Featured Guest: Paul Clark, PhD

What he does:  Dr. Clark is a Professor of Labor and Employment Relations at Penn State University where he regularly teaches undergraduate and graduate courses on employment relations.  His research has focused on employment relations in U.S. healthcare, with interests including unions, union organizing, collective bargaining, labor-management partnerships, and labor-management relations in healthcare.  His research has appeared in the leading scholarly journals in industrial and labor relations, applied psychology, and international labor issues. He is the author or editor of six books about unions and collective bargaining; and has worked on training programs and research projects for over fifty national unions, and many local and regional unions.

On risk:  "Workers don't bring in a union to wreak havoc and make a hospital or a clinic work less well. They want to have a greater voice in how care is delivered. Administrators have a tough time with that, because they've largely been taught that they're in charge. They're the ones that make decisions, but by giving up a little bit of that control, there really can be great benefits … Management still has to decide, or gets to decide, what its positions will be in bargaining.  If they don't come to agreement, however, then unions do have the right to strike.  A strike is a pretty traumatic thing, and that's part of the collective bargaining process that doesn't exist when unions aren't present in a workplace … Collaboration on a large scale can work.  There are other smaller hospitals and smaller medical centers I've worked with, and we do see really, really positive results from that, because workers see their role as not just doing what they're told, but always looking at how they can make the workplace better. And they know that if they see something that can be improved on, there are mechanisms to talk about what's going right, what isn't, what ideas do people have, and then there's a mechanism where they work together as equals to try to decide whether to implement things, and then they measure them afterwards to see if they've had positive results."

Transcript

Scott Nelson  0:01  
Welcome to The Risky Health Care Business Podcast, where we help you prepare for the future by sharing stories, insights, and skills from expert voices in and around the United States health care world with a mission to inform, educate, and help health care organizations and individuals, ranging from one doctor practices to large integrated systems and organizations throughout the dental, medical, and veterinary health care industry with risk, while hopefully having some fun along the way. I'm your host, Scott Nelson, a guy that grew up in Ohio and has been working all over the United States during my 20 plus year and counting career in the health care industry, with a commitment to accelerating health care performance through creativity, not just productivity. Let's dive in. 

The U.S. Bureau of Labor Statistics tracks work stoppages that involve 1,000 or more workers. There were 84 such stoppages at hospitals between 1993 and 2021 – one every 4.1 months.  According to an article by the Healthcare Financial Management Association, the pace has accelerated since the start of 2022, with 15 stoppages in approximately 21-months through early October 2023 – one every 1.4 months . Labor relations and union activity in the US health care system present potential risks that health care organizations can proactively address and manage. As unionization efforts gain momentum, spurred by widespread concerns over wages, working conditions, and staffing shortages, hospitals, health systems, and health care organizations face a landscape with notable challenges. The surge in labor union activity, especially in the aftermath of the COVID-19 pandemic, underscores the opportunity for health care organizations to reassess labor relations strategies. Health care workers, who have been on the front lines of an unprecedented health crisis, are increasingly vocal about their needs and expectations. This growing assertiveness among workers has led to more aggressive union campaigns, which in turn can result in labor disputes, strikes, and demands for higher wages and better working conditions. For hospitals and health systems, these developments translate into a heightened risk of operational disruptions. Labor disputes and strikes can severely impact patient care, leading to delays in treatment, reduced service quality, and potential harm to patient outcomes. Furthermore, the financial implications of increased labor costs and the legal expenses associated with labor disputes can strain already tight health care budgets.  To mitigate these risks, health care organizations can take a proactive approach to labor relations. In this episode I’m speaking with Dr. Paul Clark about labor relations and unions in the US health care industry.  Dr. Clark is a Professor of Labor and Employment Relations at Penn State University where he regularly teaches undergraduate and graduate courses on employment relations.  His research has focused on employment relations in U.S. health care, with interests including unions, union organizing, collective bargaining, labor-management partnerships, and labor-management relations in health care. His research has appeared in the leading scholarly journals in industrial and labor relations, applied psychology, and international labor issues. He is the author or editor of six books about unions and collective bargaining; and has worked on training programs and research projects for over fifty national unions, and many local and regional unions. Let's talk with Dr. Clark about labor relations and unions in US health care.  

Dr. Clark, welcome to the show. 

Dr. Paul Clark  3:32  
Hi. Happy to be here. 

Scott Nelson  3:34  
Before we begin talking about labor and employment relations and unions in health care, I want to start our conversation with your work and experiences in those areas. 

Dr. Paul Clark  3:44  
As a very young person, I began working for the United Mine Workers of America at a time when that union was going through some very difficult times and and learned a great deal about the difficulties of working in a coal mine. And of course, unions have made a tremendous difference in that kind of work setting, the kind of work setting, the blue collar work setting, where people would normally expect to see unions active representing blue collar workers. But over time, I've studied a number of American industries in terms of the labor management relationship in those industries. And as I say, I started with coal. I spent a decade or so studying the steel industry, and then I got requests from nurses unions who were trying to organize nurses. This was relatively early days, so I spent quite a time doing research on that issue. A lot of it involved survey research on why nurses and other health care personnel felt they needed a union and that evolved into looking in real depth at the kind of relationships that have developed between unions and employers, and have spent a particular amount of time looking at a small segment of that population, which is unions and employers that have developed a very collaborative, cooperative relationship. And over all that time, I really learned a great deal about the role that unions can play in health care workplaces and how they can benefit health care employees. 

Scott Nelson  5:36  
What drew you into academics and taking a look at this from from the academic and the research perspective, versus working with those organizations in a different role. 

Dr. Paul Clark  5:46  
Well, going further back, I actually worked a couple years in a glass factory as a blue collar worker, and that was my first introduction to work, and that was a unionized workplace, and I learned there that if that was the way one had to earn one's living, day in and day out, year in, year out, I recognized in that situation how useful a union would be in terms of improving that work experience. But I earned enough money, went to college, eventually went to graduate school, and made a decision that rather than actually working for a union, dealing with the day to day challenges that they had. One of my real strengths was doing research, identifying important questions that we didn't know enough about, and exploring those questions in some depth. And I published my first book at 24 that was about the Mine Workers Union. But I think that's where I found I thought I could make a greater contribution. 

Scott Nelson  6:49  
Transitioning into our conversation about labor and employment relations and unions within health care, I think it'd be helpful to start with an overview of the history of unions and how they've evolved within the health care industry. 

Dr. Paul Clark  7:02  
Traditionally, going back in Labor's history, in the 1800s the early 1900s unions were largely active in in blue collar industries, in coal, in the early days of steel, in textile manufacturing, in construction. As our economy evolved into a more mechanized, automated economy, those unions, the blue collar unions, grew, the auto workers, the steel workers, the mine workers, but in the middle part of the 20th century, we began to see white collar workers, first in those industries itself, like people who worked in the offices of steel companies or of manufacturing companies, auto companies, begin to organize. We saw government workers begin to organize, more professional workers like teachers and government workers, health care was sort of slow in evolving, because prior to 1974 health care workers really didn't have the protections of labor law to organize. So health care workers got that protection in 1974 and that's where you you saw unions in health care come online. However, it took a decade or even two for them to generate much momentum. So it really wasn't until the 1990s the early 2000s that we saw health care workers, really start to grow on a national level, and that includes unions of maintenance and support workers, nurses, nurses unions. And then in the last 20 years or so, we've even seen the rise of physician unions. 

Scott Nelson  9:01  
How does the dynamic between health care employers and unions differ from other industries? 

Dr. Paul Clark  9:07  
It does differ. And I can speak to this as someone who was a blue collar worker decades ago. When you're making glass bottles, you're doing it to make a living. You're doing it for the money. None of us were greatly invested in making glass bottles to make the world a better place. But in professional unions, right across the board, airline pilots, engineering unions, and particularly in health care, you have workers that have a great investment in the work they do and the impact that work has. So in traditional blue collar workplaces, you're dealing with for profit businesses and unions just really want a bigger piece of the pie for their members. They feel that they're creating those profits, and they should have, they should get a bigger piece of of those profits. But in an industry like health care, where there is a for-profit sector, but largely you're talking about a not-for-profit sector, you're not talking about companies that are making billions and millions and billions of dollars in profit. You're talking about organizations that are providing services to people, and certainly people who go into health care hope they can make a good living. But in my experience, virtually everybody who goes into health care has some interest in doing the work because it's going to have a positive impact on people's lives. People go into health care because they want to help people. They want to help heal people. They want people to have a better life. And in that sense, the real conflict that you see between unions and for profit companies, where there really is an inherent conflict between the workers and the employers, because the employer wants to keep labor costs as low as possible so they can make as much money as they can, and the employees are pushing and pushing to get more compensation because they feel that they're the ones making the profit, making the product. But in health care, employers and employees have much more in common, because they are both there to try to provide these services and make people's lives better. So what I've seen over time is while there, there is some conflict between employers and employees, because employers do want to try to keep the cost down, and that involves labor costs, employers and employees have something in common that they don't have in the for profit sector, and I think that provides a common ground for unions and employers. Unions made up of health care workers who want to make their workplaces better, who want to provide better and more cost efficient care. That's the same goal as the employer has. So that provides an opportunity for greater cooperation and collaboration.

Scott Nelson  12:32  
Around the idea of the pie and the employer wanting to keep costs low but the employee wanting a bigger piece of the pie, what are some benefits and drawbacks of unions from both the employer and the employee perspective?

Dr. Paul Clark  12:44  
From the perspective of health care workers, in my experience, it's very challenging to be a health care worker these days. There are a lot of frustrations. There's a great deal of stress. You have health care workers who come into the into health care, really committed to trying to provide the best care they possibly can. And then they get into jobs as nurses or technical people or even service folks, even physicians, and they find that the economics of the health care industry works against, in many cases, what they think is the best way to provide care. So you have frustration. You have people who want to have a greater voice in their work because they're so highly committed to their work. And they're they're highly trained, in many cases, and they they see ways of providing better care, of maybe providing even more efficient care, but in a traditional health care organization, there's a hierarchy. You have managers who manage and health care providers who are supposed to provide the care, and they're frustrated that they don't have a greater say in how care is delivered. So that's been a driving force. If you take nurses unions, for instance, and I've worked a lot with nurses unions, nurses are highly committed, and they are there seven days a week, 24 hours a day, that is, there are nurses working all of the shifts, weekends, weekdays. Nurses have are right there doing the nitty gritty of providing care, and they see through their day to day experiences, what's working and what isn't, and they really care that the system is working as well as it can. They want their patients to have the best experiences possible. So they look to unions as a way of giving them a greater voice in the workplace, of improving patient care, just an example, in most cases, when nurses organize, one of their highest priority demands in bargaining is to try to improve the nurse to patient ratio, because they believe when they have to care for too many patients, they can't provide the kind of level that they think their patients deserve. That's one of the things that really has driven nurses to try to organize, because they think they can improve the delivery of care and do their jobs better. Sure they also negotiate over wages and benefits because they think they're providing a very valuable service, but there's always that element of having a greater voice in the workplace. So that's the worker's perspective. From the employer's perspective, the traditional view has always been that having your employees unionize is a terribly negative thing. In fact, many managers see it as a fundamental problem that they need to avoid. And so health care managers, health care administrators, virtually always react in one way when their workers try to organize, and that is to oppose that effort, and they will hire very high priced lawyers, very high priced consultants to help them in the process, when there's an organizing drive, there'll be an election coming up, and their goal is to convince the workers that they don't need a union, to vote against the union. That, in itself, creates a tremendous adversarialism between workers and managers. It also costs a tremendous amount of money. There is a small segment of health care managers who don't take that position, because there's a lot of evidence that when unions come into a health care workplace, because, as I suggested before, one of their focuses is on making the delivery of care better than It was. Employers can see that there's some common ground and that a union can give health care workers a greater opportunity to have a voice in how care is delivered. And an alternative way of looking at this is health care managers have a tremendous resource in the people who are doing the hands on delivery of care, they know much more about what's going on on a day to day basis, at the floor level, at the bedside level, than administrators do. And so in some cases, administrators see this wealth of knowledge as a tremendous asset, something to tap into. So when unions come in, they negotiate to create structures. They're sometimes called labor management committees, labor management teams, where, on a regular basis, maybe monthly, the union members, the nurses, the tech people, will meet with their managers and talk about the problems they see in the workplace, and then they engage in a problem solving approach, not a sort of we're trying to tell you what to do, or you're trying to tell us, they collaborate, they exchange ideas. The nurses have a lot of great ideas, the tech workers, and in these instances, many of these ideas are then given the green light to go ahead and try to make changes that are going to improve health care. The really positive dynamic that comes out of this is, first of all, as I just suggested, you're tapping into a wealth of knowledge and experience in a way that hasn't been done before, when employees were employees, and they just did what they were told to do. But secondly, when people get a voice in their work and are given a chance to use their experience and their knowledge to come up with ideas to improve care, then they become very invested in those ideas. If I have an idea how to improve something on my surgical nursing floor, and you give me the green light to try to put that idea into action, I'm going to put 150% in of effort into making sure that that idea works, because it's my idea. You're listening to me. You're valuing my experience and knowledge, and that's a positive thing that comes out of unionization of health care employees. I know that most administrators are going to look at the cost of unionization because their fear is that it's going to increase wages, it's going to increase benefits, and those things are likely to happen with unions, because union exists to try to improve the work lives of their members, but there also is a positive side, and I think sometimes administrators don't recognize the positive that comes with what they see as the real challenges of union. So I think that's a point that I always when I talk to administrators, I try to get them to consider that unions don't come into wreck a workplace. Workers don't bring in a union to wreak havoc and make a hospital or a clinic work less well. They want to have a greater voice in how care is delivered. Administrators have a tough time with that, because they've largely been taught that they're in charge. They're the ones that make decisions, but by giving up a little bit of that control, there really can be great benefits. 

Scott Nelson  21:16  
Along the lines of the positives, on the flip side of that I was thinking misconceptions, misperceptions, and one of the things that comes to mind are those increased expenses. Are there other misperceptions or misconceptions when we start thinking about labor and employment relations and unions? You talk about coming in and wreaking havoc over an operating model, an organization, things like that. Yes, there are changes, but are there things that people may think about that aren't really there? 

Dr. Paul Clark  21:44  
I think there are. I think the major question or issue that administrators wrestle with is control. They feel that if a union comes in, that union is going to reduce the what in the absence of a union, is basically total control over the workplace without a union, it's true that administrators make all the decisions, but I would challenge administrators to consider that maybe that's not in the best interests of an organization where a small group of people get to make all the decisions unilaterally, without anybody being able to question or challenge. Here's one area that I think there's misconceptions about, and that involves discipline in the absence of a union an employer. Well, in this country, our labor law basically creates an employment at will situation where an employer has the right to hire, discipline and fire an employee, as we say in labor relations, for a good reason, a bad reason, or no reason at all. And so when you have employers having total power about disciplining people you might have favoritism that creeps into the system. You might have bias that creeps into the system. You may have people who are treated unfairly for whatever reasons. Employers will say, if we get a union, we're not going to be able to discipline anybody. We're not going to be able to get rid of an employee if they're a bad employee. That's absolutely not the case. The case is that if they have a union which will come in and negotiate something called a just cause clause, which means an employer now has to have just cause for disciplining or firing an employee, and they'll negotiate a grievance procedure where employees and the employer will meet and discuss discipline and try to resolve it, and if it's not resolved, it goes to a neutral third party to decide workers in a case where they have just cause, in a grievance procedure where they have due process, feel much better about their work environment because they they feel it brings some fairness into the workplace. So again, when employers say, I can't discipline, I can't fire anybody, that's not the case. The case becomes, if I discipline somebody or if I fire someone, I have to be able to justify that action. I have to be able to prove that what I'm doing meets the definition of Just Cause, that it's fair. And I think having a fair workplace, or a workplace where employees perceive that there's some fairness in the discipline system creates greater job satisfaction, probably reduces turnover. Now it means that employers, when they do take action, they're going to have to investigate more fully the circumstances of a of an incident or the record of a person, but if they can prove that a person has engaged in punishable behavior, if they've broken the rules, if they're not coming to work, if they're not doing their job as well as they can, they can discipline people. They just be need to be able to show the evidence that they've investigated it, they've considered it thoughtfully, and they've come to the decision that this discipline is required. So I think that's one area where there's a great deal of misunderstanding, particularly on the part of employers who think that once you get a union, everybody just it's a madhouse, and everybody just can do what they want, and they lose control of the workplace. What it really does is it brings in a fair system of discipline, and that has very significant benefits that I'd suggest that they they consider. 

Scott Nelson  26:04  
Earlier you mentioned the word bargaining. I want to transition into an area that is specific to union organizations, that's collective bargaining, and discuss a little bit about collective bargaining's role in health care labor relations. How has collective bargaining changed health care labor relations over the past few decades? 

Dr. Paul Clark  26:25  
I think it's important to understand that health care unions have really only appeared on the scene in maybe the last 30 or 40 years, and gradually, more and more hospitals, medical centers, clinics, health care facilities, have been organized. It's not a majority by any means. Union density, the percentage of the workforce in health care that's organized might be in the area of 18%. I believe nurses are a little higher, at 20 or 22% of nurses in this country are organized. But I think what's important to recognize is this trend has been going up, and it's going to continue to go up. If you're a non union health care, hospital or facility and you haven't had a union organizing drive, there's a good chance that you will in the next five or 10 or 10 years, because health care unions have a lot of momentum in this country, they are aggressively trying to organize non union facilities because non union workers want to have the protection of a union. When unions do win an organizing drive, what they win is the right to engage in collective bargaining with the employer if employees in a hospital vote in a union. Now that hospital's management has an obligation to sit down and negotiate with the union over wages benefits and working conditions. Those wages benefits and working conditions before the Union were made unilaterally by management. Now what our law says is you have to negotiate as a manager, as management with the union, there's a lot of fear on the part of management about having to bargain and whatever, but the legal obligation to bargain simply means you need to sit down and exchange proposals and try to reach an agreement. It does not compel management to agree to anything in specific. Management still has to decide, or gets to decide, what its positions will be in bargaining that decision making isn't taken away from them by the government, where they're told what to do, but they do have to come to an agreement with the union so both sides will make demands. Bargaining will happen over often, a several month period where a lot of issues will be discussed, and the parties slowly whittle those issues down. They agree to some keep talking about others and eventually come to an agreement. If they don't come to agreement, an agreement, however, then unions do have the right to strike. There's a special provision in the law that says that when unions go out on strike, or before they go out on strike, they have to give a health care facility 10 days notice. That's so a hospital can make alternative arrangements for their patients, move them somewhere else, or hire other staff to take care of their patients. We do see union strikes in health care in we've seen them in some of the largest medical systems, eventually, the sides work out their differences, and life goes on. But certainly, a strike is a pretty traumatic thing, and that's part of the collective bargaining process that doesn't exist when unions aren't present in a workplace. But the statistics on strikes are that strikes are really pretty rare. Unions don't strike every time they renegotiate a contract. Overall in this country, about 98% of the times that unions and employers sit down and negotiate a contract, they come to an agreement without a strike, but what you hear about in the newspapers are when there is a strike, so people think they're more common than they are from the perspective of management, where previously they got to make all the decisions collective bargaining is, is not an improvement for them. They now have to share that decision making through bargaining. But there are positive sides to collective bargaining, because management is going to learn in the process of bargaining what its employees highest priorities are. Because the union is made up of the of its employees, they talk amongst themselves. They decide what they want to try to achieve, in bargaining, what their demands are going to be, and this is very useful to employers to find out what the highest priority desires of their employees are, and that's why you generally see higher satisfaction levels and often lower turnover where you have unions, because if you think about it from a employee's point of view, wouldn't you rather work in a workplace where you get to have some input, some voice into what your wages, benefits and working conditions will be and where you'll have some protections if you're brought up on discipline charges, that there'll be due process, that there'll be fairness. So again, employers tend to discount these things, thinking that giving up any control at all is the end of the world. When unions come in employers often find that life goes on. The facilities continue to operate, and maybe there are some even positive things that come out of their workers having a greater voice in the workplace. 

Scott Nelson  32:38  
What are risks associated with contract negotiations or the collective bargaining process in a highly regulated environment such as health care. 

Dr. Paul Clark  32:47  
Well, again, as I suggested, if you don't have a union, the likelihood of a strike is virtually zero. A lot of employers don't understand that workers, even where there isn't a union, have the right to go on strike. It's called collective action, and it's protected by the law. But without a union, without the structure of a union, that rarely happens. So you do get you get a union comes into your workplace. Now, the possibility of strike becomes a something that could happen. I would think that most hospital managers administrators would see that as a risk that they didn't face before. But again, I think they have to understand that number one strikes are really pretty rare. Unions don't want to go out on strike. Workers don't want to go out on strike. Who wants to give up income, who wants all the conflict and stress that comes with a strike? Unions only strike when they really feel that management isn't listening to them, where management isn't willing to meet them halfway. But strikes are a possibility, and that's that's something that I think most managers would see as a risk, although it's it's a very low risk. I'd also say that even when there are strikes, strikes, on average, last a few days. I could explain in more detail why that is, but basically, when you have a strike, it's because the two sides have misread each other. Maybe the union has warned the employer that it if it doesn't improve its its its offer, it'll go out on strike, and management doesn't believe them, and so when push comes to shove, the union has to go on strike to make management understand that they're serious. Once management understands that, then they quickly come to an agreement. We see very, very few strikes in health care that last more than a few days or a few weeks. 

Scott Nelson  34:53  
You mentioned that strikes aren't necessarily prevalent and the number has been low. Is that increasing? Is it increasing from a low number to a slightly higher low number? Is it growing? And the reason I ask last year 2023 there were some strikes that were reported, and Kaiser Permanente had a strike that had the most health care workers in US health care history go on strike. So are they becoming more prevalent these days, whether or not there's still a low number, is there that potential, that it's increasing in any way? 

Dr. Paul Clark  35:25  
We also saw in the last year or two, some physician strikes, which is something that you wouldn't have seen in prior decades. But if you look at strikes on a macro level, we have seen an increase in strikes in the US economy. In the last four or five years. We saw a big auto strike last year, we saw UPS narrowly avoid a strike. The number of strikes are up, and I can tell you specifically why that is. First of all, it has a lot to do with the labor market. We've had a tight labor market in this country. Traditionally, workers are reluctant to go out on strike, in part because they can be replaced. If you walk away from your job and go out on strike, an employer has the legal right to give your job to someone else. Now, that's often hard to do in the context, let's say, of General Motors or Ford, but it's sometimes realistic with an employer of 50 or 100. In health care I don't know if you can replace an entire workforce of nurses very easily. You can hire temporary nurses, but that's very expensive. But in any case, when workers go out on strike, they risk their job, and they're often reluctant to do that if there's high unemployment, because there's people out there who could take their job. Most employers cannot fill jobs they have. So that emboldens workers, because they feel pretty certain that if they go out on strike, an employer isn't going to be able to find people to replace them. So the tight labor market, which is pretty unusual, has given unions a real advantage in bargaining. Second factor is we've had a presidential administration, the Biden administration, that is very, very strongly supportive of unions. And so when you have a president who says, I want to be the most pro union president in American history, that gives workers confidence that the government isn't going to come down on them like a ton of bricks if they go out on strike. A third factor is that surveys that are done every year and have been done every year for the last 80 or 90 years show public support for unions is at an all time high. So when unions go out on strike, they have the support of their communities. And the last factor is that you have a new generation of workers, the youngest strata of our workforce, Gen Z, they seem to have a different attitude about work. They have higher expectations of what they want to get out of work, and you're seeing a lot of union activity, a lot of union organizing, and even some strikes that largely involve Gen Z, like the Starbucks workers organizing campaign and this and the small duration strikes by those young workers. So there's a macro there are reasons at a macro level why strikes are up, and I think many of those same factors apply to health care. In addition, I think the challenges that health care workers have been facing in recent years, going through the Covid period, burnout of health care workers, I think a lot of health care workers are really just frustrated and sort of at the end of their ropes, and that contributes, I think, to a greater likelihood of those workers going out on strike. But we do see strikes going up, both nationally and in health care. There's not a tremendous strike, but conditions have really been as good as they've gotten in several decades for workers to go on strike, I don't think that's going to last, particularly more than several years, more or even less, when we'll sort of come back into more of a balance, but that's why it's happening. 

Scott Nelson  39:43  
Previously, you mentioned control, and we've talked you and I have talked about control before in this space, in this area, what's the role of leadership in managing labor relations, whether or not it's with this employees or with a union? How should health care leaders approach that relationship and approach collective bargaining negotiations to ensure both the organization's and the employee's needs are met?

Dr. Paul Clark  40:05  
As I've suggested before, I think health care administrators, managers, they live in great fear of the possibility of their workers trying to unionize, because they feel that then their role will be diminished. Their level of control will be diminished. But the single greatest factor, the single greatest reason why workers have been increasingly organizing unions in health care as well as other industries, is because they want a voice in the workplace. It's not really normal human behavior to enjoy being in a situation where you are totally powerless, where somebody else has all the power and can make all the decisions about this part of your life, this very important part of your life, your work life, if health care employers were to give their employees a greater voice in the workplace, if they were to provide opportunities for them to let management know problems that they see, solutions that they've come up with, that they think can make things better, if they really give workers, in a legitimate and authentic way, a greater voice in the workplace, then they would immediately diminish the desire to form a union. The problem is this issue of control. I've talked with, talked with a health care executive once who had just won a union organizing drive. That is, he had defeated the union, and I said to him, you know, you're going to have another union organizing drive in five years if you don't change your ways. And he said, What do you mean change your ways? I said, Well, workers are telling you in your workplace that they want a voice, that they want some control over their work life. You can give that to them now without a union, you can create structures for better communications, give them greater latitude to make decisions. If you do that, you might not have another Union at your door in five years. And he said to me, Hey, we can do that, ou know, we can do this. And I'd listen carefully to him, and I said, No, no, you don't get it. I'm not saying you've got to pretend to give your workers a greater voice while you retain total control. That won't work. You actually have to loosen up the grip you have on everything that happens here and trust employees, listen to them, take their advice. You really have to give up a little bit of control, or else nothing really changes in the from the perspective of an employee. So I think that's if you focus in on the single biggest reason why health care workers organize, it's because they want a voice in the workplace, and the employer is not willing to take the chance of giving up even the smallest amount of control, because they are taught that you're the administrator, you're the leadership, you make the decisions, whereas I think a smart administrator realizes it's sort of like a Chinese finger puzzle, you know, where you've got the bamboo on both fingers, and the harder you pull, the tighter it gets. If you loosen up a little bit, the thing slips right off. If administrators were willing to authentically give workers a little more say, a little more control of their work lives, in health care you've got the most committed workers possible to the work they're doing. They're going to react in a way that's positive. They can make your workplace better, and they'll be happier, and you as an administrator will benefit from the great ideas they have for the lower turnover from the greatest, greater job satisfaction. So it is all about control, in my view. 

Scott Nelson  44:31  
So to that point are the labor management committees and the labor management teams that you'd mentioned earlier, and the structures and the voice and decisions that you had just now talked about, are those the most effective strategies for managing labor relations and your relationships with employees to mitigate workforce risk and to foster better communication between management and unions and your employees? And do you have examples of health care organizations that even today or recent history that have successfully managed labor relations with unions to reduce risk?

Dr. Paul Clark  45:06  
I have both studied and worked with a number of health care facilities that have entered into what we call partnership with their union, or unions. There aren't that many in the country. I don't want to give the impression that there are. There's a very small number of these, although Kaiser Permanente, which I believe is the largest or one of the largest health care providers in the country, has a partnership that is tremendously extensive. It goes from it involves every kind of employee in in that health care system. It's been around for decades. It's very highly structured and well thought out. It doesn't work like magic, but it has shown that collaboration on a large scale can work. However, that's the only large scale health care provider in the country that does it that way. There are other smaller hospitals and smaller medical centers I've worked with, and we do see really, really positive results from that, because workers see their role as not just doing what they're told, but always looking at how they can make the workplace better. And they know that if they see something that can be improved on, there are mechanisms, these meetings I mentioned, where they might meet with management and several union representatives in a department or a floor or a section of the hospital each month to talk about what's going right, what isn't what ideas do people have, and then there's a mechanism where they work together as equals to try to decide whether to implement things, and then they measure them afterwards to see if they've had positive results. Those kind of things. There's example after example where hospitals have solved problems. I remember one had to do with scheduling of surgical suites that it wasn't being done efficiently and was sort of haphazard, and the management decided to ask the nurses who scheduled the surgical suites if they could come up with a better system. They came up with a better system that made more efficient use of those suites and brought in additional revenue. Now, the difference between those situations and most health care facilities is at some point, management has made what probably was a difficult decision, to give up some of their control and to view the union not as an adversary. And again, when you use the term union, you're just really talking about a collective of employees. You're talking about your employees. In these situations, managers have decided to trust their employees, to share power and authority in in certain areas with them, to see them as partners and allies and collaborators instead of as the enemy. That's a big step for most administrators, and it's why this isn't something that we commonly see, but in those places where administrators have done that, they've often seen really impressive results that they wouldn't have got any other way. And I believe that health care, there is elements of collaboration in the auto industry on how you make cars, there's collaboration in some of the airlines, where workers have a bigger voice. But health care is, in my view, the most optimal industry for this, because management, the administration and the workers who deliver care want the same thing. They both are in their work to try to provide the best health care service they can, and so they aren't adversaries. They aren't trying to split up the profits, and each get a bigger share. They have a common interest and a common goal, and both of them bring important skills and contributions to that. I wouldn't suggest asking nurses to create a financial system for the hospital. They're not financial experts, but when it comes to how you deliver care on the workplace, how you even how you lay out your hospital, how you place your equipment, how you structure your shifts, how you decide what supplies to buy, nurses have tremendous insight that the finance people don't have in that regard. So we've seen it work very successfully in some places. I would add that while it's very uncommon in the United States, it's much more common in in virtually every other part of the world. In Europe, most European health care systems have a partnership with their union. They're virtually all unionized, and they work in partnership together, and they make decisions jointly about almost everything. It's not perfect. There are problems people being people, but there's a lot of evidence that this, you could argue, is the optimal way to organize a health care organization, and in a lot of parts of the world, that's the way they do it, for the most part. But here, here, we don't, I think the way that this could be structured is a little bit at a time, just creating what we call unit based teams in floors or departments of a hospital, where you ask workers what their views are, what their ideas are, and then you actually let them try to implement them. I mean that can be done step by step in a small way that yields small results, and that builds trust so that you can build even bigger collaborations. 

Scott Nelson  51:26  
What trends are emerging in health care labor relations, particularly regarding union activity and workforce management, you mentioned earlier, physicians have been organizing a little bit more recently, that, which is a big change. Last year, there was reporting about residency and fellowship post med school training programs at various places in the US that had wanted to organize. How does the future of unions in health care look, especially with the rise of technology and telemedicine, and how do you see the role of unions in collective bargaining involved in health care over the next five to 10 years? 

Dr. Paul Clark  52:00  
I think you're going to continue to see organizing, active organizing of nurses, of support staff, of techs, that the momentum has been building and building over the last couple of decades. And I think that's going to continue. We see hospitals in the most anti union parts of the country, in Texas, in Oklahoma, in Florida, increasing number of hospitals are being organized. So you're going to see that trend continue. One of the most interesting trends is in the organizing of interns, residents, and even now, in the last couple of years, of physicians, unions of interns and residents have been around in mostly major cities in New York and LA and Chicago, because interns and residents are basically employees, right? They don't have much power. They're at the low end of the food chain in terms of they're in their period of training, but they still are employees of the hospital. Sometimes they really get the short end of the stick because they have no power. So you've seen them organize over the last 10 or 20 years, and you see more of that going on now. But what's even more interesting is physicians, again, I don't keep in touch with the real detailed things that are going on in health care, but I do understand that increasingly, health care or physicians practices, are being bought up by companies who invest by buying up these practices, and I understand that's happening fairly rapidly, and that physicians who in the past, own their own practices and were essentially self employed. They didn't work for anybody. They had their own practices. They made all their own decisions about how to run those practices. Now, when they're bought up, they're becoming employees, employees of the company that runs these corporatized practices, or maybe they go to work for a hospital. But what you're seeing is once those physicians transition from private practice to being employees, they immediately feel a need to have a greater voice in that situation. They're used to having a voice and having an input into decisions in their own practices, and now when they're treated like employees who are who are supposed to just take orders, shut up and do what you're told, they really push back, in part because it's such a change in their work lies, but also in large part because they think decisions are being made that aren't in the best interest of patients. And so how do physicians, just like any other kind of worker, get a greater voice in their workplace where they're employed? They organize a union. In Minnesota, there was a strike of dozens and dozens of physicians this year, the first large strike of physicians that I'd heard about, and they were bargaining over issues of patient care and how much say physicians would have about how to treat patients. And of course, just like with nurses and others, who is best positioned to make these decisions about how to provide patient care? Is it the administrators, the financial people, or is it us? The people are trained to deliver care and on the front lines, putting hands on patients, and so if this trend, and I assume it's going to continue, of of private capital coming in and buying up physicians practices, and physicians becoming employees, you are absolutely going to see physicians, I have a number of physicians in my family and in the past, if you talk to them about organizing a union, they would say it's the last thing in the world you're going to see, but once their power to make decisions autonomously were taken is taken away, then you're going to see physicians get over that stigma that unions are just for blue collar workers and not for educated, trained professionals like us, because they're just like every other worker, they want a greater voice in their workplace. They want to be recognized as having the experience and knowledge to make these medical decisions, and if they have to form a union to give them the power to get that ability, I think you're going to see that number continue to rise as well. 

Scott Nelson  57:02  
What are you positive and optimistic about in the future of health care related to labor relations or health care in general? 

Dr. Paul Clark  57:08  
Health care faces a tremendous amount of challenges. There's no question about that. They are these challenges are deep and profound, and I certainly don't have the answers to how to steer our health care system in the best possible direction, but I see union organizing as a positive and not a negative, in terms of helping us to configure our health care system to make our system work, because I think it's a strength when the people decide to dedicate their lives and choose careers, to use the knowledge and experience they have to help people with their health issues, to practice medicine, to be a nurse at the bedside. When these people have a greater say, rather than a lesser say, in how the system operates I think that's a step forward. I think that's a positive thing. And so I know that you know many health care administrators and managers just stay up at night, they can't sleep, worrying about the possibility of a union. From my perspective, that's not something to be feared, something to be fought, because giving these dedicated health care practitioners a greater role in how the system operates, in the decisions about how you provide patient care, I think those are the people who should be making those decisions, and I think that's a positive thing. So that's the one area that I think is positive and can contribute to us having a better and better health care system. It's a radical notion, but I think it really makes sense. 

Scott Nelson  59:05  
That's a great point to conclude our conversation. Dr. Clark, thank you so much for your time and your perspectives and experience today. I really appreciate it. 

Dr. Paul Clark  59:13  
Glad to help. Scott.

Scott Nelson  59:18  
Thank you for listening to The Risky Health Care Business Podcast. You can listen to all episodes from the resource center page of the SpringParker website, springparker.com, or click the Listen link in the show notes to listen and subscribe for free on your platform of choice. And remember, accelerating health care performance is achieved through creativity, not just productivity.