Silence was the first reaction when Fontana pediatrics manager Valerie Hammel announced to her department's medical assistants they would be taking on the task of administering immunizations.

 "You could cut your way out of the tension in that room," recalled labor partner Debbie Russell, a shop steward with United Steelworkers Local 7600.

Then came protests, tears and table pounding. Fontana has the second-busiest pediatrics department in Kaiser Permanente. The department already was giving 600,000 injections a year. The MAs worried the new task would make their already demanding workload impossible.

Fear and lack of confidence were in play, too-most MAs had not given shots since they were in training.

But Fontana Medical Center, in Southern California, was the sole remaining KP facility where registered nurses and doctors were the only ones administering injections. With only five RNs giving shots, patients regularly experienced long waits, sometimes as long as two hours.

"We could no longer sustain that," Hammel said.

Shortly after the announcement, a group of MAs filed a formal complaint, setting off a series of facilitated meetings filled with tough conversations.

"I didn't know what to expect," Hammel said. "But those meetings continually surprised me. I kept thinking it might bring out the worst in people, but it really brought out the best."

Better communication, better performance

Waits for immunizations are now a thing of the past-and the medical assistants have discovered they like the additional responsibility. Research bears out what the pediatrics team found as it sat down and the parties listened carefully to the different points of view: Communication improves performance.

Specifically, good communication is a key element in a "learning environment," where for focus isn't just on getting the job done but also on how to get the job done better than before.

According to a 2006 Harvard study, how well parties can talk with each other, particularly when it involves uncomfortable topics, is linked strongly to improving performance and quality. That means individuals have to bring a different attitude to work. Instead of opting for short-term solutions that bypass a chronic problem, they have to be willing to look at how to fix the underlying issue. The challenge for local leadership is to foster that willingness.

"The research shows the value of psychologically safe environments," said the study's author, A.C. Edmondson, a professor at Harvard Business School. "Just about everybody is working on some variant of this. The recognition of the importance of (openness) is greater in health care all the time."

Edmonson has written that a learning environment "is one in which people feel comfortable and capable of speaking up with interpersonally difficult observations and questions….This environment…is created locally, one clinical area or patient care unit at a time."

"The job at the top," Edmonson says, "is to set a very clear message: 'We're looking for your input and problem solving' and getting people to start trying new things."

Her work makes it clear why Kaiser Permanente's Labor Management Partnership has set a goal of having all KP employees working in unit-based teams (UBTs) by 2010. The only way KP will grow and thrive in the face of extraordinary competition, the only way it will become the solution to the U.S. health care crisis, will be to improve performance. Unit-based teams foster the sort of frontline engagement that leads to improvement on all points of the Value Compass: service, quality, affordability and work environment.

The success of those teams' efforts, however, will be determined largely by how effectively and openly team members communicate.

"It is a prerequisite," said Barbara Grimm, senior vice president of the Labor Management Partnership. "If you're not having an open dialogue, you can't move things forward."

The Rapid Improvement Model (RIM), for example, requires workers to constantly and frankly assess the effectiveness of small tests of change.

As they go through multiple RIM cycles of plan, do, study, act (PDSA), teams learn to identify and talk about what didn't work. Through repeated practice, raising questions about what went wrong becomes the norm.

There are plenty of barriers to having the sorts of conversations that lead to breakthroughs in improvement. Some of the most common include:

 

• "When one person has more power than another;
• Refusing to truly consider another's viewpoint; and
• When two parties are supposed to be on the same "side" but don't agree.

 

One of the biggest barriers to effective communication, says Jerry O'Keefe, the director of KP's Employee Assistance Program, which facilitates discussions to resolve workplace disputes in addition to providing employee counseling services, is that until people reach an impasse, it isn't obvious that they don't have the skills to work through a difficult situation.

"You didn't grow up with an instruction pamphlet in your pocket that says, 'This is how we're going to communicate effectively,' " O'Keefe said.

Edmondson's study stresses the importance of building communication skills. She found that when issues are raised early, they can be resolved before they develop into major problems.

"This capability is profoundly important in organizations that wish to engage in continuous improvement," she writes. "When small failures are neither identified widely, nor discussed and analyzed, it is very difficult for larger failures to be prevented."

Karen Roulette, the manager of internal medicine at the Santa Clara Medical Center (Northern California), deals with power imbalance in a straightforward fashion.

"I think you have to be empathetic to whatever it is that's so important (to the other person)," Roulette said. "And it has to become important to you, too, if you want to maintain that working relationship with your employees."

Flexibility is key

That attitude keeps flexibility in the conversation-a key ingredient to positive outcomes.

"Across the board, one of the characteristics that undermines successful communication is inflexibility," O'Keefe says. "To move into a conversation with a fixed position is no different than trying to go through something that is fixed like a wall."

Santa Clara medical assistant Angelique Zuniga says she often butted heads with Roulette, particularly when it came to time-off requests.

"I used to take it personally," Zuniga said. "It's easier to not communicate and just call in sick than it is to sit and try to work it out."

Then she became a UHW-West steward and got trained-with Roulette-in Interest-Based Problem Solving and other decision-making techniques.

"Now I am able to understand (her point of view) more," she said, "and it opened my eyes."

Medical assistant Tara Sisson has had a different challenge. As labor chair of the Sacramento workplace safety committee, Sisson interviews fellow union members about their injuries. To do her job well, she has to zero in on the details that are likely to raise questions. 

In one instance, a worker with a previous workplace injury had filed a complaint for a new injury that occurred just minutes after he'd been disciplined. Sisson had a frank conversation with him about the timing of the injury.

"I was fearful that I would get push back, with (him) thinking that I'm on management's side," Sisson recalled. "I'm just trying to do something before it becomes something major."

Intervening early is also important to Al Olsen, a chemistry technologist and UFCW steward at the Mid-Atlantic regional lab-but it's not always easy.

"I can't say I don't sometimes get a butterfly or two thinking, 'How is this going to affect how management sees me?' " he said. "But at least I've brought up the problem."

Several months ago, for example, when there was a vacant union job in the department, Olsen noticed that hematology supervisor Tom Philbrick was doing some of that position's work. Olsen felt he had to speak up.

"If it is a job description written for a union employee and you have a non-union or management person doing that work, it violates the contract in some aspects," Olsen said.

Olsen approached Philbrick and a top lab manager with his concerns. They came to an agreement that satisfied all sides-but, Philbrick recalled, "My initial reaction was, 'Fine thanks I get for helping out!' "

But after he thought about it for a bit, he realized Olsen was raising a valid point.

Philbrick said that as a manager, he works to assure employees that their input matters, that they can affect change.

"I give them the respect of listening," he said. If the idea as presented won't work, he said, there's always the possibility of "using part of that idea."

Early intervention

In Fontana, wait times for vaccinations have been eliminated. MAs report they have a stronger connection with patients, provide better service and feel a boosted sense of pride from expanding their skills.

The fact that management heard the MAs' concerns and worked to allay their fears helped them accept the change, said MA Sophia Garcia.

And, she said, the more they talked, the more one glaring fact stood out.

"In the end, we had to put our concerns aside and say, 'Well, how is it going to be better for the patient?' "Garcia said. "We're trying to get them in and out in a timely matter, and we couldn't deny that this would help that."

The experience has made the UBT members converts of airing concerns when they first come up.

"I think our success depends on (having difficult conversations)," Hammell said. "We shouldn't run away from them, but embrace them and look at them as an opportunity for improvement."