Take a breather from PPS: Assess staff morale

Agency creates team-building QI project

Morale was low among the home care staffs of Upper Chesapeake and St. Joseph hospitals in Baltimore as the two systems prepared for a merger that took place in early 1999.

"Of course, anytime you’re thinking about a merger, everybody is worried about their jobs and how is it going to affect them," says Debbie Chisholm, BSN, RN, CRNH, quality and staff development manager of Upper Chesapeake/St. Joseph Home Care in Baltimore.

"You could hear people talking about rumors, and then we started to lose staff," Chisholm adds. "So we decided that we would look at staff satisfaction quantitatively before and after the merger and use that data to implement changes."

The pre-merger survey demonstrated a very low staff morale and identified several major problem areas, including a lack of trust in management. Chisholm grouped the survey results according to job title and found that nurses had among the lowest morale scores, with an average of 1.93 out of a possible 5.00.

Seven-step model

Chisholm and the quality council formed a process action team that was carried over to the newly merged home care agency as well. The team’s purpose was to investigate how to enhance team-building skills among the joined staffs, brainstorm about problems and possible solutions, and then implement improvements.

A year later, the team repeated the staff satisfaction survey and found a 29.3% improvement in overall staff satisfaction. That included job satisfaction, staff morale, and the effectiveness of supervisors as coaches.

The team-building quality improvement project followed a seven-step model. Chisholm outlines what the agency did for each step:

1. Identify the process that needs improvement. The proposed merger and managers’ observations of how negative staff were about the merger made it simple for the quality council to identify the problem. Also, the agency had a number of negative rumors to deal with, and staff retention was becoming an issue.

2. Organize the team. The quality council selected representative employees from all the different disciplines to form the action team. Typically, the action team would include people whose jobs are affected by the process that needs to be improved. In this case, staff morale affected everyone.

"We chose people who are problem solvers," Chisholm says. "We didn’t want people on the team who had an ax to grind and would grumble and complain; we wanted people who would give constructive criticism."

3. Analyze and understand the process. The action team brainstormed, listing problems. Then they created a flowchart of the process from beginning to end. "That was very difficult in this situation because the problem is so subjective," Chisholm notes. "This is not a black and white issue; it involves feelings, experiences, and was difficult to flowchart."

Still, the team worked on analyzing the process and came up with a flowchart that helped identify the opportunities for improvement. "As you define the process, it becomes very evident where the problems are and where we’re falling down," she says. (See story on the agency’s morale problems and how it solved them, p. 104.)

Once all of the problems were listed, the team voted on each as a way to reduce the list to a manageable number of priorities. That helped the team focus on the key issues.

4. Identify recommended improvements. Once the team came up with the priority list of problems, team members suggested improvements. "We came up with ideas to solve the problems we were having, and then we made recommendations," Chisholm says.

Then she brought the lists of problems and potential solutions to the quality council, which would determine the financial impact of each suggestion. "On the action team, you could have grandiose ideas, but are they fiscally feasible?" she says. "That’s why it has to go to the quality council for approval."

5. Plan the improvements. This step simply involved having the team plan who would be responsible for each improvement approved by the quality council. So each recommendation was assigned to a team member to assure follow-through and accountability.

6. Implement the improvements. The people in charge of implementing improvements got to work. The implementation process started in December 1999 and ended in February 2000.

7. Check the results. The team distributed the post-merger staff satisfaction survey in April 2000 and compared its results with the results of the pre-merger survey of one year earlier. Besides looking for overall satisfaction and staff morale results, the team looked at results in specific areas. If outcomes did not improve significantly, the team concluded the changes were not as effectual as hoped. In those cases, the team analyzed the process again and continued to strive for improvements.