists them in traveling to the Moanalua Medical Center in Oahu or to a specialty care medical office. KP makes the travel arrangements and picks up the tab for travel, including airfare, shuttle service and discounted hotel rates. For minors who need specialty care, KP also pays for companion travel. “Our members love this service,” says Lori Nanone, a sales and account manager in the region.

Mid-Atlantic States

For several years, co-leads in the Mid-Atlantic States have compiled monthly reports of their UBT activities, goals and progress using Microsoft Word and Excel. Now, the region is rolling out a dashboard that automatically compiles the same information from UBT Tracker into an easy-to-reference SharePoint site, Kaiser Permanente’s new online social collaboration tool. The new dashboard will encourage more frequent updates to UBT Tracker and eliminate the need for co-leads to create separate documents, says Jennifer Walker, lead UBT consultant and improvement advisor. “Now the information we get is more timely and easier to assess,” Walker says. “Before, the information was up to a month old.”

Northern California

The Santa Rosa Medical Center Diversity Design committee is equipping employees with tools to help them provide better service to Spanish-speaking patients. The group, composed of labor and management, has been piloting a handout featuring a list of common Spanish phrases, such as ¿Necesita un intérprete? (“Do you need an interpreter?”), as well as instructions on using the phone interpreter system. The idea came from a Spanish-speaking patient on the facility’s Latino patient advisory committee, who recalled the time she was lost in the facility and no one could direct her in Spanish. The Spanish language flier is the latest in the committee’s work to help ensure all patients receive the same optimal service and care.

Northwest

Unit-based teams in the Continuing Care Services department are focusing on improving the experience for some of Kaiser Permanente’s most vulnerable members: those in skilled nursing facilities or receiving home health, hospice or palliative care. Teams are focusing on ensuring better transitions for patients as they go from inpatient to ambulatory care. By identifying issues before they become problems, labor and management hope to coordinate care more effectively, reduce emergency department visits and cut down on outside medical costs.

Southern California

Harmony comes easily when you use the tools of partnership. Just ask the Biohazards, a band of union members and a manager that uses partnership principles to guide performances. “We call ourselves an LMP project,” says Mary Anne Umekubo, a clinical laboratory scientist and Regional Laboratory assistant director who sings and plays percussion and guitar. She is among six band members who represent a variety of departments, shifts and unions, including SEIU-UHW and UFCW Local 770. Performing for friends and colleagues, band members use consensus decision making to choose songs, interest-based problem solving to fix mistakes and the Rapid Improvement Model to tweak performances. “We’re from different departments,” says drummer Eric Cuarez, a regional courier driver and SEIU-UHW member. “We come together to play music.”

Diversity and inclusion. Without both, we each tend to identify with our own clan—be it defined by race, gender, age, economic status, what have you—and all the other clans remain other.

Diversity without inclusion permits an accumulation of biases that leads to a world where, as one recent study showed, minority patients are up to 30 percent less likely to receive pain treatment in emergency rooms than whites, even though they report pain just as frequently. This matters: Pain slows healing and can create new health problems. Sadly, this huge gap in treating pain is just one example in a long list of health disparities linked to cultural biases.

Inclusion—finding what we have in common, appreciating diversity instead of ignoring differences—is key to eliminating disparities and delivering high-quality health care.

As Ron Copeland, MD, Kaiser Permanente’s senior vice president of National Diversity and Inclusion Strategy and Policy, says, “I don’t believe you can have passion for true quality or service excellence without also being genuinely passionate about diversity and inclusion practices. They’re one and the same.”

How do you get good at inclusion? Practice seeing what you have in common with others. The Labor Management Partnership’s unit-based teams—whose membership cuts across all demographics—do this daily as they use interest-based problem solving. As this issue of Hank shows, a natural next step is to address how to deliver the best possible care to all our members.

It takes only one person or one small group to spark meaningful change. Be that person. Be an active member of your team.