The Kaiser Permanente Labor Management
Partnership: Building Improvement Capacity at
the Front Lines of Care
Ray Hahn, assistant medical center administrator, Kaiser Permanente San Diego Medical Center
Marianne Giordano, president, Office and Professional Employees International Union Local 30
Problem:
Much attention is given to the concept that frontline
staff must be involved and empowered if health care performance is to be
improved in a deep and lasting way. But how can organizations unleash
the full potential of frontline teams to accelerate innovation
and improvement?
Context: Kaiser Permanente is the largest nonprofit health care
system in the United States, serving more than nine million health plan
members in nine states and the District of Columbia. From its inception,
Kaiser Permanente has been closely connected with labor unions: Harry
Bridges, president of the International Longshoremen and Warehousemen
Union, helped ensure the organization’s success early on by making Kaiser
Permanente the health plan for his union members. Since 1997, Kaiser
Permanente and the Coalition of Kaiser Permanente Unions have worked
together in a Labor Management Partnership, the longest lasting, biggest
and most successful partnership of its kind. The National Agreement
between the organization and its unions commits both parties to support
performance improvement. It accomplishes this goal by creating a system
and structure that fully engages health care unions and their members to
build and sustain high-performing unit-based teams (UBTs)—natural work
groups of physicians, managers and frontline staff. In a highly unionized
workforce, frontline workers use problem-solving techniques in their dayto-day work to improve performance, strengthen the organization and
enhance the work experience. The vehicle for performance improvement
is the unit-based team.
Kaiser Permanente’s medical center service area in San Diego,
California, provides a case study of how unit-based teams and Labor
Management Partnership are engaging frontline staff in continuous
performance improvement.
At Kaiser Permanente San Diego there are 1,027 physicians, 4,699 clinical
staff and 2,198 non-clinical staff. Fully 91 percent of all staff are involved
in 131 unit-based teams. There is one hospital owned and operated by
Kaiser Permanente, 392 patient beds and 24 locations.
Union members at Kaiser Permanente San Diego
Office and Professional Employees International Unions Local 30: jobs include licensed vocational nurse, medical assistant, courier, environmental services,
patient transportation, call center, cardiology and echo tech, supply chain management, receptionist, clinical clerk, lab assistants, radiology technologist and
others
United Nurses Association of California: jobs include registered nurse, midwife, lactation,
wound ostomy, patient care and case manager, physician assistant and nurse practitioner
United Food and Commercial Workers Local 135: jobs include pharmacy assistant
and technician and clinical lab scientist
Kaiser Permanente Nurse Anesthetist Association: certified registered nurse anesthetist
Kaiser Permanente Association of Southern California Optometrists: optometrists
Aim: Starting with no teams in April 2009, the Kaiser Permanente
San Diego Service Area will achieve 80 percent of unit-based teams at
a high-performing level by December 31, 2012. All teams are assessed
quarterly, and “high-performing” is defined as Level 4 or 5 on the Path to
Performance.
UBT Ratings– San Diego Medical Center
April 2009 - September 2012
100
90
2 year
member/
co-lead term
limit
UBT
Levels 4&5
80
Target
(San Diego)
70
Significant
focus on training and use of
scorecards and
project tracking
system
60
Began focus
on Level 5 goals and
requirements
50
UCL - 42
40
Center Line
30
Shift to more stringent
performance criteria,
consistently applied
across the organization.
Key Gap: Sponsorship
training and participation.
20
Consulting team
formed: New
UBT approaches
implemented
10
LCL - 24
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Strategy for change
Use the Path to Performance as a roadmap
LEVEL 1
LEVEL 2
LEVEL 3
LEVEL 4
LEVEL 5
Pre-Team Climate
Foundational UBT
Transitional UBT
Operational UBT
High-Performing UBT
Unit is learning what a unit-based
team is and how UBT’s work.
Team is establishing structures and
beginning to function as a UBT.
Team is demonstrating progress
on engagement and making
improvement.
Team has joint leadership,
engagement of team members and
improved performance.
Team is fully successful and
collaborating to improve/sustain
performance against targets.
At Kaiser Permanente San Diego, to reach Level 5, teams must:
Have a process to fully engage the frontline
Teams have management and labor co-leads (who are chosen by fellow
union members). Co-leads prepare for
meetings and huddles, plan training and
agendas together, keep team records,
build relationships with their co-lead
partner and communicate
with constituents.
Demonstrate proficiency by:
• Completing training in business literacy
• Showing successful use of at least one
performance improvement tool
• Demonstrating joint leadership of the
team during meetings
• Functioning as a self-managed team at the operational level
• Annotating run charts
• Meeting key performance metrics
Build a sense of shared purpose and alignment with the
Value Compass
Build subject-matter knowledge and performance improvement
skills among:
• UBT members (union members and managers attend trainings
together)
• Sponsors (leaders from both labor and management who coach team
co-leads and ensure UBT efforts align with organizational objectives
and priorities)
The teams use:
•
•
•
•
•
UBT consultants (a resource team, trained in improvement methods,
who help teams set goals and implement tests of change)
UBT Tracker, an online database to document improvement projects
and share learnings throughout Kaiser Permanente
consensus decision-making
Rapid Improvement Model (aka Model for Improvement) and PDSA cycle
Statit scorecards for metric-based goal setting and performance
tracking on the team level
Results: As of Sept., 2012, 79 percent of unit-based teams at Kaiser Permanente
San Diego are high-performing teams, with the expectation that the goal will be
met by the end of the year.
Team snapshot: Bonita Primary Care unit-based team
Additional examples
SMART Goal: Between January 2012 and April 2012, the Bonita
Primary Care unit-based team will reduce the 2011 year-end
non-payroll supply expense by 10 percent.
Improved workplace safety: One medical-surgical unit that averaged
one patient-handling injury every month suffered only one such injury
in the past two years.
Tests of change: Team agreed upon decreased par levels of stock and
made diagrams of shelves with new par levels. Staff removed all excess
stock and labeled bins. Excess stock was combined and organized,
which staff used over the next four months as the primary source of
exam room restock.
Improved service: For more than two years, the Nephrology outpatient
clinic receptionists and nurses have consistently exceeded their yearto-date target for “care experience,” a metric that is measured and
reported monthly. Care experience measures patient perception of staff
being helpful, courteous, and showing care and concern.
Results: Team exceeded its goal. Fewer supplies needed to be ordered,
fewer supplies were stocked in exam rooms, less stock expired which
would have needed to be replaced.
Our message: Labor unions and Kaiser Permanente are working
together to provide affordable health care for the members and the
communities they serve. At all levels of the organization, there is a
shared vision and business strategy to transform health care. Labor
Management Partnership principles are the operating strategy for
fully engaged employees in transforming care delivery. Frontline
workers are engaged to their full range of skills and experience to
create ongoing quality, service, financial, and workplace satisfaction
improvements. The vehicle for performance improvement is the unitbased team.
Estimated 2012 Savings: $49,400
If each of the 131 unit-based teams at Kaiser Permanente San Diego
saved this much money, it would exceed $6 million.
For more information, visit
www.lmpartnership.org