1. Mason, Diana J. PhD, RN, FAAN, AJN Editor-in-Chief


Redesigning health care must mean the empowerment of nurses.


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"Streamlining processes." "Reducing inefficiencies." "Cutting costs." We've all heard these buzzwords, especially when followed by the phrase "[horizontal ellipsis] while improving care quality and patient safety." But what will redesigning health care really look like in 2008?


I'm a member of the national advisory committee for Transforming Care at the Bedside (TCAB), a project sponsored by the Robert Wood Johnson Foundation (RWJF) and led by the Institute for Healthcare Improvement (IHI). TCAB's focus is on improving care on medical-surgical units-probably the most neglected area in many hospitals. Among its aims are safer and more reliable care, more satisfying and supportive workplaces, and changing the focus in facilities to what patients need. In the past five years, 10 hospitals have been consistent participants in TCAB, and results are promising. TCAB is founded on


* generating new ideas for change.


* testing these ideas and using data to measure outcomes.


* empowering frontline staff to lead this work with full support of top and middle management.



Staff are trained in rapid-cycle change (quick tests of small changes made to improve care in some way) and provided with the support they need to develop, test, and evaluate their ideas. Managers agree to respect the notion that workers have ideas for improving care. I have been on four site visits to TCAB hospitals and seen firsthand the nurses' satisfaction with their work, the teamwork, and the improvements they've made to care. (For examples of the work of TCAB hospitals, go to


I recently visited ThedaCare's Appleton Medical Center, a TCAB hospital in Appleton, Wisconsin. Some of the visitors questioned the staff's use of "Lean" methods of redesign that arose largely from assembly-line work at Toyota and is not a formal part of TCAB. (According to, Lean is "a business system for organizing and managing product development, operations, suppliers, and customer relations.") But Pat Rutherford, the nurse who heads up TCAB for the IHI, told me that it doesn't matter whether the facility subscribed to Lean or any other work-redesign ideology, as long as TCAB principles of empowering staff to generate, test, and evaluate changes were incorporated. I left Appleton as impressed as I have been on site visits to other TCAB hospitals. Sixty-eight hospitals have been selected to participate in the spread of TCAB, through RWJF funding to the American Organization of Nurse Executives.

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I have also spoken with nurses at hospitals undergoing redesigns not in line with TCAB principles. Some nurses at a meeting of the Minnesota Nurses Association told me that their hospitals had adopted Lean techniques, spending large sums to train personnel in the approach and imposing changes geared toward "increasing staff productivity." An example they gave was centralized control of transporting patients for tests and transfers, which the nurses believed had resulted in greater inefficiencies and dissatisfaction among nurses and patients. Even though the units had sent their own data to the group overseeing the project, the hospital had not shared pooled outcome data with staff. And two nurses at a meeting of the Massachusetts Nurses Association said that their hospital had instituted a rapid-response team that used ICU nurses. When the team is called, the nurse leaves the ICU, compromising the safety of the ICU patients. The staff never were asked to design a rapid-response team.


Such approaches would not be seen in a TCAB hospital. TCAB recognizes that patient care does not take place on an assembly line run by the front office. Let's look at how to improve the care hospitals provide, but let's do it the right way-by supporting nurses as they spearhead change on their units.