How do you improve teamwork, collaboration, mutual respect, and engagement? The leadership team in a complex cardiovascular intensive care unit (CICU) wanted to find out.
The University of Michigan Frankel Cardiovascular Center CICU leadership team included Clinical Nursing Director Diane Lopez; former Medical Director Mohamad Kenaan, MD; current Medical Director Michael Thomas, MD; Nursing Supervisor Terri Roth; and Chief Fellow Ran Lee, MD. They worked collaboratively to consider interventions to improve the culture in the CICU.
Jamie Beach, Quality Data Manager for the Frankel Cardiovascular Center, had heard about a joy in work prototype cohort being launched by the Institute for Healthcare Improvement (IHI) in the Fall of 2016. They decided to join because the unit’s employee engagement scores were in the bottom tier for two consecutive years and there was overall agreement that team work between the entire multidisciplinary team was an area of opportunity.
First Ask “What Matters to You?”
The joy in work prototype teams were asked to test the IHI Framework for Improving Joy in Work using the Four Steps for Leaders with an emphasis on psychological safety.
Joy in work was first introduced to the CICU through an email that briefly described their aim:
Engage members of our Cardiac ICU community in a discussion around joy in work. Discover what matters to us and identify as well as resolve barriers to achieving joy.
The team asked respondents on their unit (7D) to rate six statements to establish a baseline. The statements were a subset of the annual employee engagement survey:
- I would recommend 7D as a good place to work.
- I am satisfied with my work/life balance.
- I am able to achieve my potential in my work.
- My immediate supervisor cares about me as a person.
- My contributions to direct patient care are recognized/rewarded.
- I make a positive contribution to the care team.
Next, the team spent time in the CICU asking fellow staff members, “What matters to you?”
To do this, they knew they could not take staff away from patient care for prolonged periods or add more meetings to already busy schedules. They asked willing team members to join them in the break room for 10 minutes. Equipped with flip charts and stickie notes, the team would share facilitation and scribing, capturing their answers on flip charts.
They launched discussions by using questions from the Conversation Guide (Appendix A in the Joy in Work white paper). Questions included, “Why did you go into your profession or health care?” Responses led to sharing personal stories and an awareness of each other at a deeper level than previously experienced. Powerful stories helped to build camaraderie among team members immediately.
For example, at one lunch, a nurse thanked a fellow and resident for going above and beyond in providing end-of-life care to a patient. This was not only gratifying to his colleagues, but it helped everyone to understand how nurses sometimes feel alone in providing care in a patient’s last hours.
Other questions included:
- “What makes a good day for you?”
- “What gets in the way of a good day?”
- “What are the daily ‘pebbles in your shoes’ that get in the way of a good day?”
Team members found the conversations socially engaging, and encouraged others to pop in and comment on the notes posted on flip charts so everyone could contribute.
Identify What People Want to Improve
The “what matters” discussions also helped the team identify where to focus their efforts. Needs staff described included 1) more collaboration, communication, and teamwork; 2) better support around end-of-life issues and the challenge of providing potentially futile care; 3) information about what happens to patients after discharge from the CICU. (Staff indicated not knowing often left them questioning whether their care mattered.)
To provide an opportunity for deeper discussion, the CICU leadership team decided to test multidisciplinary lunches in partnership with the Office of Counseling and Resilience. The launch was highly successful with nurses, fellows, attending physicians, and other members of the multidisciplinary team in attendance. Participants actively engaged in conversations about difficult patient care situations. Some examples included end-of-life issues, advanced therapies, and challenging families. Candid and well-facilitated conversations set the stage for constructive future steps by building a sense of community among the participants, an essential element for psychological safety. The topics and participants will rotate quarterly as a means of building collaboration.
To encourage more collaboration, communication, and teamwork, the CICU leadership team implemented a set time every day for quick multidisciplinary rounds. These “flash rounds” included the CICU fellow, the charge nurse, physical therapy, occupational therapy, respiratory therapy, care management, and bed managers to coordinate disposition and essential therapies from allied health professionals. Night rounds led by the CICU fellow and charge nurse — usually at around midnight — also provided an opportunity for bedside nurses and the physician team to collaborate.
To share what happened to patients after their discharge from the CICU, the team created a joy in work newsletter to share learning and case reports about patient outcomes. After consultation with the Compliance Department to assure no violations of patient privacy, one of the fellows wrote patient profiles that included educational vignettes. For example, a profile of a patient who had delirium while in the CICU included care recommendations to avoid delirium in future patients.
Early Lessons Learned
- “What matters” conversations are an intervention in itself — After initially being surprised by the question, staff and trainees felt good about being asked what matters most to them. No one had ever asked before.
- Patients matter most — After approximately 10 hours of conversations over four weeks, the CICU leadership team found that patients matter most.
- Staff and trainees learned that they’re more alike than different — Across a range of roles, staff all prioritized caring for patients, having meaningful human connections, and continued learning.
- Don’t be afraid to get started — Make joy in work part of daily work by implementing small actions with devotion to the needs of team members and patients.
- The morning huddle sets the tone for the day — This lesson led to the development of a motto, based on the “what matters” conversations, that was read every morning:
Help, heal, and protect people.
Be the best at what we do.
Support each other with positive attitudes.
Continue to learn and grow.
Many informal observations seem to indicate progress. These include attending physicians, who have been off service until recently, commenting that “something different is going on in the CICU.” Team members report working much more collaboratively, which makes rounding a positive experience.
Actions to improve “what matters” and “pebbles in shoes” continue, including fostering a culture that provides ongoing support to one another. The team now recognizes that developing joy in work and a stronger team culture is an essential part of daily leadership. They look forward to sharing what they learn from follow-up survey results available soon.
Jamie Beach is the Quality Data Manager at the University of Michigan Frankel Cardiovascular Center. Diane Lopez is the Clinical Nursing Director of the CICU and Cardiology Step-down unit at the University of Michigan Frankel Cardiovascular Center. Barbara Balik is faculty for the Institute for Healthcare Improvement's Finding and Creating Joy in Work virtual training.
Joy in Work is a featured track at this year's IHI National Forum on Quality Improvement in Health Care.