McLaughlin: Id like to pick up on something Gary started with. Could you give us a specific example of some area thats been neglected because were tied up in old fights and not looking forward?
Filerman: Communication and transparency, and we ended up with the word together. Somehow, as I said, getting on the same page I believe is critical in a situation where resources are going to become scarcer before they become better. More and more were learning about what truly drives quality every day. Every day theres new evidence as to the true causes of poor quality and lack of access. I mean the research enterprise is very productive in that regard. And the question is, how to establish common ground with which to engage these issues?
What distresses me to some extent is my conclusion that union leaders and hospital leaders who are very much committed to establishing that new common ground find themselves beholden to audiences and constituents that expect them to be at arms length and adversarial and to see that as a reflection of effective management or maintaining union membership as the case might be so that its very difficult for the people that are expressing the view we just heard to function effectively, both to their own constituents who expect them to behave as they have in the past toward each other, and the need to look forward to establish a new common ground to deal with some of these issues.
I think the Kaiser experience is very critical in this discussion. People have a tendencythats the partnership in Kaiserto dismiss it as saying thats unreal, it doesnt apply in the real world. The fact is there are many, many lessons there that do apply in the real world. If you cut through the complexity of that organization and look case by case and project by project, there are glimmers there of a preferred future that can only result to the betterment of healthcare delivery.
Burda: Gary, see if I summarize this correctly. Youre saying left at the local level the hospital executives or hospital management could work things out with local unionized workforce, but because they belong to larger organizations, national unions, maybe some national healthcare organizations, that those expectations prevent them from working it out?
Filerman: No, Dave, Im talking about within their own operating environments, the union leader who has to demonstrate to the rank and file that they are militant and they are protecting the interests and that they are maintaining arms length, the hospital administrator who has to demonstrate to the board and demonstrate to the people that report to him or her that they are being militant and keeping the union at arms length. And regardless of their better instincts, theyre caught, I think, in a bit of a vise there, and weve got to work ... push back on those environmental factors.
Stickler: No, I dont agree. I dont agree in my practice and I dont agree in my governance, and Ill give you an example. And again, this goes back to the differences that we had with the CNA organization last year where here in Chicago we had election at the hospital that I used to be the chairman of the board of, and when the CNA announced that they were organizing, the first thing we said is we have to educate the board because the board had not been educated. Shame on us.
The second thing is we had to educate our managers as to what the legal requirements and principles were, and we did, and we had to educate the employees as to what their choice may be. Now, this is going to change with the Employee Free Choice Act, and well talk about that in a little while; but clearly if the structure of the regulation and the laws change, this whole element can be affected, but really its, from my perspective, I will say that educating the board and having the board understand that the mission is ... Its required to have the mission and to meet the mission by having everybody within the organization understand what that mission is and work toward that mission from the employees on up.
Ill give you one example. An example was a healthcare system in Ohio, and they were visited by an organization called Acorn, which was borne out of (Service Employees International Union) organization down in Lafayette, La., about 45 years ago, and this organization said we represent many people in the community. We represent the community. And there are many folks here who have had service at your organization, and that organization that is your organization has liens on property; and we said, no, we dont put liens on property. Well, we found out that there were thousands of liens that had been placed on property, and when we did that, we removed the liens. We went back to the organization. We thanked them. We set up a relationship with that organization in the community to work together so that we
for the betterment not only of the people in our community but for our own employees to understand that were not that kind of an organization. I think it goes back to what youre saying.
You can carve a relationship with organized labor if they do represent your employees that work from a management perspective agenda to meet the mission. Everything has to be designed around the mission. But if its simply an adversarial relationship, those days in the 1950s are over, its not going to accomplish anything; and indeed youre going to have wasteful spending of resources that need to be used for the betterment of quality care. So, we come down on education of the board, education of the managers and yes, education of the employees, and thats going to be required even more so when you have what we think will be the Employee Free Choice Act.
Jenkins: As the only union thats not a part of the Kaiser partnership, we have some big issues with that. Fundamentally, there is a huge imbalance of power between workers and the boss, and if youre unionizing, youre trying to equalize that imbalance of power. And its not that it has to constantly be an adversarial relationship, but you have to be able to leverage some ability to move things forward. And we fundamentally dont believe in those kinds of partnerships because I think too much gets sacrificed on the part of the worker in general, but nursing in particular, our ability to do what I said earlier, which is to stand up and advocate for the patients.
In the Kaiser system, we won the right to have quality liaisons, which are nurses jointly picked by Kaiser and CNA who work half time on maintaining quality standards because we saw a lot of de-scaling and a lot of encroachment of nursing practice going on as managed care hit in the early 90s. And thats kind of why we took that position because we really feel like fundamentally to safeguard the best interest of the patient and our practice we had to do that. So its not that we constantly think there has to always be an adversarial relationship, but we have fundamental standards that we dont feel we can compromise when it comes to actually protecting the patient as well as protecting the scope of nursing practice.
Theres a lot of things nowadays that are encroaching on nursing practice in a lot of different ways, and technology unfortunately is one of them. Theres been studies that show where nurses used to spend 55% of their time at the bedside doing direct care. Now they are only doing 35%. And coming from a hospital where weve instituted a lot of technology at the bedside, people tell me all the time, Im treating the computer, not a patient. And I know some of thats driven by regulatory practices and things like that and trying to document things so that you qualify for all the requirements to get funding, especially with the new changes that just occurred this month, so its a constant struggle.
But I think theres always going to be a fundamental push and shove and give and take there because there is a huge imbalance of power between the worker and the boss that has to be addressed. Thats why people unionized, to kind of counteract that imbalance. And I think there is a role for transparency. We try to work very closely with hospital management in hospitals where we represent nurses to get the standards we think are important, and for us its always ... the ultimate goal is the patients well-being, and I think that everyone here agrees with that, that the ultimate focus has to be the patient and providing the quality care that people deserve.
Burda: Dave, do you want to comment on this balance-of-power issue and maybe what vehicles exist at your institution or places youve worked at to keep that in equilibrium?
Hefner: Ill probably comment more generally than my institution, but I do think that there is some truth to what Geri is speaking to about a balance. I dont know if Id characterize it as a balance of power. Id probably go back more to the mistrust phenomena, but I do believe that were in an era, and this is where I can speak to kind of my different management venues where we have policies, procedures and views that wed like to distill the policies and procedures but then we dont have trained managers to actually respect those policies and procedures.
And if anything, a union will more or less force ... Thats not the word that Id prefer, but it does require a different rigor and discipline to have to manage in a union environment to then actually subscribe to your policies the way that they are actually written, and youll find that theres a pretty big disconnect. So, part of it is, Bruce, when you speak about educating your employees or management or the board, its really walking the talk of what you would want to have happen day in and day out in any case. And thats where I think theres a gap that we need to continually be working on together to bring that... fill that gap. Thats probably the better way to say it.
Stickler: Can I just respond to that?
Burda: Sure, Bruce.
Stickler: One comment; boards today, and its not true three, four years ago, now on the dashboard on your monthly meetings, labor relations is on that dashboard; and the (vice president) of (human resources), who has that responsibility, is no longer a personnel director but truly is a vice president and who is required to bring forth for the board issues related to the vulnerabilities, whether its community relations, community benefit, tax issues, things that actually impinge upon how the workforce and how others in the community feel about the organization and whether they are meeting the community obligation. This is an asset of the community, and we learn that over and over again.
We learned that here in Illinois with tax exemption in one of the hospitals that clearly is still fighting that issue as to whether its a nonprofit organization. More pressure is going to be placed upon healthcare, and all of us are right in that regard, so its a question of transparency. Are your (Form) 990s on your Web site? Are you willing to state what your executive compensation and benefits are? How willing are you to trust your employees with this information, and how do they respond to it? And how are they educated so that they understand what it is were trying to accomplish?
And youre absolutely right, it goes back to the quality that we provide to our patients because ultimately were going to be judged by that, whether its the CMS or any other organization, Leapfrog (Group), who are going to have their own data that will be open to the public to determine whether were meeting our obligation of the community. So, I think youre correct in that regard.
Filerman: Let me go back to a point that you raised. You brought up scope of practice. I would guess looking forward that quality-of-care understandings and financial constraints are going to lead to a systematic reorganization of scope of practice in this country. Scope of practice is an artifact in many respects of a past era. It is used mischievously by all of the professions on one hand to talk about protecting their self interest and on the other hand to align it with quality of care, but were going to have to redistribute tasks in ways that are directly related to outcomes.
Were going to have to start using very expensive personnel, nurses, physicians, others, in ways that enable them to use the full scope of their capabilities and to hold the organization and the individual accountable for achieving outcomes. Its an example of whats got to be on the table by the professions both at the organizational level and at the national level if, in fact, were going to move this healthcare system into the next level before it collapses.
Burda: So youre saying there are artificial barriers?
Burda: And they should be removed how?
Filerman: I think the labor structure makes that very difficult. Now, this is at the same time when I think (union) organization is growing, the health sector is going to be more and more unionized. Were having organized behavior at every level, physicians, pharmacists, technicians. More and more are behaving in a union-like fashion. In union there is strength, and the organization needs to respond to that to deal with the challenge of allocating tasks effectively, for example.
Hefner: Maybe, Gary, I could underscore that point. See if this actually is something that youre addressing, and it actually captures quality and technology and change at the same time. So, last weekend at a board committee meeting, as were enabling ourselves electronically for an electronic medical record, its pretty clear at the juncture were at we have a whole bevy of well-trained, highly-paid pharmacists who are actually doing data entry only because the risk around what they are entering from a paper-based to an electronic system is necessary at this point, so its not fully automated from the order entry all the way through to the pharmacist yet.
So theyre serving this interim role that is a misallocation of duties that is necessary where we are in our evolution. But as you think further down the road as that gets enabled, then they no longer have to do that clerical task, and they could actually do what their training calls for, which is exactly what you want pharmacists to do. And hence, youd want nurses to do the highest-level tasks that they have been educated and trained for, and yet we have a misallocation of a lot of their duties that you would hopefully begin to see that shift also.
And Ill tell you, if I go back 30 years from a nursing perspective, which is when I ... The first time I was the CEO of a health system I was very, very young, but nurses at that point in time, at least in that stage of my career, nurses called the shots. They actually ran the organization, and it was clear who was in charge of the patient 24 by 7 by 365, and nobody had any confusion about that. I think as an industry nursing has taken a step back, has been overwhelmed by the fragmentation of the market and technology and the demands, and the education has not kept up. And now you have nursing who feels like they have lost their voice, which needs to be recaptured.
Jenkins: If I could address some of this technology stuff, you know, being the first interface with the patient at the bedside, things happen in a really critical way, and a lot of technology really bogs you down. If I have a patient crashing and I need to run to the Pixus and get a med and the pharmacist hasnt verified it, then I have to call the pharmacy, and I have to go through this process and that process because the system is call-geared to safely deliver meds so theres no mistakesyou know, youre wasting critical time. So it seems like a simple transition into some of this stuff, but in reality it really can bog down critical time frames that are crucial to doing things.
And I think... personally, I think nurses should call the shots because were right there dealing with the day-to-day moment-to-moment things. And I dont discredit the fact that there has to be quality built into it and ways to track quality, but I think the frustration people feel now is theres so much change in that technology that nurses arent always in the loop on how its devised, developed, how it works. And in the day-to-day flow of your job, time constraints are different sometimes than what you theorize about when youre formulating this technology. So the frustration level I feel in nursing around all this technological change is huge.
Hefner: I think youre right, and thats how we take a major segment of the work force through change, and were not very good at that. And the software isnt where it needs to be yet, but I think even your example is kind of capturing the 1% or 2% of the time, not the 98% of the time. So we have to solve the 98%, and then we better allow for the 2%, when things go to hell in a handbasket and have the work-around that actually protects the patient.
Stickler: So the crux is how do you have your nurse executives, nurse managers, work with the nurses directly and forge that alliance even in an organized situation. Thats not easy and it takes time, and thats a focus that we have had over the past many years, to try and bring that together, to work off an agenda that is driven by, again, the mission, the patient, the quality, and lets not forget efficiency.
I mean, this state, Illinois, for example, has had an awful payment cycle from Medicaid from the state, and as the highest disproportionate-share hospital that I was chairman of the board of with a couple of days worth of cash on hand, that is absolutely essential and critical. And you cant lose sight of the fact that we dont have the resources for capital; that we dont have the resources on a national level; and that we havent had increases in the Medicaid rate for tens of years here in this state.
So it all factors in, but its the working-together relationship between the employee and the manager that makes for at least a better environment and hopefully a better outcome for the quality, and that has to be taught. It cant just happen on its own. Then before ... I just want to throw out we want to get to at some point how the law and the regulations are going to change with the Employee Free Choice Act and what implications that will have on labor relations.