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Biggest success: Employee-generated project
At small rural hospitals, obtaining buy-in for a continuous quality improvement (CQI) project can be a daunting chore, especially if the hospital does not have the money for CQI education programs, employee bonuses, or incentive programs. But enthusiastic middle-level employees who target problems and form teams to solve them can boost the success of CQI projects.
Such is the case at the 20-acute bed Humboldt General Hospital in Winnemucca, NV, which has 125 employees and no formal CQI program, but where supervisors and middle managers have spearheaded successful CQI teams.
The hospital holds quarterly CQI meetings attended by the medical director and about 80% of supervisors, a sign that Humboldt's supervisors are interested in CQI, says Erika Gratwohl, RN, Humboldt's quality services director.
When the first CQI team was formed two years ago, it appeared that grass-root employees who had an immediate impact upon the hospital's processes would make the best team members, Gratwohl says. But she and Byron Quinton, MHA, hospital administrator, soon found that generating grass-root enthusiasm was difficult.
For example, Humboldt, a nonprofit hospital, offers no employee bonuses for superior work, Gratwohl says. Because of this, Gratwohl and Quinton must deal with a mindset among employees that doing the minimum job ensures a raise. That mindset does not provide much incentive to participate in CQI projects, she says.
"I've worked at hospitals where just to keep my job I've had to go above and beyond the call of duty. Being on a [CQI] team helped you do better on an evaluation. But here [at Humboldt], it wouldn't make a difference between a raise and no raise," Gratwohl says.
"You want people at the grass-roots level, but most of our eager beavers here are the supervisors," Gratwohl says.
The first CQI team was formed because some patients were forgotten in the system during admission or outpatient testing, Gratwohl recalls.
For example, patients having multiple tests sometimes lost their way from one test site to another. If a patient came in for a test during a change of shift, the departing employee sometimes failed to tell the employee coming on duty that the patient was waiting for tests, which meant the patient sat ignored, she says.
In one instance, a patient's surgery was delayed for a half hour because of a communication breakdown between the nurse's station and surgery, Gratwohl recalls.
The problem was obvious, yet Gratwohl had trouble recruiting volunteers among grass-roots employees, such as nurses, for the CQI team. The team was made up of an admitting clerk, a surgery supervisor, a unit secretary, a licensed practical nurse from medical/surgery, and a nurse from the emergency department, Gratwohl notes. They soon began dropping out for lack of enthusiasm.
"They didn't understand their mission," notes Quinton. "It wasn't well-defined in the beginning, and there was confusion. Some people got angry."
The second team was formed in October 1995 after a needle, which had been dropped in the laundry, stuck an employee. A team composed of employees from laundry, obstetrics, purchasing, the laboratory, and Gratwohl filled garbage bags with debris found in the laundry such as needle caps, construction debris, pens, identification tags, and gauze. The bags were displayed to employees as a visual representation of the problem's severity. In addition, the laundry was monitored to prevent employees from using it for trash disposal. The team succeeded in eliminating laundry debris because employees could see the problem in the form of filled garbage bags.
"The team was good but bad," Gratwohl says of the fact that the team was made up mostly of employees at the supervisory level. "Yet the [supervisors] had more time to monitor [the laundry] because they weren't so busy with patients."
A third CQI team was formed at the end of February 1996, but this time, it was the employees' idea. They began coming to Gratwohl's office to discuss problems with surgery preadmission paperwork becoming lost in the system.
Because that CQI team was the idea of the employees, members are much more enthusiastic than members of the first two teams, who were either recruited or assigned, Gratwohl says.
"The difference I see from the first team to this team is that on this team, all the people came to me and said, 'Erika, we really have a problem,'" she explains.
Meanwhile, Gratwohl and Quinton are searching for incentives or motivational tools that will increase CQI buy-in among grass-roots employees such as housekeepers. They are trying to send the message that CQI is self-rewarding.
"My plea for help is how to make people believe in the system, that it will actually do more for them, and they will have more power in the organization," Gratwohl says.
"As the process goes on, people identify more problems that mean setting up a team and getting resolutions, rather than just accepting it as the way it's always been done," Quinton notes.
[Editor's note: For more information on Humboldt's CQI efforts, contact Erika Gratwohl or Byron Quinton at (702) 623-5222.] *