Telemetry unit moves from worst to best using redesign process

Specialty teams improve patient satisfaction, staff morale

Two years ago, a 52-bed telemetry unit at Yuma (AZ) Regional Medical Center had an unenviable record of long-standing performance: It ranked below the national benchmark in patient satisfaction as well as staff morale.

"Historically, there was always a high turnover among the staff. Morale was extremely low, and patient dissatisfaction was consistently below national norms. The dollars spent on agency nurses was phenomenal," says Karen Jensen, RN, MN, who began managing the unit in January 1997.

To make matters worse, the unit wasn’t well respected internally. "Our employee bonus program [throughout the facility] is based on patient satisfaction scores," Jensen explains. "The unit’s poor performance was holding everybody back."

Today, the unit is considered a best practice model and its practices have been implemented throughout the facility. Performance — in addition to patient and staff satisfaction — has skyrocketed as employees master leadership and decision-making skills.

We went from the worst in the hospital to one of the best," she points out. "We perform above national averages in patient satisfaction."

Patient perceptions of nursing care, comfort, and cleanliness made considerable gains.

Jensen shared with Patient-Focused Care and Satisfaction 10 best practice tips that propelled her unit to the top:

1. Staff "geographically." The unit, which is divided into four sections of 12 to 14 beds, is staffed by four six-member care teams. Each team includes: team leader, a registered nurse who partners with a second RN, one clinical associate (a certified nursing assistant with additional skills), one team associate (a position combining housekeeping, food service and transport functions), one business associate (a unit secretary on days, who turn over their patients to one RN and CA on nights. The team is supported by telemetry technicians and a resource coordinator who work with the teams to facilitate matching resources and demands. A resource coordinator, formerly the charge nurse, structures the unit’s workload. "Each team always works in the same geographic area," Jensen explains.

Each team also color codes and stores its portable equipment in a locked cabinet and has their own blood pressure monitors assigned to their geography.

This arrangement reduces equipment losses and increases productivity, she notes. "Before the redesign, frustrated staff used to stash equipment in patient rooms and it was not accounted for. They also spent a lot of time going back and forth to retrieve items. Now it’s in one central point."

As census increases, staff are "flexed into" existing teams.

2. Staff according to an objective acuity system. Previously, unit nurses used a subjective system that often created dissension. "They simply divided up patients until they arrived at a more or less equal number " Jensen says.

Central to the redesign was an acuity system that determined how many points each team should carry in its workload. Staff had input into designing the system based on their perceived workload capacity. Based on average daily census figures, four teams were created to handle 10 patients each.

The acuity system looks at whether resources needed are RNs or CAs based on patient needs and has four levels of patients with points assigned for each level. The total points determine how much work capacity exists on each team.

The resource nurse on each shift tracks each team’s acuity points and total points by posting them on a large board in the nursing station.

"With just a glance, the resource nurse can determine acuity and structure the workload accordingly."

The system also allows for a more efficient admission process, Jensen adds. "Before, each nurse took turns when the next admit came in. Now, one team may have three new admits and another may have none. It all depends on the acuity level of their current patient load as well as the acuity of the admits."

3. Promote lateral as well as horizontal teams. In addition to the "vertical" care teams, or the mix of care providers, the redesign also features horizontal teams made up of members from each specialty. For example, the business associates have their own team to discuss operational matters, as do the clinical and team associates.

4. Create a mechanism for both types of teams to communicate. The unit’s decision-making body is its Leadership Council. Members of the council include the RN leader from each of the vertical care teams as well as a representative from each horizontal specialty group.

"If you’re ushering in a new work environment that claims to promote open communication and problem solving at all levels, you must provide a means to do so," Jensen advises.

For example, instead of shouldering alone the responsibility for managing capital expenditures, Jensen turns over equipment purchases to the team.

"When the team wanted to buy cardiac chairs, I explained that we have X amount in the capital budget and showed them the vendor information. They came back to the next meeting and told me what they wanted me to order."

The team decision is not merely an empty recommendation, she adds.

5. Allow employees to learn from mistakes.

In traditional management, decisions come from the top down. In order for a redesign to be successful, however, employees need leeway to make their own decisions regarding processes — and experience the consequences.

"I don’t tell them what to do," Jensen says. "Instead, I help them identify the issues, discover the options, and encourage them to tell me what they believe the solution [should] be. Then I tell them to go do it!"

Although employees make mistakes occasionally, Jensen says, with practice, they grow more confident in the process.

6. Set clear boundaries. Instead of writing traditional disciplinary reports, Jensen has switched to a "learning contract."

"It explains what they did wrong, what they need to learn, and what both of us will do to prevent the mistake from happening again," she explains. The form includes a place for the following information:

• the mistake or error;

• manager’s expectations;

• employee’s responsibility;

• date of re-evaluation.

"[Afterwards,] we both sign it and the secretary notes the re-evaluation date on a calendar."

7. Provide leadership training for clinicians as well as the rest of the staff. "Don’t buy into the myth that if a nurse has excellent clinical skills, he or she will automatically be a good leader," warns Jensen.

To facilitate change, she relied on a process called Results Oriented Organizational Training and Support, or ROOTS.

ROOTS is the brainchild of LUMEN, a healthcare consulting company in Atlanta that teaches staff how to diagnose and solve problems and gives permission and encouragement to do so, says Terry Williams, MBA, senior consultant.

"I’d been preaching the same sermon [as the consultant]; but sometimes, an outsider is taken more seriously," Jensen says. "With both of us emphasizing leadership at all levels, we made a fundamental change in the way we identified issues as well as how we solved problems. We also learned to communicate with one another in more productive ways."

Under the old system, for example, a housekeeping or environmental service staff member had no leadership opportunities. "Now he is lead TA [team assistant]; he interviews job applicants, explaining to them what the job entails as well as his expectations. He also conducts his own [vertical] team meetings," Jensen says.

8. Resolve volatile issues from pre-design days. Even the best redesign plans will go astray if residual effects from older issues aren’t resolved, Jensen adds.

Before the redesign, some staff members were disgruntled by the way paid leave time was being manipulated by others. "There was a lot of favoritism. The leadership council developed guidelines, and now there is internal consistency. Employees are happier because the policy is followed across the board."

9. Model desired attitudes. If you truly want to promote leadership among front line employees, you can’t use the old style of dictatorship that the manager is never wrong, Jensen stresses.

"When you encourage your employees to self-actualize, you are also giving them permission to confront you," she says. "You have to be willing to admit you made a mistake and apologize. This not only models good communication skills for employees, but lets them know that mistakes are learning opportunities, not punishable offenses."


Yuma Regional Medical Center, 2400 South Ave., Yuma, AZ 85354-7170. Telephone: (520) 317-3840.

LUMEN, 1355 Terrell Mill Road, Building 1482, Suite 200, Marietta, GA 30067. Telephone: (770) 984-0606; FAX: (770) 984-0110; E-mail: