By: Nazmin Bakou
Imagine this: during a hospital stay for a routine procedure or surgery you see pictures of your nurse, physician, physical therapist, nurses’ aides — everyone on your care team — on a white board across the room. And on your bedside table you find a small notebook called “Questions about My Care” that suggests good questions to ask your doctor when she visits. And on the day you leave the hospital the nurse gives you a write-up about your hospital visit — what they did to you while you were there and why, what the tests found, what comes next, and what it all means about your health status. It’s nothing technical; more of a story about your stay in the hospital that’s simple enough to explain to your family and friends.
Such personal touches may seem a far cry from standard hospital experiences, but these are real examples of changes in patient care being implemented by a growing number of progressive hospitals that are part of a national initiative called Transforming Care At the Bedside (TCAB).
New Focus on Direct Patient Care
The program was launched in July 2003 by the Institute of Healthcare Improvement (IHI), in partnership with The Robert Wood Johnson Foundation(RWJF). It is targeting one segment in the health care delivery system: bedside care on a standard hospital medical or surgical unit. The aims for TCAB are to enhance the quality and safety of patient care and service, create more effective care teams, improve patient and staff satisfaction, and improve staff retention.
Pat Rutherford, IHI vice president overseeing TCAB, describes the program as the newest in a series of IHI redesign initiatives: “This is really the next frontier: direct patient care. We’ve already made inroads in redesigning care in the ICU, emergency departments, and the clinical office practice. Now the focus is on improving the quality of care on the standard hospital unit.”
A central principle behind the TCAB project is the link between the quality of care patients receive and the work environment in which their caregivers function. In particular, RWJF’s support for the initiative was a response to growing concerns over the crisis in nursing. The human and financial costs — to hospitals and society at large — of the high turnover and low retention rates in nursing, RWJF believes, demand bold new strategies.
More broadly, TCAB is addressing fundamental health quality issues: the need to reduce errors, enhance organizational efficiency, adapt to constant industry changes, and maintain financial viability. The initiative was designed to draw on IHI’s experience in mobilizing teams of frontline workers to make significant changes toward these goals, as well as its expertise in health system redesign.
The vision for a new model of bedside care evolved during 2003 in a series of design initiatives by a team of planners from IHI and RWJF. A key component was an intensive three-day brainstorming session, modeled on an innovation methodology led by consultants from IDEO called a “Deep Dive,” once featured on ABC’s Nightline. Through teamwork, role-playing and site visits to two Boston hospitals, the Deep Dive teams generated hundreds of ideas for how to enhance bedside care.
Field Testing the Promising Ideas
In the fall of 2003, IHI and RWJF recruited three hospitals to test the viability of the TCAB approach through a rapid prototyping process. The sites, chosen for their shared culture of innovation and strong leadership, included: Seton Northwest Hospital in Austin, Texas, part of the Ascension Health System; UPMC Shadyside, part of the University of Pittsburgh Medical Center (UPMC) in Pittsburgh, Pennsylvania; and Kaiser Foundation Hospital in Roseville, California, part of Kaiser Permanente.
Members of the TCAB design team held kick-off meetings at the three prototype sites with nurses and staff from the designated medical or surgical unit. The meetings offered background in IHI’s Idealized Design Process as well as its Collaborative learning process, which is based on the Plan-Do-Study-Act (PDSA) improvement methodology.
A focus of each meeting was brainstorming through storytelling exercises, describes Mary Viney, Director of Patient Care Services at Seton Northwest. She says: “The leaders from IHI and RWJF went around the room and asked everyone to think of examples of a patient visit they had been part of that went really well, where the patient had a really good experience. Then they asked, ‘Why was it so positive? What made it go so well?’” When they had identified the reasons, says Viney, the leaders asked them to imagine working on a unit where every patient could have that positive experience. “They said: ‘What would it take to make that happen? What would you do differently?’”
Viney says by the end of the day her TCAB team had 300 ideas. To narrow down the list, they divided the ideas into quadrants based on the difficulty of making the change and its cost. They decided to start with tests from the “easy/low cost” column, where in fact the majority of the ideas fell. After six months of testing, Viney says: “We still had 30 more ideas to test from this one category.”
According to IHI’s Rutherford, this prototype launch process reflects IHI’s overall approach to health system innovation. She describes it in a humanitarian example: “It’s the basic question, ‘Is it better to feed fish to people in a third world country, or to teach them how to fish?’ We wanted to teach the TCAB teams how to fish.”
Fresh Thinking, Simple Steps
Some of the most successful prototype tests have been simple, common sense changes in the way providers interact with patients. The personalized “discharge summary” mentioned above is a good example. Sue Martin, Director of Nursing Support Services at UPMC Shadyside Hospital, relates that this idea on her TCAB unit came from talking to patients: “We found out that what they really want to know before they leave is what happened to them in the hospital, in simple terms. Not just the generic ‘discharge instructions’ that say when to take your pills or when to schedule a follow-up appointment with the doctor.” She says: “So we write up something that tells the patient ‘You were admitted, your blood pressure was __, you had a chest x-ray, we found pneumonia, so we gave you antibiotics . . .’”
On the TCAB unit at Kaiser Roseville Hospital, a successful test grew out of an effort to help patients learn nurses’ names. Barbara Crawford, Chief Operating Officer, says her team decided to put up white boards in patients’ rooms to write names in large type. Then, she says, they decided to make it even easier: they bought a digital camera and started taking pictures of everyone — physicians, nurses, aides, respiratory therapists — everyone on the unit.
They got some magnets and attached 4” x 6” photos to the white boards, with names and titles underneath. So now, Crawford says: “Patients can connect faces with names, and know who the people are coming in and out of their rooms.” She adds that including photos of staff at all levels on the unit inspires teamwork and helps everyone make connections.
This visual approach was a hit, so Crawford says her team decided to expand it, share more information on the white boards. They started adding patients’ daily goals. She describes: “This isn’t personal information but clinical targets for the day. So, with patients’ input, we started to include goals such as: ‘Today we’re focusing on getting you to eat 100 percent of your food,’ or ‘We’d like you to get up in the chair three times’ or ‘Encourage deep breathing.’”
The impact has been powerful, says Crawford: “For the whole care team and the patient and family — everyone walking into the room sees that these are the goals for today. And because the goals are set with the patients, they participate in the process.” The team also encourages family members to write comments and questions about the daily goals, which make them feel more engaged in the process.
The project is spreading — quite literally. Crawford says: “Pretty soon we ran out of space on the white boards and needed bigger ones.” She says now they have progressed to using a magnetized iron oxide paint that helps them turn entire walls into white boards.
A white board has helped the TCAB team at Seton Northwest Hospital turn a back-office scheduling process into a meaningful shared system for managing nurses’ workloads. The idea started with a desire to improve the admissions scheduling process. Seton Northwest’s Mary Viney explains: “The TCAB floor is a very busy 64-bed unit that gets 15 to 20 admissions a day.” She says the unit can be inundated with requests to take in new patients, but relied on an inefficient process to manage this. The staff person in charge of bed placement used to go from nurse to nurse asking every one how busy they were every two hours, and made notes in a clipboard to keep track. “It was a slow, one-on-one process of portable cell phone calls around the unit,” says Viney, “and no one saw the information or could use it except the scheduler.”
Viney says a TCAB unit nurse got an idea for using a traffic light color rating scale to speed up the process when she heard about a similar innovation at Luther Midelfort — Mayo Health System in Eau Claire, Wisconsin, at IHI’s February 2004 Workforce Summit in Atlanta, Georgia. Viney explains: “She put at the top of her clipboard the check-in times: 8 AM, 10 AM, noon, and 2 PM, and on the left side she wrote the nurses’ names. Then when she talked to them, she asked them to rate themselves: red for ‘I’m swamped, I can’t take another patient,’ yellow for ‘I’m almost there, just give me another hour,’ and green for ‘I’m ready for a new patient.’” Soon, the nurse replaced the clipboard with a white board in a central location on the unit and bought red, yellow and green magnets to communicate the rankings. The board caught on right away, and is being adopted by other units in the hospital.
In the end, notes Viney with a smile: “This went from a bubble in someone’s head to implementation in four days and for about five dollars.” Moreover, she says: “There really isn’t any new information involved — we were already asking nurses how busy they were during a shift. But it feels so different for the staff: it’s empowering.” The new system is enhancing productivity in subtle ways, she adds: “Once the information became visible, there was a real sense of teamwork. Everyone could see who was swamped. And people started being proactive, pitching in to help get someone ‘out of the red.’”
A handful of the other promising innovations that have emerged from the TCAB prototype work include:
- Night shift “nursing rounds”: The night nurse and physician on the TCAB unit at Kaiser Roseville make quick rounds before the shift begins to check on patients. They anticipate problems that might come up during the night and take steps to prevent them: adjusting pain medications, cutting back the schedule for checking vitals, removing non-essential equipment. The proactive strategy has nearly eliminated pages to the physicians covering the shift — which could reach 150.
- Streamlined paperwork: The Seton Northwest TCAB team persuaded the 13 GYN surgeons who admit post-op patients to the unit to use a single, unified physician order form — the basic instructions for a patient’s medications, lab work, activity level — instead of the 13 different ones they were using. One physician champion helped them convince the surgeons how much time and energy the new process could save them, on top of the quality of care improvements tied to standardizing the system.
- Skin integrity cards: At Kaiser Roseville, nurses’ aides carry in their pockets a small card with drawings of the human body when they do bed baths. If they see reddened areas on a patient they circle that area on the card. The nurse validates the finding and flags it in the doctor’s progress notes. It’s a simple idea that turned into a powerful tool to prevent pressure sores — a leading cause of delayed discharges.
- Patient self-medication: The UPMC Shadyside team experimented with self-medication: giving patients the option of managing their own medications. Some patients found it empowering; others shied away. The clear lesson for the TCAB team, says Sue Martin, was the need for individualization: “Everyone is so different! We can’t make assumptions about what patients want.”
- Revamped food services: UPMC Shadyside is winning praise for its TCAB project creating a redesigned, patient-centered, “liberalized” dietary program. They’ve loosened restrictions, opened up the menus, extended kitchen hours and started an evening snack service in which a hostess brings around a basket of granola bars, fruit and yogurt. The initiative has not only reduced food waste, it has improved patients’ nutrition: they eat well because they get food they want.
- Van service: UPMC Shadyside offers patients a ride home when they’re ready to leave if family members are unavailable. Patients are grateful for the help and the service is easing “throughput” problems by freeing up beds earlier for new admissions.
- Workplace safety enhancement: In a TCAB spin-off project, the Kaiser Roseville team is bringing together housekeeping staff once a week to ask them for their ideas about keeping themselves safe.
Building on the Winning Innovations
Based on these early results, IHI and RWJF launched an expanded pilot phase of the Transforming Care at the Bedside project. Thirteen hospitals nationwide, including the three initial prototype sites, were invited to participate.
The pilot phase ran rom June 2004 through May 2006, and built on the most successful tests from the prototyping effort. By further honing the innovations, teams on the medical or surgical unit of each of the 13 hospitals worked toward developing best practices for transformed bedside care. Executives and frontline staff from each hospital engaged in IHI’s collaborative learning process, both through the pilot stage and as members of IHI’s IMPACT network.
Team leaders conveyed how their early victories in the initiative had been fueled by staff enthusiasm and a will to change, not operational shifts or capital investments. Seton Northwest’s Mary Viney believes “TCAB is really about a new way of thinking, having the courage to try new things, and trusting people to generate good ideas and go with them.” Barbara Crawford at Kaiser Roseville says TCAB has created an environment in which “I’m essentially there to validate the work and ideas of the people around me. That’s a really powerful message for staff.”
UPMC’s Sue Martin praises the fluid, ongoing process of rapid prototype testing: “We’re continually seeing what works best. We know we’ll continue to explore these ideas — adopt some, abandon others, but then revisit some that need further testing because they just make sense.” It is an energized process, she says, of “asking questions, making adjustments, wondering why we have to keep doing things a certain way just because we always have.”
Echoing her counterparts, Mary Viney says that regardless of her group’s future role in the TCAB initiative, her institution has embraced the overall mission: “TCAB got us going on the right path — and we’re not going back.”
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