THE importance of transforming healthcare has been extensively explored in 3 reports from the Institute of Medicine (IOM). The first report, To Err Is Human,1 outlines interventions that address external forces that influence the healthcare environment and their impact on creating change. The second report, Crossing the Quality Chasm,2 examines healthcare redesign and clinical microsystems. The third report, Keeping Patients Safe,3 examines the work environment including the structures and processes healthcare workers use in the delivery of care and emphasizes the need to design nurse's environments to promote the practice of safe nursing care. These efforts would result in improved patient care quality and service, promote effective care teams, improve staff satisfaction, increase retention, and enhance efficiency.
BACKGROUND
Healthcare organizations are at a crucial crossroad in the challenge to provide improved care for patients and attract/retain skilled nursing professionals in an environment of complex rapid change and constrained resources. The need for the greatest change in care delivery is at the hospital bedside.
In 2003, the Robert Woods Johnson Foundation and the Institute for Healthcare Improvement agreed to work together to create, test, and implement changes to dramatically improve care on medical/surgical units and improve staff satisfaction as well.4 The environment selected for this program-medical/surgical units-represents a large population of acute care patients with nurse practice patterns that could easily be generalized to other patient populations. Therefore, in an effort to redesign the work environment of nurses, the Transforming Care at the Bedside (TCAB) initiative was created. The Seton Healthcare Network agreed to take part in phase I of this project.
Specifically, the Seton Healthcare Network was 1 of 3 healthcare institutions from across the United States selected to participate. Our facility, the Seton Healthcare Network, is the leading provider of healthcare services in central Texas, serving an 11-county population of 1.4 million people. The network includes 4 acute care hospitals, 2 rural hospitals, a mental health facility, several strategically placed facilities that provide medical care for well patients, and 3 primary care clinics for the uninsured. In summary, the Seton Healthcare Network comprises 22 facilities, providing a full range of healthcare services to central Texas.
The TCAB initiative focused on one of our 64-bed general medical/surgical units. The average daily census of this unit ranged from 46 to 48 patients, with a turnover rate of 30% per day. The unit received patients from a variety of sources, such as the emergency department, operating room, intensive care unit, and direct admissions. Staff composition of the unit included 60% to 62% registered nurses and 38% to 40% unlicensed staff. Staff was asked to volunteer for the initial core work group. Ultimately, the work group or core team consisted of 8 staff nurses and a team leader, a charge nurse, a nursing director, a pharmacist, and a physician.
FRAMEWORK OF TRANSFORMING CARE AT THE BEDSIDE
In the summer of 2003, the Robert Woods Johnson Foundation and the Institute for Healthcare Improvement convened a group of healthcare experts and leaders in Boston, along with creative consultants from IDEO. IDEO, a design and innovative consultancy,5 facilitated an innovating process called the Deep Dive. The 5 specific aims of the Deep Dive were
* harvest "what is known" and build on validated knowledge about best care practices;
* generate new ideas from a brainstorming session;
* prototype new concept designs and test new ideas through rapid cycle change;
* expand existing models and/or develop new models to transform bedside care; and
* develop a conceptual framework, design measurable targets, and create change packages for dissemination.
During the Deep Dive process, participants actively shared their healthcare knowledge, made specific field observations of the current conditions, and then brainstormed and modeled their new improvement ideas in a very compressed time.4 What emerged from this meeting became the guiding framework of the TCAB initiative (Fig 1). During phase I of the initiative, the framework was spread to the 3 pilot sites, including the Seton Healthcare Network. Phase II consists of spreading the initiative to 10 other healthcare facilities across the United States.
Five premises also guided the pilot sites during the initiative (Table 1). Participating institutions and, specifically, staff had to accept these basic truths for success during the initiative. These premises challenged some of our outdated "truths" about healthcare.
Design targets, consistent with the key design themes of the initiative, provided direction to staff as they created new ideas or designed projects for implementation (Fig 1). The design targets also served as outcome measures for the initiative. Of even more importance in terms of providing the pilot sites with direction were the key design themes, which originated from the Robert Wood Johnson Foundation strategic objectives for the TCAB initiative.
These objectives, which are consistent with the IOM's 6 aims for healthcare improvement from a patient perspective, were aggregated into 4 key design themes. These design themes included the following:
* Reliability: The care for moderately sick patients who are hospitalized is safe, reliable, effective, and equitable;
* Vitality: Effective care teams continually strive for excellence within a joyful and supportive environment that nurtures professional formation and career development;
* Patient-centeredness: Patient-centered care on medical/surgical units honors the whole person and family, respects individual values and choices, and ensures continuity of care; and
* Increased value: All care processes are free of waste and promote continuous flow (Fig 1).
These themes served as guidelines to core team members as they created new innovations and interventions, also called microsystem design components. For example, as new interventions or designs were generated, staff members would ultimately have to ask themselves, "Does this idea really give the patients what they want when they want it?" (patient-centeredness).
Lastly, the simple rules outlined in the IOM report, Crossing the Quality Chasm,2 provided incentive for the TCAB initiative. These "new rules" guided the pilot sites in developing new systems of care. From both a macro-level approach and a micro-level approach, these rules stimulated inquiry, motivation, and open-mindedness when creating new ideas for healthcare.
METHODS
All 3 pilot sites used a 5-phase process to generate design components (innovations). These phases included planning, concept design, prototype testing, pilot testing, and adaptation, with resulting spread of the innovations throughout the organizations (Fig 2). Educational sessions for core team members focused on the initiative's objectives, aims, premises, simple rules, and design targets. Subsequent meetings focused on developing new innovations or design components for care delivery. The educational sessions and meetings (planning phase) had already begun to stimulate new ideas and aroused curiosity among the team members.
The business of innovation was guided by IDEO's Deep Dive process. Core team members began by asking, "What do we know?" about a design theme such as vitality and its associated target of "I contribute to an effective care team within a supportive environment that nurtures my professional/career growth." Core staff members were then encouraged to engage in storytelling. Staff was encouraged to be open, and both positive and negative stories emerged regarding the design themes and targets. Storytelling serves the purpose of stimulating thought and results in rich information that promotes insight among its participants.
After storytelling, staff members participated in a brainstorming session. Everyone was encouraged to develop as many innovations as possible that would contribute to the particular theme and target. Each innovation/idea was placed on a sticky note and was eventually discussed in some detail in terms of actual implementation. The sticky notes were then arranged on a 4-quadrant grid, with the horizontal axis reflecting time and the vertical axis reflecting resources (Fig 3).
Innovations requiring minimal time and resources support were then prioritized and selected for a rapid cycle trial. These types of innovations allowed the team to rapidly experience successes associated with project involvement. Some of the innovations identified included physician/nurse patient rounds, shared documentation, staff photos, shared patient discharge teaching, express admit, discharge teams, and registered nurse status board. After brainstorming sessions, team members engaged in phase 3 or prototype testing of these innovations/design components.
Rapid cycle change is a process that encourages testing creative change on a small scale while determining potential impact.6 The process encompasses 4 stages-plan, do, study, and act (PDSA). Two key principles for testing a change exist-testing your intervention or project on a small scale-while relying on multiple change cycles to achieve the overall aim, and collecting data over time to measure the impact of the change.5
A PDSA worksheet was completed for each innovation/project that was trialed at the Seton Healthcare Network. The worksheet identified the project name, the project coordinator, and questions related to each step of the cycle. Specifically for the planning phase, the objective(s) had to be articulated; predictions had to be made about how this change would contribute to a design theme and target; and the who, what, when, why, and how for the change and data collection methods had to be identified.
Questions about the implementation or "do" phase focused on whether the change occurred as expected and if not, what was observed that interfered with the plan. Worksheet questions encouraged staff to determine if the innovation/project worked as predicted and what knowledge was gained from the implementation phase. For the last stage of the PDSA cycle, future actions were identified from this experience. Some innovations/projects were trialed for a day while others were cycled for several weeks. The staff rated all innovations in terms of adoption, adaptation, or discontinuation.
After prototype testing occurred, pilot testing (phase 4) was initiated, and this required a second cycle of the innovation testing with a more formal measurement of the impact. If the measurable outcome, whether qualitative or quantitative, was positive, the new design was spread to other participating sites (phase 5).
FINDINGS
One of our most successful designs was the nurse status board. The hypothesis regarding this board was that if team members were continuously apprised of each other's work intensity, patients would receive more timely care because staff would be able to support and help each other during busy work episodes. More important, the board would allow nurses to have some control over their work flow. The status board had staff names and used color-coated magnetic dots to reflect each person's level of work intensity. Red dots indicated that the staff member was exceptionally busy and could use some help getting caught up, yellow dots conveyed that the staff member was getting caught up and would be ready for new assignments or patient admissions, and green dots reflected availability to help other coworkers.
This innovation supported the key design theme of vitality and the accompanying target of promoting effective supportive patient care teams. Qualitative assessment yielded positive responses on the nurse status board, and the innovation has spread rapidly throughout our institution. Success was also experienced by the other pilot sites, and this is now considered an evidenced-based practice intervention.
Another successful innovation, though not a new idea, was initiating nurse/physician patient rounds. Physicians and nurses did not always communicate systematically before their daily rounds at the Seton Healthcare Network. Often the physician would leave the unit and the nurse or patient had questions, requiring the nurse to then call the physician. As part of the initiative and to improve nurse and physician collaboration, a short form was placed in the progress notes, reminding the physician to call the nurse before visiting the patient and providing the nurse's phone number. With this process, the nurse can meet with the physician briefly before visiting the patient to address questions and problems.
The patient rounds supported several key design themes, including vitality and patient-centeredness. Qualitative assessment indicated increased nurse and patient satisfaction and fewer follow-up calls to the physicians. Other pilot sites also have had success with initiating the nurse/physician patient rounds.
LESSONS LEARNED
Overall, our participation in the TCAB initiative has revealed the importance of this work in improving the quality of care provided to our patients. The experience of participating in creating a new and an improved future healthcare system maintains our enthusiasm and commitment to innovation and change. In retrospect, the core team members believe our success has been due to several key elements. First, the medical/surgical unit that volunteered for participation had a relatively stable staff that exhibited trusting relationships and camaraderie. In addition, a shared leadership framework existed, which promoted risk taking and accountability.
Stable leaders role modeled openness to ideas, trust in others, and expanding staff capacity for innovation. These leaders also provided supportive environments and mentoring and promoted communication to other employees in the organization. The leaders' budgetary finesse also contributed to our success.
As an organization, we learned to transform our idea of change. Large multidisciplinary teams still have value; however, when focusing on creative changes in practice, rapid cycle change encourages innovation and adoption of initiatives that are immediately rewarding to healthcare practitioners and patients. We found that healthcare providers would engage in rapid change pilots because they are low risk and do not affect numerous stakeholders. If an initiative is successful, the organizational spread is easy because of the blend of right idea, place, time, and purpose. We will not return to the traditional methods of change, which encompass large groups of people, excess committee work, and extensive time for implementation.
From a team member perspective, we learned to stay focused on design targets. The core team members often had to revisit the 4 design targets during the brainstorming and piloting phase of the project.
In addition, not all innovations and new designs were successful, but with rapid cycle change, a primary aim is to determine what works and what is unsuccessful or unrealistic. If innovations do not work, the threat of failure and loss of resources or personnel are minimal. We learned that it is fine to abandon an idea. As innovations spread through the organization, we also are reminded that change is a challenge. Not everyone embraces new ideas at the same pace, but persistence and improved care benefit all involved.
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