Partnership at the Front Line: Unit-Based Teams at Kaiser Permanente

1. Partnership at the Front Line: Unit-Based Teams at Kaiser Permanente Adrienne E. Eaton (Rutgers University) Adam Seth Litwin (Johns Hopkins U.) Nicole VanderHorst (KP Organizational Research) May 2010

2. Labor-Management Partnership at KP • LPM agreement signed in 1997 • Today: 30 local unions, 10+ national unions • All regions of KP: KFHPs and PMGs • Some unions remain outside including CNA • 7 goals: • Improve the quality of health care for KP members, • assist KP in achieving market leading competitive performance, • make KP a better place to work, • expand KP in current and new markets, • provide maximum possible employment and income security, • involve employees and unions in decisions, and • work jointly on public policy

3. By 2005 negotiations… • The parties and their academic observers had identified the need to • Focus on performance improvement • Bring the LMP to the front-line • 2005 agreement did both. • Excerpt from Performance Improvement language: • “The parties are dedicated to working together to make Kaiser Permanente the recognized market leader in providing quality health care and service. This can be accomplished through creating a service culture, achieving performance goals, developing the Kaiser Permanente workforce, increasing employee satisfaction, promoting patient safety programs and focusing attention on employee health and work-life personal-life balance. The goal is to continually improve performance by investing in people and infrastructure, improving communication skills, fostering leadership, and supporting involvement in the community.”

4. 2005 agreement: UBTs • Excerpts from UBT contract language: • “The 2005 Attendance, Performance Improvement, Performance-Based Pay, Service Quality, and Workforce Development. BTGs recommended the establishment of teams based in work units as a core mechanism for advancing Partnership as the way business is conducted at Kaiser Permanente, and for improving organizational performance. • “Members of a Unit Based Team will participate in: • • planning and designing work processes; • • setting goals and establishing metrics; • • reviewing and evaluating aggregate team performance; • • budgeting, staffing and scheduling decisions; and • • proactively identifying problems and resolving issues.” • Timetable • 15% of workforce in UBTs  12/2007 • 40%  2008 • 70%  2009 • 100%  2010 • Unit Based Teams emerged as platform for PI and other programs

5. Implementing UBTs • UBTs became linked to organization’s performance improvement efforts • UBTs work on regional/KP strategic plan goals • RIM, PDSA, Small tests of change • Projects fall into one or more points of KP Value Compass: • Substantial support infrastructure • Training • Metrics: for team to use and to track teams • Process support (internal OD, etc.) • UBTs can be natural work group or representative

6. What are we trying to accomplish? 6 v.2.0 How will we know that a change is an improvement? What change can we make that will result in improvement? Act Plan Study Do Model for Improvement developed by Associates in Process Improvement ( http://www.apiweb.org) Rapid Improvement ModelFocus on rapid tests under varying conditions

7. Continued Growth in Unit Based Teams82,000 Employees in 2,600 UBTs Page 6

8. UBTs Operate at Different Levels of Development Team Development Level of the 2,085 Unit-Based Teams in place on September 1st, 2009 (See Appendix for Definitions) Note: Teams formed after 9/1/09 are excluded from this analysis to allow us to track a stable sample over time.

9. Transforming Quality & Service: Realizing our Potential 4 Key Goals Identified In KP Strategic Plan % Making Progress On or Meeting Team Goals as of Feb 2010 UBT Projects Supporting Those Goals # of Projects Aug 2009 # of Projects Feb 2010 115 208 51% • Cancer Screening • Mammography, colorectal & cervical cancers • Home as Hub/Medical Home • increased use of KP. org • Diabetes Control • Blood pressure, LDL-C min, use of ACE inhibitor, lipid prescriptions 180 162 62% • Patient Safety • Two-patient identifiers, hospital acquired infection, prevent patient falls 45 58 71% • Patient Satisfaction • Staff courtesy & helpfulness, cleanliness & quietness of rooms • Reduce patient wait times 448 1036* 57% * The relatively large increase in Service Excellence projects is a result of teams starting new projects and regions entering projects into the UBT Tracker system for the first time.

11. UBT Participation Has Positive Impact on Employee Engagement Empowerment, line of sight and continuous improvement are more favorable for those who say they are part of a UBT *Items with the largest differences

12. Attitudes of Employees in UBTs Differ Depending on the Team Stage of Development • Employee responses are more favorable in high-functioning UBTs Stage 1 (Pre-Team Climate) Stage 5 (High-functioning UBT)

13. What do UBTs Need to Become High Performing? • Research Questions: • Are there common enablers across high-performing UBTs? Which of these enablers are unique to the teams studied and which can be lifted out of context and replicated with other UBTs? • Research Methods • Review of previously collected UBT information • Process and outcome metrics (“UBT Tracker”; Employee Survey) • Case studies of 13 individual UBT’s • Observation of team meetings, huddles, department at work • Interviews with team leads and members, support staff • Content Areas Assessed • Motivation to change, team structure, training, team capacity, communication, sponsorship/support, measurement and methods

14. Team Structure • Most high-performing UBTs: • use work-improvement processes such as RIM. • include representatives from key support functions as well as physicians as appropriate. • have full involvement of labor: labor co-leads who share fully in the responsibility of the team, develop team agendas, facilitate team meetings, and do report-outs. • If a representative model is used, team membership is determined by the larger department through a nomination and voting process. • Successful teams have clear and effective communication mechanisms to the larger department • High-performing teams with representative models have employees who feel very knowledgeable to about the work of the team, feel involved in the team process even though they do not sit on the team and feel the team is effective.

15. High-performing teams communicate via several different methods so that all members of the department have a shared understanding of the work of the team. Common practices include: Posting of meeting minutes and notes in breakrooms Communication of key information to employees during daily huddles Newsletters and/or email communication of information Teams are launched with initial UBT training for all team members This training provides a common understanding of the goals of the team, and a shared understanding of the “consensus” and how it is defined by the team. This provides all team members with a structure process for on-boarding, as new team members are brought on, they all go through the same training so they have the same grounding as existing team members. Training refreshers are provided when there is turnover among UBT members. Communication Training

16. Sponsorship/Support • Consistent, aligned, and visible sponsorship is necessary for building successful relationships. • Successful UBTs have sponsors that are involved with their UBTs. They support the work of the UBT, remove barriers when necessary, coach and mentor the Co-leads and team members, and provide linkages to other resources. • Labor leadership capacity is developed to lead UBT. • Successful teams and team members are given the time and resources to meet.

17. UBT co-leads demonstrate basic meeting management skills (creating an effective agenda, maintaining group focus, time management, and facilitation). Teams utilize huddles and other methods of meeting for short periods of time. Successful UBTs are a valuable resource to other UBTs through sharing of key learnings, best practices, etc. Successful UBTs share and discuss team metrics at every meeting All team members are aware of all the metrics of team success Metrics include – UBT tracker data – service measures, attendance metrics, workplace safety metrics, employee opinion measures Teams track success on tests of change through metrics developed by the teams Methods Metrics

18. Many of these findings are not new (for instance, importance of participation on physicians, committed labor and management co-leads, strong sponsorship, regular meetings) What is new with UBTs that is making a difference: Systematic use of metrics and organizational support in accessing, analyzing, and reporting metrics. Systematic integration of UBTs into work of the department and goals of the facility, region and organization The use of explicit performance improvement models along with more traditional LMP processes like IBPS Other infrastructure support: training, facilitation, reporting, performance improvement/OD Key Findings