CHAPTER 2
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European Employee Involvement Practices

If you want to go fast, go alone. If you want to go far, go together.

—African proverb

The role of unions and the role of governmental involvement with labor differ significantly in Scandinavia and elsewhere in Europe from those in the United States. However, a number of successful European practices for employee participation can be used for collaborative healthcare restructuring in the United States. For this reason, we examine in this chapter the most relevant employee participation practices that can be adapted for American healthcare and other organizations.

Workers have had a role in making decisions, sharing responsibility, and at times redesigning work systems in Scandinavian workplaces since the nineteenth century.63 Collaborative practices have gradually influenced and spread throughout Europe, particularly since World War II, when Scandinavian governments, employers’ associations, and trade unions began funding research to increase worker decision making on the shop floor and to make work more meaningful for frontline staff. The term used in Europe for worker participation activities is industrial democracy.64 Within the framework of industrial democracy, all social partners (workers, management, and government) work together toward shared goals that benefit the national economy, local communities, and workers. The workplace becomes, in the minds of these social partners, a locus in which democratic principles are practiced, usually through shared decision making.65

The four main goals of industrial democracy as practiced in Scandinavia are as follows:

•   Most important, expansion of opportunities for workers to directly participate in deciding about their working conditions.

•   The second goal, adopted since the 1980s, has been to use worker participation projects to improve the productivity of Scandinavian companies66 and of their national economies.

•   The third goal, which emerged initially in Norway, views worker participation activities as critical for providing workers with the tools to engage more actively in civic affairs. Workers who have had leadership opportunities, who have learned how to problem-solve and to resolve conflicting viewpoints about work system issues, participate more actively in local civic organizations. The Norwegians, sensitized to how easily fascism spread in the 1940s among disenfranchised, alienated workers in Germany, have viewed this outcome as crucial in order to sustain their active democracy.

•   A fourth goal in Denmark and Sweden has been to reduce staff turnover and absenteeism, each a significant societal problem.

In Germany, worker participation initiatives focus on including frontline staff in corporate decision making, as a result of legislation67 requiring most organizations to have worker representatives on boards of directors. In Norway, Denmark, and Sweden, increasing organizational productivity was not the initial goal of industrial democracy activities.68 Instead, they sought to allow workers a voice in matters concerning their workplace and its functioning. Yet all social partners understood that loss of productive capacity and earnings was not an acceptable outcome for their nations’ economies.69

Four Key Practices of Industrial Democracy That Can be Adapted to an American Setting

Self-Managing Work Groups

In the last chapter, we described unit-based teams tasked with solving problems about production, patient care, or other job-centered matters in some American industries. U.S. teams most often contain a management representative. In contrast, self-managing groups, pioneered in Great Britain, give workers the responsibility and authority to organize their own work without the need for a supervisor or manager. This system initially emerged from the work of Eric Trist and Fred Emery, social scientists at the Tavistock Institute in the United Kingdom. The Tavistock Institute is known for its extensive research on new work systems, on labor relations, and on developing effective leaders. Another Tavistock Institute division studies the application of psychoanalytic understandings of group processes to consultations with industry and to issues confronting the larger society.

Trist and Emery discovered the potential of self-managing work groups while conducting research for the British coal industry. England had nationalized its coal mines following World War II to fuel postwar reconstruction. As coal was a key power source, the British economy depended on its being plentiful and inexpensive. There were extensive labor disputes and stoppages involving the coal mines during the 1940s, however, and absentee rates exceeded 20 percent in many mines during this period. The postwar decision to nationalize the industry was motivated by the government’s desire to resolve these issues.70 Continued absenteeism, however, motivated coal industry executives to hire Trist and Emery to analyze what would contribute to better working conditions, improved labor relations, and increased productivity in the mines. They were also interested in learning why certain coal mines were highly productive while others were not.

Observing operations and talking to miners, owners, union leaders, and managers at both low- and high-performing coal mines, Trist and Emery discovered that in the productive mines, the miners had organized themselves into self-managing work groups. This arrangement enabled workers to be much more efficient and effective. They took ownership of their equipment, discovered better ways to use available technologies, created an ongoing schedule for maintenance and repair of equipment, and took the initiative to communicate between shifts. They ordered the tools and supplies that they needed, scheduled timely preventive maintenance on equipment, and organized a vacation schedule. These miners made sure that everyone in their work group had sufficient time to master the skills needed to operate and maintain all pieces of equipment. Creating multi-skilled workers enabled the miners to switch easily from one operation to another. Morale increased among workers using this method, reducing both turnover and absenteeism.71 On the other hand, in coal mines with low productivity and high absenteeism, researchers observed that miners had traditional discrete jobs with little opportunity to make decisions or switch operations when needed. Once Trist and Emery shared their findings, many mines in the UK shifted their production process to self-managing teams.

Because of the close relationship between the Tavistock Institute researchers and workplace researchers in Norway, Sweden, and Denmark, several self-managing work group projects started in Scandinavia once reports of the experience in the British coal mines were shared internationally.72

As described in chapter 1, the environmental services workers at Maimonides Medical Center in Brooklyn shifted to self-managing work groups after the Study Action Team completed its work. Similar work groups were developed at the Hathaway shirt company to implement the new production process that helped keep the plant open. These examples demonstrate the usefulness of self-managing work groups in an American setting.

While most employee participation teams in the United States are not self-managing, accumulating evidence suggests that this strategy is well worth considering here. The practice has not been widely adopted in the United States largely due to the fact that most managers do not learn about it in business schools and are unsure as to its implementation. Unions as well tend to be unfamiliar with this approach.

Socio-Technical Systems Approaches to Work Organizations

The second significant approach emerging from the European experience has been their focus on optimizing socio-technical systems (STS).73 After observing workers in industries who were organized into self-managing work groups, Trist and Emery realized that these workers were optimizing their social organization, their use of technology, and the interfaces between the two. Based on these observations, the researchers developed a new theory of organizational design, known as socio-technical system design.74 This approach to creating effective organizations recognizes the interrelatedness of the social dimension of work (whether employees’ assignments, for example, are collaborative or occur in isolation, and how they are treated) and the technical systems utilized in their workplaces. “Technical” here encompasses more than just equipment; it refers to both work tools and work processes. The theory emphasizes the importance of finding a better fit between how one works and how one uses available technologies. After their coal mining project, Trist and others at the Tavistock Institute focused on understanding what contributes to an effective “socio-technical system design.”75

Trist and Emery’s pioneering work on socio-technical systems in the UK led to several national projects in Norway and Sweden. One important socio-technical project involved a collaboration between the Swedish National Institute for Working Life, the Volvo Car Group, and the union representing Swedish autoworkers. By the early 1970s, Volvo senior management had decided that they needed to expand their manufacturing capacity in Sweden to produce more cars while simultaneously improving their employees’ quality of work life. As in the UK and the United States, absenteeism and staff turnover had become a problem due to workers’ alienation from routinized, assembly-line work systems.76 Planners hoped that by carefully designing new plants in ways that improved the quality of employees’ work lives, they could maintain, if not improve, quality standards while reducing absenteeism and employee turnover. The company and union had previously failed to improve these via job enrichment and job enhancement strategies such as making jobs more interesting by rotating workers to different assignments or by adding new responsibilities.77 These approaches only modified existing production processes without significantly improving them through incorporating workers’ ideas and observations.78

Ultimately, Volvo senior management and trade union leaders decided upon a more comprehensive systemic change. Pehr G. Gyllenhammar, then president of the Volvo Group and a progressive manager who respected the importance of frontline staff, articulated the challenge that both management and labor faced: “We need to create an environment that will give satisfaction to the employees in their daily tasks. Due to the advanced economic and social structure of Swedish society, we have encountered earlier than most countries new problems in the organization of jobs and the working environment.” Facing these problems, he contended, “could well lead to an improvement in competitive ability.”79

Under Gyllenhammar’s leadership and with the full involvement of various Swedish trade union leaders, a new assembly plant in Kalmar, Sweden, was designed using a socio-technical analysis to create new production processes. The design was intended to maximize available technologies for assembling high-quality cars while creating a new work system to provide greater decision-making responsibilities for workers. To apply the socio-technical approach, an Action Committee was formed with an equal number of labor and management members to design the new Kalmar plant. The Action Committee studied other car assembly plant production processes and the technologies they used. The committee then designed the new plant so that groups of employees assembled sections of a car together, instead of having each worker standing at separate workstations, toiling at a repetitive job for 8 to 10 hours each day. The new work groups that were created stayed with the car until they completed all their operations, which usually took 45 minutes to an hour. The car chassis then moved to the next work group, who together assembled the next section of the car. Kalmar began producing cars with this process in 1974.

By the early 1980s, Volvo decided to increase its manufacturing capacity even further. Building on the success of the Kalmar plant in terms of quality and number of cars produced, a second assembly plant design process was initiated with full trade union involvement. The Action Committee for the Uddevalla assembly plant developed an even more radical production process than at Kalmar. In keeping with socio-technical system design practices, this second plant was designed so that work teams of nine individuals had the responsibility for together assembling an entire car. Modern technology was installed to make it easier to weld and assemble each car section. Special carriers were designed so that workers could swivel and turn the entire car, enabling easy access to every area. Working in self-managing groups, employees could determine the rotation of jobs, the pacing of their work throughout the day, and the schedule of workers and training needed. This new process enabled the frontline staff teams to identify production design problems immediately, as they oversaw the entirety of the production process and could identify problems as they occurred. Workers at both the Kalmar and Uddevalla assembly plants received training so that they could perform all assembly jobs in their work group. At the Uddevalla plant, workers could easily observe the fruits of their labor, and they developed a sense of ownership and gratification from assembling an entire car.80

The quality and productivity of the Uddevalla and Kalmar plants were equal to, if not better than, those at other Volvo assembly plants,81 and absenteeism and employee turnover decreased radically at both plants as well.82 Chapter 8 presents more details about establishing such new systems.

Employee-Driven Innovations

Scandinavian countries have continued to explore ways for frontline staff to improve the effectiveness of their organizations. In recent years, both union leaders and managers observed that innovative ideas were often sparked by the need to work around day-to-day problems on the job83 or by employees observing that some work processes or equipment consistently caused problems. The Danish LO (Confederation of Trade Unions) initiated Employee-Driven Innovation (EDI) projects in 2007 to expand opportunities for frontline staff to create new services or products. In Denmark, EDI activities primarily focused on increasing innovations in their healthcare systems. These are discussed shortly. Other European countries that adopted the EDI approach have focused on the technology and manufacturing sectors.84

Like the United States and other countries, Denmark needs to control costs so that healthcare is affordable. Although the Danish national health system provides all citizens with free healthcare, the government has needed to find alternatives to raising taxes to pay for healthcare services. As in the United States, this has become an increasing challenge as citizens live longer and tend to require more medical and home care services as they age. With funds from regional health departments, private foundations, and the Danish Confederation of Trade Unions, hospital and regional health departments have hired staff to identify workers with fresh ideas for improving patient care while also controlling costs. Projects they have developed include discovering newer, more cost-effective technologies and developing new strategies for providing better home- and community-based care.

EDI staff help frontline workers to frame and develop their new concepts for particular services or potential medical devices. Once such a concept is developed, the frontline employee (doctor, lab technician, or ward clerk) is connected with an expert to help refine the idea, and then to develop a prototype for the new device or conduct a pilot new service. This expert also helps the employee to develop a business plan for financing the implementation of the concept. At Aalborg University Hospital, for example, the Idéklinikken (“Ideas Clinic”) serves as a health-care service incubator85 providing time and space for frontline staff to develop their ideas for improving services.

“Many times, frontline staff have great ideas but don’t have the ability or time to continue to refine their ideas—turning ideas into real products or service changes,” commented Kristine Rasmussen, the Idéklinikken’s project manager, during a November 2015 interview.86 Nurses and physicians are the most common initiators, but any healthcare practitioner can propose a product, a piece of equipment, or an idea for changing a hospital’s delivery system or regional health department service.

EDI activities represent a major shift in emphasis from the common practices of employee participation/industrial democracy in Europe. In Denmark, the basic emphasis of EDI activities has been on creating new devices to help patients, particularly aging individuals, have a better quality of life, or creating new processes to improve clinical outcomes. Developing a new product to generate funds for regional health systems is also encouraged.87 The income from developing a new device is jointly shared by the inventor, EDI, or a particular hospital or health department.

Some products and services created from Danish EDI projects include a mobile app to help adolescents control their diabetes, new home-monitoring equipment for cardiac patients, a pacifier for premature infants to provide them with oxygen while in the intensive care unit, stretch sensors to control for excessive load to an injured foot, a method for improved patient medication management, a new process to connect the physically disabled to community services, and a redesigning of emergency room departments to keep patients comfortable and informed of the status of their care while being treated.

In addition to supporting the development of specific worker-identified projects, beginning in 2007 the Danish LO established the Employee Driven Innovation Network (EDIN) to enable scholars, consultants, practitioners, funders, product developers, and graduate students throughout Europe to share research findings and develop methods to accelerate the spread of EDI practices. This network has used its funding to assist frontline staff in refining their suggestions for new products and services.

EDI activities have greatly helped Scandinavian countries, enabling them to stretch their limited resources to continue providing all citizens with comprehensive health services at affordable costs. EDI projects have created more meaningful jobs for workers as their ideas are put into practice: “ideas for new products and services and more meaningful work that no one would have thought about if it weren’t for the EDI process,”88 stated Kjeld Lisby, head of innovation at Aalborg University Hospital.

Organizations in the United States that are beginning to use this model are described in chapter 7.

Participatory Action Research

Industrial democracy researchers in Scandinavia and the UK rely on a dynamic research method known as participatory action research (PAR). PAR is a tool that supports frontline staff participation by offering practitioners (frontline staff and administrators) the opportunity to work alongside researchers to define questions relevant to their work and to develop methods of documenting outcomes of their projects. Involvement in deciding which information to obtain and then in actively collecting those data tends to strengthen the commitment of frontline staff to implementing the solutions their research reveals. This method, along with their inclusion in the overall project execution, fosters the ownership of frontline staff at all stages of the change process.

One of the first to use the PAR approach was the activist Paulo Freire, who employed this methodology in Brazil to encourage deprived communities to research, analyze, and document the structural basis for their lack of resources.89 Their analysis found persuasive approaches for rectifying the inequitable allocation of resources and was greatly empowering. From these community roots, PAR has developed into an important research method for all types of organizations, from grassroots community groups to medical centers.

PAR differs from traditional research in three ways. First, its goal is to assist in efforts at change within a community or organization, so it is driven by the needs and concerns of members of that group. The goal of traditional research, on the other hand, is to conduct robust, disciplined studies controlling critical variables in order to identify specific causes that result in statistically significant outcomes. Such research aims to discover answers to particular questions of scientific relevance, but it is not focused on implementation or on the needs of a particular organization or community.

Second, PAR projects use a variety of approaches: collecting both qualitative and quantitative data using questionnaires, surveys, focus groups, observation teams, document analysis, etc. Traditional research methodology does not usually include constituents because of concerns about biasing the results, but the variety of tools used in a PAR process affords the opportunity to cross-check and validate findings.

Third, researchers and frontline staff work together to determine how best to share results and lessons learned so that the data gathered can lead to action.90 With this co-generative research method, an organization creates a comprehensive process to document and analyze current systems and practices, as well as discover information that can lead to the development of new breakthroughs. The process of bringing together researchers and frontline staff affords each group a broader understanding of the others’ concerns.91

Summary

Discovering ways to sustain and deepen worker participation has been a core focus of numerous workplaces and research organizations in Scandinavia and England since World War II. In Scandinavia, these activities were initially created to increase decision making for workers, to make work more meaningful, to reinforce democratic principles of engagement and participation, and to create labor peace. Gradually the focus of industrial democracy shifted to initiatives to improve the productivity and effectiveness of organizations, to control costs, and to respond to such labor issues as increased absenteeism and staff turnover.

The tools of self-managing work groups, of socio-technical systems design, of Employee-Driven Innovation, and of participatory action research have demonstrated value and are beginning to be employed in the United States, where they can be easily applied to healthcare Labor-Management Partnerships.92 In addition, the increased participation of workers in civic affairs, resulting from the skills and confidence that such partnerships engender, has been a critical outcome of industrial democracy in Scandinavia.93 This has great relevance to the United States, where, for example, only 61 percent of voters participated in the electoral process in the 2016 national elections, and where few citizens involve themselves in local or national civic organizations.94 Details and data about the relationship between workplace and civic participation are presented in chapter 8.

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