Healthcare Insights: 10 Years of Labor Management Success At Bellevue Hospital

In many articles in Healthcare Insights, I write about systems change and innovations in collective bargaining designed to enhance the voice of frontline healthcare workers, the essential factor in achieving healthcare improvement.  In this month’s article I will illustrate how such innovations provide opportunity for in depth dialogue between frontline physicians and their teams with executive leadership to solve real problems which stand in the way of improving quality patient care and reducing physician demoralization and burnout.

It is an honor to know the executive and frontline leadership, and to be able to write about these dynamics inside the nation’s oldest public hospital, Bellevue (today known as New York City Health+Hospitals/Bellevue).  Founded in 1736, "Bellevue turns no one away. I mean, that has always been the mantra of Bellevue Hospital. And they come to Bellevue knowing that they will be treated, and they will be welcomed. And it's because Bellevue has always taken in the worst of the worst cases that it's drawn the best of the best in medicine. (Bellevue, Three Centuries of Medicine and Mayhem at America’s Most Storied Hospital, David Oshinsky, Vintage, 2017).  

For this article I interviewed Drs. Nathan Link and Caralee Caplan-Shaw.  

Nathan Link MD, MPH is Associate Chief Medical Officer for NYC Health and Hospitals/Bellevue since 2025. Dr. Link served as Chief of the Bellevue Medical Clinics from 1986 to 2001, and Chief of the Medicine Service from 2001 to 2012.  From 2012 to 2025, Dr. Link served as Bellevue’s Chief Medical Officer. Dr. Link’s responsibilities have included oversight of quality and safety across the continuum of care, co-executive sponsorship of lean-based value streams in patient flow and patient experience, several stints per year as inpatient ward attending (hospitalist), and he has conducted   many inpatient and outpatient teaching conferences for internal medicine house staff and medical students.  

He was Co-Chief Editor of the “Bellevue Guide to Outpatient Medicine,” winner of the American Medical Writers Association award as Book of the Year for Physicians in 2001.  His research and educational interests include evidence-based medicine, patient safety, and the use of information systems to promote effective clinical care.    

Dr. Caralee Caplan-Shaw is an Associate Professor in the Division of Pulmonary, Critical Care and Sleep Medicine at NYU Langone Medical Center / NYU Grossman School of Medicine. In 2007, she joined the medical staff of Bellevue Hospital as a pulmonologist in the Asthma and Chest clinics, the World Trade Center Environmental Health Center, and the inpatient pulmonary service. She has served as Director of the Bellevue Chest Service and the Medical Director of the Bellevue Hospital Tuberculosis Program since 2017. Having joined the Bellevue Facility Based Collaboration Council (FBCC) at its inception in 2016, she is proud to work with colleagues at Bellevue and across NYC Health + Hospitals to improve patient experience, physician engagement, and quality of care.

Dr. Link (back row, 3rd from right, Dr. Caplan-Shaw, far right) serve as the co-chairs of the Bellevue Facility Based Collaboration Council (FBCC).  The FBCC is a unique example of the type of forum developed for innovation and improvement that evolved through collective bargaining between Doctors Council and the Health System over a decade ago.  Ten years later, FBCCs function at all 22 major facilities that make up the largest public health system in the nation, NYC Health+Hospitals, which serves 1.4 million patients annually.

The experience of the Bellevue FBCC highlights the challenges that most, if not all collaborative labor-management experiments face.  Leadership change, staffing shortages, learning to shift away from grievance-driven dialogue to a problem-solving dialogue, and confronting the lack of time during the workday for anything other than work itself were among the challenges that all of the FBCCs faced, including at Bellevue.  It is very common that these challenges often prevent collaborative efforts to get underway, and often stymie success once undertaken.

As Dr. Caplan-Shaw told me, “when the Collaboration Councils were first announced, many of the more senior physicians exuded an attitude that “problems at Bellevue would never be solved.” 

The agreement to establish Collaboration Councils was reached as part of collective bargaining for a successor contract between Doctors Council and the health system.  Those negotiations were very difficult.  The DeBlasio administration had just taken office with a pledge to conclude bargaining that had failed to resolve important economic issues from the previous administration.  While there was a hopeful atmosphere, negotiations were very complex as the parties tried to achieve both fair settlements for deferred wage increases, as well as trying to close the gap in salaries between public and private sector physicians. This negotiation took place in an atmosphere of austerity and financial stress with forecasts of a $1 billion deficit. 

Ultimately, the economic settlements were reached.  

Importantly, even in this difficult atmosphere, Doctors Council pushed very hard to achieve a formal agreement to include the voice of frontline physicians in decision-making to enhance patient care.  As stated in its white paper on the essentiality of frontline doctors’ voice:

“Responding to the enormous challenges we face of increasing demand and shrinking revenues, Doctors Council SEIU members are committed to become an active partner with management, our patients, community members and other frontline staff to continue the transition of the public hospital delivery system towards fully integrated care models that improve quality for the communities of New York. We are deeply committed to ensuring the viability of a strong safety-net hospital system to provide essential services for the City’s patients. Frontline doctors see our union as a vehicle for the establishment of doctor-based participation in decision-making that will directly impact the improvement trajectory for quality, safety, patient experience and cost reduction. This is the path for high doctor engagement. The path that must be followed is one of empowerment of doctor.”

Bargaining concluded with a formal agreement to establish Collaboration Councils in all NYC Health-Hospitals.  The Agreement was not overly prescriptive about how the Councils could function.  The core goals and structure were established in the collective bargaining agreement:

“The members of the System-Wide Committee and the Facility-Based Committees will engage in a dialogue process, utilizing interest-based problem-solving approaches. This requires deep listening and sharing of information. The members of the committees approach the conversation with a sense of curiosity and openness rather than staking positions.  Learning about the underlying interests is critical. These committees are, among other aspects, a forum for sharing of information and problem solving. Development for the team members will be available early in the process so that the parties can jointly learn these skills.

Decisions of the committees will be derived at by using consensus where each of the parties feel that they have been “heard” and that they can “live with” the decision even if it isn’t their first choice.  If, however, either party can demonstrate that a vital interest may be impacted by the decision, then an alternative to consensus will be used. 

For the parties to have full and open dialogue, there needs to be a safe environment. The parties are committed to sharing information necessary to accomplish the objectives of the committees. The parties will share information to the extent permitted without violating any statutory, regulatory, or common law privacy, privilege, non-disclosure rule, or confidentiality;

Each of the parties has a unique role and responsibility in this endeavor.  Committee members will recognize the similarities and differences and while not always agreeing, will work to respect and understand the differences; 

The work of the committees shall be informed by appropriate evidence and available data, and the committees shall make evidence-based decisions using available data and metrics; 

HHC will make every effort to educate and fully brief members of the committees about current initiatives, business plans, and the business environment in which it operates.” (from Memorandum of Agreement between Doctors Council and NYC Health+Hospitals, 2015)  

With the foregoing as background, I asked Drs. Link and Caplan-Shaw what some of the reactions to the Agreement were as leaders in the facilities became aware of the Collaboration Councils for the first time. Caplan-Shaw was very hopeful, unlike some of the reactions from others who were very skeptical.  She told me: “I saw the Collaboration Councils as a way to get away from a “top-down” approach to how things worked and to acquire the tools I needed to make a difference, and to have access to hospital leaders who would support projects moving forward.”

Dr. Link told me, “Initially we weren’t clear if the Council was only for Doctors Council members, and initially participation was very small.  There was a general fear that nothing would come of the Councils even though a lot of effort would have to be put into it.”

These reflections from the leaders of the Council are very common in my experience when agreements are made at a system leadership level but must be executed by executives and frontline workers at the facility and unit levels of health systems.  What evolved at Bellevue is a wonderful example of how facility leadership and staff at the frontline adapt, learn, and execute to make the opportunity for Collaboration successful.  Here is a summary of their story.

Caplan-Shaw: “We faced barriers pre- and post-COVID. Such barriers, pre-COVID included physician time/availability due to scheduled service time/clinics (both for meetings and leading QI projects), limited knowledge of Quality Improvement (QI) methodology. Early on, the bulk of the work fell on physician members, and there appeared to be limited resources for QI support through the FBCC.

Often the biggest barrier to improvement was not knowing which individuals in the organization needed to get into a room together to do the problem-solving. This is where support of hospital leadership was transformative. With hospital leadership support I was able to work on a project that led to the creation of the “TB Rule Out Panel” and the one that led to improvements in access to timely PET scans. 

The goal of the TB improvement project was to achieve more accurate and rapid TB diagnosis which will improve quality, outcomes, safety, and the care experience by reducing TB transmission and allowing patients return to home and work more quickly. The new process provides rapid access to the highest quality, evidence-based evaluation available. Because the GeneXpert ($50/test) is already being performed regularly at Bellevue, even if the total number of tests increase slightly, this cost would be offset by the much greater savings associated with decreased length of stay in airborne isolation.

Result: Time to complete a TB evaluation decreased from 54 hours to 24 hours, and time in airborne isolation decreased from 114 hours to 71 hours. 

These were two projects that involved representatives from multiple departments brainstorming who worked together between meetings.  They enhanced patient satisfaction and improved quality.  It was extremely energizing and a boost to our satisfaction as clinicians.”

She continued, “Post-COVID, we got Physicians Assistants (PAs) involved when one of the members suggested a project on "moral injury," and we held focus groups to explore experiences during the pandemic. A robust PA Council grew out of that project.

We also got into a highly effective “just fix it” mode, starting every meeting with "hot topics," a time for members to bring up problems that seemed like low-hanging fruit for improvement.  This effort evolved such that hospital leadership really held managers of individual departments accountable for ensuring their processes were having the desired outcomes. 

The "Just fix it" concept--the notion that not every problem was an extensive QI project truly advanced the success of our FBCC.  Some really thorny issues for front-line staff were quick fixes if hospital leadership made it a priority:

• We pulled in people from different departments - radiology, finance, phlebotomy- to solve systemic issues.
•  We held huddles between meetings to plan agendas. 
• We set a clear expectation of progress by the next meeting.  
• And we emphasized that the notion that front-line physicians could raise important issues but were not always the ones who needed to do the solving.  This resonated deeply with our executive counterparts.

I can summarize our success this way: we solved real problems and solved them quickly, solved quickly through multidisciplinary conversation, Our leadership brings the right people together. And stands by the commitment of not taking "no" for an answer. Success has a lot to do with simply maintaining high standards and the attitude that change is not only possible but essential.”

Dr. Link, the executive co-lead of the FBCC, shared his experiences which confirm Dr. Caplan-Shaw’s view of success:  

“We learned early on that having many successful QI projects was difficult to maintain. Dr. Caplan-Shaw was deeply committed to the projects she developed as described by her and we supported her efforts.  During this early period of the Council our attendance was fairly small and we suffered through some frustration because of that.  The focus on QI projects seemed a stretch for most given the focus on patient care.

A major breakthrough occurred when we heard about problems faced by our large contingent of Advanced Practice Professionals (APPS, including Nurse Practitioners and Physicians Assistants).  As they started attending, I encouraged our facility CEO, Chief Finance Officer, Chief Nursing Officer and other leaders to attend the Council meetings.  We learned that gaps in care impacted many others, including attending physicians, our interns and residents, and nursing staff.

We in the C-Suite learned about delays in lab results going to doctors and nurses. Such delays of course led to delays in care plans which was a deep source concern among our staff. As a result, we learned that there were many vacant positions among phlebotomists and authorized the rapid hiring and deployment to fill those gaps.  To be honest, we would not have known about this problem without this forum.  My conclusion was that “executives needed to feel the heat” and solve real problems brought to our attention.

This forum gave us the opportunity to solve problems in patient transport and radiology.  When we understood gaps in staffing we were able to intervene.

With these experiences in mind, I can clearly define success for our FBCC: “frontline staff can come to our Council with the confidence that problems will be solved, and improvements will be made”. 

He concluded that “all participants in the Council know that it is a safe space for dialogue and discussion and problem-solving.  We believe in just culture and live by the tenets of openness and listening.”

Dr. Link shared that the Council has grown in both participation and effectiveness organically as participants experience improved outcomes from problems brought to the Council.

Doctors Council and New York City Health+Hospitals will meet on March 18, 2026 to celebrate 10 years of experience of the Collaboration Councils across the system, looking ahead to the next decade of evolution and further success.

We at the Scheinman Institute are proud to have supported the development of the Collaboration Councils since their inception.

John August is the Scheinman Institute’s Director of Healthcare and Partner Programs. His expertise in healthcare and labor relations spans 40 years. John previously served as the Executive Director of the Coalition of Kaiser Permanente Unions from April 2006 until July 2013. With revenues of 88 billion dollars and over 300,000 employees, Kaiser is one of the largest healthcare plans in the US. While serving as Executive Director of the Coalition, John was the co-chair of the Labor-Management Partnership at Kaiser Permanente, the largest, most complex, and most successful labor-management partnership in U.S. history. He also led the Coalition as chief negotiator in three successful rounds of National Bargaining in 2008, 2010, and 2012 on behalf of 100,000 members of the Coalition.