ONS Innovations Award Program

James A. Haley Veterans' Hospital, Tampa, Florida

**Transforming Care at the Bedside in a Medical-Surgical Unit**

**Summary of Initiative:** A patient-centric work redesign model was
implemented on a medical-surgical unit to improve patient and nursing
outcomes through an interdisciplinary collaborative team, utilizing a
systematic process and performance improvement framework. The model was
implemented as part of "Transforming Care at the Bedside (TCAB)", a
national demonstration project funded by the Robert Wood Johnson
Foundation (RWJF) in partnership with the Institute for Healthcare
Improvement (IHI).

**Date of Implementation:** The TCAB demonstration was initiated at the
James A. Haley Veterans' Hospital (JAHVH) in June, 2004 along with 12
other hospitals in the country. Participation in this project was by
invitation only. Likely factors in the selection of this facility were
our achievements both as the first VA to receive American Nurses
Credentialing Center (ANCC) Magnet recognition and as the first
recipient of the ANCC Magnet Prize which recognizes "extraordinary
innovations that transform the work environment." Along with active
participation in the TCAB demonstration, the JAHVH has shared this model
locally, regionally, and nationally as a best practice within acute
care.

**Background:**

The JAHVH is the only VA facility participating in the TCAB national
demonstration project. The project is primarily designed to target one
segment of the healthcare delivery system \-- bedside care on hospital
medical-surgical units. The goals of TCAB are to

-   Enhance the quality and safety of patient care and service

-   Create more effective care teams

-   Improve patient and staff satisfaction

-   Improve staff retention

Several recommendations with the Institute of Medicine's (IOM) *Crossing
the Quality Chasm* report and *Keeping Patients Safe: Transforming the
Work Environment of Nurses* created an organizing framework, as well as
actions and measures for the TCAB demonstration. TCAB also responds to
the growing concerns over nursing shortages and how healthcare
organizations can impact nurse satisfaction and retention. The TCAB
model addresses fundamental healthcare quality issues: the need to
reduce errors, enhance organizational efficiency, adapt to constant
industry changes, and maintain financial viability. The TCAB initiative
is designed to unleash the creativity and marshall the enthusiasm of
frontline workers to make significant changes toward the project's goals
and its redesign aim.

Four design targets were identified for TCAB to be addressed by the
implementing team. They include:

-   Zero unanticipated deaths and no needless pain or suffering

-   Clinicians, staff and students are able to say "I contribute to an
    effective care team within a supportive environment that nurtures my
    profession/career growth and continually strives to attain
    excellence"

-   Patients are able to say "They give me exactly the help I want (and
    need) exactly when I want (and need) it"

-   Documentation is reduced by 50% and clinicians spend 70% of their
    time in direct (value added) patient care

There are ten new guiding rules for TCAB units that were also adopted
from IOM reports that help healthcare organizations build an ideal
system of care delivery. These new rules that are integrated into the
team's philosophy are:

1.  Care is based on continuous relationships

2.  Customization is based on patient needs and values (individual
    preferences)

3.  The patient is the source of control for his/her healthcare

4.  Shared knowledge and the free flow of information is essential for
    patients

5.  Evidence-based decision making should be the norm

6.  Safety is a system priority in reducing errors and harm

7.  The need for transparency must occur for patients and families to be
    active partners in their care

8.  Anticipation of needs for patients ensures a more patient centered
    approach

9.  Continuous decrease in waste is essential for system improvement

10. Cooperation among clinicians as the primary patient team is critical
    for coordinated care

**Rationale for the Innovation:**

Hospitals abound with new technology, workforce innovations, and
advances in the delivery of health care. Traditional medical-surgical
nursing units in acute care hospitals employ 31% of all registered
nurses[^1]. At the JAHVH, this figure is 23%. Despite many new
technologies and much workforce manipulation, this concentration of
nurse resources in medical-surgical units has not experienced intense
redesign of the work they do. The IHI asserts that a lack of systematic,
carefully thought-out and staff-empowered redesign of medical-surgical
work settings results in high turnover, excessive error rates, waste and
less than optimal patient outcomes.[^2] Our experience with turnover is
instructive since prior to TCAB, the total unit turnover in FY 2003 was
25.82%. In FY 2004 it decreased to 20.77%, and for the current FY it is
7.60%. During the past year, after implementation of TCAB, only one
registered nurse has left the unit and this was due to health reasons.
Turnover rates on other medical-surgical units during the same time
period (FY2004) compare at 27.55%, 28.15% and 32%. Even for the current
FY 2005, rates are greater than the TCAB unit at 10.14%, 17.09%, and
18.02%.

Medical-surgical units are often the most challenging of nursing care
settings because of perceived strained staffing levels, complex patients
with multiple conditions, rapid movement of patients in and out and lack
of glamour for nurses who might want to specialize. Since many different
physician teams work on a single unit, and multiple disciplines
generally cross several of these units, close professional relationships
are difficult to forge, leading to communication difficulties and less
than optimal patient outcomes. New graduates may perceive working in
this setting as temporary work until they have sufficient clinical
experience to transfer to other specialty units. Medical-surgical units
must energize, create new models for care, and become the setting for
renewing energy and the passion for nursing.

The literature clearly supports the principles associated with the TCAB
model. Collaboration among nurses/physicians is one of the 14 Forces of
Magnetism identified through nursing research as one of the factors
present in organizations that are able to attract and retain nurses, and
is well documented in the *Magnet* *Hospitals Revisited* by McClure and
Hinshaw (2002) as well as the *Magnet Manual*. The IOM report *Crossing
the Quality Chasm* further delineated patient centered concepts that
contribute to increased coordination of care and patient satisfaction.
*Keeping Patients Safe: Transforming the Work Environment of Nurses*
report added the concept of a supportive work environment that nurtures
professional growth and career development while promoting patient
safety.

The TCAB model provided a great opportunity to increase participation in
care and shared decision- making with patients. When the TCAB model was
initiated, the unit had recently established a unit council for shared
governance that helped support the change. The 5 South medical unit at
the JAHVH was selected for TCAB based on unit leadership, physician
support, and interdisciplinary effectiveness as well as staff
cohesiveness. These factors were instrumental in making the model
successful.

**Evidence of Nursing Leadership in Collaborative Effort**

The TCAB implementation team consists of the Associate Chief of
Staff/Nursing (ACOS/N), the Associate Chief of Nursing Service/Acute
Care, the Nurse Manager of the medical-surgical demonstration unit (5
South), staff nurses on 5 South, the Chief of the Department of
Medicine, the Social Work Team Leader, Union Steward, and the facility
Fiscal Officer. All of these team members have attended national
training and been instrumental in creating a strong interdisciplinary
approach to improving patient care. This leadership base clearly
demonstrated to all disciplines the importance of this project and
collaboration to improve patient outcomes. This leadership commitment
was mandated to ensure the support would be present from all of the
senior leaders in the organization.

The facility's experience in the first five years of Magnet designation
enhanced and extended relationships and close collaboration between
nursing and medicine. Despite a recent report which finds that
physicians are not sufficiently engaged in quality improvement
efforts[^3], our experience in this facility is just the opposite as a
result of participation in TCAB. The Chief of the Medical Service and
other hospitalists in that service are consistently and firmly
supportive of TCAB, which is at its core a performance improvement
model.

One or more hospitalists, including the Chief of the Medical Service,
attend weekly TCAB project meetings. The hospitalists have provided
vigorous support and active participation in the management and
operation of the TCAB initiative. The Chief of the Medical Service has
attended two national meetings of the TCAB project along with the other
members of the implementation team. The support of medicine cannot be
over-emphasized throughout the first year of this demonstration project
since the Chief of Medicine is also instrumental in the "spread" of the
TCAB initiatives to other medical-surgical units throughout the
hospital.

Presentations of the TCAB initiatives have been widely accomplished
locally, regionally and nationally.

-   Locally, the ACOS/N and Nurse Manager on 5 South presented to the
    JAHVH Executive Level Board, the Nursing Performance Improvement
    Committee, the VISN Executive Level Board and, individually, to five
    other nursing units.

-   At the regional level, the TCAB demonstration was included in a
    presentation to Congressional staff of Congressman Bill Young, and
    the (Florida) Governor's Sterling Conference.

-   Nationally, JAHVH hosted a tour and demonstration of our TCAB
    initiatives to approximately 100 members from all participating
    hospitals across nine states in the TCAB demonstration. Another
    national presentation will be *Enhancing the best of the old: one VA
    hospital's experience in a national demonstration,* at the 8^th^
    Annual Forum on Health Care Leadership in Las Vegas, NV, August 13,
    2005.

This facility has also described the TCAB initiatives for the nursing
press, and three articles have appeared to date in *NurseZone, Nursing
Spectrum* and *The American Journal of Nursing*.[^4]^,^[^5]^,^[^6]

**Scope of Initiative:**

During year one, June 2004-June 2005, the demonstration unit sponsored a
"deep dive," or think tank brainstorming session. The participant group
consisted of all levels of staff from environmental services through
physician caregivers, in order to generate ideas which were felt to
contribute to the goals of TCAB. Several of these initiatives were
selected for testing, adoption or adaptation based on results of the
evaluations of the initiatives. The contribution of each initiative
toward patient centeredness and/or staff vitality (joy of work) was
measured, generally by paper and pencil questionnaires. Ninety percent
or higher scores on these instruments led to adoption of the initiative
into the work of the unit. This created a rapid cycle improvement
process by the entire interdisciplinary team.

Based on the enthusiasm of the staff, work began mid-year of year one to
"spread" the initiatives and the process and improvement program across
acute care units within the facility, as well as within selected units
in the Spinal Cord Injury (SCI) Center. The TCAB model that began on one
unit has now officially spread to 7 North medical unit and SCI-D.
However, some of the improvement ideas generated from TCAB have spread
across additional units, demonstrating how teams have shared best
practices. The improvement ideas that have been spread on other units
even before formal adoption of the TCAB model are italicized in the
table of Initiatives and Outcomes.

A physician and other staff from Bay Pines VAMC have received a formal
orientation to the original performance improvement project (TCAB)
because of their interest in implementing a similar project at that
facility. Presentations of the incidental findings at regional and
national meetings as well as reports in news media to date have
increased the likelihood that the initiative will have impact within and
outside the VISN. National attention is also present on the IHI web page
which describes this unique project as well as the hospital
participants. Through this visibility, our organization receives
national attention, and requests have been received from private
hospitals requesting guidance on our successful processes and
benchmarking. This national networking opportunity has expanded the
concept of TCAB across multiple sectors.

**Impact on Workforce Challenges/Patient Outcomes:**

At the conclusion of year one, about 100 ideas for testable initiatives
have been generated by all levels of staff from medical, nursing, social
work and ancillary services. Several of these initiatives were tested on
a small scale, adopted or adapted based on the results of the small
scale tests, and outcomes were measured. There were positive, directly
attributable patient quality indicator outcomes for these initiatives.

Some of the initiatives developed and tested to date are listed in the
table below.

  ----------------------------------- -----------------------------------
  **Initiative**                      **Outcome**

  *Erasable white boards placed at    Patients have more sense of control
  each bedside for patient goals,     and feel their own goals are
  procedures, estimated discharge     considered. There is less chance
  date.\**                            for communication slippage from
                                      patient-to-nurse-to-physician about
                                      goals of treatment.

  *Change in daytime medication       More time for both day and evening
  administration time from            shifts to organize and plan care,
  9AM-1PM-5PM to 10AM-2PM-6PM for     as well as provide faster
  multi-dose medications.\**          turnaround of patient discharges
                                      and new admissions. This outcome
                                      proved so beneficial the time
                                      changes are being integrated
                                      hospital-wide.

  *Lists of the day's medications are Patients may report "I'm not taking
  printed for each patient at the     that any more"; list provides
  start of each day\*.*               opportunity to change hospital
                                      standard dosing time to patients'
                                      own, often different, home dosing
                                      pattern. This reconciliation
                                      process provides accurate data for
                                      the entire team. This outcome
                                      proved successful in meeting the
                                      Joint Commission's national patient
                                      safety goal and is being spread
                                      across other units.

  At change of shift, a               More opportunity to clarify and
  nurse-to-nurse in person "sign-off" amplify tape-recorded shift change
  is given at each patient's bedside  information. The visible presence
  instead of a taped report.          with patients improves continuity
                                      and coordination of care.

  Shift report was split into Team 1  Reduced by half the amount of time
  and Team 2, each on separate tape   all staff spent in shift report
  recorders to increase efficiency of (from 45 minutes to 25 minutes).
  report.                             

  In consultation with the clinical   Hospital acquired pressure ulcers
  specialist, staff developed and is  are measured each month with
  using a skin care regimen to        all-hospital pressure ulcer
  prevent pressure ulcers and treat   incidence reports.
  Stage I pressure ulcers.            

  An evening transporter position was Licensed and unlicensed personnel
  approved and staffed (Monday        spend less time away from the unit
  through Friday) to reduce nurses    to transport patients or doing
  performing non-nursing tasks.       non-nursing tasks.

  Social Work Service developed an    Patients were not aware of some
  orientation packet that is given to services that are helpful to them
  each patient on admission.          at home or in hospital. The new
                                      packet provides education and
                                      resources that had not been tapped.

  Small storage cabinets were         The increase in storage for
  installed at the ends of both halls supplies reduces steps needed to
  on the unit.                        get selected high-use supplies and
                                      improves efficiency.

  Extra telephones were installed at  The increased availability of
  the mid-point of both halls on the  phones reduces steps to pick up
  unit.                               phone messages.

  Daily multidisciplinary rounds were Enables wider collection and
  expanded accompanied by wireless    validation of assessment and
  computer.                           discharge planning information.
                                      Orders can be entered at the
                                      bedside, improving timely accurate
                                      orders.

  \*These initiatives have been       
  implemented even on some units that 
  have not yet adopted the TCAB       
  model.                              
  ----------------------------------- -----------------------------------

Additional, difficult to measure, and more anecdotal outcomes of the
demonstration at James A. Haley VA Hospital are nonetheless powerful,
and include:

1\. Staff praise the improved communication between families, physicians
and nursing staff.

2\. Patients state they more clearly feel a part of the healthcare
decision process.

3\. Closer and more positive working relationships are demonstrated
among physicians and nurse.

4\. Staff report that patients are empowered.

5\. Staff have "taken over" the generation of new ideas to test and
implement, in order to accomplish patient- centeredness and a joy of
work for staff. Their enthusiasm for making change in patient care has
not waned, and the ideas for change continue to come forth from these
energized staff.

A matrix of patient and staff outcomes developed by the TCAB project
includes a balanced list of indicators, which are reported monthly. Some
of these are concurrently reported to the National Database of Nursing
Quality Indicators (NDNQI), a requirement of the American Nurses
Credentialing Center for Magnet hospitals. Three measures utilized PDAs
worn by RNs on selected shifts. The PDAs vibrated at random times,
prompting the RN to indicate what activity was engaged in at that
moment. The PDA data was then downloaded to IHI and percent of RN time
was calculated for the tasks identified on the PDA screen. Improvements
in indicator scores are described in the following table.

  -------------------- --------------------------------------------------
  Indicator            Improvement after year one of TCAB

  Nursing hours per    This measure has increased for the past year from
  patient day          5.95 to 6.36 hours

  Falls incidence      The number of falls have increased from 3.75 to
                       5.30 per 1000 patient days. This rate is better
                       than the NDNQI national benchmark; the percent of
                       falls with moderate or greater injury has been
                       zero for over six consecutive quarters.

  Pressure ulcer       The 5 South unit has not had a hospital acquired
  prevalence           ulcer for the past three consecutive quarters.

  Percent of RN time   Time RNs spend in value-added care has improved
  in value added       from 64.6% to 77.5%.
  work\*\*             

  Percent of RN time   Time RNs spend in direct patient care has
  in direct patient    increased from 48% to 53.3%.
  care\*\*             

  Percent of RN time   Documentation time was reduced from 9.3% to only
  in documentation\*\* 5.5% of time which provided the increased time
                       that nurses spent in direct care.

  \*\*Performance on   
  these items exceeded 
  all other hospitals  
  in the TCAB          
  demonstration.       
  -------------------- --------------------------------------------------

.

Additional quality indicator data is drawn from random chart reviews
using a complex tool developed by the IHI. Scores on two quality
measures, unscheduled returns to ICU and adverse events, have improved
slightly over the course of year one. Dramatic change was not expected
since our scores were already good when benchmarked with the other TCAB
hospital cohort. For scores on the remaining quality indicators, no true
pattern emerges as yet.

Strong support for the TCAB project has come from patients. Patient
satisfaction scores on the demonstration unit (NRC+Picker survey data)
reflect this support. Ten of the twelve individual items from
July-September 2004 showed improvements compared to July-September 2003,
with three scores being 100% positive:

> "Nurses were courteous and caring"
>
> "The nurse told me about my medications and how to take them at home"
>
> "I was told how to take care of myself at home"

In the October-December 2004 time frame, which was midway through the
first year of the TCAB demonstration, six scores on the twelve items
were reported as 100% satisfaction. There were improvements on ten other
patient satisfaction items comparing results from July-September, 2003.
The additional three 100% scores were:

> "I received medication for my pain in a timely manner"
>
> "My call light was answered in a timely manner"
>
> "Procedures and tests were explained to me in simple terms"

The process of unleashing staff creativity to accomplish mutually-agreed
upon, patient-centered goals has achieved a joy of work and a high level
of enthusiasm among the staff of the demonstration. This enthusiasm and
patient-centeredness is leading the spread to other units. Staff now
tend to focus on patient outcomes rather than a set of tasks which need
to be done before the shift ends. We believe this best practice model is
easily transferable to other medical-surgical settings within the VHA
and we heartily endorse its use.

[^1]: Spratley et al., *The Registered Nurse Population, March 2000.*
    Washington, DC: US Department of Health and Human Services.

[^2]: Institute for Healthcare Improvement. Innovation Series 2004.
    Transforming Care at the Bedside. p. 24
    <http://www.ihi.org/NR/rdonlyres/2351AD3E-FFCE-45EC-8A4C-E0E186DCD8B9/0/TCABWhitePaper2004.pdf>
    Retrieved May 25, 2005.

[^3]: Audet AMJ, Doty MM, Shamasdin J, Schoenbaum SC. (2005) *Measure,
    learn and improve: physicians' involvement in quality improvement.*
    Health Affairs. 24:3:843-853.

[^4]: Rothwell K. Hospitals take steps to transform care at the bedside
    (online) in NurseZone electronic journal. Retrieved 3/18/05:
    http://www.nursezone.com/job/HospitalProfiles.asp?articleID=13347

[^5]: Williams S. Med-surg makeovers (online) in Nursing Spectrum
    electronic journal retrieved 3/18/05:
    http://community.nursingspectrum.com/MagazineArticles/article.cfm?AID=13676

[^6]: Nelson R. Improving patient care at the bedside: two new
    initiatives to create safer environments. (2005) American Journal of
    Nursing 105:4:25-26.