CHAPTER 7
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Future Approaches for Labor-Management Partnerships

Insanity is doing the same thing over and over again and expecting different results.

—Albert Einstein

As Lazes wrote earlier, my journey to improve patient care systems began in Newark during the 1970s when I was alarmed by the disjointed and inferior care that patients were receiving at Martland Hospital. Dr. Rudden experienced similar dismay while training at Bellevue Hospital in the early ’70s. Sadly, similar problems persist today in most communities. Patients still face long waits to see care providers. Many have difficulty obtaining appointments with specialists. There is often limited follow-up and support available to patients with complex conditions or behavioral health issues that require ongoing care and monitoring. Patients with chronic health problems, in particular, remain underserved by our healthcare systems. Many insurance plans, further, do not commonly pay for preventive measures even though these would yield long-term cost savings as well as better health. Over 8.5 percent of Americans—27.5 million people—still lack any health insurance226 and must seek care in emergency rooms when they require medical help. This is not just an inner-city problem, but a national crisis.227 Our systems of delivering comprehensive care are broken.228

In the preceding chapters, we have discussed the fact that most state and federal approaches to the healthcare crisis primarily seek to increase access to insurance coverage and to cut costs but do not address many of the deepest flaws in our healthcare systems. We have offered practical approaches for initiating and expanding Labor-Management Partnerships in our medical centers to tap the knowledge of frontline staff in a cooperative, organized manner in partnership with management. This approach can improve individual care systems, often increasing job satisfaction while simultaneously cutting costs. We have shown specific ways in which collaborative leadership grants all stakeholders a voice in crafting systemic changes. We have cautioned that creating extensive organizational changes is a complex and time-consuming process:229 staff, unions, and managers need time to accept, to learn how to engage together in an LMP process, and to envision its expansion to tackle system-wide issues. We now explore additional innovative processes that, along with Labor-Management Partnerships, have transformed current care practices to offer new methods for delivering more coherent, accessible, and integrated care.

The Worker Lab

The Worker Lab was created by David Rolf, the dynamic former president of SEIU 775, in Seattle, Washington, in 2014. He developed this initiative to encourage workers, regardless of where they are employed, to identify methods of improving existing services or creating new systems and products. The Worker Lab resembles the Danish Employee-Driven Innovation initiatives (EDI) described in chapter 2 and was informed by the work of Silicon Valley entrepreneurs. It provides a worker or a small group of workers with start-up funds (upward of $150,000) to develop their ideas for new products or services. Project ideas can come from SEIU 775 members or from any other worker who has learned about this resource.

Potential projects are submitted to the Lab’s advisory board, which chooses which proposals to support. Once a project is selected, consultants are assigned to assist each project leader in refining the idea and in examining its feasibility. The Worker Lab provides additional consultants to assist in developing business plans and in securing more funds to test the viability of the new product or service. Periodically, the Worker Lab brings together the leaders of recently funded projects to share their experiences and thus maximize their learning about starting up a small business or services.230

The Lab solicits ideas for projects annually. Financial support for its work comes from several progressive foundations, entrepreneurs, and the SEIU. Describing his inspiration for the Lab, Rolf explained, “The use of innovative strategies has been critical for Silicon Valley companies to be successful. We have tried to adopt this strategy to help our labor movement benefit from the creative ideas of frontline staff. We know that some ideas won’t be successful, but through this process of creating new systems and products, we are certain to fund some important breakthroughs. This why we see the Worker Lab as so important.”231 Rolf views the creation of such new products and services as benefiting the labor movement by expanding our economy and creating new jobs. For Rolf, the Worker Lab is part of a larger national strategy to reposition unions so that they can grow and remain an important force for social justice.

Although the approach of the Worker Lab is not currently part of the repertory of most healthcare Labor-Management Partnerships, it could become an extremely important means for soliciting and supporting creative ideas from frontline staff who are already focused on patient-care improvement projects. When this approach was implemented in Denmark via the Employee-Driven Innovation initiatives, numerous ideas from frontline staff resulted in making it easier for patients to access care and receive treatment at home. An early example from the United States of a frontline worker contributing her ideas toward a striking and highly profitable new invention is that of Lupe Hernandez, a student nurse from Bakersfield, California, who invented the hand sanitizer in 1966. Hernandez observed that sanitation was a considerable problem for people with no immediate access to soap and water and realized that putting alcohol into gel form would provide similar or even better protection. This nurse called in her idea to an inventions hotline and the product was developed.232 A National Healthcare Labor-Management Partnership Workers Lab could achieve similar outcomes. Such a dedicated effort, along with newly developed processes or technologies, could generate new revenue streams for hospitals and community health centers.

Technology Innovation Centers

A second approach to creating healthcare delivery system breakthroughs would be for a group of healthcare Labor-Management Partnerships to directly support expansion in the use of existing technologies and in the development of new ones. New, more user-friendly technologies, from improved robotics for surgery, to devices for self-monitoring the progress of an illness or a patient’s response to treatment, to new equipment to support home care, to smart cards enabling patients and providers to quickly access a patient’s history, medications, test results, and contact details can all help control healthcare costs and improve patient outcomes.

In the 1960s and 1970s, a brilliant and innovative engineer, Mike Cooley, known as a scientist with shop-floor credentials, pioneered an innovative way to use existing and new technologies in industry. Working at the Lucas Aerospace Company in England, Cooley became distressed by the almost yearly cyclical downturns that occurred there, causing workers to be laid off for extended periods of time. After observing these downturns for several years, Cooley and some of his trade union colleagues decided to find a way to avoid the layoffs and benefit the communities where they lived. After discussions within the union, with municipal leaders in London, and with academics, Cooley and his colleagues obtained funding to create community-based technology development centers in the neighborhoods surrounding Lucas. These centers developed prototypes and then manufactured products that made profits, hiring Lucas workers to produce them during cyclical downturns. Lucas workers stipulated that the products be not only profitable but socially and environmentally responsible.233 These centers eventually became part of the Greater London Enterprise Board (GLEB), a citywide economic development organization that enabled the centers to operate all year.

The British Technology Development Centers served as industrial incubators, similar to the Worker Lab, but emphasized current and new technologies. Staffing the centers were Lucas workers, university faculty, and student experts in production methods and new technologies. Within two years, the centers developed more than 150 new products such as electric bikes, small-scale wind turbines, energy conservation services, devices for individuals with various disabilities, children’s play equipment, and community computer networks. The Technology Development Centers established training programs for Lucas workers to learn new skills so that they could easily obtain such jobs during downturns. Cooley’s creativity harnessed the knowledge and skills of frontline workers to maintain full employment.234

Although hospital and health systems do not have cyclical downturns, creating technology incubators sponsored by a group of healthcare Labor-Management Partnerships is well worth considering. New self- or home-monitoring devices can avert medical crises, reducing costly emergency room visits and hospitalizations.

Currently, U.S. equipment manufacturers are the primary investors in research and development for new medical devices. These companies lack regular access to the knowledge, ideas, and skills of frontline staff aside from the physicians they hire as consultants; hence their devices are not always user-friendly. These manufacturers retain all profits from new inventions. The experience of the Lucas aerospace workers thus poses an alternative process, in which frontline healthcare workers directly contribute to enhancing current technologies and developing new ones. Supported by healthcare Partnerships, this approach might provide new income streams while ensuring that the new technologies are used to expand rather than eliminate jobs.235

Funding for healthcare technology incubators and expanding the Worker Lab approach might stem from hospital research and development budgets, foundation grants, the national unions representing healthcare workers, private foundations, and state and federal budgets. A portion of revenues from new products might be funneled back into healthcare incubators to cover future research and development costs. Employee Driven Innovation funding in Denmark has come from national unions, hospitals and health departments, and the federal government. Universities might provide another source of support for these initiatives. In the past, student and faculty at academic centers played important roles in helping several manufacturing companies reduce costs, create new products, and save jobs.236

Accelerating the Creation of New Healthcare Delivery Systems

Although many healthcare Labor-Management Partnerships will continue to focus on incremental change, future LMPs should also use interventions to promote significant breakthroughs for providing more integrated, high-quality, affordable care. Practitioners such as Stu Winby, president of Spring Network, argue that “only by more radical and transformative activities237 will we be able to create healthcare delivery systems that provide better outcomes.”238 A practical method to speed the process of transforming healthcare delivery systems is Winby’s Work Innovation Network (WIN) process, which begins with a large-system intervention. Although there are several kinds of large system interventions,239 we chose to highlight the WIN approach since it has been conducted within hospital settings and research exists about its composition, process and outcomes.240 Winby, a consultant trained in clinical psychology, behavioral medicine, and human factor engineering, created and directed HewlettPackard’s Factory of the Future process from 1989 to 2000. This initiative was established to continue ongoing innovation at HP, which was considered at the time to represent the gold standard in manufacturing.

The WIN process begins with an intensive two-day retreat, a “Decision Accelerator,” to which all stakeholders in a healthcare system are invited: administrators, frontline staff, patients, insurers, and community and health department representatives. The latter groups, whom Winby terms “end users,” present their unmet care needs or explore new ways of restructuring reimbursements within a redesigned healthcare system. Guests (termed “radicals”) from other organizations that have accomplished transformative activities are invited to encourage participants to consider outside-the-box remedies for their systemic shortcomings.241

The retreat creates the case for changing the current system by identifying central organizational problem areas and envisioning new structures to correct them, with all stakeholders accorded time and space to offer their input. Action Teams are established during the Decision Accelerator to work on each area identified as requiring change. The teams comprise a cross-section of participants to ensure a broad range of experiences, knowledge, and skills among their membership. Each Action Team is tasked with creating a process or structure to “enhance the patient experience”242 while better integrating the system. These teams are provided time to analyze their work area and to obtain more detailed feedback about their task from other participants.

Following the retreat, each Action Team meets weekly to set quantifiable goals and to continue designing structures and processes that accord with the overall strategy established during the initial meeting. The teams’ work is reviewed by senior organization leaders on a 30-, 60-, and 90-day basis after the retreat. During this working period, teams ideally receive support from internal consultants, which is critical to their functioning. Teams usually require three to four months to complete and submit their new process recommendations (“design specs”) to senior management. Once the leadership accepts suggestions for the new processes, Action Team members implement their solutions and submit monthly reports to senior management about their outcomes.

Like Labor-Management Partnership teams, WIN Action Teams work on solutions through an iterative process243 of devising experiments that test multiple potential solutions in order to finalize an outcome with significant results (see figure 4). Unlike in the LMP process used at Maimonides and LA-DHS, unions have not had a role in helping to design the WIN process, identifying teams once goals are established, and overseeing implementation of solutions by Action Teams. The WIN process is thus management-driven, although it does powerfully engage the thinking and efforts of frontline workers.

WIN is extremely successful because it creates an opportunity for all significant stakeholders in a healthcare delivery system to intensively analyze the current system and collectively identify aspects that require change. The approach enables all participants to picture the issues facing their current system and creates a scenario in which the authority and will to revamp the delivery system is present “in the room.”244 A significant aspect of this large group intervention is that it enables key stakeholders (not only clinical staff of a hospital system but community organization staff, state and federal health department staff involved in reimbursement policies, and insurance company representatives) to meet and exchange ideas from various points of view. One advantage of this large group approach is that it encourages “debate intensity”—which can contribute to the formulation of unique and novel solutions.245

Figure 4. Steps in the Work Innovation Network Process

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Winby has implemented the WIN process at both Alegent Health (Omaha, Nebraska)246 and Fairview Health Services (Minneapolis, Minnesota).247 Each of these systems used traditional inpatient and outpatient silos prior to WIN, with patient care provided in a fairly fragmented fashion. Neither had instituted meaningful relationships with local community health groups. These organizations used the WIN process to successfully transform their delivery systems into Patient-Centered Medical Homes as well as to strengthen specialty services in their delivery systems. Fairview also established care coordinator positions to oversee patients’ overall treatment in the care system and in the community. It developed new reimbursement arrangements with Medicare and with several private insurance companies to pay for coordinating patients’ care. Creating these new reimbursement agreements was critical to compensating Fair-view for the new services they offered and for their loss of revenue due to reduced hospital admissions. “Without ‘out of the box’ thinking, our delivery systems would still be locked into their older ways of working,”248 stated Terry Carroll, former senior vice president for transformation, Fairview Health Services.

As healthcare organization leaders continue to explore methods for creating integrated delivery systems, approaches like WIN (a systemic intervention focused on a desired future state) can be helpful. Although WIN has not been applied to current healthcare Labor-Management Partnerships, its approach offers an important method for expanding the repertoire of Labor-Management Partnership activities and complements the values and philosophy of partnership work.

Despite the fact that WIN and similar large group interventions have been successful in launching teams that study patient care problems and suggest cost-control measures, their approach is at times compromised by an uneven power gradient between the teams and the administrators who eventually control all decisions about their work. To address this problem, new approaches have helped to encourage all stakeholders to speak up, although these are implemented only during the initial large group meeting:

1. Opportunities were created for less “powerful” stakeholders to have the time to pull together their ideas and concerns by themselves. An effective process has been pre-retreat caucusing of these stakeholders.

2. High-powered stakeholders were coached on listening and trying to understand the views of all contributors. This helped to create an atmosphere of freedom for all present, so that they could suggest changes to the current system. It helped to uncover important issues that high-powered senior leaders didn’t see.

3. A balanced number of all stakeholders were invited, so that clinical staff and managers at lower levels felt able to speak.249

Including Excluded Actors

It is critical that the next phase of Labor-Management Partnerships include patient representatives in the decision-making process for systemic change. Other than the WIN approach, which included patients in the design phase of the change process,250 patients have been excluded from a direct role in LMP activities. Without their involvement, however, healthcare leaders and frontline staff lack essential information about the impact that the changes they are devising might have on patients’ lives.

It would be extremely useful for Action Teams, as they experiment with changes in the care process, to meet with focus groups of the patients whom their units or departments serve. This feedback would have particular value for patients with chronic and complicated health issues, who may have special needs in accessing care, and who often struggle to understand diagnoses and treatment plans devised by multiple, nonconversing specialists. Such patients often need advocates to help understand their intersecting diagnoses, to advise them on monitoring their symptoms, to review multiple medication regimens, and to help navigate the delivery system.251 Systems that offer more coordinated care will be a boon, but such patients will still likely continue to need care managers.

The Affordable Care Act created funds for “patient navigators,” a job similar to patient advocate, on a national level. Sixty-three million dollars were allocated to healthcare systems that made these navigators available to their patients.252 In practice, however, these jobs have focused only on helping Americans understand their healthcare insurance options so that they can make informed choices about which plan to purchase. Creating patient advocate positions would complement the roles of these patient navigators to ensure that patients benefit from new care systems.

Including patient feedback in planning systems changes is crucial. As many care system departments, such as billing or finance, remain siloed, caregivers often have little information about the larger systemic issues their patients face. Kaiser Health News reported in November 2019, for example, that the University of Virginia Health System had sued 36,000 patients over the course of six years for more than $100 million, “seizing wages and savings and even pushing families into bankruptcy.”253 The news created an uproar for the UVA system’s medical and nursing staff, as well as its larger community. Three senior staff members, Drs. Scott Heysell, Rebecca Dillingham, and Michael Williams, wrote a widely circulated letter in response to the report, decrying this practice: “We felt betrayed . . . and we had, by extension, betrayed those who had relied on us . . . we are outraged. We stand with those that have been financially injured, whose bank accounts have been looted, whose homes have been swallowed as if they were built on quicksand . . . all as a result of having sought our care.”254

Kimberley Acquaviva, a professor of health policy at UVA’s nursing school, wrote on Twitter about her discussions in class that this issue “has been painful for them as nurses who care deeply about the patients and families they serve. . . . As a class, we talked about the power that nurses have to shape the lives of the patients and families by advocating for system change.”255 Without patient input about the full impact of the care system on their lives, however, it is unlikely that LMPs in their current form will address such practices.

By contrast, and with an eye to future goals for our health systems, consider the highly collaborative design process for the new Orbis Medical Center in the Netherlands: “The overall concept of designing the hospital was to create the best environment for patients: a healing environment with a true human interaction between patients, nurses, doctors and other staff.”256 The design process for this new hospital involved all relevant stakeholders: the Patients’ Board, the Workers’ Council, the unions. In addition, it incorporated extensive staff member recommendations about creating an environment in which they might work more productively and happily.

The hospital, completed in 2008, features a huge atrium, a food court, comfortable chairs in waiting areas, chairs that convert into beds for family members in patient rooms, and bedside media terminals allowing patients to order meals, watch TV, call nursing staff, and view their chart, including all recent test and procedure results. Smart cards were developed for doctors and nurses, enabling providers to quickly access their patients’ history, medications, test results, and information about the patient’s outpatient physicians, pharmacists, family contacts, etc. Hospital designs in the United States have incorporated some of these patient-friendly features, which derived from soliciting patients’ concerns.

However, Theodora Swenson notes that many hospitals have adopted generic “hotel or airport” designs with the intent to comfort patients without actually doing so: “We need to stop designing hospitals in isolation and first answer the question: What is healthcare? Only once we understand the purpose of what we are designing for can we then decide how to build it. We need to understand the ecosystem—the complex infrastructure of healthcare—before we can design hospitals.”257

To actively consult and incorporate the expressed needs of staff and patients through a collaborative process should be a future goal for our unions, healthcare workers, and administrators.

Summary

In this chapter, we considered strategies that offer the potential for increasing revenue to medical centers while at the same time enlisting the creative and practical ideas of their staff. The Worker Lab, established in Seattle and based on practices used in Silicon Valley, offers encouragement for workers, regardless of where they are employed, to identify methods to improve services or to create new systems and products. The Worker Lab provides a worker or small group of workers with startup funds to develop their ideas. While the Worker Lab focuses primarily on the development of new processes for patient care, we also encourage groups of healthcare Labor Management Partnerships to form Technology Development centers such as the one developed at Lucas Aerospace in England and supported by surrounding universities. The development of new methods for healthcare technology may provide a source of funds for medical centers and their Labor Management Partnerships.

In addition, we discussed intensive large group work sessions that can accelerate the initial work of Strategic Alliances, Labor-Management Partnerships, or new health systems development. A particular methodology based on programs employed in Silicon Valley by Stuart Winby (The Work Innovation Network Process) and used at Alegent and Fairview Medical Centers is described in detail.

Finally, we discussed the need for Labor Management Partnerships to include patient feedback about care access and care provision from the very beginning of their work. Further, clinical staff need to be made aware of their center’s approach to patients who are late in paying their bills so that they can ensure that such practices meet the ethical standards of their professions.

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