Cambridge nonprofit cuts nursing turnover

The community hospital in South Dakota's fourth-largest city, Watertown, has just 81 beds and is nestled in the heart of camping and fishing country, but that doesn't mean hospital nurses there lead tranquil lives.

On the general medical-surgical unit, which holds the majority of beds at Prairie Lakes Healthcare System , nurses were harried, stressed, and basically burned out. They quit in droves, with a nursing staff turnover rate at a startling 65 percent. With about 40 full-time nurse jobs on that unit, administrators often coped with 10 vacancies at a time, exacerbating stress levels.

Now, six years later, administrators and nurses participating in a pilot program engineered by the Institute for Healthcare Improvement , a nonprofit in Cambridge, have redesigned the way nurses work. They have reduced the amount of wasted time and increased the amount of time nurses spend at the patient's bedside.

The result: Nursing staff turnover at Prairie Lakes is down to 10 percent or less, and patients are getting more attention.

"Now, when we have an open position on this unit, we have 10 qualified applications for the job," said Jill Fuller, chief nursing officer at Prairie Lakes Healthcare. "The reputation of the unit has changed so much that people want to work here. That wasn't the case six years ago."

Researchers from the Institute for Healthcare Improvement said they have seen similar improvements in nurses' morale and efficiency at the 13 hospitals around the country, large and small, that are participating in the pilot program, called Transforming Care at the Bedside. They have reduced turnover from an average of 14 to 15 percent to about 5 percent -- a critical milestone in an industry plagued by nursing shortages.

The institute is best known for its initiative to save at least 100,000 lives a year by reducing infections and medical errors at more than 3,000 hospitals. Less well known are its efforts to improve care in less visible ways -- by scrutinizing the way hospitals go about their daily business.

The institute's programs are based on reducing complexity and waste while increasing standardization, using the same production principles Toyota honed for making cars.

Institute specialists, including vice president Pat Rutherford , a former nursing administrator at Children's Hospital Boston , have analyzed the workflow of nurses and made a series of recommendations on how to improve efficiency. They use a standard template, and nurses on individual units are encouraged to come up with ways to improve their workflow.

Among the key steps: getting medications and supplies closer to patients, so nurses spend more time with patients and less time at central supply cabinets.

These kinds of common-sense steps have reduced the potential for medication errors and have made nurses feel happier about their work at Prairie Lakes, Fuller said.

"They can have more time at the bedside," she said, "and not spend time hunting and gathering for their medications."

At The University of Texas M.D. Anderson Cancer Center , a 512-bed research hospital in Houston, the nurses on two surgical units with a total of 58 beds are participating in the pilot program. They established a system of white boards in each patient room, where the clinical goals for the day, patient goals for the day, and nurse's photographs are posted. The boards have been so successful that they are being used in the rest of the hospital.

In a time-saving measure, M.D. Anderson nurses developed an Excel spreadsheet system to use during change-of-shift patient transfers, replacing meetings, which were consuming time and making nurses stay past the end of their shifts. In its first year it saved the hospital $80,000 in overtime payments. It is being rolled out hospitalwide, said Beverly Nelson , director of nursing practice programs.

M.D. Anderson also introduced an experimental "nurse tranquility project," a fancy name for a recliner set aside in a quiet space, where nurses can nap during a lunch break. Two nurses have been using it, Nelson said, one who has small children at home and a second who is a cancer survivor and naps before driving home from her shift.

It all adds up to better, smarter work environments that will improve patient care and help institutions reduce staff shortages, Rutherford said.

"It's this ripple effect. You create a better work environment," she said, "and nurses want to stay there."

Christopher Rowland can be reached at crowland@globe.com.