Prairie Lakes Healthcare System's nursing turnover rate on its med-surg-pediatric unit was 65 percent when Jill Fuller came on board six years ago. But after revamping its nursing-care delivery model, Prairie Lakes Hospital, the system's 60-staffed-bed flagship facility, has reduced its turnover rate to less than 10 percent. The Watertown, S.D., hospital also improved employee satisfaction on the unit by 130 percent from 2000 to 2006, and although nurse-to-patient ratios have remained constant, productivity has climbed by 20 percent. "I now have six to 10 nurses apply for every open position on this unit," says Fuller, the chief nursing officer.A key catalyst in Prairie Lakes overhaul is the Transforming Care at the Bedside initiative, Fuller says. Sponsored by The Robert Wood Johnson Foundation and the Institute for Healthcare Improvement, the program strives to improve the quality of patient care, create more effective care teams, and increase nursing staff engagement, retention and efficiency. Prairie Lakes began working with TCAB roughly two years ago as the only small rural hospital among 13 facilities involved in the project, including the University of Pittsburgh Medical Center, Cedars-Sinai Medical Center in Los Angeles and The University of Texas MD Anderson Cancer Center in Houston. Each hospital has a designated med-surg unit that tests different ways to address the project's four targets: safe and reliable care, vitality and teamwork, patient-centered care and value-added care processes, explains Shelly Turbak, Prairie Lakes' director of medical-surgical pediatrics. "We are all looking for various 'tests of change' as we call it, whether it is how you staff, how you recruit and retain your staff, or how you remodel your environment."Ten hospitals are participating in the program's third phase, which began in 2006 and involves partnering with nursing schools. Prairie Lakes' partnership is with South Dakota State University College of Nursing. TCAB's goal is to influence the curriculum and educate students about these goals before they are in the work environment, Turbak explains. Students can also offer feedback and ideas to the hospitals during their clinical training. Fuller hopes the program shows new graduates that small rural hospitals are a great place to practice and can be a professional model. "A lot of new graduates want to go to big cities, so we are hoping that they see that the bedside nurse is the professional nursing role at our hospital."
Less red tape Prairie Lakes, located roughly 90 miles north of Sioux Falls, has focused its efforts on providing safe, reliable care in the most cost-effective manner. "Instead of doing more with less, we really worked on decreasing work intensity without adding labor cost, and we call that doing less with less," says Fuller. For example, the hospital revised its documentation process by implementing an electronic medical record-a project already under way prior to TCAB. It also down-sized committees, redesigned the supply room, created mini-gyms on the med-surg floor for physical therapy, and placed medications and supplies at the bedside-in locked cabinets. Now, nurses spend less time hunting down supplies, medication and equipment, says Turbak. In addition, Prairie Lakes reduced bureaucracy by eliminating the charge nurse roles and case managers. Originally, charge nurses rounded with physicians and were the liaison between the doctors and the nurses. Case managers did utilization reviews and discharge planning. As a result, the bedside nurses were disconnected from the doctors and didn't know the overall plan for the patient, says Turbak. Now, bedside nurses round with physicians and handle the discharge process, and the newly created position of "resource nurse" facilitates the admissions process and assists other nurses when needed. "Nurses are more in tune with what is going on with the patients," Turbak adds. Both Turbak and Fuller agree that one of the most beneficial outcomes of the program has been getting the frontline team engaged and understanding how to test and make changes. "It is not my job as a leader to decide or to dictate how the work should be done," Turbak says. "It is my role to support the ideas and to really foster creative thinking."
Empowering staffDeveloping a culture that challenges the status quo has been one of the biggest hurdles of the program. Turbak says staff members often have considerable anxiety over changing the way something has always been done. For instance, Prairie Lakes recently deployed walkie-talkie-type devices to all of its nurses. The devices have an ear piece and enable nurses to communicate without an overhead page or a trek to the nurse's station. Initially, some nurses didn't want to carry it because they viewed it as one more thing to carry around and keep up with, Turbak recalls. But the hospital tested it for a couple of weeks and "it was just unbelievable how quickly it gained support and credibility," she says. Not every new initiative fits the culture, however. Other TCAB participants, for instance, have shown great success with red, yellow and green boards that monitor a nurse's workload throughout the day, says Turbak. Every couple of hours, nurses update the board to reflect their status; green means the nurse is doing fine and can take on more patients, whereas red means the nurse needs help. But the initiative filed at Prairie Lakes. "The staff [here] just felt like this was an added step in their day and that we really communicated well enough as a team that we didn't need it," Turbak explains. Rural hospitals need to approach change in a way that is reasonable and engages staff members, says Fuller. Frontline staff know where the waste is and usually come up with good ways to address it, she says. "I had to learn how to give up control as a leader, and I have to prepare myself to be surprised every once in a while."
-Carrie Vaughan
Magazine
