CHAPTER 3
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Core Practices of Successful Labor-Management Partnerships

The current system cannot do the job. Trying harder will not work. Changing systems of care will.

—Institute of Medicine and the Committee on Quality of Health Care in America

Over the past 30 years, Labor-Management Partnerships have increased frontline staff participation in decision making within manufacturing, technology firms, federal and state governments, school systems, and healthcare organizations. These joint activities have improved the quality of services and products and contributed to considerable cost reductions in the organizations that have adopted them. As already noted, after creating a comprehensive Labor-Management Partnership, Xerox reduced its manufacturing costs by over 30 percent; in healthcare, Maimonides Medical Center dramatically increased safety by reducing patient falls and hospital-acquired infections by 50 percent and improved overall patient satisfaction with hospital cleanliness by over 75 percent, with a cost savings of 45 percent in supplies.95

Current research on best practices of Labor-Management Partnerships conducted by American and European scholars, including the first author,96 and advice garnered from many practitioners of this method suggests that seven LMP core practices lead to successful outcomes:

(1) Hiring an initial consultant familiar with the most effective methods for enlisting frontline staff and management involvement in Partnership activities.

(2) Developing extensive educational activities for frontline staff and senior leaders so they can understand why changes are needed and how productive change can occur.

(3) Creating a social contract between labor and management that spells out clear ground rules; a defined structure for joint work and decision-making processes; and specific, mutually advantageous goals. When possible, the contract should include an employment security clause.

(4) Developing internal consultants and coaches to support problem-solving work groups and teams.

(5) Improving overall labor relations to encourage employees to work with management, contributing their ideas and advice.

(6) Using sector strategies to identify known ways of achieving successful change.

(7) Creating an effective process for documenting results.

Not every healthcare Labor-Management Partnership initiative focuses on all core practices at once. However, the core practices presented in this chapter serve as a basic roadmap for labor and management leaders in healthcare systems or in other organizations seeking to develop or deepen joint activities.

We illustrate these core practices through two case studies of developing Labor-Management Partnerships in healthcare organizations. The first case study concerns the development of a Labor-Management Partnership at Maimonides Medical Center, a stand-alone hospital offering extensive outpatient services and actively interfacing with community groups. The second case study involves the Labor Management Partnership at the Los Angeles County Department of Health Services (LA-DHS), the second-largest public health system in the United States, encompassing four major hospitals and 17 ambulatory care facilities.

As W. Edwards Deming, the quality control guru in the 1980s, stated, there is “no instant pudding for transforming organizations—it is a marathon, not a sprint.”97

We have tried to capture enough basic details from each case to illustrate the nature of these “marathons” and to describe how these core activities supported Partnership work. We indicate the key roles that collaborative leaders have played in implementing these core practices.

Case Study 1: Maimonides Medical Center

Over 100 years old, Maimonides Medical Center is a respected treatment facility and academic medical center in Brooklyn, New York. Serving people of all faiths and backgrounds from the borough’s extremely diverse population, Maimonides Medical Center has 705 inpatient beds and more than 70 primary care and subspecialty programs. Each year it records more than 80,000 emergency room visits, 210,000 ambulatory care visits, and 6,700 infant deliveries. As such, it is one of the busiest medical centers in New York State. It also trains more than 400 medical and surgical residents annually.

Maimonides started its Labor-Management Partnership process (referred to as their “Strategic Alliance”) in 1997. The Alliance reflected the shared vision of Executive Vice President Pam Brier and the late John Reid, then executive vice president of Service Employees International Union (SEIU) Local 1199, to establish a joint working process for labor and management to meet the challenges of the rapidly changing healthcare environment. The 1994 collective bargaining agreement between SEIU 1199 and the League of Voluntary Hospitals and Homes of New York, to which Maimonides belongs, articulated the importance of such joint work to improve patient care in League hospitals and nursing homes. This historic agreement did not, however, detail which activities would be most helpful, nor how to implement them.

The success of the eventually robust Strategic Alliance at Maimonides Medical Center to a large extent reflects the collaborative leadership98 of Brier, Reid, and eventually Bruce Richard, former executive vice president of SEIU 1199, and the extremely motivated frontline staff who contributed to redesigning work processes in many areas of the hospital.

Pam Brier, a progressive healthcare administrator who worked for many years in New York City hospitals, was a pro-worker community activist who was passionate about improving patient care. She teamed up with John Reid a little over a year after she became executive vice president of Maimonides in 1995. Brier eventually became the president and CEO of Maimonides in 2003. For years she had wanted to find ways to improve the working relationship between labor and management. Reid was a veteran union leader, deeply involved in civil rights issues, who was already beginning to move SEIU 1199 away from being a traditional union to one proactive about the changes taking place in healthcare systems. Later, Bruce Richard, another SEIU 1199 executive VP, assumed Reid’s role as the key union leader working with Brier at Maimonides. Richard, a community organizer and social justice advocate, brought his own experience working as a meter collector in New York, where he had experimented with implementing self-managing work teams.99

The Affordable Care Act of 2010, which placed quality control demands on hospitals and provided health insurance for close to 20 million Americans, had not yet been conceived in 1997. It was nonetheless clear to Brier and Reid that healthcare delivery systems in Brooklyn and elsewhere in New York State needed to radically improve their quality of and access to care, while at the same time controlling costs. Brier and Reid shared the goal of using a worker participation process to address these issues within the Medical Center while creating meaningful work for frontline staff.

As there were then very few Labor-Management Partnership models in healthcare organizations, Brier and Reid hired Lazes as a consultant to advise them about initiating their Strategic Alliance process (Core Practice 1). He suggested that they visit the Saturn Corporation for a close-up view of an existing, highly successful Labor-Management Partnership process. Lazes was familiar with the Saturn Partnership, having served as an early consultant to their process. The Saturn trip provided a valuable experiential education (Core Practice 2) for key union and management leaders from Maimonides in what a Labor-Management Partnership (LMP) process could achieve and in how it worked.

Reid and Brier quickly formed a delegation of hospital union and management leaders to meet with personnel in corresponding positions and with frontline staff at Saturn’s manufacturing plant in Spring Hill, Tennessee. They hoped to learn about how the LMP process at Saturn had been developed, how its employees had experienced its growth, and how management and labor had worked out their differences. From this site visit, they learned firsthand the importance of the key practices described in this chapter. Most impressive, according to Brier and Reid, was their observation of the extensive research undertaken by the workforce, union leaders, and plant management before constructing the factory (Core Practice 2), in order to learn the most up-to-date sector strategies (Core Practice 6) for automobile manufacturing. A labor-management task force at Saturn (“the Committee of 99”)100 had spent a year amassing considerable data about what was working and what was not for their parent company, General Motors, and their competitors, and had investigated cost controls with an eye toward producing an affordable, attractive compact car to compete with popular Japanese models.

Maimonides representatives were also impressed by the details incorporated into Saturn’s social contract (Core Practice 3). This document, which they closely examined, set ground rules from which a culture of collaboration took shape and continued to grow, as well as a clear process for problem identification, problem solving, and decision making. At Saturn, management and the union agreed to a decision-making process in which the union would be a full partner in all decisions.

This educational site visit provided an experience that was crucial for convincing union leaders, as well as middle-level and senior managers at Maimonides, of the value of initiating an LMP for their hospital. Upon returning to Maimonides, union and management leaders established a two-hour educational workshop for all employees. The goal was to share with all staff the challenges facing Maimonides and other hospitals in New York City (Core Practice 2). Maimonides was facing changes in state and federal reimbursements, particularly payments for Medicare patients, that now tied levels of reimbursement to treatment quality and patient satisfaction scores. There was also the possibility that for-profit hospitals might be entering the New York healthcare market as competitors for patients.

In order to model a joint process for Partnership at Maimonides, these and subsequent educational workshops were conducted by a joint team comprising a union leader and a manager. For frontline staff, this collaborative leadership approach demonstrated a radical change in the hospital’s practices. Collaborative leadership is a style of organizational management that fosters the roles of labor and management as co-leaders who encourage frontline line staff to share their knowledge and expertise about problems in their institution. Collaborative leaders enable staff to identify and solve problems that they experience firsthand, and to implement their solutions. Such an approach encourages staff to eventually become leaders in their organization.

The co-facilitated workshops also conveyed to frontline staff that the unions at Maimonides SEIU 1199 and the New York State Nurses Association [NYSNA])101 were active partners in these activities. Beyond sharing information about the changing healthcare landscape in New York City, the workshops solicited suggestions from frontline staff about patient care problems that required resolution. Attending physicians, department chairs, residents, and interns went to these participatory educational workshops along with nurses, social workers, environmental service employees, security guards, dieticians, pharmacists, food service workers, and receptionists.

A few SEIU 1199 and NYSNA shop stewards initially resisted attending the workshops, convinced that their unions would essentially be colluding with management, whose job it was to solve patient care issues, not theirs. Reid, however, used one-on-one meetings with these individuals to explain how true collaborative Partnership activities, such as the one at Saturn, had actually increased union membership and member involvement in union activities. It had also given workers a voice in daily decision making about their jobs and the equipment they used. Several managers similarly did not accept the need to consult frontline staff about ways to improve patient care, or to decide on the purchasing of equipment or supplies. In similar one-on-one sessions with these managers, Brier found that a successful strategy was to encourage hesitant managers to begin with a low-risk project that might help them learn through experience the specific benefits of frontline staff participation.

Having completed the initial educational and focus groups, Brier and Reid organized a daylong retreat with key management, union leaders, and frontline staff. This highly interactive work session focused on clarifying why and how a Labor-Management Partnership would be helpful for Maimonides, drafting some joint goals for their Strategic Alliance process, and identifying some initial joint activities. I (Lazes) facilitated the work session, which included breakout meetings for discussions with small groups of frontline staff. Throughout the day, Reid, Brier, and I encouraged all participants to express their concerns about the Partnership process and suggested areas in the hospital that could benefit from the initial Partnership work groups.

This retreat created an opportunity for frontline staff, from environmental services employees to attending physicians, to comfortably contribute their ideas and concerns. For most frontline staff, inclusion in a conversation with the president of the hospital and several medical department chairs was an uncommon experience. To create a respectful and welcoming setting, the retreat had an agenda based on understanding the concerns of all stakeholders, not just those of senior management. This helped to create a more level playing field so that all participants gained comfort in expressing their viewpoints without fear of criticism. Participants were encouraged to contribute to large and small group work sessions throughout the day.

The agreements reached at the retreat became the heart of the LMP social contract (Core Practice 3). This document included goals for joint work (that is, issues important to Maimonides unions and managers for the Partnership to address), a plan for initial project activities, a budget for relieving frontline staff of their usual responsibilities to work on problem-solving teams, and the creation of a Labor-Management Strategic Alliance Council as a governance structure that would oversee hospital-wide and unit-level projects. Three new positions for internal consultants (Core Practice 4) were established to support Partnership activities. Finally, an innovative agreement was forged concerning who would decide whether to accept the recommendations of the various problem-solving teams. Such decisions would be arrived at jointly, rather than solely by management, and would be based on the data that the different teams gathered in support of their proposals. It was agreed, too, that administrators would share departmental budgets and patient care data with frontline staff teams, so that they would have the necessary information to further their work. This social contract also clarified that no employee would lose his or her job as a result of LMP activities.

Membership in the Labor-Management Strategic Alliance Council comprised union and management leaders, as well as frontline employees from the inpatient and outpatient laboratory, and from the Departments of Food and Nutrition, Engineering, Ambulatory Care, Nursing, and Medicine. The hospital’s chief medical director, the director of the Emergency Department, the director for labor relations and performance improvement, the chief financial officer, and the president/CEO of Maimonides were also Council members. Additional members were added to the council as work expanded to other departments of the hospital.

Initially, frontline staff participation activities focused on three departments: Radiology, Food and Nutrition, and the inpatient and outpatient laboratory. A hospital-wide committee, the Joint Hiring Committee, was established to develop joint goals for hiring new managers and supervisors. In each department, I provided unit-based teams with conflict-resolution and problem-solving training and taught them how to use workflow diagrams to analyze work roles and processes in underperforming areas. Details of how such unit-based teams accomplished their work appear in chapter 4.

As at Xerox, to support the transformation to a frontline staff-participation culture at Maimonides, Brier and Reid created the position of internal consultants (termed “Developers”) to assist and support Partnership work groups (Core Practice 4). These leaders witnessed the need for neutral mentors, working with both labor and management as coaches and educators, during their Saturn visit. Such mentors oversaw the progress of the work groups and ensured that their members received education, training, and support to accomplish their goals. The Developers worked with Maimonides’ middle managers and shop stewards to ensure that frontline staff were freed from their normal duties to attend work group meetings and that meeting rooms were available to them. Co-chairs of the committees found the internal consultants’ assistance with work group preparation and follow-up assignments quite helpful.102 Besides assisting individual work groups, the internal consultants (“Developers”) met periodically with shop stewards and supervisors to discover new approaches that might help support Strategic Alliance activities and overall labor relations (Core Practice 5).

In these basic ways, internal consultants helped ensure that Partnership activities were well organized and that the various teams focused on the problems they were tasked to solve. This, along with ensuring that teams consulted with any worker whom their recommendations would potentially affect—an important aspect of collaborative leadership—helped most teams to achieve positive results. Having internal consultants has enabled Maimonides, over the years, to broaden and sustain worker participation activities without relying further on my consultations.103

At Maimonides, all three Developers (one rank-and-file member of each union104) and one manager were paid by the hospital. They were chosen by senior union and management leaders. Selecting employees for this role was based on their ability to work with others, on their communication skills, and on their ability to encourage employees to work together. Their training included education in successful methods for achieving organizational change, effective Labor-Management Partnerships practices, methods to support groups and group leaders, and the use of socio-technical analysis tools to optimize the interface between jobs and various technologies. In addition, they learned methods for developing workflow and cost-benefit analyses, and strategies for unblocking teams when they experienced an impasse.105 More details about how to unblock groups that are not functioning well are presented in chapter 5.

Cornell University’s Healthcare Transformation Project, the Performance Improvement staff of Maimonides, and the SEIU 1199 League Labor-Management Project staff106 provided the training for the Developers, each of whom was assigned to a specific department. Notably, several of the original Developers eventually assumed important leadership roles at Maimonides and SEIU 1199 after leaving these internal consultant jobs. Two Developers were appointed to positions in the Labor Relations department—one became its director—and a third Developer was elected a vice president for SEIU 1199. This resulted from their effectiveness in helping frontline staff work together, their ability to get others to work out differences between staff, and their passion to create meaningful work for employees.

Creating a budget for internal consultants and selecting talented and flexible staff for this role has proved critical at Maimonides, as well as in all of the Labor-Management Partnerships cited in this book. The expectation that effective joint work can occur without supportive infrastructures, including a governance process and internal consultants, is one of the most frequent reasons for the failure of Labor-Management Partnerships to achieve effective organizational change.107

The fifth Core Practice cited in almost all Labor-Management Partnership research is the importance of strengthening labor relations so that they are fair and respectful. “Without a positive relationship between frontline staff and management, it is hard, if not impossible, to encourage employees to share their knowledge and skills,”108 asserted Diane Factor, director of the Worker Education and Resource Center at LA-DHS/SEIU, whose LMP is discussed shortly.

At Maimonides, although labor relations were reasonably unconflicted from the beginning, their Labor-Management Strategic Alliance Council took specific steps to strengthen it, using a threefold approach. In the departments where Labor-Management Partnership activities were initially focused, the Developers, along with labor relations staff, organized workshops for both management supervisors and shop stewards. These workshops, held during lunch hours (Lunch and Learn Sessions), offered an opportunity to discuss in more detail why changes were needed at Maimonides and to explore ways to practice proactive and positive labor relations. Role-playing exercises eased what had sometimes been an adversarial or distant relationship to become collaborative, problem-solving endeavors.

One example of how this process worked occurred in the Environmental Services Department. An employee on the first shift, an excellent worker with a stellar attendance record for several years, began to experience difficulty getting to work on time for her morning shift. After several warnings and one suspension by her supervisor, the employee was notified that her job was in jeopardy.

Using this situation to practice a problem-solving approach to labor relations, the supervisor and union steward in her department explored, via role playing, ways to inquire about and resolve this problem. Upon meeting with the service worker, they discovered that she had a young daughter who had recently developed asthma. When her child’s asthma flared up at night, the worker needed to arrange a babysitter on short notice, and occasionally, when the flare-up was severe, she brought her daughter to the pediatrician the following morning. What would have normally resulted in another suspension for tardiness shifted to what could be done to respond to her family situation. After much discussion, a solution emerged: the employee would start her shift an hour later than usual, giving her sufficient time to secure a sitter if her daughter became ill. And if her daughter required medical attention, the employee agreed to immediately call the department to inform them of her situation. This solution was implemented, and tardiness was no longer an issue.

Several other activities have been helpful in improving labor relations at Maimonides. One has been to incorporate information about the Maimonides work culture, emphasizing the importance of frontline staff engagement, into the orientation process for all new employees. Orientation sessions describe specific examples of how labor and management work together at all levels of the organization to improve patient care and job satisfaction. The annual review process for managers, supervisors, and department heads now routinely evaluates their record regarding labor relations and their participation with frontline staff in joint activities. These reflection sessions are also used to explore additional ways for the managers to improve labor relations and worker participation opportunities in their department.

A third important activity for supporting positive labor relations has been the creation of joint hiring committees, one of the first hospital-wide projects. These committees were established in each area of the hospital to strengthen the interview process for new department heads, supervisors, and managers, determining whether a particular candidate fits the Maimonides philosophy and values. Even if a candidate previously worked in an organizational culture similar to that of Maimonides, it is important to assess her or his managerial philosophy to determine whether the candidate would be able to contribute to the hospital’s joint work culture. The joint hiring process requires all candidates for management and supervisory positions to be interviewed by both frontline and labor relations staff. Their recommendations on whether or not to hire the candidates are then presented to senior management, who make the final hiring decision. Over the years, senior management has accepted all of the recommendations of the joint hiring committees.

Establishing processes that measure the changes resulting from the Alliance work groups (Core Practice 7) has been pursued rigorously at Maimonides. Their monitoring and documentation process has been a joint effort spearheaded by researchers from Cornell University’s Healthcare Transformation Project109 and assisted by the three internal Developers and the director of leadership development. Involving Cornell and the Developers has helped ensure timely and organized data collection on each project.

Biannual reviews of Partnership activity outcomes by the Labor-Management Strategic Alliance Council has made it possible to track and analyze factors contributing to project successes and shortcomings (see table 2). Having updates available on the current progress of all teams and committees is particularly important “so that frontline staff can receive information about the successes or shortcomings of their new processes and then make adjustments,”110 observed Susan Goldberg, director of performance improvement at Maimonides Medical Center.

Case Study 2: Los Angeles County Department of Health Services

The Los Angeles County Department of Health Services (LADHS), the second-largest public health system in the United States, includes four hospitals, two large multiservice ambulatory care centers, 17 community health centers, and more than 160 community partner clinics providing primary care. LADHS treats 750,000 patients annually, most of whom receive Medicaid or are uninsured, and employs more than 18,460 staff. The unions representing workers at LA-DHS are the Committee of Interns and Residents (CIR); the Union of American Physicians and Dentists (UAPD); the American Federation of State, County and Municipal Employees (AFSCME) 2712 and 3511, which represent social workers and psychologists; and SEIU 721, which represents most other hospital workers, including nurses, lab techs, and coders.

Table 2. Summary of Prominent Outcomes of Maimonides’ Strategic Alliance Activities

Areas for Improvements

Outcomes

Absenteeism in housekeeping staff

Reduction of absenteeism by 25%.

Equipment and supplies available at the beginning of each shift for environmental service workers

100% of the time as opposed to rarely.

Housekeeping supplies

Reduction of 49% of costs.

Obtaining uncollected bills

Increased 75% of collections.

Medication reconciliation completed

From 35% to 95%.

Patient overall satisfaction scores for the cleanliness of rooms and public areas

From 67 % to 85%.

Patient meals delivered on time

Increased from 68% to 93%.

Productivity of engineering department

Increased efficiencies by 80%.

Reduction in hospital-acquired infections

Reduced by 50%.

Reduction in labor-management arbitrations

Reduced by 100%.

Reduction in grievances

Reduction of 63%.

Reduction in turnaround time to and from ER to radiology department

From 90 minutes to less than 30 minutes.

Reduction in patient falls

Reduced by 50%.

Response time to cardiac monitors

From 2.5–8 minutes to less than 1 minute.

Transport time for patients to and from the ED for x-rays

Reduced by 40%.

Turnaround time of lab results to the ER

From two to three hours to 30 minutes.

The passage and funding of the Affordable Care Act (ACA) in 2010 allowed formerly uninsured Los Angeles residents to purchase care from various county hospitals. Hospital administrators and union officials at LA-DHS realized that they needed to become a provider of choice for patients in order to remain competitive. They recognized that creating better access to care and ensuring better integration of services so that patients routinely received coordinated, respectful treatment, were imperative.

When Dr. Mitchell Katz, an internist, was hired as director of LA-DHS in 2011, he quickly initiated discussions with Bob Schoonover and Gilda Valdez, SEIU 721’s president and chief of staff, to explore ways to collaborate on changing their system’s structure and culture. Before coming to Los Angeles, Katz was the director of the Public Health Department for San Francisco and the director of outpatient services for San Francisco General Hospital. He had found working with healthcare unions in San Francisco quite productive.

Some LA-DHS senior managers were skeptical, however, about establishing a Partnership process with SEIU and the other unions. Accustomed to top-down initiatives, they had doubts about the capacity of the unions and frontline workers to collaborate productively and efficiently.111 Similarly, many of SEIU 721’s executive board, senior leaders, frontline staff, and shop stewards questioned whether management was serious and committed to a bona fide partnership. In 2007, an early Partnership process established at LA-DHS had suffered from a lack of clear, long-term joint goals, the absence of a mutually acceptable governance and decision-making process, and a failure to free up frontline staff from their daily responsibilities to participate in the various work groups. It had failed dismally.

Acknowledging the skeptics’ concerns, Katz, Schoonover, and Valdez decided that they needed a more comprehensive and effective Partnership process. They felt pressured by the new Affordable Care Act regulations about access, quality of care, and patient satisfaction, which threatened the survival of several hospitals in their system.

After meeting a number of times, Schoonover, Valdez, and Katz agreed to establish a new Labor-Management Partnership process based on creating joint goals and structures that would better support and sustain frontline staff participation. These leaders acknowledged that for patients to achieve better access to coordinated care, many frontline staff jobs would need to change, and the culture had to as well: patients needed to be treated with more respect and dignity, which had not always been the case.112 “A significant paradigm shift was needed—not just minor changes,”113 commented Valdez. This time, the LADHS Partnership process was envisioned by both union and management senior leaders as one that would be forward-thinking and that would incorporate the interests and needs of all stakeholders and employees as well as patients.

Schoonover, Valdez, and Katz decided to model the Partnership process on the core practices established at Maimonides, which by this time had achieved demonstrable success. They agreed to lead these activities jointly, collaborating with each other on all aspects of the Partnership. Because of co-author Lazes’ strong relationship with the national SEIU leadership and his involvement at Maimonides, they hired him as the outside consultant to guide the initial phases of the LMP (Core Practice 1). Lazes suggested a one-day retreat for all key stakeholders to begin a new and different Labor-Management Partnership process at LA-DHS. The focus of the retreat was to help labor and management leaders, middle managers, and frontline staff at LA-DHS understand the financial and quality of care requirements now being demanded of the county’s healthcare system and begin a process that would identify practical methods for meeting them. Another objective for the daylong work session was to encourage frontline staff and managers to articulate goals that were important to them for the Partnership process to address (Core Practice 3).

Three initial goals for the new Labor-Management Partnership process were important to the unions. The first was to establish an intensive educational process throughout LA-DHS (Core Practice 2) so that all employees could learn about current state and federal mandates to improve patient care and the patient experience.114 These educational activities, to be conducted primarily by the SEIU 721 leaders, would clarify that the county’s healthcare system needed to be restructured to become more patient-centered. This meant that many jobs and services would have to be redesigned. The second goal, articulated by the unions and by all frontline staff at the retreat, was that training be provided so that employees could learn the new skills required for their new jobs and job responsibilities. The third goal for the union was to improve labor-relations practices in the LA-DHS.

For management, major goals for the Partnership consisted of reducing the time it took for patients to register and to see a primary care provider; establishing a system so that patients would be seen by the same primary care provider for each of their visits; and ensuring a speedier process for obtaining appointments, particularly with specialists.

Participants at the retreat identified two additional system-wide goals. The first was to standardize the emergency response codes that notified emergency teams across all LA-DHS hospitals and ambulatory clinics of the need for their immediate assistance. The second was to develop a method to monitor and document Partnership activities (Core Practice 7) across the county health system to determine their impact and to communicate the results of their efforts throughout the system.

Work groups formed to address each of these goals composed of members of the LA-DHS Labor-Management Transformation Council and other frontline staff: nurses, housekeeping staff, nursing assistants, and coders. Each work group formulated a quantifiable goal and an anticipated time frame for when this goal would be achieved (e.g., to reduce clinic waiting time for patients by 40 percent in the next two months). After two meetings following up from the retreat, a full social contract (Core Practice 3) and an agreement to create seven internal consultants (Core Practice 4) were established.

The initial work of the LA-DHS Partnership process included implementing Core Practices 1–4, a start at rectifying historically uneven labor-relations practices (5), using a sector strategy (6), and the creation of processes for monitoring and documentation (7). We focus here on Core Practices 6 and 7 (creating sector strategies and documentation/measurement processes), which this system pursued in depth and as such illustrates particularly well.

As mentioned in chapter 1, employing a strategy of proven use in similar organizations can be extremely helpful when attempting to transform an unproductive work system into one that is more effective.

Research by the Commonwealth Foundation, the Robert Wood Johnson Foundation, the Kaiser Foundation, and other organizations has documented that the Patient-Centered Medical Home care process is a successful structure for improving patient care by creating an integrated healthcare delivery system.115 As noted, this approach improves overall patient outcomes, enhances the patient experience,116 and controls healthcare costs. The latter is accomplished through reducing hospitalizations, hospital readmissions, duplicate lab work, and unnecessary radiological studies. Creating a “Medical Home” can achieve a better coordinated care delivery system. This includes such practices as the following:

•   Patients seeing the same primary care provider at each appointment.

•   Patients receiving active follow-up and education about their diagnoses and treatments so that they can more actively manage their health.

•   Patients with chronic conditions such as diabetes, heart disease, hypertension, and asthma being treated based on protocols that emphasize best practices.

•   Specialists and primary care providers following well-defined processes for documenting and communicating their findings and recommendations with each other and with behavioral health practitioners. In most Medical Homes, this involves the use of some type of electronic medical records system to share lab data and test results.

Healthcare systems that employ these methods, such as Kaiser Permanente, also use a reimbursement system that pays for staff time to integrate services and provide educational support for patients. Creating Medical Homes requires a fundamental shift in how care is delivered, and it takes time to implement all aspects of this new system.117

A key goal that Katz emphasized when he came to Los Angeles was the importance of creating such Patient-Centered Medical Homes within the countywide system. The challenge for the county has been how to transform their large and fragmented delivery system into a more accessible and better integrated one.

To enable the key unions participating in the Partnership process to understand this approach and to determine how to support it, the union’s research department located many articles regarding the use, practices, and outcomes of PCMHs. This research revealed that while Medical Homes are quite successful, implementing them within existing healthcare systems is not easy. The new delivery system required changes in the jobs of frontline staff, from primary care providers (doctors, nurses, nurse practitioners, social workers, pharmacists, etc.) to receptionists and call center staff, in order to succeed. The union learned that frontline staff would generally need to work in teams, rather than as solo practitioners. Despite initial resistance, key union leaders became convinced of the necessity for changing the delivery systems to obtain crucial funding for both hospital and ambulatory care facilities. After several internal meetings, leadership from all unions agreed to support the transformation of LA-DHS facilities into PCMHs. Schoonover assigned Patricia Castillo, an energetic and effective union staffer known for her intense involvement and passion for providing a voice for workers, to work with LA-DHS management on devising effective ways to implement the Medical Home model as well as in the overall Labor-Management Partnership process. Castillo was highly valued for her immense creativity and personal warmth. While mentoring the internal consultants, she established strong personal relationships that were highly motivating and that enabled her to offer crucial suggestions to them without being perceived as critical.118

To understand the role of frontline staff in implementing Medical Homes at LA-DHS, it is important to know how the county delivery system functioned beforehand.

At the outset of the LMP’s formation, county facilities were far from patient-centered. Patients did not have an assigned primary care provider. When they came for clinic appointments, they were seen by whichever doctor or nurse was available, often someone who was unaware of their medical history. Scheduling of doctors in outpatient services was largely based on the educational needs of interns and residents rather than on patient care considerations. Besides not having a permanent primary care practitioner, patients had difficulty in obtaining appointments and limited access to behavioral health providers and other specialists.

Further, patients were given block appointments—that is, all patients were told to come to the clinic at either 9 a.m. or 1 p.m. and consequently often spent hours waiting to be seen. This practice produced a large no-show rate.119 This type of health-care delivery structure resembles that of other U.S. public health systems, such as those at Cook County Health in Chicago and in parts of the NYC Health + Hospitals system. Thus, at LA-DHS the challenge was not whether the transformation into PMCHs was the right strategy, but rather, how to put this new care model into practice.

Here are examples of how frontline staff contributed to implementing aspects of the Medical Home care delivery system in two LA-DHS ambulatory clinics. Initial efforts in the Hubert Humphrey Comprehensive Health Center involved improving patient access to care: creating an appointment system so that patients could be seen more quickly and reducing the time that patients waited to be seen. The second clinic, the Martin Luther King Jr. Outpatient Center, which had already changed its appointment process, focused on improving clinical outcomes.

Improving Access to Care

Continuous improvement teams (CITs), similar to the unit-based teams established in the Kaiser Permanente Partnership process, were already slowly being implemented in several LA-DHS facilities at about the time that Katz and Schoonover established the new Partnership process. After creating Medical Homes became a central goal, more teams were established to get them up and running in ambulatory care clinics throughout the system.

At the Hubert Humphrey Comprehensive Health Center in South Los Angeles, for example, one team, aimed at improving the method of scheduling primary care physician and specialist appointments, was composed of registration staff, a primary care practitioner, staff from the LA-DHS call center who arranged patient appointments, and the manager responsible for registration and preregistration activities. A second CIT team, with similar employee composition, worked on lowering clinic wait times. The teams studied different ways to schedule nurse and physician visits and researched more efficient methods for obtaining patients’ insurance information before they arrived for their appointments. Each CIT analyzed ways to reduce no-show appointments.

Both CITs created flow charts to map current patient wait times for appointments and their actual wait times at the facility itself. After analyzing these charts, consulting co-workers, and speaking with patients about what would help them, the teams posed solutions for removing bottlenecks and for streamlining the scheduling, intake, and preregistration processes.

Some of the results that CITs achieved at the Humphrey Health Center were as follows:

•   All patients now receive individual appointment times, rather than a block appointment.

•   All patients are now assigned a care team.

•   A new preregistration process was established for all Humphrey patients, ascertaining their insurance coverage and obtaining advance information needed for the appointment, which increased preregistration from 28 percent to 76 percent.

•   Wait time to see a primary care provider, once a patient arrived at the clinic, was reduced from 23 minutes to 3 minutes.

CIT work at the Humphrey Health Center continues to focus on these issues. Such an ongoing process is essential to ensure that the new process becomes fully implemented and functions optimally.120

“The engagement of frontline staff in creating more access to care, reduced wait times, and coordinated care has been significant. The fact that workers had a voice in planning the new systems resulted in their endorsing the changes in staff jobs that came along with the new scheduling methods. Staff feel better about working here now,”121 observed Nicole Moore, director of CITs at LA-DHS.

Implementing Medical Homes and Improving Patient Care Outcomes

The Martin Luther King Jr. Outpatient Center in South Los Angeles, another county facility, transitioned in 2007 from being a small inpatient hospital to a multiservice outpatient center offering a full spectrum of primary care and specialty services. With this transition came individualized appointment systems for patients for primary care and specialty services, and streamlined processes guaranteeing timely patient appointments. Now part of the new Partnership process, King used its continuous improvement teams primarily to convert their outpatient facility into several high-functioning Patient-Centered Medical Homes and to improve clinical outcomes.

In early 2012, the King Center began this process. There are now four King Medical Homes serving adults, children, and patients with HIV diagnoses. If patients come to King who are not already assigned to a specific Medical Home, they are first seen by the Urgent Care Center and then referred for continued care in a particular Medical Home unit.

To improve patient care in the new structures, Partnership action teams are encouraged to work on any clinical problem of importance to their group, but they largely tend to focus on meeting specific patient care outcomes that will help their center secure state and federal funds. This is important financially, as patient care outcomes are tracked by California’s Department of Public Health, which sets reimbursements based on outcomes classified as “prime measures.”122 Prime measures include educating diabetic and chronic pain patients about managing their conditions, ensuring that patients obtain a yearly flu shot, increasing screenings for breast and cervical cancer, improving medication reconciliation after each visit to avoid complications caused by drug interactions, and helping patients control their blood pressure. Many King teams have focused on improving outcomes of these measures. These work groups have functioned much as did the ones at Humphrey: following a disciplined process of analyzing current practices, reviewing relevant articles about best practices, consulting with co-workers and patients, and then establishing trial runs of the newly devised processes.

Recent outcomes of these clinical Partnership teams at the King health center have included the following:

Breast cancer screening: Increased by 31 percent

Colorectal cancer screening: Increased from 35 to 72 percent

Controlling blood pressure: Decreased the number of patients with uncontrolled blood pressure by 29 percent

Clinical depression: Screening increased by 10 percent

Diabetic education for patients: Increased by 96 percent (from 31 to 75 percent)

Flu vaccines: Increased the number of flu vaccines by 757 percent from 54 to 409 given through February 2019

Flu shots for patients (Women’s Clinic): Increased by 359 percent

No-shows in Gastroenterology: Decreased from 34 to 18.5 percent

Patient satisfaction scores for the health center: Now are over 91 percent

Skin cancer—compliance with treatment protocols: Increased to 96 percent123

Creating the structure of Patient-Centered Medical Homes and developing ways to improve clinical outcomes at LA-DHS has been, of necessity, a gradual process. “Although this new care model has not been fully implemented within all county facilities, over 350,000 patients are now empaneled [e.g., assigned to a specific PCMH]. What is proving to be most important is that patients are getting more access to care and feeling better about the care that they are receiving,”124 observed Dr. David Campa, director of the Primary Care/Ambulatory Care Network, about the process. He added that “if we hadn’t started this process with a clear model [the Patient-Centered Medical Home], it would have taken much longer and we would still be experimenting with different approaches.”125

One important investment that has enhanced the King Center patient experience has been the hiring of community health workers to follow up with patients after their appointments. Community workers ensure that patients understand and follow care recommendations prescribed by patients’ primary care teams. They help their patients practice self-care measures and encourage them to follow recommended dietary changes. They also gauge medication compliance. Hiring these new frontline staff, plus new processes established to better coordinate primary care and behavioral health providers, has substantially improved patients’ experience at King.126

Creating an Effective Process to Document Results

Establishing procedures for documenting the work teams’ recommendations and outcomes (Core Practice 7) has presented a challenge within this large system. Typically, work group members have wanted to focus on implementing their newly created solutions and have resented somewhat the time it takes to document each specific intervention and its outcome. “Why document what we are doing, when we can see for ourselves that it works?” has been a sentiment commonly voiced by some labor and management leaders and frontline staff.

It is difficult enough to free frontline staff from their regular duties to analyze and formulate solutions to institutional problems. Making the time for them to document results can be very difficult to justify in institutions with tight budgets. Yet, ensuring that there is a process to measure the outcomes of problem-solving teams at LA-DHS has been essential in order to gauge whether or not their interventions are achieving the intended results. Further, timely documentation shared with staff (as cited previously) enables them to evaluate how their interventions are working and to adjust them accordingly. Finally, these data are important to justify the investment in Partnership activities to management and to union leaders.127

To address this challenge, the Continuous Improvement Team Oversight Committee, established to support and monitor team activities, was assigned the responsibility of ensuring that documentation was being accomplished in each setting. The local union assigned Patricia Castillo to work with Nicole Moore, chair of the CIT Oversight Committee, to make sure that documentation processes were practical and could be easily implemented. In addition, senior management and union leaders on the Labor-Management Transformation Council formally agreed that data collected from Partnership activities would not be used to discipline frontline staff if their goals were not met, but rather would be used to identify continued areas for improvement. This ground rule was particularly important for frontline staff. “We weren’t sure how the results of our team would eventually be used. We initially feared that this information might be used to discipline us. After several months of measuring outcomes of our work, though, we saw that this data was being used only to identify areas of work where improvements continued to be needed. Making sure that patient feedback and care improvement practices are not used as a disciplinary tool has been really important so staff don’t resist getting feedback about their team’s work,”128 commented Wilson Mendez, a physical therapist and a Healthcare Transformation Advocate, at the King Outpatient Center. Mendez, an energetic man with gentle yet persuasive charisma, assisted numerous teams in their work. He was known to possess a special skill for helping his teams stay focused at solving the clinical problems they had chosen to address. In recognition of his work, Mendez is currently being considered for membership on the County’s Committee to Oversee Partnership Activities.

Besides overseeing the overall documentation process, the Continuous Improvement Oversight Committee captured how some of the work groups functioned by videotaping their team meetings and presentations. These videotapes provide useful qualitative data to analyze CIT leadership approaches and member participation. They also help to identify teams that might need assistance in working together or in choosing more realistic projects. To a large extent, the Healthcare Transformation Advocates (internal consultants) have become central to mining this information to determine which of their assigned groups need assistance.

Summary

The case studies of Maimonides and LA-DHS in this chapter illustrate seven core practices that enable Labor-Management Partnerships to achieve and sustain highly positive outcomes. We have provided information to demonstrate how these practices have been implemented in the two settings, information that we will address in more detail in the following chapter.

Although these central practices might be difficult to implement in all Labor-Management Partnerships, it is important to understand how each helps to shape and then sustain a successful process (see figure 3). Once the rationale for each practice is understood, organizations can creatively explore how to fit them into their particular culture, budget, and need.

Lastly, it is important to develop a succession planning process to smoothly transfer responsibilities to newly appointed management and union leaders as the Partnership process matures. It takes time to significantly alter the culture of an organization to fully support worker participation initiatives. Continuing to nurture such a culture is extremely important, requiring ongoing education of new entries into the system about the values and practices of such a culture. Particularly when senior managers at the union and administrative levels change, it is crucial to carefully introduce them into the ongoing Partnership process. The challenge facing healthcare organizations is to make performance gains “permanent” by hardwiring the learning from individual projects and initiatives into the way the organization does business. Continued progress will also require deepening levels of teamwork, developing more data systems, and evaluating progress to ensure that changes really are producing the intended results.129

Figure 3. Starting a Labor-Management Transformation Process

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