Nurse Alliance of SEIU PA Advancing the Movement for Quality of Care

1. Nurse Alliance of SEIU PAAdvancing the Movement for Quality of Care - Successful Quality Partnerships - Front-Line Employees and Managers What’s Making a Difference? Harrisburg, PA October 6, 2010

2. The Healthcare Transformation Project at Cornell University • Action research to track and monitor delivery system changes and impact of unions on improving quality of care • Technical assistance to assist with needed work restructuring and organizational structures to improve our healthcare delivery system • Educational programs for management and union leaders responsible for delivery system changes

3. Organizations are perfectly designed to get the results that they get.

4. Getting to the “Right Process” “I’m astounded by people who want to know the universe, when it’s hard enough to find your way around Chinatown” Woody Allen

5. What are the most critical problems that our health system faces? Why Do We Have A Crisis?

6. Current Challenges of Our Healthcare System • Greater Access to Care and Payment • Better Quality and Patient Safety • Affordable Costs • Having an Integrated Delivery System

7. Complexity, Turbulence, and Chaos • The future is no longer clear due to speed of change • There is no longer a single source of change • Networking and the involvement of the people doing the work is critical • Organizations will need to be ambidextrous working innovation while strengthening current practices • New patterns and order will emerge • It takes a completely different mindset and set of skills • You can’t control the change….

8. Recent Stimulus Package • Electronic Medical Records • Emphasis on Prevention • Medicare and Medicaid Pilots Projects

9. A shift in mental models occurs as a result of one discovering something new about the world…

10. Our Healthcare Crisis and Situation of Unions • Healthcare Issues - U.S. citizens pays 53% more for healthcare - 31 million more Americans will now have health insurance coverage • Bottom quartile in terms of quality of care • Union Density Crisis - 1950’s 35% - 1980’s 20% - 2010 > 12%

11. Mirror, Mirror: Ranking of Six Nations Source: K. Davis, C. Schoen, S. C. Schoenbaum, M. M. Doty, A. L. Holmgren, J. L. Kriss, and K. K. Shea, “Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care,” The Commonwealth Fund, May 2007 * 2003 data

12. Building off of what others have done • Auto and Manufacturing Companies • High Tech Firms • Innovative practices in hospitals

13. Leadership for Changes Some important theories/approaches: Irv Bluestone & Don Ephlin - Industrial Democracy, union leaders Richard Beckhard - Transitional organizations Tars Larsen - FACO (Oslo peace agreement) Kurt Lewin - Social psychological forces David Nadler - Discontinuous change W. Edward Deming - Quality Improvement Eric Trist & Fred Emery - Socio-tech (Tavistock Institute) Clayton Christensen - Disruptive Change

14. Current Approaches to Organizational Change & Worker Participation (An International Perspective) U.S. • High Performance Work Systems • Learning Organizations • Fast Cycle Change Processes • Gainsharing & Other Productivity Compensation Processes • Re-engineering & Restructuring Activities • Total Quality • Union Development • Adaptive and Ambidextrous Organizations Norway/Sweden • Industrial Democracy Projects • Socio-Technical System Design • Technology Committees Japan • Quality Control Circles (QC Circles) • Total Quality Control (TQC)

15. Current Approaches to Improve the Quality of Care and Care Management Solution Shops - Transforming Care at the Bedside (IHI) - Six Sigma Value Added • Toyota Production System—Lean Manufacturing • Appreciative Inquiry Networking and Disruptive Innovation to Achieve Systematic Changes • Strategic Work Design and New Work Systems as a result of Front-line Staff Involvement and networking with others.. creating “new knowledge” • Developing a balance between optimization and adaptive strategies (a significant different mindset and skill set)

16. Critical Components of Competitive Work Systems • Core work gets done by as few people as possible • Employees have the ability to make decisions about how their work impacts the services and/or products • As much as possible, employees do a complete task • Employees are consulted in the process of redesigning work • Employees are provided regular feedback about their work

17. Taylorism Keep jobs simple Low skill Jobs Complete management control of every step of the process High Performance Work Systems Teamwork Consultation and worker access to information Worker autonomy over day to day activities Worker involvement in terms of changes including the use of new technology Choices of Work Systems

18. Principle of Dynamic Tension (Driving and Restraining Forces) Lewin Change Model Unfreezing Making Change Refreezing

19. Critical Areas of Work that are Emerging in Healthcare Delivery System Reform Critical Approaches that are making a difference in Healthcare Institutions • Unit-based work • Hospital-wide interventions • Delivery System Integration

20. Examples of Labor-Management Partnerships - Saturn Corporation - Kaiser Permanent - Maimonides Medical Center - Fairview Hospital

21. Maimonides CIR, NYSNA and 1999/SEIU Strategic Alliance Labor-Management Council (LMC) Developers Cornell Researchers Labor-Management Oversight Com. (LMOC) Measurement & Documentation Workgroup Environmental Serv. DLMC Cardiology DLMC

22. Maimonides Medical Center • 706 bed hospital • 5,600 employees • A tertiary care, teaching hospital • In Brooklyn, NY • Three unions– - Committee for Interns and Residents (CIR) - New York State Nurses Association (NYSNA) - 1199/SEIU United Health Care Workers (1199)

23. Strategic Alliance A Labor Management agreement to work together in defined areas of shared interest, while understanding that each organization will at times work independently in other areas.

24. Strategic Priorities for Maimonides Medical Center 2010 • Clinical Excellence and Patient Satisfaction • Strategic Growth (e.g. new Cancer Center and Children’s Hospital) • Technology Enhancement (e.g. electronic medical records) • Workforce Development • Union Building (greater voice and more active members)

25. Departmental Labor-Management Committees1998-2007 • Ambulatory Services • Blood Bank • Cardiology • Case Management • Engineering • Environmental Services • Finance • Food and Nutrition Patient Accounts • Health Information Services • Medical-Surgical Units • Pathology and Laboratory Medicine • Patient Accounts • Radiology

26. Aligning Sub-Systems Informal Organization Input (response to a specific problem or system) Environment Resources History Output / Performance System Unit Individual Work & Technology Formal Organization (Structure, Roles. Procedures) Strategy Culture Engagement of People,Skills, & Accountability Source: Nadler and Tushman

27. Critical Work In Departments DLMC Department Improvement Work Preventive Problem Solving OutstandingIssues Joint Project Work 6-Step Problem Solving Process

28. Critical Elements for Creating Better Jobs(Based on the principles of industrial democracy, competitive workplaces and total quality) • Access to information about one’s job • Create and challenging jobs • Employees have an opportunity to learn and grow — the practice of live long learning • Employees have opportunities to learn from each other

29. Chart 1: Breaking Down the Problems: Reducing Response Time to Alarms and Monitors in the Cardiac Department

30. Challenges for Unions • A struggle with creating solutions and accepting responsibilities for implementing them • Some union leaders will feel threatened by the process of working on economic and quality issues • Union staff, officers and activists need new skills to become value-added rather than just reactive • Member representatives and delegates need to be effective in representing the needs of co-workers and other stakeholders and not just their own

31. New Roles for Unions GOALS COMMON PRACTICES FUTURE STRATEGIES • Multi-Skilled Jobs • Greater Control Over Daily Decisions • Involvement in Business & Economic Issues • Interest-Based Problem Solving & Bargaining • Focus on an Active Workforce • Training of the Workforce • Job Classification • Grievance Handling • Collective Bargaining • Contract Administration • “Service Focus” • Job security • Equity/Due Process • Higher Wages • Union Building 13

32. Challenges for Management • Sharing information and decision making is threatening to some managers • It feels uncomfortable to approach workers and the union with a situation that needs to change instead of with a situation in-hand • Line management sees worker participation as a threat to their job • Not all managers can easily shift from control to coordination and coaching responsibilities

33. PAST PRACTICES • Control the work of employees • Limit jobs to simple tasks • Reward employees as individuals • Manage around the contract New Roles for Management FUTURE STRATEGIES GOALS • Create opportunities for extensive worker participation • Expand jobs to be multi-skilled, meaningful and challenging • Involve and consult with the union as important stakeholder • Share economic gains with the workforce –pay for group and departmental improvements • Get the work done • Being seen as a Good Manager • Get Promoted

34. Outcomes • Senior management and union leaders meet on a regular basis • Patient Fall Reduced by 50% for patient over 60 years old • Reduce Call Bell response by 50% to < 1 min. • Alarm and Monitors responded to in < 1 min. • Unions involved in floor layouts, move to a new building, and purchasing of new equipment • Over 70 Joint Hiring Committees have been conducted

35. Outcomes (continued)Strategic Alliance • Enables the unions to have input & influence in changes at work which they couldn’t do in the past • Difference between project “based” labor-management activities rather than a broad range of issues • Unions have gained access to quality and financial information so they can be helpful

37. Creating Delivery System ChangesIntegrated Care: The Medical Home Model • A medical home provides care that is accessible, continuous, comprehensiveand coordinated and delivered in the context of family and community. (Berenson, Hammons, Gans, Zuckerman, Merrell, Underwood and Williams) • Introduction to Patient Centered Medical Care: a short video http://www.emmisolutions.com/medicalhome/pcpcc/index.html

38. Components of an Integrated Care Delivery System

39. Integrated Care Fragmented vs. Integrated Care Delivery Systems Fragmented Care No care coordination among physician, staff, family and community System reacts to needs Fee for service reimbursement Limited tools/processes for preventive care or patient progress Patient centered coordinated care involving all parties in patients healthcare Needs are anticipated Bundled/Pre-paid reimbursements Electronic/staff tools to track patient progress and monitor chronic conditions

40. Integrated Care Reduces Costs • Importance of improving transitions in care, doctor to doctor, and post-hospital • Follow-up care following hospital discharge could reduce re-hospitalization • High cost care management could reduce errors and lower costs • Will require restructuring Medicare benefits and incentives Source: M.D. Naylor, Making the Bridge from Hospital to Home,The Commonwealth Fund, Fall 2003.

41. Integrated Care Reduces Costs Effect of Advanced Practice Nurse Care on Congestive Heart Failure Patients’ Average Per Capita Expenditures • Importance of improving transitions in care, doctor to doctor, and post-hospital • Follow-up care following hospital discharge could reduce re-hospitalization • High cost care management could reduce errors and lower costs • Will require restructuring Medicare benefits and incentives Dollars $9,618 $6,152 Source: M.D. Naylor, Making the Bridge from Hospital to Home,The Commonwealth Fund, Fall 2003.

42. Other Significant Findings Significant Upfront Costs 25 to 30 % Cost Reductions When Fully Implemented Rand Study- Congestive Heart Failure Patients have 35% fewer hospital days, Asthma and Diabetes Patients were more likely to receive appropriate therapy

43. Critical Strategies Union and Management Leaders to Drive the Process Engagement of Front-Line Staff (not just Doctors and Nurses) in Each Phase of the Process Reimbursement Reforms Taking the Time to Do It Right

44. Implementing an Integrated Care Delivery System

46. CLARIFY NEXT PHASE WITH SPECIFIC GOALS Creating Integrated Healthcare SystemsA 5-Step Model to Improving Quality of Patient Care with Front-Line Staff • Establish Partnership & Goals –Align “Whole System” and • Identify High Impact Projects • Exploration & Assessment for Readiness • Identify Areas of Improvement • Launch High Impact Projects: • Focus on Improving Quality of Care and Efficiency 5. Create Support System to Sustain Long-Term Changes 4. Reflect, Evaluate, & Modify

47. Critical Factors • Vision/Values • Leadership • Practical First Steps • Continuous Improvement Activities

49. Activity Alliance work (Yes/No) Informed Consulted Developing Solutions Input In D-M Full Decision Making Role Training employees in new jobs YES b Reducing supply and material costs YES b b Reducing Workers’ Compensation Cost Yes Developing strategic plan YES b Decisions on hospital closures No b EXAMPLE:Strategic Alliance Matrix With SEIU b b

50. Learning Organizations • Living biological and environmental systems  • Prescription: • Start small! Pilots • Grow steadily • Don’t plan the whole thing • Expect challenges • Source: Senge et al, 1993.