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Title: 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
  • Whats 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
  • Im astounded by people who want to know the
    universe, when its 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 cant 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
  • - 1950s 35
  • - 1980s 20
  • - 2010 gt 12

11
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
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 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)

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
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

18
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
    Childrens 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
Outstanding Issues
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 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

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
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 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

35
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

36
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
37
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

38
Components of an Integrated Care Delivery System
39
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

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
45
(No Transcript)
46
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

48
(No Transcript)
49
EXAMPLEStrategic Alliance Matrix With SEIU
b
b
50
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.

51
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

52
  • No doubt that a small group of thoughtful
    citizens can change the world. Indeed, its the
    only thing that ever has.
  • Margaret Mead

53
  • 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

54
Important Books
  • Agile Organizations
  • Disruptive Innovation
  • Innovation
  • Joint Labor-Management Work
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