Eager for strategies to tackle workplace stress, a group of nurses in Southern California—including Denise Duncan, RN, president of UNAC/UHCP—sought out a workshop on the issue.

Workplace stress undermines employee health and safety, they knew, and erodes patient care and service.

But what they learned at the conference, which was offered by an outside organization, rang hollow.

“They told us the work isn’t going to go away: Have a hot bath, light candles and take a deep breath,” says Duncan. “You can work a 12- or 14-hour day. Go home and relax. The same workload is going to be there again the next day.”

A majority of workers in the United States—especially those in health care—tell researchers their main source of stress is at work, not home. Long hours, job insecurity, poorly designed workflows and fear of violence or injury top nearly every list of common causes.

Focusing on the individual’s behavior may help a person cope with such issues, Duncan says, but does nothing to address the root of a problem that some studies suggest affects three in four U.S. workers. Part of what’s needed, she says, is more accountability from both management and the unions to fulfill the National Agreement’s commitment to fixing backfill shortages. The safe-staffing campaign UNAC/UHCP ran last year was part of that call to action.

Duncan and her fellow leaders in the Coalition of Kaiser Permanente Unions want to step up the conversation on workplace stress and make sure it:

• includes worker voices on scope of practice and other issues
• addresses unhealthy work environments
• develops resources in partnership

 “We have talked about work-life balance. I am not sure there is one yet,” Duncan says. “We are at a tipping point.”

Opportunity for action

“Issues related to workplace stress are often collectively caused,” says Ron Ruggiero, the president of SEIU Local 105 in Colorado. “They need a collective solution.”

Kaiser Permanente is not immune. In a survey done before 2015 National Bargaining, 94 percent of workers represented by a coalition union placed a high priority on reducing stress in the workplace. Scores on the “KP supports me in having a healthy and balanced life” question on the annual People Pulse survey have stayed flat, with mid-range favorable ratings, from 2007 through 2015. 

But partnership and unit-based teams offer an opportunity for action, says Ruggiero, whose union represents 3,000 KP employees.

“At each and every worksite,” he says, “workers should be listened to and solutions could be figured out—and implemented.”

The chances are good you are a person who deals—directly or indirectly—with life and death every day. You might be an EVS worker who keeps patient rooms germ-free to reduce the odds of infection, or an ER nurse helping a baby with a high fever. If you are not on the clinical front lines, you likely support this honorable work from behind the scenes.

We put others first. We give everything to give the best care to our patients. But far too frequently, we don’t leave anything in reserve. We neglect to take care of ourselves. This imbalance undermines the admirable ethic of our modern health care system.

One survey showed 60 percent of health care providers are burned out. In this issue of Hank, we provide practical tips and tools that individuals, leaders and teams can use to reduce workplace stress.

But more than that, we challenge the notion that the responsibility for preventing burnout lies solely with one of these groups. Let’s call it the “yes, and” approach. Yes, individuals need to eat better, exercise more and cultivate a positive outlook to reduce their own stress. And, leaders need to ensure safe staffing levels and create a solution-oriented workplace culture.

Our Labor Management Partnership gives us a third “yes, and”: Yes, individuals and leaders matter. And, our unit-based teams can fix inefficient processes that cause unnecessary stress and interpersonal conflict.

Every day, Kaiser Permanente’s 3,500 UBTs use performance improvement tools that make our work go more smoothly. Moreover, those tools and the foundation of trust and openness fostered by partnership give everyone a voice in making improvements.

And that also reduces our stress.

Our National Agreements commit us to operating principles that you won’t find in most labor contracts:

Power of partnership

Interest-based bargaining doesn’t guarantee success. It works for us because our partnership works.

The partnership between Kaiser Permanente and the Union Coalition came about in 1997, in a challenging environment. The company had a long and close history with the labor movement. But amid growing market pressures and labor unrest in the 1980s and ’90s, we were at a crossroads. Most of the local unions representing KP workers formed the Coalition of Kaiser Permanente Unions to launch a unified corporate campaign.

Facing what would have been a mutually destructive strike, the leaders of both parties took a chance on an alternative approach. They agreed to:

• Work collaboratively to improve the quality and affordability of care for the patients and communities we serve
• Help Kaiser Permanente lead the market in health care
• Involve unions and individual workers in workplace decisions
• Provide job security and be the best place to work in the industry.

Solving tough issues

Today it is the largest, longest-running and most comprehensive such partnership in the country. It covers 80 percent of our represented workforce and includes 43 local contracts, in addition to the national agreement. It has delivered industry-leading contracts, and helped Kaiser Permanente achieve industry-leading quality, solid growth and a culture of collaboration.

In short, our partnership is more than a labor relations strategy, it’s an operational strategy that provides strength and stability for Kaiser Permanente and our workforce, and better care and service for our members, patients and customers. It provides an infrastructure for continuous performance improvement and a way to better resolve difficult issues.

For example, during the Ebola crisis of 2014, health care providers and members of the public were concerned about how to best control spread of the disease. Kaiser Permanente, our union partners and the Centers for Disease Control and Prevention stepped back from the fear and misinformation that prevailed elsewhere. We worked together to develop training processes, educate people and agree on steps to ensure the safety and compensation of employees involved in caring for patients with the Ebola virus. Two of our hospitals were among the first in the United States to be recognized as part of the nation’s Ebola preparedness and response plan.

Frontline teams lead change

Day-to-day partnership is most evident in more than 3,400 unit-based teams—our term for the natural work groups that deliver care and service. Team members are trained in performance improvement techniques to spot opportunities, conduct small tests of change, assess results and implement solutions. They provide a new level of learning and decision making about the quality of their work and how to do it better.

UBTs are co-led by a union member and the manager or supervisor. In clinical settings they include physicians. We track the performance quarterly of every team, based on jointly set measures of performance, and we set aggressive goals for the number of teams to reach high performance, measured on a 5-point scale.

Seventy percent of them are rated high performing. That’s important because our data show that high-performing UBTs get better outcomes on service, quality, safety, attendance, patient satisfaction and employee satisfaction.

New tools and skills

Amy Edmondson, Novartis Professor of Leadership and Management at Harvard Business School, has studied Kaiser Permanente’s model of teaming and offered this assessment:

Unit-based teams are a way to be entrepreneurial and a way to build greater accountability by those on the front line. The teams push people to brainstorm, to be attentive to what they see and to put their own experience to good use. The teams have the opportunity to identify challenges and they have tools and skills with which to work, but it’s up to them to put them to good use to make a difference for patients.

Our teams now have more than 7,700 frontline improvement and innovation projects under way. To align local team efforts with the organization’s broader strategic goals, all projects are focused on one or more points of the Kaiser Permanente Value Compass – a guidepost that shows our four shared goals of best quality, best service, most affordability and best place to work, with our patients and members at the center of all we do.

Kaiser Permanente Value Compass

About 35 percent of these projects are focused on reducing waste or improving affordability. And 267 of those projects, produced joint savings of $10 million in 18 months; potential savings are much more. Twenty-eight percent of projects are focused on service enhancement. Here’s a snapshot of improvement projects conducted at each point of the Value Compass:

• Best quality: A medical imaging team worked across departmental lines to ensure that patients who visited the medical office for a flu shot, and also were due for a mammogram, could get one promptly, many within 20 minutes.
• Best service: A cross-functional team of service center workers redesigned work processes to handle incoming calls in the wake of the Affordable Care Act. The team cut the number of customer handoffs by 60 percent and reduced mean processing time for members’ issues from 26 days to three days.
• Most affordable: An inpatient pharmacy team launched a cost-reduction effort that is saving more than $600,000 a year by better managing inventories, alerting physicians to less costly equivalent drugs and reducing drug wastage.
• Best place to work: As part of our voluntary workforce wellness program, 62 percent of eligible employees – more than 80,000 people – participated in a confidential health assessment to identify potential health risks. 

Getting measurable results

We know our strategy is having an impact on organizational performance and the workplace experience. Our 2014 employee survey showed strong correlations between several measures of employee engagement and job performance.

Departments that scored high on an index of 18 measures of workforce effectiveness (including things like taking pride in the organization, information sharing, understanding of goals and being held accountable for performance) reported significantly better results in service, quality, workplace safety and attendance. For instance:

• 9 percent higher patient satisfaction scores
• 18 percent fewer lost work days
• 41 percent fewer workplace injuries
• 91 percent fewer bloodstream infections in at-risk patients

In addition, members of high-performing unit-based teams are far more likely to say they have influence in decisions affecting work, are comfortable voicing opinions, and feel co-workers are respected despite differences.

Higher job satisfaction also contributes to significantly lower employee turnover. In California, for instance, our turnover rate for all hospital-based employees ranges from 6 percent to 8 percent, depending on the job type – versus the 2014 industry average of 9.4 percent statewide reported by the California Hospital Association.

Union Coalition members and Kaiser Permanente also collaborate on many issues rarely open to union participation. For instance:

Workforce planning and development: We invest heavily in workforce training and development – and we develop and implement most of that work jointly. For instance, a union-management Jobs of the Future Committee in Southern California is identifying emerging technology, assessing the impact on workers, managers and physicians, and developing training plans and career paths. More such efforts and investments are under way.

Market growth: Bringing together union members and Kaiser Permanente sales and marketing teams, our joint growth campaign helped win, expand, win back or retain 33 accounts covering 125,000 Kaiser Permanente members in 2014.

Meeting organizational challenges

Our partnership is not perfect. It can stretch us to engage and educate our many stakeholders, and find time to solve problems and improve work processes in the course of day-to-day operations.

But in my experience, the biggest challenge is spreading innovation – facilitating the exchange of ideas and the adoption of successful practices from one team, medical center or region to another. We know that new initiatives can take root faster and more consistently if they’re modeled on a proven concept – especially when they are championed by our own work teams. Variation can be a plus when you’re looking for new and better ways to do things; when you’ve found the best way, you need to make it a work standard.

We recognize and spread success by communicating with teams regularly in multiple formats; through peer consultants and sponsors in every facility; a system-wide database that tracks teams’ tests of change and outcomes; and UBT Fairs, where teams share their findings in person.

Keys to success

Our Labor Management Partnership is now in its 18^th year, and we are still learning how to take it further. We continue to believe it can be a model for labor relations and health care delivery. Four factors in particular are essential to success:

• Develop leadership at all levels: Since its founding, our partnership has thrived under three different Kaiser Permanente CEOs and three different Union Coalition executive directors. Change is not sustainable if it depends on one top leader. Frontline and mid-level leadership, on both the management and union side, is key. We train for partnership at all levels, and have found that interest-based problem solving and bargaining are powerful learning development tools for up and coming leaders.
• Build trust: To work together, partners must trust one another. That trust must be earned, and is established over time. It will be tested, but the building blocks are well known: Do what you say you will do. Honor your commitments. Treat others with respect and deliver results.
• Measure results and share data: We set goals and track performance for all our teams. We share business and financial data with our partnership unions in bargaining, and share departmental and unit-level results with teams working on performance improvement projects. Teams can’t succeed without good information upon which to set clear expectations.
• Create a shared framework: Our workforce is diverse in every way – demographic, geographic, professional and technical. We also have different (and sometimes competing) needs, interests and concerns. But we share a desire to make our members’ and patients’ lives better. The Value Compass – with the member and patient in the center – provides a common touch point that we use to set priorities and guide decision making.

Our union and organizational leaders know how to do business in traditional, more adversarial labor relations settings. We’ve done it. We choose to work in partnership – not because it feels better (though it does) or because it’s easier (it’s not). We do it because it gets results – for the organization, the unions and workers, and the members, patients and communities we serve.

It’s time to look beyond labor relations and find new ways to innovate and engage teams. Our leaders took a risk 18 years ago to listen, understand and work together. It proved to be better way to deliver health care and achieve our social mission.

This article was originally published in “Perspectives on Work,” the magazine of the Labor and Employment Relations Association (LERA), Volume 19. Reprinted with permission. For more information, visit LERAweb.org.

Also see a PDF of the original article, with additional information about Kaiser Permanente and the Labor Management Partnership.

1933-1945: ‘There is no such thing as labor relations’

The health care program now known as Kaiser Permanente began in the Mojave Desert when Dr. Sidney Garfield, fresh out of medical school, opened a clinic for 5,000 Colorado River Aqueduct workers in 1933. Dr. Garfield soon found his practice foundering because insurance companies were sending the most serious—and most profitable—cases to Los Angeles hospitals. He developed a prepaid plan with a focus on safety and illness prevention, and it worked. The hallmarks of what would become the Kaiser Permanente Health Plan—prepayment, prevention and group practice—were forged here, but it would be 12 years before members of the public could join.

In 1938, Henry J. Kaiser and his son Edgar persuaded Dr. Garfield to create a similar medical program for workers building the Grand Coulee Dam in Washington.

The resulting industrial health plan was so popular, the unions insisted dam workers’ families be included. That feature carried over when Dr. Garfield built the largest civilian medical care program on the World War II home front, covering almost 200,000 Kaiser workers in California, Oregon and Washington.

With the traditional labor pool—young, healthy white males—serving in the military, thousands of African Americans and other people of color migrated to the shipyards, securing good union jobs after the long hurt of the Great Depression. Women came out in force, too. The Permanente Foundation Health Plan, both the on-the-job care and the broad coverage of the 50-cent-a-week supplemental plan, was extremely successful.

For the first time in their lives, ordinary people could count on affordable medical care.
 

1946-1989: ‘If not for organized labor’

On July 21, 1945, with the war in Europe over and the shipyards beginning to close, the Permanente Foundation Health Plan opened to the general public. A year later, on Aug. 1, 1946, Dr. Garfield signed the Permanente Foundation’s first union contract, with the CIO-affiliated Nurses’ Guild. The contract, in a first for Alameda County hospitals, established a 40-hour workweek, down from 48 hours.

Key support for the Permanente health plan came from unions. Harry Bridges, president of the International Longshoremen and Warehousemen’s Union, was an early advocate. He defended the plan against attacks by professional medical associations, whose members called prepaid group practice unethical, and brought all 6,000 ILWU members on the West Coast into the plan. Almost 15,000 members of the Retail Clerks Union in Los Angeles, a large and prominent union led by Joe DeSilva, joined in 1951.

But by the mid-1960s, financial pressures began creating divisions. In 1966, registered nurses in Northern California, represented by the California Nurses Association, became the first nurses in the state to conduct a work action. Major strikes erupted in 1968 in both Northern and Southern California. The strife simmered, and in 1986, a seven-week strike by SEIU Local 250 had some 9,000 clerks, certified nursing assistants and technicians walking the picket line at 14 Kaiser Permanente facilities in California. The action didn’t prevent a two-tier wage restructuring plan, but there was one positive outcome: The first Joint Conference on Service Issues, a precursor to the Labor Management Partnership agreement.
 

When Marianne Henson, RN, left her position as clinical operations manager of the Burke Primary Care team in Virginia, she took something with her—a plan.

In 2011, Henson helped launch a project at the Burke Medical Center that boosted the percentage of patients with their blood pressure under control. Instead of creating a brand-new plan to solve the same problem at her new facility in Falls Church, Virginia, she became a copycat.

“Why reinvent the wheel?” Henson says. “We already knew what worked.”

When Henson was in her role at Burke, other clinical operations managers and physicians from the 10 Northern Virginia medical centers held regular area-wide meetings that allowed teams faced with similar issues to learn from one another. As a result, other facilities began adopting Burke’s practice of having clinical assistants call members with hypertension to ask them to come in for more frequent blood pressure checks. Burke had already discovered that members ignored requests sent via mass mail, so the other centers didn’t waste time or money repeating that experiment.

“We have members waiting only five to 10 minutes,” says Andrea Brown, a clinical assistant at Falls Church and member of OPEIU Local 2. “We let them know over the phone that this will be a quick visit and they will be on their way.”

Brown and the other clinical assistants try to call at least five members each day to see if they can pop in for a check while at the pharmacy or when they have an appointment with a specialist. And each day, depending on the weather, between three and five patients take advantage of the mini-blood pressure appointments. “This brief visit is cost effective, saves time and helps us make sure the member is on the right track,” Brown says.

Brown says members have given her positive feedback because of the convenience.

“It made sense because the whole region was expected to bring hypertension control up to better levels,” Henson says. “We standardized what we do.”

 “I was almost devastated,” says Karen Cardosa, a grocery clerk in Albany, Oregon, “when UFCW told us they were no longer offering Kaiser Permanente as an insurance option.”

Cardosa and her family had been KP members for years through the union’s Local 555 Employers Health Trust. That changed in 2009 when a variety of issues resulted in KP losing the account, which covered many Local 555 members. The union continued to represent nearly 2,000 Kaiser Permanente pharmacy and radiology employees, who—as KP staff members—continued to have KP health care.

Today, it’s a new story. Thanks to a 36-month KP offering that was finalized in April, Kaiser Permanente is again an option for up to 15,000 UFCW members and dependents in the Northwest region who are covered by the health trust.

“Our work with LMP is probably some of the most important work done in Public Sector strategy in the last two years. Working with our union partners, we’ve been able to come to the table with customer solutions that meet everybody’s needs—including the unions that aren’t part of KP, who have tremendous influence in purchase decisions. We are unique in having a strong labor partnership in our own business, and we can speak that language.”

—Kate Kessler, a Member Sales and Service Administration director

“When I was hired four years ago, my manager told me my Number One job was to get UFCW back,” Ehren Cline, a KP Sales and Account manager. Cline, including Jeston Black, the region’s senior labor liaison, and other colleagues partnered with Dan Clay, president of Local 555, to do just that.

“KPNW brought us a package we couldn’t refuse,” Clay says. An affordable price, high quality, a new hospital, expanded clinics and a new billing system helped seal the deal.

Clay’s own union members pushed for the new commitment.

“I have not been to a union meeting in the last five years where someone didn’t ask, ‘When do we get to go back to Kaiser?’” Clay says.

But something else was also at play. Thanks to Labor Management Partnership, Kaiser Permanente enjoys a joint union-management approach to winning and keeping health plan members that is almost unheard elsewhere in this country.

Read on and learn how it all comes together.

How the LMP Growth Campaign Works

Click to enlarge.