1. Hotra, Rives


A new initiative focuses on the staff nurse's perspective.


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A registered nurse for 28 years, Robert Vos, RN, MS, CNAA, BC, knows first-hand that the best way to make and sustain process changes in a hospital is to put nursing at its center. Vos is at the forefront of nurse-led changes at Cedars-Sinai Medical Center, Los Angeles, Calif. Along with nine other hospitals, Vos's facility is part of the Transforming Care at the Bedside (TCAB) initiative, a program that's making a marked difference in patient care and nurse satisfaction at Cedars-Sinai and in other hospitals around the nation.


A nurse manager on the medical pulmonary and medical gastrointestinal units, Vos is part of a team of nurses that meets weekly to brainstorm and explore new ideas to test, so they can ultimately share solutions that'll improve patient care throughout their respective units. In a year-and-a-half, Vos's team has generated 76 "tests of change," as participating members of TCAB call their interventions, 27 of which have been successfully implemented and yielded improvements in either patient care or nurse satisfaction. These changes are all part of a program to improve the quality and safety of patient care, and increase retention of experienced nurses by empowering staff to develop innovative changes.


Facilities aim to transform care

Hospitals currently participating in Transforming Care at the Bedside are Cedars-Sinai Medical Center (Los Angeles, Calif.); Children's Memorial Hospital (Chicago, Ill.); James A. Haley VA Medical Center (Tampa, Fla.); Kaiser Permanente (Sacramento, Calif.); North Shore-Long Island Jewish Health System (Great Neck, N.Y.); Prairie Lakes Healthcare System (Watertown, S.D.); Seton Healthcare Network (Austin, Texas); ThedaCare (Appleton, Wisc.); University of Texas M.D. Anderson Cancer Center (Houston, Texas); and UPMC - Shadyside (Pittsburgh, Pa.).


Source: Institute for Healthcare Improvement. Transforming Care at the Beside. Available at: Accessed September 18, 2006.


A nationwide initiative

Cedars-Sinai is one of almost a dozen hospitals in the United States participating in TCAB, an initiative of the Robert Wood Johnson Foundation (RWJF) and the Institute for Healthcare Improvement (IHI).


The IHI estimates that 35% to 40% of unexpected hospital deaths occur on medical/surgical units, where much of the nation's in-patient care is delivered.1 Nursing vigilance is essential for keeping patients safe, so the nation's serious nursing shortage has alarmed healthcare experts. The TCAB program aims to address both issues-improving patient care and nurse retention-head on.


What makes TCAB a different kind of quality improvement initiative is the make up of its team and its unit-based process. Changes in care are identified by those who deliver the majority of care in hospitals-staff nurses-unlike traditional hospital approaches, in which managers propose ideas and direct staff to implement them. The TCAB program puts nurses and other members of the care team in charge of developing new procedures that'll improve patient care and make their jobs more efficient, so they can spend more time with patients and less time on routine administrative tasks that detract from patient care.1


The TCAB initiative launched in the fall of 2003 with three hospitals recruited to test its viability through a rapid prototyping process. Today, 10 hospitals are participating in the program, building on the most successful tests from the prototyping effort and generating, testing, and implementing new ideas. They're also working to spread the program's principles, processes, and innovations to other units within their own hospitals and to other hospitals within and outside their systems. (See "Facilities aim to transform care.")


Process yields early results

When a unit's TCAB team identifies a viable idea, it's further developed and quickly tested through a rapid-cycle improvement process.1 Ideas that seem to work, or have potential to work, are further refined to become operational. Ideas that seem less promising are scrapped and the team repeats the process again.


Vos said that creating the interventions the hospital will test is liberating for many of his colleagues.


"We work so closely with patients that we have a lot of thoughts, and most front-line nurses are thrilled to be asked about them," he said. "All ideas are welcome, and no idea is too small or too simple, as long as it's positive."


Transforming Care at the Bedside innovations across participating hospitals have included the introduction of rapid response teams, liberalized diets, fall prevention techniques, quiet hours for patients, interdisciplinary rounds, and stronger forms of communication among nurses and other healthcare staff, patients, and their families.1 Though these interventions may be in place at other hospitals, with the TCAB program staff nurses are at the forefront of suggesting and implementing these innovations.


Participants emphasize that the change in unit culture and engagement of front-line staff in improvement activities are central to their TCAB experience. Creating this change has involved not just change at the unit level, but complementary changes in the culture and style of quality improvement, performance improvement, and leadership at the hospital level.


Tests of change

The TCAB "tests of change" implemented at Cedars-Sinai include, for example, bedside walking rounds to help ease the transition of nurses going off and coming on their shifts. With the new process, after the change-of-shift report is given, both the off-going nurse and the oncoming nurse conduct rounds. This gives nurses the opportunity to ask questions, clarify information from the report, and assess patients' immediate needs.


"Not only is TCAB good for the safety of the patient and the comfort of the family, but it's also more satisfying for the nurse," Vos said.


Another innovation implemented at Cedars-Sinai is a safety program for patients at risk of falling. The TCAB team puts bright orange armbands and booties on these patients so staff can easily identify them. Additionally, an orange sign on the door alerts staff members as they enter the room that the patient is at risk and needs extra assistance moving about.


Responding to an increasing tendency of ventilator patients to fidget, which often resulted in them pulling out their tubes, Vos's team explored options of giving patients something to handle and play with. The team decided to distribute squeezable rubber lungs for the pulmonary patients and little stomachs for gastrointestinal patients. These small, stress-ball-like objects deter patients from disturbing their ventilators.


The team's other innovations include creative methods for improving communication between nurses and physicians, interdisciplinary discharge rounds, restructuring nurses' stations, and safety awards.


Retention benefits

As the nursing shortage increases, and with the turnover of just one nurse costing an average of $46,000 to $64,000 per position in recruitment and training costs, hospitals must be creative to improve nurse satisfaction and retention.2


Vos said the opportunity to develop these innovations as a team "has helped to showcase our clinical nurse floors and promoted a lot of professional development, which keeps people interested in their jobs." Since implementing the TCAB program, turnover rates at Cedars-Sinai have decreased. Though this improvement could have stemmed from a number of initiatives, administrators believe TCAB likely contributed to the lower turnover rates.


"It's great to watch a team of people promote positive change and to know you're leading that team," Vos said. "The team does such phenomenal work that I think all of us feel an even greater commitment to our careers because of it."


The TCAB program started with two "test" units at Cedars-Sinai and has spread to more than 16 medical/surgical units, six perinatal units, three pediatric units, two psychiatric units, one acute rehabilitation unit, and several ambulatory units. The final areas of the hospital to incorporate TCAB principles include the intensive care units, outpatient, and procedural areas, which is expected to be completed by June 2007.


Patient satisfaction

The successes of the initial pilot program at Cedars-Sinai include: 95% patient satisfaction, 95% employee satisfaction, an increase in direct time spent with patients, an improvement in patient admission and transfer processes, and a decrease in adverse/unexpected events. Vos said collaboration between administrators and medical directors was instrumental in the success of TCAB at Cedars-Sinai.


Across the 10 sites, preliminary evaluations suggest that participating hospitals value TCAB. Several facilities report that initiatives have spread to other units, and they express interest in continuing the program. Unit staff, nursing leadership, and hospital leadership in most TCAB hospitals report increased vitality (staff engagement). Hospitals are conducting tests on a range of process changes with notable successes, such as the restructuring of admissions processes, implementation of rapid response teams, and increased multidisciplinary activities.


Linda Burnes Bolton, RN, DrPH, FAAN, vice president and chief nursing officer at Cedars-Sinai, said that TCAB is different from other programs she's been involved with.


"I've been in the healthcare field for 36 years and in that time, I've seen a lot of process and structural changes come and go-but TCAB is a turning point," she said. "Through efforts with our team internally and hospitals nationally, we have the opportunity to engage some of the smartest minds in medicine to determine how to improve the work environment and the delivery of care for patients in hospitals throughout the United States."


Empowering nurses

The hospitals participating in TCAB are sharing promising ideas with their colleagues in other units and other hospitals, and in the next 2 years they'll work to spread TCAB processes and principles in a more systematic method. An evaluation of the program and the outcomes in each of the sites is underway to capture which elements of the program have an impact: Hospitals are collecting data on measures such as nurses' time with patients, voluntary staff turnover rates, and patient outcomes (such as falls prevalence).


"The program is a success for the nurses and patients in the participating TCAB hospitals," said Susan B. Hassmiller, RN, PhD, FAAN, senior program officer at RWJF. "These nurses are professionals who are doing their best to take care of patients in a high-stress atmosphere and aren't traditionally asked their opinion about how to improve the processes. Through TCAB, we're creating an environment where nurses feel empowered to think creatively about work environment solutions, share ideas, and be part of the process that improves patient quality."


Hassmiller said these system changes are needed. "When you allow nurses to help design programs that put patients first, you also help nurses do their best work-efficiently, effectively, and with great pride and satisfaction."




1. Rutherford P, Lee B, Greiner A. Innovation Series: Transforming Care at the Bedside. Cambridge, Mass.: Institute for Healthcare Improvement; 2004. [Context Link]


2. Kosel K, Olivio T. The Business Case for Work Force Stability. VHA Research Series 2002. Irving, Texas: VHA; 2002, 6-7. [Context Link]