Massachusetts has a long tradition of collaboration in health care, exemplified by the passage of our landmark health reform law in 2006 that resulted in near-universal health insurance coverage for our residents. That effort brought together businesses and consumers, labor and management, hospitals and health plans. Divergent interests each gave up a little in furtherance of the common good. This culture of collaboration has allowed us to enjoy some of the best health care in the world — but our spirit of cooperation is showing signs of stress.
Question 1 on the Massachusetts ballot, which was rejected by voters on Nov. 6, would have mandated nurse-to-patient staffing ratios in all hospitals. The nursing union pushing the measure had argued for years that such ratios were necessary in law to ensure patient safety. When their advocacy efforts failed in the Legislature, they took the issue directly to the voters. The ensuing public debate stirred deep passions and exacerbated divisions — and not only between nurses and hospitals. The discourse became ugly and hurtful at times, with some nurses publicly shaming other nurses who chose to support the opposition.
Now it is time to heal, though the underlying issues that gave rise to the initiative have not gone away. Hospital care is increasingly complex and specialized, and the demands on staff, especially nurses, are significant. Hospital leaders must redouble efforts to find alternative ways of collaborating with nurses to ease their burden and improve care to our patients. One innovative model might show us the way.
Will Erickson is a representative of SHARE, the largest union at UMass Memorial Health Care, the hospital system where I work. SHARE represents about 3,000 members here, including radiology technologists, respiratory therapists, personal care attendants, and employees who support bedside care (registered nurses are represented by a separate union). Along with another senior manager, Erickson is spearheading an initiative that encourages the creation of newly formed unit-based teams: department-level improvement systems co-led by a union member and a manager. There are currently five such teams at UMass Memorial, which will soon expand to 13. These teams study big problems that front-line workers are uniquely situated to identify. They craft an experiment designed to solve the problem and then monitor its progress. If that doesn’t work, they try again. Unit-based teams empower caregivers to improve patients’ quality of care.
One team is in our Heart and Vascular Center, which performs interventional cardiac catheterizations — a nonsurgical treatment used to open narrowed coronary arteries to improve blood flow to the heart. This team has developed a simple daily communication system to help improve patient wait time and address safety issues in the lab. Their employee satisfaction scores in the unit improved almost 20 percent as a result. Recently, a team in our outpatient pharmacy observed that prescription orders were getting delivered to patients in a timely way only 30 percent of the time. After discovering that faulty inventory practices were a key contributor, the team fixed the problem, and the proportion of on-time deliveries surged to 90 percent. By eliminating significant waste in inventory, along with other measures, they also saved $1 million.
The idea is not new, but it has yet to be widely embraced in Massachusetts. It began at Kaiser Permanente, a large California HMO, in 2005. Kaiser and its unions concluded that effective collaboration was necessary to “deliver modern medical care in all of its complexity.” The benefits of such collaboration stretch far beyond improving processes and saving money. Erickson says involving his union members in leading change improves their experience at work. “They got into health care to improve lives,” he says. “This initiative gets them really excited to come to work.” The process breaks down barriers at the front line between labor and management and allows each side to see things from another perspective. It gives his union members ownership over issues, which breeds confidence and creates career development opportunities for them.
Perhaps the biggest surprise is the impact it is having on management. UMass Memorial employs Toyota’s lean system as our method of process improvement, which pushes decision making as much as possible to the front line. Unit-based teams are a great enabler in this regard, as the process gets managers out of the top-down, command-and-control mentality and nurtures them into becoming mentors and coaches.
Are unit-based teams scalable to other unions or hospitals? We don’t know yet. This is an early experiment for us, and what works for the SHARE union may not be acceptable to others. Each union has different issues and priorities. But given the state of affairs, shouldn’t we try? Effectively identifying and eliminating waste in one’s daily work is an equal-opportunity burden reducer. It is agnostic to union affiliation.
Unit-based teams are not a panacea for all labor-management conflict in health care. But they do offer one creative approach to help return to our spirit of collaboration and align the entire system around how to deliver the best possible care to our patients.