Shelly Turbak, R.N., director of medical and surgical services at Prairie Lakes Healthcare System in Watertown, S.D., faces the same daily challenge as many in middle management—how to balance the administrative responsibilities of her position with the need and desire to spend time supporting and mentoring her frontline staff.

Recognizing Turbak's quandary, Jill Fuller, R.N., Ph.D., chief nursing officer at Prairie Lakes, took action. Fuller asked Turbak to identify obstacles that prevented her from being with her staff on the med/surg unit and propose solutions that might streamline her responsibilities.

Prairie Lakes has a strong history of encouraging nurses to improve quality by addressing some of the complexities often found in health care delivery. The hospital is one of 10 participating in Transforming Care at the Bedside (TCAB) (a program supported by the Robert Wood Johnson Foundation (RWJF) and the Institute for Healthcare Improvement (IHI)) which empowers nurses and other staff to develop, test, and implement changes that will dramatically improve care on medical/surgical units. Since TCAB demonstrated how nurse-led change can result in innovative solutions, Fuller knew that Turbak was in the best position to develop a new, more effective approach to her work.

Although Turbak believed in the importance of providing employee feedback, she felt the existing system of doing so was exceedingly inefficient. For each of her 65 direct reports, Turbak averaged almost two hours per annual employee performance review (30 minutes completing the written assessment; scheduling the appointment; and conducting a one hour meeting to discuss the performance appraisal). To address this, Turbak proposed an unconventional solution—eliminate traditional annual performance reviews.

Upon researching the idea further in the nursing literature, Fuller and Turbak realized that Prairie Lake's compensation model supported the change. Prairie Lakes does not have a pay-for-performance model; instead it offers staff across-the-board pay increases and market adjustments as needed.

Using principles learned from TCAB, Fuller and Turbak implemented a pilot that began in August 2006 and still continues. This new system does not altogether eliminate staff evaluation. Each employee is still required to perform a mandatory set of skills required for his/her position that are documented as part of annual training. Employees are also evaluated on Prairie Lakes' Qualities of Defined Success—communication, service, growth, teamwork and attitude.

However, under the new system nurses and staff on the Prairie Lakes medical/surgical unit no longer complete annual performance appraisals. Instead, routine patient care tasks that nurses competently perform during every shift are observed. Documentation only occurs when a deficiency exists, a complaint is made about employee performance, and counseling about job performance is required.

For example, during the traditional annual performance appraisal, managers assessed nurses' ability to complete standard nursing skills such as medication administration, by checking a box indicating that the nurse possesses this competency. In the pilot program, managers observe nurses performing their tasks, but only document substandard performance. Because of the nursing director's increased time on the unit, deficiencies are identified and corrected immediately, resulting in improved patient care.

Convincing the Human Resources Department this model can work has been challenging for Fuller and Turbank. Before the pilot even began, Human Resources raised concerns that proper counseling and documentation of performance problems and workplace issues may not be handled appropriately, and the department remains a proponent of formal, annual evaluations.

However preliminary feedback from the staff has been positive. Stephanie Namken, R.N., who works under Turbak on the Prairie Lakes med/surg unit, prefers the new system. She never regarded the traditional performance appraisal process as important because it seemed like she was answering the same question repeatedly.

Namken added that Turbak's management style is a significant factor in the program's success. Turbak begins her day on the med/surg unit and returns several times, monitoring the nurses and providing them with continuous feedback. She sends notes to nurses who demonstrate exemplary skills and service.

Turbak has also instituted an open-door policy, encouraging staff to visit her any time to share problems and concerns. She has even told staff to contact her at her home phone number, if necessary.

Several months into the pilot, Turbak prefers this new process of employee evaluations because it leaves her with more time to build connections with her staff through mentoring and coaching.

Fuller anticipates continuing the pilot program for at least a year. Prairie Lakes will evaluate the program's effectiveness by tracking employee opinions about the feedback they received from Turbak. Fuller will also review how well Turbak handled conflict resolution, communication and peer-to-peer reviews of performance during the pilot. The health system will also evaluate staff competencies and disciplinary actions with respect to appropriate and timely responses.

Following that evaluation, Fuller anticipates eliminating annual performance appraisals in other departments and units at Prairie Lakes, an idea that will be welcomed by the system's middle management. Fuller also reported that nurse managers are "lining up outside my door" to begin similar programs for their staff.