CHCM Makes the Grade at a Major Academic Medical Center

Unit Practice Councils Lead to Major Improvement


A major academic medical center, ranked number one in a large competitive region and top-ranked, by US News & World Report has achieved exceptional outcomes. This kind of achievement doesn’t happen by accident, and it doesn’t happen overnight.

One of the key drivers to excellence was Relationship-Based Care. (RBC) This academic medical center leveraged RBC as a key component of their professional practice model, investing in proven methods to continuously improve and sustain the work of their Unit Practice Councils.

Their story highlights the extraordinary focus that resulted in significant improvements in clinical outcomes, and increased levels of satisfaction for both patients and their nurses.


Shared governance—essentially a decentralized organizational structure in which Unit Practice Councils are empowered to plan, implement, and evaluate improvement efforts for their unit—is a pre-requisite and central component of professional practice. The concept had been in place since the mid 1990s. But it wasn’t functioning at full advantage—the staff was less than fully engaged, and didn’t take complete ownership of outcomes. Also, the staff wasn’t entirely proficient in interpreting data and measuring outcomes.

In the case of this health system, Unit Practice Councils focused on improved quality, satisfaction and patient outcomes.


The solution had five parts.
  1. An investment in Relationship-Based Care, an ongoing program that promotes excellence in nursing.
  2. The implementation of Unit Practice Councils to drive continuous improvement.
  3. Incorporating best practices in co-worker communication and teamwork, using Manthey’s Commitment to My Co-Workers© behaviors and integrating them into job descriptions and performance evaluations.
  4. Holding an annual hospital-wide RBC summit during which UPCs celebrate and present measurable outcomes of their work and how they support patient care and the professional practice model.
  5. A series of experiential learning seminars called Re-igniting the Spirit of Caring, which helps people connect with the meaning of their work, and to discover the best in themselves and share that with others.
Re-igniting the Spirit of Caring participants had some telling comments

I think everyone should be offered this class/program. In order to create change, it first needs to be within ourselves and if not given the opportunity to stop and reflect, then change will not happen. This class gave me a chance to do just that.

I had an amazing time. The workshop was very challenging, inspiring and it did re-ignite my desire to improve as a caregiver.

I can’t say enough good things about this. It was truly life-changing in addition to career changing. Please continue to have guest patients come tell their stories. The emotions were raw and real. This class is awesome.


The Organization-Wide Metrics on Improvement are Striking.
Patient satisfaction jumped from 55th percentile to 88th percentile between 2013 and 2015.
HAPU rates decreased dramatically, with sustained performance over a three-year period.

Nurse satisfaction went from underperforming to outperforming in four out of five criteria.

The academic medical center achieved its 3rd Magnet® designation in 2015—and in 2016, a 2nd medical center in the system received a Magnet® designation for the very first time in 2016.

Department Outcomes are Equally Impressive

Designated as a Baby-Friendly hospital.
Rates of parental satisfaction in the Neonatal Intensive Care Unit have gone up significantly.
The number of falls and Hospital Acquired Conditions has dropped dramatically.
The number of nurses certified for the operating room has increased.
There’s been a stunning decline in CLASBI rates.
And in the adult psychiatric unit, the incidence of assault has been significantly lowered.

Simply put, our efforts have strengthened relationships, exceeded expectations and more than paid for themselves.