1

Objectives:

At the end of the presentation the audience will be able to:– Describe innovative methods of creating a

culture in which excellence is the standard.– Describe how operationalizing “every nurse is a

leader” results in nursing excellence. – Appreciate the critical role that employee

engagement plays in achieving excellence.

Established: September 6, 1896Number of licensed Beds: 188

ADC 100ER Visits: 36,000

“Sole Community Hospital”

Rutland Regional Medical Center

Nursing at RRMC

Collective bargaining Unit 450 RNs Nationally Certified 45%ANCC Magnet Recognition 2010

2

2005 The Definitive Care Unit

17 bed ADC 17, high turnoverComplex patientsRN turnover 34%Low employee satisfaction 31%RN certifications 6%High Utilization of agency staff No employee engagement

2006 Quote from exit interview of a resigning staff RN:

“Never enough staff, and the staff we do have are burnt.

Very sick patients that come and go like a revolving door. Not a place I can continue to

work.”

2006 Quote from Employee satisfaction survey of a Staff

Member

“I love what I do but both patients and new staff come and go so

quickly it is not worth the effort to connect with them. I am not sure

how much longer I can tread water.”

3

Staff behaviors

Unsuccessful strategies

Not for me to fix…

4

How to engage the team?

How to shift from a leader wish approach to a solution based team?

Traditional Performance Improvement tools

Proven success with– Processes– Data– Root causes– Special causes– System & Process

Inefficiencies

Not proven with

Appreciative Inquiry-Cooperrider

A systematic approach to build from the positive core of what is present.

What are our strengths and how can we build from them?– a system or teams capacity to succeed is

strengthened

5

13

Why It Works

Doesn’t focus on changing peopleInvites people to engage in building the kinds of organizations and communities that they want to live/work in/for. Helps everyone see the need for change, explore new possibilities, and contribute to solutions.Translates shared vision into reality and belief into practice.Learning that surfaces through AI shifts the collective image.Causes individual acts at both conscious and unconscious levels

Problem Solving

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What to fix

Underlying language = problem, symptoms, causes, solutions, action plan

Breaks things into pieces & specialties, guaranteeing fragmented responses

Takes a lot of time and positive emotion to make real change.

Assumes organizations are constellations of problems to be overcome

What to grow-appreciating the best of what is.

New language of the true, good, better, possible – root causes of success.

“Problem focus” implies that there is an ideal. AI breaks open the box of what the ideal is first.

Expands vision of preferred future. Creates a “pull” - new energy fast.

Assumes organizations are sources of infinite capacity and imagination

Appreciative Inquiry

From the employee perspective…

Never ending process of frustration. “We never get it right”Change is always looming and threatening Feeling of no control become disengaged

Continual process of improving our strengths“we are good but we want to be better”

Change is expected, anticipated and exciting. Empowered to be part of the solution

6

16

The 5-D AI Change Process-dynamic circular wheel

Definition:Decide what to learn aboutWhat you want more of

Discovery: The best of what is, illuminate the Positive Core

Dream: Envisioning what might be; shared images for a preferred future

Design: Finding innovative ways to create that future

Delivery:Implementing and Sustaining the Change

D

D D

D

D

DEFINITION: WHO ARE WE?

WHAT DO WE VALUE?

Who are we??? Identity

DCU to PCU– RRMC Nursing Annual Mtg

Alignment with AACN– Embrace our specialty– Operational Framework– Synergy Model – Medical Director Partnership

Reframes how we see ourselves and how we are seen by others.

7

VISIONING DAY

Initial Staff Response

What are our values?

Organizational values:– Entrust– Integrity– Caring– Teamwork– Superior Service

Working sessions team report outsDiscover commonalities

8

Entrust:We entrust each other by empowering, mentoring and nurturing our team members to be successful.

We cultivate a culture of open, constructive feedback. We recognize each individual’s contribution to the quality of our service.

Caring:We care for our patients and our team. We strive to be approachable, compassionate and forgiving

Integrity:

We say what we mean and we do what we say.

Our communication is effective, honest and open.

We respect our peers and are accountable for our own actions.

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Teamwork:

We achieve our common goal of providing excellent patient care by using skillful communication to teach, mentor and share knowledge and ideas.

We work together as a strong solution-oriented team.

The Outcome:Superior Service

SUPERIOR SERVICE

Behavioral Expectations

Marie Manthy “Commitment to My Coworker.”Code of ConductAdoption of AACN Healthy Work Environment InitiativeSilent majority was finding their voice.The turning point……

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What does success look like?What is our shared vision?

It is January 2010 and PCU is an amazing place to work.

– Employee satisfaction is high– Staff retention is high– Pt outcomes are world class – Staff development is cultural and ongoing

What structures must be in place to achieve this?

What path should we take to get to our vision?

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Discovery: Illuminate the positive core build from

your strengths

Excellence Framework: AACN HWE Initiative

Beacon &Magnet Criteria

Leadership Structures & SystemsAppropriate Staffing & Staff EngagementEffective Communication, Knowledge, Learning and Development of Best PracticesEvidence Based Practice & Processes

Leadership Structures & Systems:Leading from Within

Leadership Development Formal & Informal leaders– Leading from Within/AACN EONMO/VONL– Changes in leadership ( skills vs. tenure) – Clear expectations and empowered to lead

Monthly Meeting – Core agenda for CM– Standing session for relief charge

Performance Appraisals – Personal Development Plans (staff input)– Quarterly mtg (two way communication)

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Leadership Structure

Nurse Director-Medical Director 4 Clinical Managers – 2 7a-7p & 2 7p-7a– Sunday night 7p-Saturday night at 7p– Saturday 7p-Sunday 7p relief charge

Clear accountability and expectationsCoaching communication to give feedback in a timely fashion

Appropriate Staffing

Business case to align core staffing with other progressive care units.Anchored our identity as a progressive care unit.Education around productivity and the role each of us play to maintain fiscal solvency. No longer a barrier

Leading From Within Organizational & PCU Teams

Departmental Teams – Professional Development Team– Safety/Education Team

Skin Care EMR

– Patient Satisfaction Team

Nursing Councils – Professional Development Council– Professional Practice– Quality Improvement– Research– MARC– Informatics

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Team Expectations

Set measurable goalsQuarterly report outs at staff meetingsClear posting of dates and timesPosting of minutes/portalStaff led with leadership sponsor-their team

Team Accomplishments

Pt Satisfaction– Advocate Program– Call backs/Sympathy cards– Quietly We Heal

Professional Development Team – Values & Commitment to Coworker – Debriefing – Beacon GAP Analysis– Beacon Application

Team Accomplishments

Safety Team– Fall Free Days– Busy Box– Partner with Local Nursing Homes– Rocking Chair– Safety Police “Ticket the good behavior”

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PCU Nursing Tech Team

Purpose/Structure/RolesBrainstormDetermine Goals for FY2012Survey so each LNA has a voiceLit Search-Prof OrgPresent results to entire team at Visioning

PCU Nursing Tech Team

“ I am so excited to have an LNA team, because I feel we are important too.”

Helen Parker LNA

Tech/Secretary

Solution Thinking..

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REWARD & RECOGNITION

Staff Education & Development

Partnership with Clinical EducatorThorough and ongoing education needs assessmentContinued alignment with professional standards– ANA Code of Ethics– AACN Healthy Work Environment – Magnet and Baldrige Criteria

Performance Appraisal (CAP, certifications)

Soft Skills:What every nurse needs to have

CommunicationPersonality Styles Conflict ResolutionRole PlayingCrucial ConversationsShared “Code Words”

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Staff Developing Staff:a culture of learning

PCCN Certification CourseLNA Educational Day-RN led

BLS/ACLS/Mock Codes“What I have learned”Continued Education

Hire for Core Values Train for Technical SkillsBehavioral Based – Past behavior predicts future behavior

Work EthicValuesTeam playerCaringCompassion

Hiring Process: Who do want working next to you?

•Team Recruitment

•Screen Interview

•Job Shadow

•Team interview

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Retention: Nurturing your new hiresOrientation ~6monthSkills, establish relationships, connect with

coworkers, community

Preceptor/trainee pairing Preceptor Training Formal VNIP Staff take accountability for developing their future team mate

Mentoring Program

Professional Development Team GAP– Best Practice Maine Medical– Team built structure– Formal Education– 1yr for GN post orientation – 6 months for new hire post orientation

Our current structure

Daily briefings-briefing sheet– Value Story – Safety Tip of the week

Quarterly Team mtgMonthly Leadership & Team mtgsStaff Reps on All Nursing CouncilsDept Teams

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Visioning Day Agenda

IcebreakerBold Voices Commitment /Beacon Gap AnalysisOrganizational Update CEO Nursing Update CNO & CouncilsPCU results/progress (NDNQI)Team Report (goals/progress/results)Dr Shapiro Educational Session over lunchGuest SpeakersTeam Building Exercises (Beacon, Personality, Dress, Games)Solutions BoxOpen Discussion –review of previous yr, goals for next Likes/Wishes

Team Building Games

Children games are hardly games. Children are never more serious than

when they play.-Montaigne

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Beacon Application Process

Feedback :progress to goals

Post resultsDiscuss resultsHow can we do it better?Fall boardsChart Audit dataFeedback Two street: Likes/Wishes

The train is leaving….are you on board?

TURNOVER HITS ALL TIME PCU RECORD 42% !!!!

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2011 PCU SO where are we now?

18 bed Progressive Care Unit ADC 18 High Patient turnoverComplicated patients

2010 PCU Employee Engagement Data-GPTWChange from measuring satisfaction to “engagement”Organizational restructuring-3N closing Survey was conducted at the same time Top 100 HC facilities in US 6,672

PCU 2010 GPW Survey

Criteria GPW top 100 HC PCU

Credibility 84

Respect 84

Fairness 82

Pride 90

Camaraderie 88

Average of all scores 86

“Taking everything into account this is a great place to work”

91

8389

77868885

94

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NDNQI %RN Hrs Agency Staff

0

1

2

3

4

5

6

7

8

2Q09 3Q09 4Q09 1Q10 2Q10 3Q10 4Q10 1Q11

National Mean

PCU

NDNQI Controllable Turnover

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

1Q10 2Q10 3Q10 4Q10 1Q11

National Mean

PCU

NDNQI: Unit Acquired Pressure

Ulcer

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

1q09 2Q09 3Q09 4Q09 1Q10 2Q10 3Q10 4Q10 1Q11

National Mean

PCU

22

NDNQI Restraints Goal: restraint free Dept

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

4Q09 1Q10 2Q10 3Q10 4Q10 1Q11

National Mean

PCU

NDNQI RN Certifications

71% of all PCU eligible RNS are certified With another review course scheduled for this

fall -6 more newly eligible RNs

0

5

10

15

20

25

30

35

40

45

50

2Q10 3Q10 4Q10 1Q11

National Mean

PCU

The 90th percentile is

23.81PCU 43.78

NDNQI FALLS/1000 pt days

0

1

2

3

4

5

6

7

8

1q09 2Q09 3Q09 4Q09 1Q10 2Q10 3Q10 4Q10 1Q11

National Mean

PCU

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NDNQI: FALL INJURY/1000 pt days

Our last fall with injury wasQ3 2009 skin tear

0

0.5

1

1.5

2

2.5

2Q09 3Q09 4Q09 1Q10 2Q10 3Q10 4Q10 1Q11

National Mean

PCU

2010 PG MDEngagement survey Org Wide

Quality of RN staff 99th percentile

Staff concern for your pts 96th

percentile

Overall rating of physician nurse collaboration 99th percentile

Lets hear from the PCU staff……

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Delivery Sustaining the Change Next steps

AACN BEACON AWARD LNA Development– Team– LNA education orientation, mentoring

Silent Night-HCAHPSMentoring program t/o org. Research Scholar Med Admin InterruptionsPublish & share with others

In summary:There is no OZ!

The yellow brick road ….Discovering and appreciating the

very best in each other…..

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Employee Engagement

Building from the positive core and creating a shared vision results in a solution oriented team that is engaged.

Define-who you are Discover-what you have in commonDream-what is your shared vision

Design-how to get thereDeliver-every day improving on the previous

This ongoing process creates a culture that feels empowered, respected and driving the change by asking

“how can we did it better tomorrow?”

Special gratitude to Debbie Mills RN, BSN, PCCN

PCU Clinical EducatorMarch 25, 1960-March 31, 2011

“It is amazing how much you can accomplish when it doesn’t matter

who gets the credit.”

Questions ?

I am willing to share any materials presented today please send me

an email :

jmarkowski@rrmc.orgSubject Employee Engagement