1. Stefancyk, Amanda L. MSN, MBA, RN


This is the second in a series of articles from Massachusetts General Hospital in Boston describing one general medical unit's experiences with Transforming Care at the Bedside (TCAB). An initiative begun by the Robert Wood Johnson Foundation (RWJF) and the Institute for Healthcare Improvement, TCAB was developed as a way to improve care on medical-surgical units, patients' and family members' experience of care, and teamwork among care team members, and to increase nurses' satisfaction and retention. The TCAB philosophy engages all care leaders, but empowers bedside nurses to generate ideas and solutions for change. Mass General is one of 68 hospitals participating in a two-year TCAB initiative led by the American Organization of Nurse Executives and funded by a grant from the RWJF. For more information on TCAB, go to


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Last summer, with tangible excitement from the staff about being selected to participate in the Transforming Care at the Bedside (TCAB) initiative, we suddenly found it was time to begin work on it (see "Transforming Care at Mass General," Transforming Care at the Bedside, September). The work began in Philadelphia, 320 miles from White 10, Massachusetts General Hospital's 20-bed general medical unit, where I am the nursing director. Members of our TCAB steering committee joined hospital teams from across the country for a two-day TCAB "kickoff" meeting. The goals were to learn about the background and principles of the TCAB initiative and to network with staff from other participating hospitals.


We accomplished a lot during those two days. Staff from hospitals that had participated in earlier TCAB initiatives shared their success stories, best practices, and lessons learned. Representatives from design and innovation consulting company IDEO taught us new brainstorming techniques such as "deep diving" and "snorkeling." As I developed a better understanding of TCAB, my excitement about working on the initiative also grew. Past participants had achieved some impressive results, such as reducing staff turnover, increasing the time spent on patient care, and decreasing the average length of patient stay, and I was hoping we would do the same. I couldn't wait to return to Boston and get started. In fact, Susan Kilroy, MS, RN, the clinical nurse specialist on White 10, and I began planning a staff TCAB retreat in the taxi on our way to the airport.


Although the directors of the TCAB initiative had said that holding a retreat to introduce the staff to TCAB wasn't necessary, our unit had always had an annual retreat and we decided to use that to our advantage. We invited all 62 members of the White 10 staff-nurses, nursing assistants, unit secretaries, and housekeeping personnel-to participate in either of two all-day retreats designed to teach them about TCAB, brainstorm ideas, build teamwork, and introduce a rapid-cycle testing framework that we would use to implement and evaluate changes.


We organized the retreats into four main sections: TCAB 101, providing background information on the program's history and aims; What's Stopping Us, exploring barriers to providing the best patient care and working together as a team; Snorkeling, brainstorming about changes that might improve care and teamwork; and Plan-Do-Study-Act (PDSA), during which we created templates for making the changes happen. Working groups, consisting of representatives from each role group, were formed each day.

Figure. There are si... - Click to enlarge in new windowFigure. There are simple rules for discussing solutions, such as suspending judgment, encouraging wild ideas, allowing only one person to speak at a time, and focusing on the quantity rather than the quality of ideas, all of which are written on self-stick notes and affixed to a flip chart. Above is White 10 staff nurse Jillian Murray, BSN, RN.

In TCAB 101, we outlined the TCAB initiative and talked about our hopes for empowering direct care providers to initiate change; streamlining processes to allow more time at the bedside; ensuring that practice is always safe, reliable, and patient centered; and providing a work environment that supports the staff. We also emphasized that although it was unlikely that everyone would fully embrace every idea we would test, it was important for the whole team to support and participate in a two- to three-week trial period.


Our work began with an icebreaker exercise in which staff members shared good customer service experiences. Stories of rental car companies, banks, and supportive coworkers who had gone "above and beyond" flew around the room. Then we asked a provocative question: "What's stopping us?" What stands in the way of our staff having the ideal nursing unit that provides superb care to all patients? Silence and low whispers quickly gave way to active conversation at each table. The answers were probably typical of the problems found on most medical-surgical units: a lack of time, paperwork duplication, staffing challenges, a lack of space, and communication difficulties with other groups in the hospital, among others. I had expected this to be the easy part, and in fact the staff did an excellent job of identifying the problems and barriers to providing the best possible care. But I knew our success would depend on giving the staff the right tools to take the next step-developing solutions.


Snorkeling. IDEO, the consulting firm, described snorkeling as a modification of the deep dive brainstorming technique, which is an intensive, multiday period of observation, brainstorming, and looking deeply at specific issues and developing solutions. Snorkeling is an abbreviated approach in which questions are posed and possible solutions are discussed. We divided into working groups and, to get staff members thinking about the future on White 10, we asked an open-ended question, "How might we [horizontal ellipsis] ?" After 20 minutes' discussion, each group shared its answers. The ideas were abundant and similar at both retreats: how might we focus more closely on patients at the bedside, improve patient safety, rearrange supplies to make them more easily accessible, improve intra- and interunit communication, reduce paperwork, and increase patients' knowledge about their illnesses and treatments, among others. Eight themes emerged: the patient's experience, the nurse's experience, patient safety, teamwork and morale, the work space and environment, admission and discharge processes, "hunting and gathering" (such as getting supplies or researching a question), and communication.


The team was now ready to explore these themes in greater detail. We handed out stacks of self-stick notepads and pens and asked each group to develop ideas for addressing one of the eight themes. IDEO had recommended these simple rules: suspend judgment, encourage wild ideas, allow only one person to speak at a time, build on others' ideas, illustrate ideas with diagrams or drawings if needed, and focus on quantity rather than quality (to generate ideas in abundance). Each idea was to be recorded on a self-stick note, read to the working group, and then affixed to the flip chart dedicated to that particular theme. Half an hour later, each group shared its ideas with the larger group and then repeated the process with a second theme.


The volume of ideas generated was impressive. Row after row of brightly colored notes-more than 500-lined the walls of the room with an emerging blueprint for bringing TCAB to life on White 10 in both the short- and long-term. The ideas ranged from rather simple-clearly posting daily goals of care for each patient, taking a lunch break off the unit, getting more glucometers, and stocking often-used supplies at bedsides, for example- to more complex, such as providing private rooms for all patients, completing all documentation electronically, and having a medication-dispensing machine in each patient room. Other ideas focused on alternative types of care, such as offering massage and music therapies, being "fully present" at each interaction by focusing intently on the patient, and promoting healing by ensuring that the unit is quiet.


Plan-Do-Study-Act. Next came the real test, coming up with plans to translate these ideas into action. Using PDSA, the rapid-cycle improvement model, each small group came up with ways to test the idea of their choice by developing an aim statement, an implementation plan, and a set of measures for evaluating the effectiveness of the change. By the end of each retreat, two ideas had emerged better developed than the rest, and they became our first real tests of change-having the nurse participate in presenting the patient during morning rounds and taking lunch breaks away from the unit.


Clearly, our retreat was a success. One staff member wrote afterward that TCAB "is a huge opportunity for us to make positive changes that will not only provide safer and more effective nursing care, but will also improve both patient and staff satisfaction." I had sensed, during the retreat and after, that we had grown closer as a team and that the staff members were engaged in implementing the initiative, had a clear plan for instituting the next steps, and now possessed knowledge that would help them move beyond identifying problems and on to developing solutions. The possibilities seemed endless!!


Moving forward, we would focus on small tests of change within the unit-"one nurse, one patient, one shift," as the TCAB approach is characterized-that would expand to include more nurses, patients, and shifts. As we tested changes, they would be adopted, adapted, or abandoned-and quickly, thanks to the PDSA model. Changes that proved to be a good fit for the unit would be adopted, whereas those that did not work would be adapted and tested again. Those that did not work after we had exhausted our ideas for adapting them would finally be abandoned.


Was it smooth sailing after our two retreats, or were choppy waters ahead? Next month I'll relate our experience with rolling out our first test of change: having the nurse participate in presenting the patient in morning rounds.