A tip sheet for creating a high-performing culture, and examples of six characteristic behaviors.
This table lists six ways that team members' mindsets evolve on successful UBTs.
This chart lays out for sponsors and leaders the difference between new, transformative mindsets that help create a team-based approach to member/patient care and traditional hierarchical thinking.
This chart defines division of labor between management and leadership, from the beginning through the outcome of projects and changes.
The folks at the Denver Regional Pharmacy found their unit-based team to be a major improvement over the steering committee it replaced.
Team members found the committee to be unwieldy, and felt it largely bred distrust and miscommunication between union and management.
So, they regrouped.
A major problem they had encountered was the time pharmacy technicians wasted researching prescriptions that weren’t properly "batched." Often missing was the required electronic stamp from a pharmacist that tracks and closes the prescription.
Technicians spent roughly 1-4 hours a day per pharmacy tracking down misbatched prescriptions. The team aimed to cut that time by 50 percent.
"The biggest thing is if you view your situation as a failure you'll never succeed," management co-lead Luanne Petricich says. "When something is not working that's where your opportunity is. Don't be afraid to change something if it's not working."
The team modified the way pharmacists attached their electronic signature. That saved technicians hours of research time and freed them to spend more time with patients. Almost immediately the team saw a drop in the number of prescriptions that needed to be researched.
In the two pharmacies where the team instituted new batching practices, they saw a 75 percent drop in the number of prescriptions requiring research. The new protocol was introduced to 20 pharmacies in the region, and 70 percent of those saw similar gains.
This collaborative effort produced positive results as their projects improved customer service and affordability. The new UBT also gained some hard-earned trust.
Since that success, the regional team has become a model and a sponsor for smaller, pharmacy-specific UBTs launched in the region.
"I like the focus on efficiencies and waste because it ends up translating to a better work environment for employees," Petricich says. "Especially with this project, we found the technicians were doing redundant work that did not provide job satisfaction. So taking that away allowed for more time with patients, which is what many would rather be doing."
Regional Pharmacy UBT in Colorado uses PDSA to improve 'batching' procedure.
The MRI unit at Kaiser Sunnyside Medical Center had a challenge.
The department was receiving an average of 120 cases each day, but they were able to see only 71. As a result, patients were being referred outside of the Kaiser Permanente system. This drove up referral costs, inconvenienced KP members, and increased dissatisfaction.
In addition, referring patients to outside services posed a delay in getting results back to the ordering doctors. Schedulers who received the request for appointments also had a tough job—when they were not able to accommodate patients within the KP system, they had to make arrangements with outside services, which took additional time.
And finally, the patients didn’t like it.
The feedback from patients to department manager David Barry, was that they didn’t want to have to go elsewhere for services. Patients preferred to have their MRIs performed at the Sunnyside Medical Center.
The team's first step was to increase capacity to see more patients and reduce outside referrals by at least 10 per week within two weeks. To acccomplish this, they reduced the overlap in staffing and changed the schedules of two technologists, increasing their ability to see more patients.
The new staffing schedule, which didn’t infringe on union contracts, came out of a brainstorming session and was supported by staff and physicians.
After the first two technologists adjusted their schedules, a third technologist, seeing the difference it made, offered to adjust his schedule. By the end of one week, about 15 more patients were added to KP’s schedule and not referred to outside services. This resulted in a cost savings of about $7,500 per week, or about $30,000 per month.
"One of the big advantages that we have found is that we have openings for certain appointment types within a day or two, not a week or two," says labor co-lead Heather Thompson.
In addition to the work done in the UBT, a mobile scanner was added to the department. This enabled an additional 11 patients per day to be seen—or about 55 patients per week—for an additional per week savings of $30,000 in outside referral costs.
"There is a downside to that, though,” Thompson says. “Since patients are able to get the appointment so quickly, it seems as though we have a lot more short-notice cancellations and we do not have a wait list to fill them with. That is something that we will need to monitor and try to come up with a solution to."
Sunnyside Medical Center's MRI department was receiving more cases each day than it could handle.
The Mammography Department at Sunnyside Medical Center was seeing about 370 patients per week, but 25-30 percent of those appointments were running behind schedule.
Appointments ran late because information was missing from the file, additional forms were needed or the wrong test had been ordered. This cost the technologist additional time tracking down information or following up on needed documentation during the patient’s appointment, which had a cascading effect.
The unit-based team (UBT) realized that many of the issues causing delays during appointments could be handled in advance of the patient's arrival. The team came up with the idea of setting time aside every afternoon for a technologist to review the following day's orders.
"Many times patients who are coming in for an appointment are here because something has shown up on a prior screening and their anxiety and stress levels are high,” Cheryl Maize, manager of Mammography, and UBT co-lead says. “By streamlining our appointments and ensuring appointments run on time, we are hoping to allay some of that stress."
Initially, a 3-4 p.m. window was set, but as staff began to test the new process, they learned that starting the work that late in the afternoon was not ideal.
In some cases, they needed to return phone calls or required additional information, and they couldn't get everything done by the end of the day. The team pushed up the pre-work orders to a 1-2 p.m. time slot and the results improved.
In addition, the team implemented a "double-check" system at 4 p.m., so orders were again reviewed to make sure any outstanding items had arrived and everything was ready for the patient's appointment the following day.
The technologist reviewing the orders also would leave notes in the file if there was something the technologist who was seeing the patient needed to know.
Patient experience improved with the new process. Appointments were on time, and technologists were better prepared to work with their patients because the orders had been reviewed in advance.
"The implementation of the screening of orders 24 hours prior to patient arrival has allowed us to maintain our allotted appointment times and has made it easier to accommodate surprises such as late arrivals and walk-ins," Laura Wellnitz, technologist, and UBT labor co-lead says.
Eventually, a technologist was checking orders and printing out appropriate paperwork for diagnostic mammograms one day in advance of the appointments. This eliminated 10-20 minutes per appointment. As a result, most diagnostic appointments were completed in the scheduled 30 minutes, so subsequent appointments started on time.
Other staffers also preferred the new process. They decided to take turns verifying and reviewing orders, which provided a welcome break in the daily routine.
Mammography UBT implements case review process, reducing late appointments for patients.
When UBT co-leads at Sunnyside Medical Center took a closer look at their patient safety assistant usage, they agreed that reducing the number of hours was a top priority.
The patient safety assistants, also known as PSAs, were certified nursing assistants and provided a key service. They were assigned to sit in a room with a patient who had dementia, was confused or at risk of a fall. They could help if the patient tried to get out of bed, remove their IV lines, or became disoriented or restless.
And patients getting out of bed is not unusual.
Some try to get out of bed because they're bored and restless or they might need to use the bathroom. Restless patients often need a change of scenery, which might mean moving the patient to the nurses' station or to a public area. There might be a need to reduce noise by closing doors at shift change to keep it quiet.
During a five-month stretch, the Sunnyside nursing unit had used 1,550 hours on PSAs. At a cost of $62,000, they wanted to bring those hours down without adversely impacting patient care.
So staff members made it a priority to talk with the patients and families to learn about the patient's interests and hobbies and offer specific activities for patients to do during their stay.
"Using the activity boxes (which contain games, crafts, videos and more) with patients has been a great way to help patients stay busy, and it makes them feel better," according to UBT labor co-chair Glenda Vosberg, RN.
The goal was to reduce PSA usage by 10 percent in four months. Knowing this was going to be a full-team effort, a mandatory in-service was scheduled and the co-leads explained the situation to the rest of the team.
They trained staff on the options to using PSAs. They provided the team with baseline data and information on the financial impact of using PSAs, and had nurses assess patients to determine whether a PSA is needed.
The results were immediate.
In a month, hours dropped from 549 to 32 without any negative impact on patient safety. Within another two months, PSA usage fell to eight hours.
"Staff were given the data and information to help them understand the impact of the situation and get their feedback on alternative options to using a PSA," says Imelda Zapata, department manager and management co-lead.
The team also enlisted the assistance of Susan Woods, the clinical nurse consultant in the hospital.
One of Woods' responsibilities was to provide consultations with patients who were assigned PSAs. She worked with the patient, family and nurse to develop a plan that best fit the needs of the patient.
Kaiser Permanente also invested in several different equipment options, including low beds, which can be put all the way down to the floor, and bed and chair alarms that let nurses know if a patient tries to get up.
The combination of equipment, changes to the environment, and activities for patients allowed the team to keep their patients safe and improve their morale while decreasing the usage of PSAs.
"Often staff is concerned about patient safety when we talk about alternatives to assigning PSAs and may be reluctant to try other options. However, literature (and our local experience) shows that having a PSA in the room does not guarantee the patient won't fall or pull out their IV lines," Woods says. "We've found that reduction of PSA usage has not negatively impacted patient safety, just as the literature suggests."
Nursing unit takes a patient-centered approach to watching over patients and ends up saving over $60,000 in just a few months.
The medical/surgical staff at Fontana Medical Center had a problem with pressure ulcers. The 59-bed unit averaged about 10 of these hospital-acquired bed sores a quarter.
It's painful for the patient and costly for the hospital, which can average about $43,000 per incident. But pressure ulcers are also preventable, and that can lead to shorter hospital stays and improved patient satisfaction scores. Reducing the rate of pressure ulcers can also eliminate inquiries from the California Department of Health Services.
Based on recommendations from the UBT, the staff implemented an education program and provided one-on-one training on how to spot, rate and reduce bed sores.
The team established a strict regimen that included rating patients on the Braden Scale, which helps identify those at risk for pressure ulcers. They performed morning assessments, and used waffle mattresses and moisture-protective barriers for at-risk patients.
They also rounded hourly for turning and got patients out of bed three or four times a day to decrease their risks. This allowed patients to use the restroom and to keep them clean.
“It’s pretty much a collaborative effort among nurses, nutritionists and wound specialists,” says charge nurse and UBT co-lead Toni Leonen. “The nurses are receptive to implementing the various methods we use to prevent pressure ulcers.”
In a span of two years, the new process helped the team reduce the number of bed sores to 0.
“We’ve created this environment where the staff thinks safety and thinks patient comfort,” Kathy Smith, RN, assistant department administrator says. “It’s automatic. They just come in and make sure patients are turned. Nobody has to remind them.”
Coming up with a new process to combat pressure ulcers helped the team build a sense of unity and staff satisfaction, but they also know the work continues.
“Sustaining our success is the biggest challenge because you can revert back to old practices,” Smith says. “You have to keep emphasizing what we’re doing and what the reasons are. Make sure they know you appreciate them so they continue to do well.”
Fontana medical-surgical UBT's work on reducing incidence of pressure ulcers results in six consecutive quarters without any at all.
The Clinical Home Health Care team in San Diego needed to see discharged patients within 24 hours.
But they were hitting less than 50 percent success, and given their patients included those in hospice and palliative care, this was a problem.
At issue was a patient discharge list that might have 50 or more names. An intake nurse would dictate patient information to a department clerk, who would complete the forms. Only then would a home health visit get triggered.
This wasted time.
Modeled after a successful practice at Riverside Medical Center, the team did two things. First, they eliminated the clerk from the workflow and had the nurses process the patient information directly.
And second, they trimmed the list of names being referred to Home Health Care to only those patients who were getting discharged within the next 48 hours.
“We plan our day based on that list,” says Daniele Wilson, director of patient care services for home care. “But we cannot plan if that list is not updated. We needed to focus on the work that needed to be done more immediately.”
Home Health Care intake nurses also communicated with the discharge planners to get up-to-the-hour information on which patients will be released that day and need to be seen by a Home Health Care provider within the following 24 hours.
That group was reduced to about five daily patients, and in two months the number of referrals seen within 24 hours grew from 44 to 77 percent.
“It’s much easier to tackle when a list has a handful of names,” Wilson says. “When it was 50-some it was difficult to even know where to begin. It felt futile.”
The team included daily morning huddles to review the number of newly referred patients and their needs, as well as ongoing patient needs. They also improved communication with the referring departments, such as orthopedics and primary care.
“We reached out to different heads of departments to figure out how they operated,” Wilson says. “By understanding how they operated, it helped us know how we can interact with them.”
Lisa Tuckwell, RN, public health nurse and UNAC/UCHP member, learned to speak doc.
“We figured out the buzz words that got a doctor to act.”
San Diego's Clinical Home Health Care unit-based team borrowed a "best practice" from Riverside that helped them see more patients within the requisite 24-hour window following discharge from the hospital or referral from a physician.