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

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Nurse Alliance of SEIU PAAdvancing the Movement
for Quality of Care

• - Successful Quality Partnerships -
• Front-Line Employees and Managers
• Whats Making a Difference?
• Harrisburg, PA
• October 6, 2010

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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

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Organizations are perfectly designed to get the
results that they get.
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Getting to the Right Process

• Im astounded by people who want to know the
  universe, when its hard enough to find your way
  around Chinatown
• 
  Woody Allen

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What are the most critical problems that our
health system faces?

• Why Do We Have A Crisis?

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Current Challenges of Our Healthcare System

• Greater Access to Care and Payment
• Better Quality and Patient Safety
• Affordable Costs
• Having an Integrated Delivery System

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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 cant control the change.

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Recent Stimulus Package

• Electronic Medical Records
• Emphasis on Prevention
• Medicare and Medicaid Pilots Projects

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A shift in mental models occurs as a result of
one discovering something new about the world
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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
• - 1950s 35
• - 1980s 20
• - 2010 gt 12

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Mirror, Mirror Ranking of Six Nations
    AUSTRALIA CANADA GERMANY NEW ZEALAND UNITED KINGDOM UNITED STATES
OVERALL RANKING (2007) OVERALL RANKING (2007) 3.5 5 2 3.5 1 6
Quality Care Quality Care 4 6 2.5 2.5 1 5
Right Care 5 6 3 4 2 1
Safe Care 4 5 1 3 2 6
Coordinated Care 3 6 4 2 1 5
Patient-Centered Care 3 6 2 1 4 5
Access Access 3 5 1 2 4 6
Efficiency Efficiency 4 5 3 2 1 6
Equity Equity 2 5 4 3 1 6
Long, Healthy, and Productive Lives Long, Healthy, and Productive Lives 1 3 2 4.5 4.5 6
Health Expenditures per Capita, 2004 Health Expenditures per Capita, 2004 2,876 3,165 3,005 2,083 2,546 6,102
Country Rankings Country Rankings
1-2.66
2.67-4.33
4.33-6.0
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
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Building off of what others have done

• Auto and Manufacturing Companies
• High Tech Firms
• Innovative practices in hospitals

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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

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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)

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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 SystemLean 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)

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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

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Choices of Work Systems

• 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

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Lewin Change Model
Unfreezing
Making Change
Refreezing
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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

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Examples of Labor-Management Partnerships

• - Saturn Corporation
• - Kaiser Permanent
• - Maimonides Medical Center
• - Fairview Hospital

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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
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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)

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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.

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Strategic Priorities for Maimonides Medical
Center 2010

• Clinical Excellence and Patient Satisfaction
• Strategic Growth (e.g. new Cancer Center and
  Childrens Hospital)
• Technology Enhancement (e.g. electronic medical
  records)
• Workforce Development
• Union Building (greater voice and more active
  members)

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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

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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
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Critical Work In Departments
DLMC
Department Improvement Work
Preventive Problem Solving
Outstanding Issues
Joint Project Work 6-Step Problem Solving Process

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Critical Elements for Creating Better Jobs(Based
on the principles of industrial democracy,
competitive workplaces and total quality)

• Access to information about ones 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

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

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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

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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

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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

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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 lt 1 min.
• Alarm and Monitors responded to in lt 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

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Outcomes (continued)Strategic Alliance

• Enables the unions to have input influence in
  changes at work which they couldnt 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

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Union Building Outcomes 2002 2003 2004 2005 2006 2007
Number of Members 2,422 2,602 2,267 2,175 2,569 2,569 ( 6 )
Contribution to PAC 58 65 71.7 83. 84. 89.
Number of Delegates 23 35 61 67 84 98 (326 )
Holding regular delegates meeting/assembly 20 45 55 47/60 50/67 50/60
Attending political rallies 622 925 0 464
Grievances/Arbitration 1 1 1 1 2 0
Communication with the union
Delegates training 1 2 2 1 2 1
Union Skill building (individual Skills) 2 2 1
Delegate/members ratio 251 251 201 18 1 181
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Creating Delivery System ChangesIntegrated
Care The Medical Home Model

• A medical home provides care that is accessible,
  continuous, comprehensive and 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/in
  dex.html

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Components of an Integrated Care Delivery System
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Fragmented vs. Integrated Care Delivery Systems

• Integrated Care

• 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

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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.
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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.
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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

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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

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Implementing an Integrated Care Delivery System
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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
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Critical Factors

• Vision/Values
• Leadership
• Practical First Steps
• Continuous Improvement Activities

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EXAMPLEStrategic Alliance Matrix With SEIU
b
b
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Learning Organizations

• Living biological and environmental systems ?
• Prescription
• Start small! Pilots
• Grow steadily
• Dont plan the whole thing
• Expect challenges
• Source Senge et al, 1993.

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Summation

• Health Institutions are complex organizations and
  the times are challenging
• Unions can add value if they are included in the
  processFront-line managers are also needed
• Importance of creating sufficient resources for
  change to create the needed tipping point
• Leadership is critical
• Nothing works all of the time

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• No doubt that a small group of thoughtful
  citizens can change the world. Indeed, its the
  only thing that ever has.
• Margaret Mead

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• Left alone, every group stumbles on a process
  and its usually lousy
• From the book
• What to Do When Your Team Doesnt Act Like One

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Important Books

• Agile Organizations
• Disruptive Innovation
• Innovation
• Joint Labor-Management Work