CHAPTER 6
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Union-Driven Innovations

If you are not at the table, you’re on the menu.

—Lee Saunders, president of the American Federation of State, County, and Municipal Employees, White House conference on “Worker Voice,” January 26, 2016

Labor unions in the United States have contributed powerfully to improving wages, working conditions, and the health and safety of workers. They have ended the soul-killing practice of child labor and have protected workers’ rights to fair evaluation and termination procedures. They have saved jobs and at times have initiated changes in organizational systems that made work processes more effective and more meaningful. It is difficult to overestimate the contributions of labor unions to American life.176

On the other hand, unions—with their survival under attack for the last several decades—have sometimes succumbed to the bane of all organizations: the concretization and ritualization of their ways of thinking and working. This has afflicted both union groups and the management/administration in some sites where we have worked. When two groups in conflict become entrenched and inflexible in their positions, they often drive each other further into maladaptive practices. As this occurs, managers may overlook unions’ vital contributions to the American middle class—and thus to the stability of our nation— and may see them merely as enemies who demand unaffordable salaries and block innovative work practices.177 Conversely, some union officers may deride managers’ efforts to seek workers’ input into certain strategic decisions as “empty attempts at co-optation.”178 In this chapter, we try to look beyond such polarization to demonstrate the benefit that joint work, and particularly active Labor-Management Partnerships, can provide to unions and to managers/administrators, especially within healthcare organizations.

Union membership was fairly robust in the 1950s, when over 35 percent of the workforce was unionized. Since the 1960s, however, unions have undergone a steady decline, attacked by federal and state legislators as well as by corporate litigators intent on increasing profits by lowering wages and by thwarting union work rules. By the mid-1960s, union membership had fallen to just over 20 percent of the workforce. Now, as corporations outsource work to poorer nations where wages and safety standards are minimal and unions rare or nonexistent, American labor unions represent barely 10.7 percent of American workers.179 Finally, the new corporate emphasis on hiring part-time and contingent workers makes organizing workers much more difficult.180

As if these pressures were not enough, in 2018 the Supreme Court created new burdens for unions, mandating them to represent all workers in an organization even if not all employees pay union dues or fees. The ruling overturned the practice of dues deduction from employees’ paychecks when unions had negotiated their wages and working conditions.181 As a result, public sector employees must now indicate to their employer whether or not they want union dues deducted. This new practice has greatly reduced unions’ income.

The increasing, often enforced, marginalization of labor unions has put them on the defensive, struggling to organize new members while protecting their basic rights and benefits. Needing to focus on survival, many union leaders stick to their traditional roles of negotiating and enforcing collective bargaining agreements. Labor activists, however, contend that this is a dated approach.182 Activists feel that to stay viable, unions must directly address the significant changes in the workplace caused by technology, and must share in developing new work systems that enhance job satisfaction and contribute to the survival of the organizations for which their members work while also representing the rights of workers.183

One such leader is David Rolf, former president of SEIU 775 in the Pacific Northwest, who contends that unions must adopt innovative strategies such as codetermination (in which workers have the right to vote for representation on a company’s board of directors),184 a common practice in Europe; worker ownership;185 and Labor-Management Partnerships in order to add value to their organizations and the general economy. Health-care unions may attract new members—and accrue power within their organizations—by giving frontline staff a voice in decision making about how they can best care for their patients.186 It has been shown that healthcare unions that do so simultaneously attract new members, improve patient care, and advocate for social justice.187

Unlike in industry, about 20 percent of healthcare workers belong to unions, including doctors and nurses. This makes health-care organizations an important sector in which to focus union energies. Healthcare is also predicted to produce more jobs than any other part of the economy until 2026.188 Further, frontline staff can directly affect the quality of patient care and patient satisfaction: factors contributing to how current healthcare delivery systems are reimbursed. Healthcare unions can address this potential source of power by encouraging hospitals to undertake employee participation projects such as Labor-Management Partnerships that improve care. Such projects can in turn reconnect frontline staff members to their union leaders, seeing them as more than negotiators for their salaries and benefits. As labor organizer Sidney Hillman stated during World War II,

Certainly, I believe in collaborating with the employers! That is what unions are for. I even believe in helping an employer function more productively. For then, we will have a claim to higher wages, shorter hours, and greater participation in the benefits of running a smooth industrial machine.189

Although Hillman and other union leaders have embraced the strategy of partnership between labor and management, some union leaders view worker participation activities as undermining needed militance, bringing the worker too close to management, where he or she can be co-opted.190 These union leaders consider that “helping to improve the efficiency of an organization is the job of management, not the union.”191 Yet, working in partnership does not mean erasing the differences in perspectives and goals between labor and management. In participating in a Labor-Management Partnership, unions do not surrender their ability to leverage the use of strikes, protests, walkouts, or community and political pressure to force management’s attention when problems affect their members. They might even use these tactics as a means to get management to the table to create a joint process on issues critical to their members and to patients.

Recently, for example, the Vermont Federation of Nurses and Health Professionals, a local of the American Federation of Teachers union, conducted a two-day strike at the University of Vermont Medical Center to induce management to accept a joint process for setting staffing levels.192 This strike, initiated over working conditions rather than salary, resulted in a robust process that created reasonable, responsible staffing levels for all hospital units and outpatient clinics.193 Before the strike, management was unwilling to listen to frontline concerns about staffing levels.

There will always be times when union and management leaders disagree on wages, benefits, political activities, and changes in job responsibilities. Such disagreements should not affect the value of joint work for improving patient care, nor should either party hesitate to exercise its responsibility to disagree on matters it deems important.194 Unions will always need to fight for what they believe is best for their members,195 and management needs to monitor cost, operational, and legal issues. It is important for them to address their differences, in order to at least clarify divergent perspectives.196

Unions, local and national, have employed varied strategies to support joint work. We highlight Labor-Management Partnerships in healthcare organizations, but their fundamental strategies can benefit unions in other economic sectors as well. The main strategies include the following:

1. Creating a consensus within the union about the value or risks of adopting a partnership or engaging in other types of joint work with management.

2. Clarifying union goals for such activities: What do the members want to gain from joint involvement?

3. Creating research initiatives to examine the potential use of a Partnership process and its impact on union membership.

4. Building the capacity of local unions to support Partnership work.

5. Obtaining support from national unions for Partnership work.

Creating Consensus about Partnership Work within the Local Union

It is critical for local unions to conduct internal conversations about the value of Partnership work with their staff and national union before meeting with management to explore initiation of such activities. Discussions with the national union can create a foundation of support for the local’s efforts, helping the local to understand exactly how much their national leaders can contribute in influence, advice, educational materials, and research assistance.

Whether or not a national union has considered supporting Partnerships, the local union will need to discuss with its own leaders and activists, and those in the national union, why Partnership activities might help to solve care-delivery problems that directly and daily affect their members’ work.

Internal discussions within a local union can be helpful to consider exploring why and how members might contribute to changing the nature of patient care, and hence their jobs. Union leaders, activists, and frontline care staff have seen firsthand that top-down solutions have not significantly improved patient care outcomes. Recent research studies confirm these observations.197 Such approaches have certainly not benefited workers, as they often tend to involve onerous staffing schedules and an overriding focus on the bottom line, rather than finding new ways to care for patients.198

Initial internal discussions within union locals offer space for thoughtful conversations about why it might be important to work in tandem with management and with other unions, if several unions are involved in a hospital or healthcare delivery system. It is worth exploring what it will mean for union staff, officers, and frontline staff to adapt to a Partnership process. In such a process, the union will need to move away from a predominately adversarial relationship with management to working with management while maintaining separate views and concerns: they will need to learn “to both dance and box at the same time.”199 Union leaders and activists should take the time to reflect on what it means to take responsibility for decisions, rather than allowing management to make mistakes and then take all the blame. These internal, reflective conversations give union leaders time to share their views without getting too far ahead of members. As discussed in the previous chapter, union leaders need the support of their members and staff to sustain the work of a Partnership process without sabotage.

If there is significant resistance to or misunderstanding among union members about working collaboratively, the local leadership might find it helpful to conduct one-on-one conversations with members who have concerns about the new process before launching a Labor-Management Partnership. It is often useful to invite leaders from unions who have already engaged in Partnerships to meet with the local union so that local members can learn about the results of an effective Partnership process. This exchange enables members and leaders to explore the benefits and risks of the process before committing to it.

For some organizations with years of adversarial interactions with managers/administrators, union leaders and members will need to see management demonstrate good faith that they are committing to a nonhierarchical, transactional process. A useful example of how a local union engaged in effective internal conversations about the value of a Labor-Management Partnership took place in Los Angeles with SEIU 721. As described in chapter 3, in late 2012, senior union leaders, shop stewards and rank-and-file members conducted several internal work sessions to discuss forming a Labor-Management Partnership with the new director of the county’s health system. The union used these work sessions to craft an approach to management that would challenge its past record with labor and to gain assurances that this would change. They further examined how the process might achieve their own union-building objectives while improving patient care and access. The local’s senior leaders envisioned that Partnership activities would better connect them to member concerns about their work lives. The Partnership process was seen as allowing the union to give frontline staff something new and important to them: a real voice in decisions about improving patient care and their own working conditions.200

Clarifying Union Goals for Partnership Work

Along with conversations at the national and local levels about how a Labor- Management Partnership might benefit the union, local unions must create specific goals for working in Partnership. Some past LMP activities have failed because the involved unions did not develop or articulate these.201 These will be discussed in chapter 8.

The questions that unions need to consider are as follows:

1. What do we need and expect to gain from a Partnership process with management?

2. How can we directly link Partnership goals to the interests of the union and its members?

3. How can we use Partnership activities to improve patient care and safety?

4. Which elements of a Partnership contract should be lobbied for, in order to provide our members with greater opportunities for training?

5. How might our members derive more meaningful work from a Labor-Management Partnership process?

6. How can our involvement in Partnership activities enable us to organize new members to join our union?

7. How can we encourage employers to make it easier for staff to join the union—e.g., through allowing card checks and promising not to undermine union organizing efforts?

8. How can we clarify to staff that Partnership activities were a direct result of the union’s negotiating this arrangement?

Clarifying union goals by addressing these questions can help a local union to decide whether it will be worthwhile investing time and funds to support a Partnership.202

Common goals that healthcare unions have established for Labor-Management Partnerships include:

•   Establishing more direct communication with members by routinely attending problem-solving team meetings, by helping to conduct Partnership training sessions, by conducting meetings in which teams share how they approached their work and their solutions, and by highlighting the work of teams in various newsletters and blogs

•   Providing members with time apart from their daily work to address patient care issues and to reduce work-arounds203

•   Devising ways to improve patient satisfaction and staff and patient safety

•   Creating opportunities for frontline staff to weigh in on new purchases of equipment and supplies

•   Developing training programs to enable employees to master the new skills that might result from the restructuring efforts

•   Shifting labor relations from an adversarial to a problem-solving process based on mutual interests

•   Creating more meaningful work

•   Increasing union membership by creating new jobs and by having workers who are not in the union join the union

Both qualitative and quantitative research methods can be used to track the achievement of such goals.

As an example of this process, the six specific union-building goals adopted by SEIU 1199 at Maimonides Medical Center were (1) to deepen communication and engagement with members; (2) to improve labor relations problems and reduce arbitrations; (3) to increase members’ contributions to political action activities (to a union PAC fund); (4) to improve attendance at political rallies that support state and city funding for Maimonides and for political candidates who endorse workers’ rights and social justice issues; (5) to increase communication within the hospital about the Partnership process and the union’s role in it; and (6) to recruit more employees to join the union.204

These union goals were eventually incorporated into the overall goals of the Maimonides Medical Center’s Labor-Management Strategic Alliance.205 These goals were tracked quarterly, and major improvements occurred in all areas.206

Union Building Outcomes SEIU 1199/Maimonides

Attendance at political rallies: Increased by 48 percent

Arbitrations: Reduced by 64 percent

New shop stewards: Increased by 265 percent

Political action contributions: Increased by 45 percent

Union membership: Increased by 18 percent

Research Initiatives

Getting involved in Partnership activities will require health-care unions to broaden their research activities. One shift will require unions and their members to assist in conducting research to document the extent to which Partnership activities improve patient care and create more meaningful jobs. This is quite important since often this documentation doesn’t take place.

Unions should also consider conducting, in the future, their own research on delivery system issues and trends, as hospital administrators tend not to share their research findings about such matters with labor leaders lest their data be used against them.207 Such research is quite important in order to make strategic decisions about where to deploy resources for Partnership activities. It turns out that unions are often in a better position than management to collect this sector data, as they have access to information from a broad range of healthcare systems.

As healthcare organizations continue to increase the use of various technologies and have access, to some extent, to a global workforce (even within the healthcare sector), U.S. healthcare unions would also benefit from expanding the scope of their research to include understanding how new technologies will impact future jobs. Having this information will help union leaders prepare members for these jobs and have sufficient time to organize needed trainings.

Whereas many local unions have not conducted such research, national unions often have funds for, and experience with, these investigations. National unions that represent healthcare workers, such as the American Federation of Teachers, the Committee of Interns and Residents, the Doctors Council, and the Service Employees International Union have assigned staff to research the areas cited previously. Some larger healthcare locals, such as SEIU 721 in Los Angeles, SEIU 1199 in New York City, and SEIU Healthcare Pennsylvania, have allocated funds for this nontraditional union research.

This expanded research approach is a significant departure from current union research priorities that focus, for the most part, on preparing for contract negotiations and helping to structure new organizing campaigns.208 By expanding research activities, U.S. healthcare unions can ensure that Labor-Management Partnerships focus on the most important issues.209

Building the Capacity of Local Unions to Support Partnership Work

When a hospital or delivery system begins a Labor-Management Partnership process, or another approach using frontline staff input to improve patient care, they frequently reassign staff to manage the new initiative. They also generally hire experienced consultants to advise about approaches that have succeeded in similarly structured organizations. Unions should ensure that this occurs and should make similar reassignments, as well as considering whether or not to hire their own consultant.

Because Partnership activities often result in changes in delivery system processes, and sometimes even staffing changes, healthcare unions (local and national) must determine the best way to become full partners in guiding the process, particularly in educating the workforce to handle the resultant work changes. Again, to actively participate in the Labor-Management Partnership with the Los Angeles County Department of Health Services, the president of the local union assigned a key senior adviser, Patricia Castillo, to work part-time at developing the Partnership process.

After two years of productive Partnership activities, it became apparent to union leaders that the local needed to strengthen its capacity to keep up with and sometimes to initiate joint projects. After considering different paths forward, they decided that Castillo should be freed to work full-time on the Partnership. Two research staff members were also assigned to work with her to support the work teams as they set about their increasingly complex tasks. With these resources, Castillo could work more closely with the union’s shop stewards and with hospital and clinic staff to continue building enthusiasm and support for Partnership activities. CEO Katz also agreed to relieve county employees from their full-time jobs to work with Castillo as Healthcare Transformation Advocates (internal consultants and mentors). As of 2020, there are now 17 such Advocates. The county has paid their salaries, while the union has funded Castillo and her assigned staff.

SEIU 721 found that reassigning their own staff and creating Healthcare Transformation Advocate jobs has enabled them to become an active partner with the County Department of Health Services in the joint work. Investing in these personnel changes made the union ambidextrous, working on partnership matters in addition to traditional union activities. However, they have discovered challenges to sustaining this new role. “Working sometimes jointly and sometimes separately with management is not an easy process after a history of fighting tooth and nail with the county administration. Nevertheless, it has become a crucial strategy for our union to get stronger and to grow. We have worked very hard to make this transition,”210 stated Castillo.

Like SEIU 721, other locals have decided to make staff changes to work more fully in partnership processes. These locals include the Committee of Interns and Residents (CIR),211 the Doctors Council,212 and SEIU Healthcare Pennsylvania.213 They have concluded that broadening their capacity for partnership work by hiring new staff members enabled them to become more effective in improving patient care and in advancing their union-building initiatives.214

At Kaiser Permanente, the Coalition of Unions, which initially represented most of the locals within Kaiser,215 has taken a different approach to supporting partnership activities. Although union leaders from each local are members of the Kaiser Partnership process, most staff who work on Partnership initiatives are hired by the Coalition of Kaiser Permanente Unions itself: local unions have not for the most part reassigned internal staff. There are benefits and risks to this approach. Because the participating locals in the Coalition had little need to reassign staff to new roles and responsibilities, they did not need to train them in the new skills crucial to do this work. Instead, funds from these local unions contribute to the Coalition of Kaiser Permanente Unions’ hiring staff for Partnership projects. This saves locals time and effort, but since they have not incorporated Partnership activities as a core practice for themselves, they have not developed the relationships with the employees working on these projects that win their loyalty and grow local membership.216

Support from National Unions for Partnership Work

Although most Labor-Management Partnerships are established at the local level, several national unions have supported these activities.217 The Amalgamated and Textile Workers Union (ACTWU), American Federation of Teachers (AFT), Service Employees International Union (SEIU), and United Auto Workers (UAW) have all invested in Labor-Management Partnerships, each employing different methods.

The ACTWU established an Industrial Research department. Its research helped ACTWU locals anticipate and prepare for changes in the textile and garment industries and led the national union to propose the Partnership processes at the Hathaway shirt company, Levi Strauss, Hickey Freeman, and others, which created new modular manufacturing systems. Hundreds of jobs were saved in assembly plants and distribution centers as a result. The ACTWU provided funds to local unions to educate their members about the changes affecting their manufacturing sector. It has also funded union-friendly partnership consultants to establish and consult to Partnerships.

The American Federation of Teachers’ Division for Nurses and Health Professionals established a Learning Collaborative in 2016 to accelerate joint activities between AFT local frontline staff and management counterparts.218 The Collaborative attempts to bring together labor and management safety committees from different hospitals on a yearly basis to study effective practices for ensuring staff and patient safety. The workshops feature a highly interactive process between union and management representatives and have resulted in several successful new endeavors by participants.

SEIU’s Healthcare Division has established yet another approach to encourage Labor-Management Partnerships. Dr. Toni Lewis, a recent director of this division, began to convene quarterly meetings with several of the larger SEIU locals representing healthcare workers to expose them to the experiences of workers who have already adopted LMPs in their hospital systems. The Healthcare Division funded three Labor-Management Partnership projects, in the Los Angeles County Department of Health Services, Cook County Hospital in Chicago, and Allegheny Medical Center in Pittsburgh. Dr. Lewis retained Cornell’s Healthcare Transformation project219 consultants, including co-author Lazes, to provide education, research, and additional consultants to support the new LMPs.

We have already described the first site funded by SEIU, the LA-DHS Labor-Management Partnership. At Cook County Hospital in Chicago, the funds were used for an intervention focused on enabling labor and management, who had a history of considerable friction and mistrust, to collaborate better. It was hoped that an outside consultant could encourage labor and management leaders to find areas for joint work. To this end, an initial Labor-Management project at Cook County focused on reducing wait times in the outpatient clinic and on expediting the scheduling of specialty care appointments. Results of this effort are discussed in chapter 8.

The third Labor-Management Partnership process funded by SEIU was at Allegheny General Hospital. The focus of their Partnership activities has been establishing unit-based teams on all inpatient units to improve patient care and safety and reduce costs. Nurses constituted the initial team members, as SEIU represented only the nurses at Allegheny. Their work produced significant improvements in patient and staff safety discussed later. Unit-based work continues at Allegheny General Hospital.

Beyond providing funds to support the three Partnership projects, Lewis used national union leadership meetings, SEIU board meetings, and several meetings of their national Health-care Quality Advisory Committee to broadcast the experiences of these Partnerships. Her vision has been to encourage locals to establish similar activities, learning from what has worked and what has not in these sites.

National unions can be useful in encouraging, or even pressuring, health systems administrators to establish Labor-Management Partnerships. This assistance might be extremely helpful when a local union cannot marshal enough pressure on the administration themselves.

Summary

Union leaders are acutely aware that their membership is declining because of widespread antiunion laws and corporate practices, particularly the ongoing practice of moving jobs offshore. They understand the need to do things differently in order to keep their mission alive.

Unions in all economic sectors still need to represent workers when their rights are ignored or abused. Several national unions have now articulated, however, that it is also important to involve frontline staff in efforts to improve manufacturing processes or patient care practices. As Bruce Richard of SEIU 1199 states, “Being extremely proactive is much more critical now for unions than it was in the past. New and innovative approaches must be adopted to protect the jobs and wages of workers. Traditional approaches are no longer sufficient.”220

Healthcare organizations are currently undergoing drastic changes as they try to better coordinate and integrate care systems, use new technologies, and respond to different reimbursement arrangements. Such systemic shifts will result in significant job changes: eliminating some, creating others. In the past, redesigning services, creating new jobs, and finding ways to improve patient care rested solely in the hands of management. Creating comprehensive healthcare Labor-Management Partnerships enables unions and frontline staff to be included in the design of new delivery systems that they can ensure will be patient and worker-centered. In addition, establishing Partnerships expands the ability of employees to work in a safe environment in which they are able to raise problems without fearing reprisals.221

A new development initiated by SEIU 721 in Los Angeles County offers an additional benefit for unions who participate in Labor Management Partnerships. A system-wide process focused on creating a “just culture” in all county healthcare facilities encourages staff to report to management, without retaliation, any errors, near-miss events, adverse events, or unsafe conditions with these facilities.222 This new system has helped employees to report mistakes without fear of reprisal and allows the LMP to access important data about clinical care practice.

To summarize the benefits to unions of joint labor-management activities, Fran Todd, a nurse practitioner involved in the LA-DHS Partnership, observed, “These activities have mobilized significant numbers of members, who now see their union as providing them opportunities to have a voice in decision-making and in improving patient care.”223 Todd stressed that “many new union activists were not interested in the traditional work of the union, but once worker participation became a priority for our local, they saw the benefit of being part of this process.”224 David Rolf and other union leaders have agreed: “Unions need to change if the labor movement is to thrive again and workers are to find greater dignity at work.”225

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