In May and June Doctors Council members ratified Collective Bargaining Agreements (CBAs or contracts) with the New York City Health and Hospital Cooperation (HHC) and its affiliates (the Mount Sinai School of Medicine, NYU and PAGNY) creating the largest collectively bargained doctor-management partnership in a U.S public hospital system. This was achieved by bargaining into our contracts Collaboration Councils that were created following our White Paper and its call to action. Read our contract language on Collaboration Councils with HHC and the affiliates.
The road that first led Doctors Council to do this transformative work was announced in our 2014 White Paper “Putting Patients First Through Doctor, Patient and Community Engagement.” The premise of the paper was that “If doctors’ knowledge of the work we do were utilized by HHC, our hospitals and facilities would have better outcomes and be more cost effective.”
In a moment of massive health care reform and instability we believe that it was almost an ethical imperative to use the contract negotiations with HHC to move the issue of doctor involvement in patient-care decisions to the center of the union-management and doctor-administration relationship.
By placing the question of “joint decision-making bodies” with front line doctors, “overall accountability of the entire system,” just culture and a real evidence-based engagement with metrics and outcomes at the center of union negotiations we have redefined the role of a professional doctors union.
Perhaps most importantly we believe that our White Paper’s proposals follow from the best evidence in the literature about how to transform a hospital or system to best serve the patients and community.
The literature on joint decision-making includes many successful labor management partnerships including Kaiser Permanente’s model -the most developed health care partnership in the country. Thomas Kochan’s study demonstrates the leading role that Kaiser has taken in developing a team approach to quality that includes front line providers throughout the system. Peter Lazes and his team use the case study method to explore how front line provider involvement can improve both the quality and cost of the health care delivery system by engaging in labor-management partnerships.
Yet in the medical literature what we call cooperation is often discussed as a management style. Thinking about collaboration with organized doctors is still a new idea for most health care systems. For example as we documented in a recent blog, front line involvement and joint decision making is described in much of the literature as physician hospital alignment or engagement or buy in.
Another example is in a systematic review of literature on physician hospital integration in which Trybou et al writes “Physician–hospital integration is clearly more than just strengthening the economic ties between both. Instead, from a policy perspective, added value is realized by increasing the underlying day-to-day cooperation in order to improve efficient care delivery and to improve the quality of the delivered care.”
Adding value is precisely the goal of the Collaboration Councils, but in our model this does not only come from above in the form of a management directive, it comes from below in the form of a union demand for its members (doctors) to be heard.
Forbes magazine recently brought this point home: “health care organizations need to redouble their efforts to involve physicians in key decisions from the very start of the process. No longer can administrators rely on support for decisions in which the physicians had no real input…. implementing it will take significant commitment…. There must be meaningful action and follow-through…. Fixing these areas of friction can increase cooperation, and that can improve care quality, lower costs and eliminate significant wasted effort.”
We believe that this form of involvement is too important to leave to the health care administration. Doctors need to demand it.
Another key part of our White Paper is the importance of a just culture that will encourage physicians to discuss problems and not fear a punitive environment. Dr. Dauterive, and Dr. Armin Schubert discuss the important role of culture in creating a safe environment as “An effective safety culture is characterized by an environment in which frontline personnel are comfortable disclosing errors, including their own, without fear of repercussions. The ‘just culture’ concept codifies this approach as a job performance expectation that maintains professional accountability.”
The importance of a just culture was recently made very clear in the failure’s and staff blaming at the Veterans hospitals where the Project on Government Oversight highlighted the problem of culture in its report and concluded, “’Until we eliminate the VA’s culture of intimidation and climate of fear, no reforms will be able to turn this broken agency around.” The project quotes a former VA nurse who says “’There’s a culture of bullying employees….It’s just a culture of harassment that goes on if you report wrongdoing.’”
Finally, an engagement with metrics from both a provider and a community perspective is an important aspect of the Collaborative Councils. Pay for performance is a good example of the approach. Doctors Council’s response to Pay for Performance is one in which we encourage plans that create overall accountability for the entire system, but we have real concerns with pay for performance models more intent on blame and individual gain.
The Collaboration Councils represent an evidence-based approach to doctor advocacy through collective bargaining that we hope to continue in the future. Doctors must be engaged and our voices and input heard for our patients and communities we serve to receive the best quality care, for our health systems to survive and get ahead, and for our professional practice, morale and satisfaction to improve.