Shaw, Lindsey
Health Systems Learning

Understanding Performance Improvement in a Post-Surgery Unit

Faculty Mentor: Bret Lyman, BYU College of Nursing

Introduction

The purpose of this study was to discover how a health system, specifically a
hospital unit, learned to improve patient and hospital outcomes. This study builds upon previous
research in which the Learning History research method was used to discover and describe the
pathway by which a critical care unit learned to achieve and sustain excellent outcomes. The
previous study focused on hospital unit situated in a regional medical center that was part of a
large, not-for-profit health system. That hospital unit’s history of learning improvement extended
over 10 years, and included several distinct developmental eras, progressing from creating staff
ownership and a positive identity for the unit to striving for reliable performance and sustained
excellence. This study generated a detailed description of rural hospital unit’s learning history,
thus offering an opportunity to begin identifying patterns of health systems learning across
hospital units.

Methodology

The unit of focus for this study is a specialty post-surgery unit, embedded in a
rural hospital that is part of a national, for-profit health system. The Learning History research
method was used to identify five of the unit’s notable outcomes. These notable outcomes
include, 1) collaboration among nurses and with physicians, 2) patient and family satisfaction, 3)
low rates of hospital acquired infections, 4) effective shift change/report, and 5) clinical
protocols. Individual interviews were conducted with unit nursing staff and other
inter professional health care members. Artifacts, including relevant forms, were gathered to
further understand how this unit achieved excellent patient outcomes. Data was collected through
interviews until saturation was reached. This data was then analyzed to gather themes, regarding
the stages of learning the hospital unit has gone through. After the gathered data was distilled, a
validation process with selected participants took place to confirm that the findings of this study
were accurate. The data and themes from this study were then compared to the results of the
previous learning history study to determine if there are any patterns of health systems learning
across hospital units.

Results

The post-surgery unit is a rather young unit, as it was developed only 11 years ago with
the intent to create a unit that would optimize patient care and outcomes of surgical operations.
The staff on this unit was pulled from other successful units within the hospital. From the data
distillation process, five themes were gathered. These included: 1) implied structure, 2) authentic
caring, 3) shared leadership, 4) thoughtful change, and 5) sustaining culture. This unit has
implied structure, as the unit was created rather quickly without any formal structure. There are
few structured meetings to care for patients and most decisions on the unit are made through
informal and open discussions. Authentic caring on the unit entails that the staff genuinely care
for their patients and other staff on the unit. Unit staff is motivated to provide excellent care
because they are authentically invested in the success and happiness of the patient. The postsurgery
unit demonstrates shared leadership and thoughtful change by making meaningful
decisions for the unit as a team. The nursing manager is open to staff input and policies are
implemented in a way that is meaningful for staff, on the staff’s terms. This is very unique in a
hospital unit. Finally, this unit is successful at sustaining unit culture as they focus on patient
centered care. In order to sustain their culture of patient centered care, staff on the unit only hire
individuals who share their same ideals.

Discussion

The findings of this research study build upon a prior learning history gathered by
Lyman et al. on a hospital unit within a regional medical center (in press)1. Interestingly, the
regional medical center and the rural medical center units both worked through similar stages of
development yet, differed in the rate of progression through the respective stages of
development. These four stages of development are: 1) identity and ownership, 2) team and
respect, 3) accountability and support, and 4) reliability and sustainability. Identity and
ownership developed almost immediately for those working on the post-surgery unit, while the
regional medical center unit took almost 6 years to develop this attribute (Lyman et. al, in press).
This may have been because staff on the post-surgery unit were carefully selected to be on the
newly developed surgery unit and most staff members felt a sense of honor. Alternatively, staff
in the regional medical center originally had little pride in their unit as most staff members felt
that their positions were undesirable. Identity and ownership developed overtime as staff
members slowly began taking pride in their unity as they began caring for higher acuity patients.
Team and respect developed quite quickly on the post-surgery unit as staff felt a sense of
ownership for their unit. As the identity of the post-surgery unit was created, staff members
quickly came together to work as a successful team. However, members of the interdisciplinary
care team on the unit within the regional medical center struggled to get along (Lyman et al., in
press). This led to a delayed development of team unity and respect. On the post-surgery unit,
accountability and support developed informally as staff naturally grew comfortable expressing
ideas in staff meetings and reaching out to others for help throughout their shifts. However, the
regional medical center unit developed accountability and support through formal improvement
programs at the unit and hospital level (Lyman et al., in press). Both hospital units utilize formal
tools to achieve reliability and sustainability. These tools include hourly rounding sheets, report
sheets, shift group huddles, among others. The ability to maintain excellent outcomes may have a
correlation to level of general patient acuity seen on each unit or the age of the unit. More
research is needed to confirm these correlations.

Conclusion

Both the post-surgery unit and the regional medical center unit advanced through a
series of developmental stages to become an organization that produces excellent patient care
outcomes. Future research should be performed in order to better understand organizational
learning within health systems. Nursing managers may also use this template to assess where
their unit is at on the developmental spectrum and plan for improvement.

¹ Lyman, B., Ethington, K., King, C., Jacobs, J., & Lundeen, H. (in press). Organizational
learning in a cardiac intensive care unit: A learning history. Dimensions of Critical Care
Nursing.