Pressure ulcers are preventable—but until recently, the 5 North/South medical-surgical unit at San Diego Medical Center had never gone more than 58 days without one.

Yet once the department’s unit-based team got to work on the issue, that number practically doubled—to 105 days as of mid-July. What happened?

Dozens of small tests of change, for one thing—which, along with support from two improvement advisers and observation from the Definitive Observation Unit, helped the unit-based team come up with a “turn team” process that’s working.

Teams alternate

Patients are selected by the staff based on their risk for developing pressure ulcers, which are painful and dangerous, interfere with patients’ recovery, lengthen hospital stays and increase the risk of infection. A four-person team turns those patients once every two hours. The turn team may include a charge nurse, RN, LVN and unit assistant. One person is the captain—it doesn’t matter which one—and the teams track the turns on a whiteboard. On any given shift, there are two teams that alternate doing the turns, so each team does  the turning only once every four hours.

Daily, five-minute huddles sped change throughout the unit dramatically by increasing communication between monthly UBT meetings.

Open communication

“We’re not afraid to ask, ‘Why are we doing this? Can we do it differently to be more effective?’” said Nancy Purdy, the department administrator and management co-lead. “We are OK with changing day to day.”

At first, for example, the UBT tried having one turn team do all the turning. That proved to be too taxing, so they switched to two alternating teams—which brought workplace injuries from turning way down.

Early on, the charge nurse kept a piece of paper in her pocket noting which team members were part of each turn team. But too often, some staffers didn’t get the word they were to be part of the turn team. An RN who’d just graduated from nursing school suggested listing the names on a whiteboard, which is working much better.

Effect on morale

“When a patient gets a pressure ulcer, it affects morale” among frontline staff, said Mary Ellen Mueller, RN, a UNAC/UHCP member and the unit-based team’s labor co-lead. Nurses want the best care and outcomes for their patients, she said, and want to be involved in improvements.

“If you aren’t engaged in making change, you feel stagnant,” she said.

Purdy and Mueller agreed that the fact that everyone on the unit has a say in the turn team, via huddles and through the unit-based team, is what’s fueling the shift on the unit.

Frontline engagement

“The UBT is very engaged,” Purdy said. “I used to think, ‘I’m the manager, I should set the expectation.’” Now, she said, she’s increasingly aware of the benefits of engaging frontline staff in making improvements.

“When you watch the results,” Purdy said, “it tells me it’s the right way.”

Recently, two patients on 5 North/South did suffer pressure ulcers—and team members reacted with a higher level of awareness than they had before, Purdy said.

Root cause analysis

“We took it to heart, and people were talking more openly than ever about what they might have done differently,” she said. The team also engaged a root cause analysis of the incidents.

The culture shift is improving employee satisfaction. In a survey, asked whether “in my work unit, everyone’s opinions are taken seriously,” nearly 73 percent of the staff agreed in April 2009, up significantly from 53 percent in November 2008.

“It’s very liberating to try ideas that will enhance your own workplace,” Mueller said.