CHAPTER 8
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Analyzing Value, Preventing Failures

Success is not final, failure is not fatal, it is the courage to continue that counts.

—Winston Churchill

A society characterized by generalized reciprocity is more efficient than a distrusting society. . . . If we don’t have to balance every exchange instantly, we can get a lot more accomplished.

—Robert D. Putnam

We have repeatedly underscored that the development of healthcare Labor-Management Partnerships channeling the knowledge and experience of frontline staff is a highly rewarding process, but one that presents challenges. The challenge for labor involves shifting from an adversarial relationship with management to collaborating to create change in the workplace. An LMP process requires unions to balance working jointly on organizational change strategies with their traditional responsibility to represent workers in conflicts with management. For management, the Partnership process necessitates sharing production, quality, and financial information with staff and unions, and involving them in decisions ranging from purchasing equipment and supplies to designing new care structures and uses of technology. For an organization to fully commit and carry through a successful Labor-Management Partnership, leaders on each side must come to identify the value of this work and commit to it.

A primary value of workers’ involvement with decision making in healthcare settings is that, as we have shown, patient care is improved while employees’ work lives become enriched and more satisfying. More efficient delivery processes and increased patient satisfaction scores also result in cost savings in several dimensions. What is rarely addressed, however, is that participating in these workplace activities contributes to employees’ increased confidence, improved skills, and motivation for contributing to civic life beyond the hospital. The first section of this chapter focuses on this finding, which is of great importance for our society. In the second section, we will provide an analysis of site-specific difficulties encountered while starting or sustaining some Labor-Management Partnership processes, with an eye toward preventing similar problems in the future.

Increasing Civic Participation

The shrinking of civic participation among U.S. citizens has reached alarming proportions. The decline in numbers of citizens voting in national elections provides a startling example of their alienation from a process central to democracy. Only 61 percent of U.S. citizens voted in the 2016 presidential election, the lowest voter turnout since 1996.258 Further, there is a documented decrease in citizens participating in community organizations. For example, Americans are about half as likely to work for a political party or attend a political rally now as they were in the 1970s. The number of office seekers from school boards to town councils has shrunk by about 15 percent.259

In the United States, Ron Putnam, a prominent sociologist and observer of civic life, has documented how civic passivity contributes to a decline in community resources; a lack of public policies to improve education and healthcare, especially for poorer citizens; and a rise in crime.260 Putnam also argues that declining civic participation in our nation undermines our democracy and perhaps even our political stability.261

Scandinavian countries, particularly Norway, have found a direct connection between citizens participating in workplace involvement activities and subsequent engagement in their wider communities. Worker participation activities are viewed there as a vital approach to encouraging civic activism. Norwegians feel that to preserve an active democracy in which citizens can retain individual and collective freedoms, participation in their communities and in their nation is critical.

Political scientist Max Elden and sociologist Bob Karasek have each documented the connection between greater workplace decision making and greater civic participation. Karasek, in seminal research conducted in Sweden based on national aggregate data from 1968 and 1974,262 demonstrated that workers’ “job decision freedom” (the ability to make decisions) and their control over their work pace and job responsibilities directly correlated with their degree of political and civic participation. His studies revealed that workers holding more “passive” jobs that lacked decision making and broad job responsibilities were much less likely to engage in either political or leisure activities.263 Elden’s research, complementing Karasek’s, again documents that greater workplace autonomy in self-managing work groups increases workers’ civic participation.264 This synergy clearly seems to reduce civic passivity.265

To investigate the connection between workplace and civic participation in the United States, co-author Lazes approached labor and management leaders at Maimonides Medical Center for permission to research this question. Pam Brier, then CEO of Maimonides, and Bruce Richard, executive VP of SEIU 1199, became co-investigators. In addition to their intensive involvement in Labor-Management Partnership activities at Maimonides,266 both Brier and Richard were extremely interested in whether hospital worker participation influenced their community activism, as both Brier and Richard have for years been directly involved in multiple community endeavors. Over the years of the Maimonides Partnership process, Brier, Richard, and Lazes had each heard anecdotal evidence from frontline staff about their new involvement in various community activities. Was there a real connection between workplace and civic participation, or did frontline staff chosen or electing to participate in Partnership activities already tend to participate in community organizations?

After much discussion, we decided to track two outcomes relevant to community participation that were relatively easy to measure. The first was to assess the degree to which frontline staff participated in political action events (such as rallies and protests supporting state and local funding for the hospital and community health organizations) or volunteered for community work. The second traced whether employees contributed part of their pay, on a regular basis, to support their union’s political activities. Anonymous surveys were distributed annually to frontline staff participating in departmental labor-management committees and various work groups from 2002 to 2006.

Over the five years of this study, we found a 48 percent increase in attendance at political rallies and involvement in community work by frontline staff participating in Labor-Management Partnership activities. Contributions to political activities also increased by 45 percent over the five years. These outcomes were particularly noteworthy because SEIU 1199 had already achieved high levels of attendance at political events and had encouraged members to work with community organizations prior to the LMP at Maimonides.

Focus groups of frontline staff participating in Maimonides’ LMP process explored this question qualitatively. These groups revealed that employees felt more inclined to participate in civic activities because of the leadership and decision-making skills they had acquired in their work with the LMP. Specifically, many staff members articulated that their opportunity to improve patient care through working as a team267 made them feel newly respected by both management and their peers.268 Increased self-confidence from running groups and handling the inevitable conflicts that arose within them was mentioned as contributing significantly to the workers’ motivation to apply their skills elsewhere.

Apart from the significant benefits that Labor-Management Partnerships bring to healthcare organizations by reducing costs and solving significant problems in patient care delivery and integration, this civic contribution is vital. During turbulent times in which citizens seem alienated from government and from the essential practices of democracy, it is crucial to discover ways of strengthening their skills and motivation to participate in national and community organizations at every level. As we documented in this chapter and in chapter 2, workplace participation can reduce the feelings of disenfranchisement and helplessness bedeviling many citizens. Strengthening understanding of civic structures and offering opportunities in our schools to assist community groups269 will help to acquaint future voters with the importance of participation in community and national democratic structures.

As Einar Thorsrud, a key Norwegian scholar of both workplace and civic participation, stated several years ago, “Continuous learning, support between colleagues, and meaningful [work] relations is important to workplace productivity and civil society.”270

We will now provide an analysis of healthcare Labor-Management Partnerships that did not work—either from the outset, or from some later point—so that frontline workers and managers interested in creating a new Partnership can learn from these failures and avoid their missteps.

Labor-Management Partnerships That Failed: An Analysis

The cracks in Partnership processes can show quite early on if labor and management partners are not prepared to support joint activities. The Labor-Management Partnership experience at Cook County Health (formerly Cook County Health and Hospitals System) offers an example. Cook County Health, the third-largest public health system in the United States, treating more than 500,000 patients each year, has been struggling for years to provide reasonable access to care for patients. In 2013, labor and management leaders began meeting with a Cornell consultant to develop a partnership process in hopes of improving access to care and improving patient satisfaction. The latter, which was regularly very low, posed a significant problem throughout the delivery system, as hospital reimbursement levels partly depend on patient satisfaction ratings.

For this process, Lazes appointed a consultant who was new to the work of Cornell’s Healthcare Transformation Project but quite familiar with Kaiser’s Partnership. Cook County union and administrative leaders met with this consultant several times to set initial goals and to agree upon basic ground rules for their work together. They identified improving access to outpatient services, including specialists, and improving outpatient satisfaction scores as the initial areas on which to focus Partnership problem-solving work groups.

Lack of Preparation

Unfortunately, neither labor nor management at Cook County were fully prepared for the Partnership activities. Each group was skeptical about these endeavors, feeling that the other “was not really serious.” They did not establish the essential educational activities for frontline staff, supervisors, and senior leaders to prepare for this work, nor did they arrive at a budget or a clear-cut agreement about the respective roles of management and frontline staff. In addition, the unions involved (SEIU 73, the Doctors Council, and the American Federation of State, County and Municipal Employees local 31) did not create goals for the project that would be to their benefit, as inter-union friction hampered their ability to achieve consensus. Further, neither the unions nor the administration appointed internal consultants to support the new work groups. As a result, the initial work groups floundered due to a lack of training and support, including the fact that they had not been offered enough time to pursue their work. Because of these failures, the Partnership process fizzled out within 18 months.

Given the existing friction between unions and the entrenched hostility between labor and management at Cook County, establishing a good working Partnership there was destined to be a difficult and arduous process. However, it is regretful that the external consultant assigned to the Partnership, new to Cornell’s approach to Partnership implementation and uninterested in receiving guidance about it, failed to fully implement three core practices described in chapter 3. He did not spend enough face time to adequately prepare the constituents for a Partnership process, did not help management work with frontline leaders to identify areas of common interest to which they might be committed, and did not work closely enough with labor and management leaders to guide them in their initial work group process.271 Finally, he did not emphasize the need for hiring or developing internal consultants, particularly since his available time to follow through on their process was limited. Some of these failures seemed to occur because the consultant appeared to be skeptical from the beginning that the process could succeed in this setting, preferring to focus his time in another hospital system.

The history of this particular failure underscores the necessity of employing all core practices, and especially the importance of patiently educating and cultivating each constituency group during the initial steps of their collaboration. It never pays to initiate problem-solving groups without first preparing leadership and frontline staff for the endeavor. In the end, however, some sites are simply not ready or able to make a joint commitment to the Labor-Management Partnership process, as a result of biased leadership or of a genuine inability to commit adequate resources to it.

Too-Rapid Change Leading to a False Start

Another factor that can contribute to an LMP failing early in the process, even after having established basic goals, ground rules, and work teams, is a too-hasty attempt at change. For example, study teams need to carefully prepare employees whose jobs may be altered through the process before they finalize and attempt to implement their recommendations.

An example of such an omission occurred several years ago at a small hospital in central Harlem, New York, whose Partnership was initiated with the goal of improving overall patient care. Gene McCabe, the CEO of North General Hospital, and Betty Hughley, the vice president of SEIU 1199, were co-leaders able to elicit both labor and management support for a Partnership process at this site. Both were well-liked, their enthusiasm for starting a Labor-Management Partnership process was well received by frontline staff, and their positive and uplifting spirit was contagious in this small community hospital.

Two initial problem-solving groups were established after a half-day meeting held to launch the Partnership process. One work group focused on reducing patient wait times in the outpatient department; a second attempted to reduce turnaround time for laboratory results. These two work groups started immediately brainstorming possible solutions. Frontline staff in the two groups were extremely enthusiastic about the opportunity to make changes that would improve patient care and rapidly developed potential solutions to their assigned problems.

Unfortunately, neither group consulted with those staff whose jobs would need to change if their proposed solutions were implemented. As a result, most frontline workers in the two departments where the problem-solving teams were focused refused to consider their recommendations. Although senior management and union leaders at the hospital felt that Partnership activities would eventually have value for both patients and staff, the false start led to North General Hospital terminating Partnership activities at that point.

Importance of Consulting with Affected Staff

This experience underlines another important practice to keep in mind in partnership work. At Xerox, Study Action Team members constantly interacted with the shop-floor members whose work their recommendations would eventually affect. Work groups who anticipate promoting significant changes in work practices need to introduce their data and reasoning and to obtain feedback from affected staff as their work progresses, rather than presenting the involved staff a fait accompli. This constitutes an important aspect of collaborative leadership: those designated to make significant workplace changes, even if they are managers and frontline staff working in tandem, need to consult with staff who will be affected before recommending significant changes.

Both Partners Need to Participate

Another example of a challenge to establishing an LMP process can be found when only one of the two partners is willing to engage in joint work. This recently occurred at the Cambridge Health Alliance in Cambridge, Massachusetts, a community-based healthcare delivery system just outside of Boston. Two unions representing workers in the Alliance (CIR and the Union of Social Workers, a local union of AFSCME) made frequent attempts over a six-year period to encourage senior management to enter a joint process for improving patient care. The two areas suggested were (1) improving access to behavioral health services and (2) addressing the dilemmas caused by inadequate health insurance reimbursements for patients needing behavioral healthcare.

Although initially seeming receptive to establishing a joint process, the Alliance administration was ultimately unwilling to agree to a joint process. Some psychiatrists and primary care doctors in the administration favored such an endeavor, but their support was superseded by senior management, who preferred to respond to these challenges solely through their own initiatives.272 Lacking a partner, the unions retreated from their proposal, yet they remain hopeful that they will eventually convince management of the value of working together.273

Sabotage by Those Feeling Left Behind by Change

Apart from process failures, or those related to difficulties in gaining the full commitment of management or union leaders, our research and that of others suggests that certain difficulties within organizational cultures are particularly hard to overcome in sustaining Partnership processes.274 In systems that have developed a “hybrid organization,” in which some parts of a large system adopt cooperative work structures, while others continue to work with the traditional top-down arrangement, the asymmetry may breed unhealthy discontent, envy, and competition.

This was the case at the Saturn plant in Spring Hill, Tennessee, described in chapter 3, which was organized on a team-based work system with extensive frontline participation and a nonadversarial labor relations system.275 Saturn’s labor agreement included provisions for multi-skilled, flexible jobs and profit-sharing. Over time, this agreement became increasingly perceived as a threat by the United Auto Workers union’s new national leadership, who were unfamiliar with the rationale for the agreement and suspicious of the entire Partnership process.

Simultaneously, new senior General Motors management became hostile to how the Saturn plant was structured, with freedom to design its own cars and access to significant, separate funding from GM.276 They were concerned that workers and plant managers elsewhere at GM might demand similar labor decision-making authority. Facing financial pressures in early 2000 resulting from the over-capacity of other GM assembly plants and a dip in sales of small cars, senior GM managers reduced production at the Saturn plant, despite its strong market share and strong customer loyalty.277 They stopped Saturn engineers from updating the car design and forbade them from exploring the manufacture of new Saturn models, such as midsize cars and SUVs. These decisions resulted in a steady decline in production at the plant. In 2010, GM management decided to stop manufacturing Saturn cars.

Thus, late in Saturn’s tenure, the national leadership of the UAW and of GM changed. Most of the new leaders had not participated in Saturn’s founding, felt uncomfortable with the culture that had been established there, and had more traditional mindsets and biases, which viewed union and management as adversaries.278 These new leaders actively opposed the Partnership process from the start. Interpersonal conflicts between the local union leadership at Saturn (UAW Local 1853) and national UAW leaders had also developed. As a result, the national union never fought the increasing restrictions on Saturn’s production or GM’s decision to halt production of the car.

Clashes of Cultures and Regression in Groups

One aspect of these decisions seems rooted in the human tendency to retreat to traditional solutions when conflict arises or when economic pressures move organizations to cut back. However, other forces may also be at work when traditionalists wage war with perceived upstarts. In chapter 5, we illustrate how such a war within an organization can happen: a “fight” regression may occur when a business is challenged economically, beginning with a search for an external or internal scapegoat to blame. Often this may be a subgroup that is already the object of envy or misunderstanding. The regression inflames the emotions of workers who fear for their jobs and leaders who feel pressed to arrive at a solution, which often prevents them from making a focused, unbiased analysis of all contributing factors.

The tendency to isolate and exclude the “new” group is exacerbated when a real pay disparity exists between workers with new, evolving jobs that carry increased responsibility and those remaining in lower paying, more mundane positions without advancement opportunities. This wage and decision-making discrepancy took place in the coal mines of the UK and at Volvo, as discussed in chapter 2.

Anticipating and preparing for this potential clash of cultures in any hybrid system is crucial. Such culture clashes tend to occur when an organization becomes challenged economically, testing its commitment to the new processes; when wage and decision-making differences stir up workers on opposing sides of the pay and advancement differential; or when intraunion difficulties arise in a multiple-union system.279 The latter has been the case recently at Kaiser, where conflict among its unions may impair their frontline-staff work group process. We discuss this possibility shortly. In such cases, the tendency to find blame in the “newfangled” work system, coupled with momentum to keep the old, more familiar, culture, may override attention to the merits of new process.

Another example of the challenge posed by different, coexisting, work cultures was seen at Rushton Mining Company, a coal mine in Osceola Mills, central Pennsylvania, in the early 1970s. Arnold Miller, then president of the United Mine Workers of America, wondered whether Eric Trist’s work with coal miners in England, described in chapter 2, might benefit his members. After securing an agreement with Warren Hicks, Rushton’s president, and with the local union membership to establish new work systems that might improve mine safety and overall productivity, Miller oversaw the establishment of several self-managed sections of the mining operation. The remaining sections operated in more traditional ways. These sections of the mine were monitored for a year on safety issues, including reported accidents; on absences; on productivity; and on maintenance costs, as well as on the daily tonnage of mined coal products.280 If the self-managing production proved helpful, then the entire mine would shift to this production process.

The results of the research, conducted a year after pilot work groups were established, revealed that the self-managed work groups had fewer safety problems, experienced a significant reduction in lost-time accidents and absenteeism, and achieved slightly greater production numbers than other sections of the mine. Interviews with mine workers in the self-managed work groups revealed that they felt extremely proud of their work, felt recognized for their good ideas by their co-workers, and were “no longer tired after getting home.”281 Despite the positive outcomes, though, union members voted down a proposal in 1974, a year after the implementation of the new work system, to expand self-managing work groups to the entire mine. Many workers feared that expanding the new system would give only the most senior, experienced workers the interesting jobs and increased pay within the new structure.

This fear arose because miners who participated in the initial self-managed work groups had begun to receive pay increases, as many of them were now performing multiple jobs. If other areas of the mine formed self-managing work groups, these miners would have obtained similar increases in pay, but envy of the higher-paid colleagues and overall anxiety about losing out seemed to override this calculation. Further, some foremen described fearing loss of their influence at the mine if the self-managing work groups expanded and hence did not support the process.282

These examples suggest that LMP leaders must anticipate organizational regressions that can occur due to members’ anxieties about the loss of familiar theories and practices, and about losing power, prestige, or economic benefits in the new system. In the face of such anxieties, constituents may favor the old, even when confronted with data that identify a superior, potentially more remunerative, process.

It is therefore important that Partnership leaders continue to nurture relations with senior union leaders (particularly with the national union president, as in the Saturn example) and with senior management leaders throughout the LMP process (again seen at Saturn). It is wise to ensure that Partnership processes will enable all employees to eventually have the ability to work in new ways and receive similar pay, overall benefits, and decision-making capability—not just those in the initial work groups. Otherwise, resentment is created between those who have garnered the new opportunities and those who have not. One cannot assume that the workforce will automatically understand such future benefits. At Maimonides, employing continual reinforcement about the gains that workers have made within the new systems, and built-in reminders to new managers about their value, have helped to prevent such misreadings. Without a clear strategy to prepare for and address such possibilities, the Labor-Management Process is put at risk.

Responding to Challenges

Even when implementing less radical work systems or quality improvement initiatives, challenges may still threaten their being sustained. At Kaiser, the Los Angeles County Department of Health Services, and Maimonides Medical Center, some frontline staff voiced resentment at not having the opportunity to participate in an Action Team, a particular work group, or a unit-based team. Addressing these concerns immediately resolved the conflict between those inside and those outside the process. Importantly, in the face of such resentment, leaders in these change processes found ways to include frontline staff more widely in their projects. It seems apparent that employees who feel denied opportunities will subvert implementation of the new systems from which they feel excluded.

Besides cultural or economic changes, changes in union and management leaders can greatly affect whether healthcare LMP practices are sustained or eliminated. Again, employee participation activities are time-consuming and require the commitment of both union and management senior leaders to support the process. Although there is no foolproof vaccination against a potential disruption caused by a change in labor or management leaders, a clear social contract between labor and management about the goals, structures, and resources for joint activities can help sustain a healthcare Labor-Management Partnership process through times of stress. At Maimonides Medical Center, the fact that SEIU 1199 had defined from the outset how Partnership activities would achieve union-building outcomes helped to sustain the Partnership even when senior union leadership at the hospital changed. Similarly, when Dr. Mitch Katz, the director who had instituted the Partnership process at LA-DHS, left his position in April 2018, the already-established governance process and funding arrangement sanctioned by the Board of Supervisors of L.A. County283 to support Partnership activities served to keep their Partnership process alive.

The need to create support for new work systems entails ongoing education of both leaders and frontline staff and requires continuous communication about the results it has achieved. Just as democratic forms of government require constant struggle and revival, so the educational and communicative processes of Partnerships must function throughout their duration. A lapse in these practices risks the entire endeavor.

A final example of a challenge facing a healthcare LMP is now occurring at Kaiser Permanente. The initial labor group involved in creating the LMP, the Coalition of Kaiser Permanente Unions, represented workers from the 22 major local unions. After 21 years of their Partnership process, significant conflicts developed among the participating unions. Ten unions (Hawaii Nurses and Healthcare Professionals, International Brotherhood of Teamsters, International Longshore and Warehouse Union, International Union of Operating Engineers, Kaiser Permanente Nurse Anesthetists Association, Oregon Federation of Nurses and Health Professionals (AFT), United Food and Commercial Workers, United Steelworkers, Unite Here, United Nurses Associations of California/Union of Health Care Professionals) decided to leave the coalition in October 2018 to form their own organization, the Alliance of Health Care Unions. This split in the union coalition stemmed not from issues within the Kaiser Partnership process itself but from fights among the unions concerning leadership and decision making within their coalition.

It is not clear to what extent this rift will affect frontline staff participation and the overall Kaiser Labor-Management Partnership process. Frontline staff continue their involvement in the unit-based teams, in which both the Coalition and the Alliance now represent workers.284 The Kaiser Partnership process needs to anticipate the impact that these new developments may have in their work going forward, and needs to interface with each union group to ensure that neither withdraws from the Partnership. Here again, founding agreements that have a history of implementation over time may help considerably to sustain their work.

Throughout this book, we have outlined strategies that can overcome resistance to positive organizational disruption. As David Bornstein, in his book How to Change the World, states,

The capacity to cause change grows in an individual over time, as small-scale efforts lead gradually to larger ones. But the process needs a beginning—a story, an example, an early taste of success—something along the way that helps a person form the belief that it is possible to make the world a better place. Those who act on that belief spread it to others. They are highly contagious. Their stories must be told.285

Summary

In this chapter, we reviewed research from Scandinavia and from Maimonides Medical Center indicating that staff who participate in workplace activities that increase their conflict-resolving, analytic, and communication skills are more apt to engage in civic involvements outside the job. This is crucial, since widespread civic alienation and disengagement has become quite destructive to American democracy.

We also analyzed the failures of two Labor-Management Partnerships with an eye toward preventing their recurrence in the future. One Partnership did not engage in central core practices, particularly those about preparing both labor and management for their endeavor: educating administrators and union officials about what is possible and helping them to establish workable goals. That Partnership also did not provide adequate assistance to their teams.

In another setting, a very enthusiastic group of staff and administrators quickly launched teams that proposed new ways of organizing work on their units. Without preparing the workers who would have to engage in the new systems, however, the process foundered. When significant changes in work are introduced, it is crucial to have discussed the reasons for and the impact of such alterations with those most affected.

In another situation, despite considerable preparation on the union’s part in proposing a Labor-Management Partnership, managers decided to address clinical issues themselves. LMPs are by nature a two-way process. It is to be hoped that the union might be able to convince these administrators in the future of what they have to offer. Unfortunately this will not always be the case.

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