by Khari Johnson

Kaiser Permanente nurses who answer advice and triage calls say their duty of care for patients is being increasingly threatened by workplace surveillance.

Seven current and former nurses told CalMatters that those who spend more than 15 minutes on a call with a patient routinely face criticism from Kaiser management or get called into performance evaluation meetings. Call time, they said, factors into monthly performance scores they receive.

In addition to tracking call length, they said Kaiser uses software that tries to predict on a daily basis whether they’re being unproductive or failing to answer calls quickly. Artificial intelligence systems have also been used to rate their empathy and tone of voice.

Their comments come as the California Nurses Association begins negotiating a new contract with Kaiser this month with AI a likely issue. Kaiser nurses went on strike against AI for one day in March and picketed against AI last fall. The CNA is bargaining for 25,000 nurses, including 1,000 in call centers.

At the same time, California lawmakers are considering several bills regulating AI in the workplace, including one that would protect from retaliation doctors and nurses who override automated care recommendations.

Kaiser defended its use of AI, saying it deploys the technology with patient safety in mind and does not use “average handle time” to assess performance.

Kaiser Permanente is the largest private employer in California, providing healthcare services to more than 9 million people in the state and to 3 million other Americans. That means the company’s use of artificial intelligence could set important precedents for managing workers with AI. It could also have a big impact on patient care, providing an early example of how the healthcare sector balances cost-cutting automation with human presence or touch.

Raquel Alvarez Sanchez, a Kaiser Permanente advice nurse in Vallejo since 2010, said she was on a call with a patient who was suicidal last year that took more than an hour because she had to wait for police to arrive before hanging up. She tried to make the man feel cared for, even though she was cognizant that staying on the call that long would throw off her average call time for weeks and could lead to questions from management. Sanchez, a union steward, said she’s accompanied colleagues to performance evaluation meetings, where they were found to have done everything right on a call — except staying on the line for more than 15 minutes. She said she hasn’t seen nurses get fired for doing that, but she fears that continued pressure can lead nurses to quit or retire early.

“I think at some point all of the nurses have been talked to about their average handle time,” she said. “The only thing I can think of is they’re doing it for profit.”

Another nurse who spoke with CalMatters on condition of anonymity due to fear of retribution described how that surveillance affected a call with a patient last year. Initially she thought her patient, an elderly woman who just received a terminal cancer diagnosis, was suicidal, but quickly came to understand that she was in shock and really needed somebody to talk to.

The nurse wanted to take time to show compassion or comfort to the woman, who acts as a caretaker for her daughter, but she stopped herself out of fear it would hurt her monthly performance score and lead to a reprimand from her manager. She became a nurse to provide people with compassionate care, but “I had to ask myself: Am I going to get disciplined for going off script or saying more than what is necessary?”

Kaiser Permanente says its performance evaluations help improve patient outcomes. A company spokesperson said, “Kaiser Permanente does not use Average Handle Time to assess agent performance or enforce call time metrics. Any tools used in contact center settings support our quality assurance efforts and have human review and oversight.” In a statement provided to CalMatters, spokesperson Vincent Staupe added that Kaiser uses AI responsibly, with human oversight, and by “prioritizing patient safety, privacy, and equity,” but he said, “As a large organization, we do not share specific information about internal technology systems for security and operational reasons.”

Is technology putting patients at risk?

It’s not clear how patient care is affected by algorithmic management, nor is the impact of limiting the length of triage and advice calls on patients. Kaiser call center nurses can’t say for certain whether the pressures they face results in adverse outcomes for patients because their contact with patients ends after they hang up the phone. A 2024 public records request by CalMatters to the California Department of Managed Health Care found no complaints by patients against Kaiser related to call times. But nurses insist the risk to patient safety and quality of care is real.

Consumer Watchdog patient advocate Michele Ramos said many Kaiser patients begin their care on the advice line. They later complain to her, mostly about things that happen in Kaiser facilities, but “I can see now where a lot of the problems” start, given the call constraints nurses are under.

Ramos said the time pressures may fit a broader pattern at Kaiser of putting costs over quality. The health giant was hit with a record fine, $50 million, as part of a settlement over findings from the California Department of Managed Health Care that it delayed behavioral health appointments beyond statutory limits and too often moved patients into group rather than individual therapy. Kaiser also settled with the U.S. Department of Labor after investigations into its substance use and mental health services. Kaiser faced criticism in 2002 for paying bonuses to call center workers who aren’t nurses for keeping calls short, though call center nurses who spoke with CalMatters said they encountered no such practices today.

“Kaiser’s been known through the years to manage dollars over managing care, and I think this would be a contributor to that, which is only going to fail patients,” Ramos added.

Nurses said they are pressured to stay under 15 minutes even for the sorts of calls that often take more time, like diagnosing a patient with multiple symptoms, chronic illnesses, new parents in need of advice and assurance, people who desire extended health education, or people who are overwhelmed after receiving life-altering news who could use some compassion. Nurses say calls that involve interpreters often take 30 minutes or more. About four in 10 Californians speak a language other than English and half of them do not speak English well, according to a state environmental health agency.

“The amount of time that Kaiser is giving us to complete a call is sometimes not safe,” said one nurse, who asked to remain anonymous due to fear of retaliation.

“People can get hurt,” said Charlotte Capulong, who has worked in nurse call centers for 22 years and helped organize Kaiser nurses against the AI tone-of-voice tool. Capulong said nurses felt harassed by managers in meetings she attended as a union rep, even if they successfully carried out all other duties of their jobs except completing calls within 15 minutes.

“You aren’t calling Comcast. We’re dealing with life here,” she said.

Nurses are instructed to stick to a script on phone calls and give no more than two to three pieces of advice, Capulong and other nurses said, which means they may sometimes need to decide whether to withhold advice or face a performance evaluation hearing.

The nurses say artificial intelligence could make the surveillance nurses encounter on the job worse.

In summer 2024, Kaiser began testing an AI tool that attempts to assess empathy and tone in the voices of nurses and patients, according to nurses who spoke with CalMatters. In response, nurses circulated and signed a petition in favor of the right to patient privacy, more transparency, and the right to exercise their professional judgement and encouraged management to involve nurse’s input and feedback. The signature campaign used the same tag line that nurses used at protests outside San Francisco hospitals earlier that year: “Trust nurses, not AI.” The AI tests ended in November 2024, but union representatives were told that managers may bring the program back in the future.

Nurses reported feeling harassed by existing surveillance, “and that was intensified when they said we’re going to use AI to evaluate our calls and grade us,” said Sanchez.

Another nurse speaking on condition of anonymity said “AI did not understand our job and would grade us wrong all the time.”

A Kaiser spokesperson declined to respond to questions about the AI tool or answer questions about the use of AI and other automated systems in the company’s call centers and healthcare facilities, including for evaluating nurse performance or whether patients were informed about the use of AI to evaluate their empathy and tone.

Nurses also said they get little time between calls even if that call involves speaking with a patient who is suicidal, experiencing a mental health episode, or near death. In years past, nurses got around 10 minutes to finish writing notes in a patient’s chart or collect themselves after a particularly tough call. Today they say they typically get 30 seconds or less when lines are busy, although more at slow times, like late at night, or if they get a manager’s permission after a particularly challenging call. The overall pace they say, can lead to mistakes like missing important cues into a patient’s wellbeing.

CNA reps declined to talk about specific provisions they intend to seek related to AI ahead of their talks with Kaiser this summer.

How surveillance and AI shape nursing

Critics say excessive workplace monitoring can lead to lower morale as employees feel less trusted and autonomous, relegated to being no more than algorithm monitors. UC Berkeley Labor Center Technology and Work Program director Annette Bernhardt has warned that algorithmic management can turn people into fleshy robots, echoing complaints from an Amazon factory worker who CalMatters interviewed last year. A 2023 academic survey of call centers in four developed countries found that using AI for management or monitoring left workers with less time between calls and more likely to feel emotionally drained by their work. Nearly half of respondents said that AI tools made their jobs more stressful. A prior study by the same researchers, Virginia Dolleghast of Cornell University and Sean O’Brady of McMaster University found that performance monitoring leads to higher rates of emotional exhaustion.

Dolleghast, who has studied the impact of surveillance technology on call center workers for more than a decade, said what Kaiser call center nurses are experiencing is part of a broader trend: Across different industries, persistent surveillance is increasing stress levels for workers who are resolving complex, emotionally-charged problems.