Purpose for the program: Nursing leaders and staff identified nursing practice in Labor and Delivery as complex with many variables influencing workload and productivity. Observation of clinical practice reinforced the dynamic nature of the unit with high risk patient presentations and co-morbidities requiring multi-tasking, critical thinking and expert care. Staff nurses described inefficiencies and discrepancies that added to nursing workload and interfered with clinical care. Themes and patterns emerged in their observations which represented eight areas for improvement.

Proposed change:   Eight staff performance improvement groups were formed to address the issues. 

Implementation, outcomes and evaluation: Eight groups were constructed with two-three staff nurse members, a staff nurse as chair, a leadership resource and a facilitator.  Each group was given a charge, data and drivers for their work, education and support for performance improvement processes and a timeline.  The course for each group was complicated and took longer than planned. Their motivation and commitment prevailed to produce a recommendation for pilot implementation of practice change in six of the groups and ongoing progress to goals for the other two.  Workload and Allocation of Resources developed a nurse-driven patient acuity/complexity scoring system for pilot and integration with the institution's QuadraMed patient classification system.  Post-Delivery Length of Stay validated activities that occur between delivery and transfer to PostPartum Unit for vaginal and C-section deliveries and proposed improvements.  Induction group collected and analyzed data to describe utilization patterns and proposed redistribution of work and resources.  Communication/Collaboration conducted extensive on-unit analysis of communication behaviors and designed an intervention for daily interdisciplinary rounds.  Environment of Care identified LDR room readiness as a problem, collected data, worked with support departments to construct a reliable system for equipment and supplies.  Professional Growth/Development assessed staff needs and designed an education, mentoring, accountability program using experise and resources from within the staff.  The Documentation group is evaluating elements of nursing documentation that influence perinatal outcomes and including  those in new electronic medical record.  The Outcomes group is identifying evaluation methods for perinatal outcomes, patient and staff satisfaction, regulatory compliance and financial indicators.

Implications for nursing practice:   Best practice innovations come from clinicians. Staff performance improvement groups will continue to monitor the results of their implementations and look for opportunities for other practice improvements.  We will move toward identifying stategies that strengthen interdisciplinary, collegial  and collaborative practice.  The work of the eight performance improvement groups has built a foundation for continuing development of clinician-driven practice improvements to assure successful outcomes for mother, baby and family.

Keywords: practice, workload, productivity, innovation, empowerment, outcomes.