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Cultivating Collaboration

3. Think Like a System

Connect and Transform

Crossing boundaries: Critical Care Nursing Director Colleen Connelly, Nurse Manger Julia Beynon, and Huntsman Cancer Hospital Nursing Director Sue Childress combined forces to create one unit with two locations.

Bridging the gap between hospital units and nursing staff to boost efficiency

Coming together isn’t always easy. Especially when you’ve got over 3,000 nursing staff working in four different hospitals, 10 dispersed community clinics and more than 50 separate medical units. In this decentralized environment, we found that our teams naturally formed their own independent domains. But this was causing duplication in staff, management, equipment and other costly services. So we decided to think differently—and to start working together as a system.

Connect distant units with similar specialties

To kick-start our transformation to systems thinking, we created a pilot project with our orthopedic hospital to transform two independent units into one synchronized unit with two different sites. This involved merging our intermediate care University Orthopaedic Center (UOC) with our higher-acuity Ortho Trauma and Surgical Specialty Unit (OTSS), which was two miles away at our University Hospital.

300% reduction in turnover

By integrating orthopedic nursing staff, we have reduced RN turnover at our small UOC unit by 300% over a two-year period, saving $111,600 in actual training and orientation and an estimated $525,000 in turnover and recruitment costs (based on the industry average of $35,000 per vacancy).

Although the distance wasn’t far, the two locations had been functioning as separate islands in a vast sea, even as they both struggled with a similar problem: fluctuating census levels and unpredictable staffing needs. “We were definitely faltering,” says Janiel Wright, nurse manager at the UOC. “But we weren’t asking for help.”

It was a perfect opportunity to try a system-thinking approach. We knew that if we could train all our orthopedic nurses to work seamlessly at either location, we could keep staff from getting called off when things were too slow—and we could keep both sites from becoming understaffed when things got too hectic. But before we could make it work, new levels of collaboration and coordination would have to be achieved.

Train your team for a new clinical setting

$1.7 million saved

By combining SICU and Huntsman ICU staffing, we avoided $1.7M in additional staffing costs.

93% patient satisfaction

From January-September 2012, 93% of HCAHPS survey respondents rated the Huntsman ICU as a 9 of 10, and 100% said they would “definitely” recommend it.

Although the nurses on both units had experience in orthopedics, they worked with distinctly different patient populations with disparate clinical needs. To be successful at our OTSS location, where patients are typically sicker, the UOC nurses cross-trained on site before they actually started working there, learning to handle complex emergency care and intensive orthopedic procedures they simply hadn’t seen at the UOC.

Training OTSS nurses to work at the UOC site posed different challenges altogether—small things (like how to get into the building at night), critical details (like how to admit a new patient) and life-or-death issues (like how to handle an emergency). Lance Littledike, nurse manager on our OTSS unit, worked with Janiel to orient OTSS nurses to every little detail within the new setting. “We made sure that no one was sent into the unknown,” says Laura Adams, nursing director for acute care and rehab at our University Hospital.

Standardize policies, supplies and staff

To further remove cognitive dissonance at both locations, best practices were identified and standardized across UOC and OTSS, float nurse coordination and scheduling was centralized with the help of our resource nursing team, and supplies were stored and tracked consistently on both units. This created two predictable and safe clinical environments, where nurses had the constant support and stable infrastructure needed to make smart decisions.

The result? Both units fortified their financial strength, relying on skilled internal nurses instead of expensive agency nurses who were less familiar with our orthopedic settings. And the nurses got the hours they needed to stay productive—all while building their orthopedic skills. “Now, our nurses float effortlessly between the two sites, without any grumbling,” says Laura. “It’s like going from the family room to the living room. It’s home.”

Use existing resources to solve new organizational challenges

We used a similar one-unit, two-sites plan when our Huntsman Cancer Hospital decided to establish an on-site intensive care unit. Because they’d never built or managed an ICU, they were, fundamentally, starting from scratch. They needed to know everything from where to position monitors in critical care patient rooms, to what types of workspaces to provide for nurses who rarely sit down. They needed ICU experts—and they needed them fast.

With the success of our orthopedic pilot, we felt confident that a similar approach could work at the Huntsman Cancer Hospital. So we connected our experienced SICU nurses with the fledgling Huntsman team and began developing a systems-thinking plan for managing and staffing the new ICU.

Take the burden off individual shoulders—and put it on the team

We asked Julia Beynon, our SICU manager, to be nurse manager for both sites. It was, admittedly, a daunting task. For starters, she was busy enough on the SICU.

“Academic medical centers can’t be about individual people or personal agendas. They can’t be about one leader trying to build a kingdom. They must always be about coming together to do what’s right for the patient.”—Colleen Connelly, Critical Care Nursing Director

What’s more, the new ICU would be in a different hospital altogether, a 10-minute walk from her unit through a labyrinth of tunnels. And then there was the issue of asking her staff to float between two sites—and explaining to them why it mattered.

To overcome real and perceived barriers, Julia talked openly about her concerns with Colleen Connelly, critical care nursing director, and Sue Childress, Huntsman Cancer Hospital nursing director. “Sue asked me what we needed to be successful,” says Julia, “and I realized that the burden wasn’t just on my shoulders. No one person was expected to know everything. If we all worked together as a team, we’d have everything we needed to get the job done.”

Stay focused on what’s best for the patient

With the support of both hospitals’ leaders on her side, Julia accepted the difficult mission and set off to accomplish her first big task: communicating the plan to SICU and Huntsman nurses. She spoke candidly with her team about the challenges, but framed the discussion around what was best for patients, not what was best for individual nurses. After that, everything began to fall in place. “My nurses agreed,” says Julia, “because it was the right thing to do for our patients.”

Colleen, who serves as Julia’s director, was pleasantly surprised by the universal staff buy-in. “ICU nurses are particular; they have strong personalities and they’re really attached to their units. These are nurses who tell it like it is. But not a single one of them questioned why we were doing this.”

To make the cultural exchange a little smoother, Julia and Colleen focused on respecting the differences between the two groups of nurses. Instead of challenging the culture or trying to change it, the SICU team helped the Huntsman Cancer Hospital build its vision. And the Huntsman team welcomed the help. “Sue let us into her home,” says Colleen. “And she trusted us to rearrange the furniture.”

As our nurses continue to float between ICUs and learn from each other, the distance that once seemed so vast has become insignificant. “With this project, we’ve created the building blocks for system-wide thinking,” says Colleen.

Sue is equally positive as she looks toward the future of the Huntsman Cancer Hospital and the entire University of Utah Health Care system. “There’s not a border we can’t cross,” she says. “After all, we’re doing it every day.”

Share your own systems-thinking ideas, and see what others have to say.