Teamwork turns around troubled Arizona hospital maternity unit

Now I look forward to coming to work,’ staff say

When staff aren’t happy, nobody’s happy. And for several years at the maternal child center at Yuma (AZ) Regional Medical Center, a lot of people were dissatisfied. But the traditional top-down management was too busy fighting fires to tackle chronic problems of patient, physician, and staff dissatisfaction.

For example, from 1993 to 1997, turnover rates were running about 18% and expenditures on agency nurses ranged from $5,000 to $25,000 a month. Patient satisfaction averaged at or slightly below national benchmarks.

"The unit was one of the worst performing in the hospital," says Terry Williams, MBA, a senior consultant at LUMEN, a healthcare consulting company in Atlanta. The maternal child center, which has 23 labor-delivery-recovery-postpartum rooms and seven antepartum rooms, performs about 3,100 deliveries per year.

By March 1998, patient satisfaction rose dramatically, and the turnover rate decreased by 10%. "For the first time in this unit’s history, all the core positions were filled; we were $100,000 under budget — and there was no agency usage," says LuAnn Zieba, RN, BSN, interim manager, maternal child services.

And the unit was getting more compliments than complaints from the physicians. Moreover, all levels of staff were giving such feedback as, "Our team is really clicking, and now I look forward to coming to work," and"We have more decision-making power than ever before."

What turned this unit around in three months’ time?

An employee-driven decision model, says Zieba, who joined the unit in August 1997 after serving as staff employment coordinator during a hospitalwide re-engineering.

Yet, as Williams points out, a facilitywide initiative doesn’t guarantee implementation at every unit level. (See related story, p. 3.)

"We’ve seen time and time again that it is difficult for an organization to change behavior on the front lines to match operational changes," he says.

Hence, LUMEN created a program, Results Oriented Organizational Training and Support (ROOTS), to teach all levels of staff how to work as teams to facilitate change by diagnosing and solving problems.

Together with consultant Jon Hunt, Zieba outlined the goals to bring the redesign spirit to the unit for its 120 full-time equivalents (FTEs):

1. Shift management focus.

"We wanted to move away from day-to-day fire fighting and spend time on strategic activities," Zieba explains. "We also wanted to clarify the process of shifting from manager to leader."

2. Increase decision-making ability.

"We wanted both management and staff to be able to diagnose, investigate, and creatively solve issues within the department; as well as join other departments in solving those that crossed departmental lines," she says.

3. Build and broaden accountability.

"We set the vision for the outcome, provided the expectations and boundaries, and let the team’s creativity go to work," she says. For example, team members now make recommendations regarding capital budget purchases.

4. Incorporate outcome measures.

"It’s important to know historical and current performance both house-wide and as a unit in patient and physician satisfaction, quality of care, environmental and economic measures," she says.

For instance, housewide outcome measures include accurate disposition coding, correct discharge dates per number of discharges, timely receipt of discharged charts, mislabeled blood samples/total samples, and contaminated blood cultures/total cultures drawn.

Unit-specific outcomes measures include salary, cost per patient, overtime wages, supply costs, expenses per patient day, non productive wages, productive wages, total labor expenses, and total expenses.

5. Create a more flexible and effective work environment.

"For example, we wanted employees to learn to self-schedule," she says.

The redesign also called for three multidisciplinary roles: The team associate, or TA, who focuses on the comfort and cleanliness of the patients and the unit; and combines housekeeping, food service and transport functions. Clinical associates, or CAs, are certified nursing assistants who have additional skills in phlebotomy and EKGs. Business associates, or BAs, combine the skills of unit secretary, admissions, insurance payer verification, and health records.

A team of two RNs and a CA are situated in one area for two weeks, then rotate between the three "pods" in the unit, she adds.

Additionally, the traditional charge nurse role no longer exists, says Zieba. "A resource coordinator is responsible for matching workload to demand. It’s is not a role of authority. The resource coordinator does not supervise; he or she facilitates."

There’s also a leadership council, consisting of the unit manager, the clinical resource expert, representatives from the central department, and RNs from the care teams. The BA, TA, and CA teams also have a representative on the leadership council. (See leadership matrix, p. 2.)

Although the transition happened fairly quickly, it wasn’t necessarily stress free, says Zieba."The teams did not understand change; many staff, managers and physicians were skeptical," she says.

In fact, three to four months into the change, the unit was experiencing "the depths of despair."

"We had all the classic signs of storming," she says, referring to the team development cycle of forming, storming, norming, performing, and transforming.

"People really challenged the need for teams and questioned whether they really wanted empowerment. Empowered means you are now accountable and that can be pretty scary."

Turning the corner on team development

In early 1998, the staff faced the first critical decision regarding scheduling and coverage. "The question was whether the unit should address this as a whole; or if it should be dealt with within each team," Zieba explains. "Opinion was split. Because we wanted to focus on outcomes, the leadership council chose the unit

That decision charted the course for real change, she notes. "We were starting to turn the corner on patient satisfaction and economic improvement." For example, in 1993, the variance from the national norm was -2.09; now, it is -.52.

An overall increase in staff morale occurred as team members provided increasingly greater input into daily operations. For example, they successfully experienced how to make recommendations for capital equipment, such as a case cart/supply cart system and upgraded fetal monitors.

The unit also saw economic gains as staff retention and scheduling improved. For instance, once core vacancies decreased, the need for agency nurses went away. Staff also began to understand why it was important to use data instead of anecdotes to make decisions that drive change.

"Prior to implementation, it felt like the weekend was the busiest time, but the data proved that we had our highest delivery volume midweek," she says. "This information allowed us to adjust the schedule to balance resources to match the workload."

However, one of the most exciting successes has been seeing managers move out of the old paradigm and emerge as leaders. (See chart, p. 5.)

Before the initiative began, managers made decisions without staff input — Level I. Or perhaps the managers made the decision and then sought input (Level II).

However, at Level IV, manager and team jointly make decisions. At Level V, leaders provide the vision, coaching, and facilitating, but team members actually make decisions.