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Micro-Clinics, Macro-Partnership

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Faced with opening five clinics in 11 weeks, Ohio proves working collaboratively and reaching consensus doesn’t always take longer

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What works on the micro scale can become sticky at the macro. Take, for instance, partnership.

True partnering and consensus can be difficult to achieve even for the smallest team or department. The challenges multiply at the grander, operational level, where more people are involved and the interests increase in complexity. But that didn’t stop Ohio from collaborating successfully when it expanded for the first time in several years and opened a handful of small clinics in late 2011.

From early on, union and management partnered on what the clinics would look like and how they would operate—not only working with architects on the clinics’ design, but also figuring out how to staff the new positions.

“I had a physician say to me, ‘They aren’t really listening to you,’ ” says Monica Ussai, a licensed practical nurse and OPEIU Local 17 steward who joined Ann Scott, director of primary care services for the region, and Lydia Cook, MD, the assistant medical director for primary care services, in hammering out the details of the clinics’ operation. “That may have been true in the past, but not in this case. They actually took my suggestions. I felt heard and really valued.

“I believe we were truly in real partnership.”

Breaking new ground

With the Cleveland population moving farther into the suburbs and beyond, the region wanted to provide easier access to Permanente physicians while also facing a Jan. 1, 2012, deadline for reducing use of network (non-Permanente) providers. In response to those competing interests, Ohio decided to open five small “micro-clinics” in outlying areas—and did so with breakneck speed, in just 11 weeks.

“Whether it is delivery system redesign or performance improvement, we make sure our labor partners are at the table,” Scott says. “So this was a natural evolution of that….We used the partnership infrastructure that was already in place.”

When it came time to turn the idea for the micro-clinics into a reality, the team members who had been developing the vision approached Ussai, who already sat on several care delivery and workforce planning committees for the region, and asked her to join them.

“They said to me, ‘This is different. We need (support staff) to do everything,’ ” Ussai recalls.

From concept to implementation

The small clinics are modeled on the concept of “medical homes,” in which doctors’ offices are comfortable places where patients and providers are on a first-name basis. The micro-clinics have micro-staffs, with just one or two care providers and six support staff, while providing the basic services of a typically sized medical office. To do that, medical assistants and licensed practical nurses must do it all—from registering members at the front desk to drawing and processing labs.

Immediately, Ussai worried that internal staff would be excluded from the new positions because they were unlike any other positions they had had before and, as a result, few if any internal candidates would qualify. In addition, she was concerned about what would happen to an LPN or MA when the Permanente physician he or she supported moved from an existing medical office to one of the new clinics.

“I didn’t want them to lose a job because that doctor was being taken away,” Ussai says.

So she proposed an unorthodox solution that everyone involved, including the union, agreed to. Traditionally, an employee with the most seniority gets priority for a position. In this case, however, Ussai suggested that first dibs on the new positions be given to the LPN or MA working with the physician being transferred. If that person chose not to transfer with the physician, the opportunity then went to fellow team members. If there were no takers, the position then was opened to general internal and external candidates to apply.

The linchpin to this plan was training. Ussai requested that LPNs and MAs who wanted to move to a micro-clinic receive training in the additional reception and lab duties they would be assuming. Management agreed.

“By doing that, we created the least disruption, by keeping the team intact,” Ussai says. “But you have to be really careful with something like this, because you have to be responsible for the end results.”

Ussai had to do some convincing of her own union leaders and constituents. “But I felt really strongly about it, that it was the most fair for everyone.…I never made any decision that I wouldn’t have wanted made for myself.”

The timing imperative

It’s no secret that consensus decision making can take longer than the traditional, top-down approach. But in this case, “labor understood the urgency and that allowed us to move quickly,” says Dr. Cook.

The region needed to ensure the new clinics and the Permanente providers were ready to meet the needs of the members whose access to outside network providers was being cut back. This meant constructing, supplying, staffing and opening all five clinics between October and December 2011.

“Labor’s understanding of the business need was key,” says Seona Goerndt, director of diagnostic and support services, who oversaw the opening of the clinics. “They understood the ‘why’ behind what we’re trying to do and embraced change more than I’ve seen in other things.”

Indeed, Ussai says having an understanding behind the decisions was critical in explaining the process to, and gaining buy-in from, employees.

“They knew how things were going to be,” she says. “They were happy that they knew their whole lives weren’t going to be changed.”

All involved agree the strong relationship that already existed between labor and management was the foundation for the success. And despite the varying interests that needed to be considered, the single common interest shared by everyone boiled down to the patient’s needs.

“It wasn’t about us or them,” Ussai says. “It was more about us working together on what was best for the clinics and members.”

Ussai, who grew up in a union family, understands how radically different this experience was from traditional management-labor relations.

“My dad used to always tell me that unions were here to protect workers from unfair treatment,” she says. “But what we have here (at KP) is totally different. We’re there from the beginning, not just for the problems.”

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