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


This is the 10th 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 nurse satisfaction and retention. Mass General is one of 68 hospitals participating in a two-year TCAB initiative led by the American Organization of Nurse Executives and funded with a grant from the RWJF. For more information on TCAB, go to


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Nurses spend an inordinate amount of time walking among patient rooms, the nursing station, and supply closets. They constantly document their actions and patients' status. Because direct care can take up such a small percentage of a shift, the Transforming Care at the Bedside (TCAB) initiative aims to help medical units implement "value-added processes"-those that are "free of waste and promote continuous flow."1


Value-added processes make up one of the four "focus areas" of TCAB, in which White 10, a 20-bed general medical unit at Massachusetts General Hospital, is participating. The other categories include patient-centered care, safe and reliable care, and vitality and teamwork.

Figure. Tiana Bellon... - Click to enlarge in new window Bellone, BSN, RN, saves steps by retrieving linens from one of the unit's hallway carts. Photo courtesy of Amanda L. Stefancyk.


One of White 10's earlier changes involved moving frequently used clinical supplies to the patient's bedside ("High-Use Supplies at the Bedside," February). This success led us to rethink how we stocked linens. White 10 consists of a long hallway with a centrally located nurses' station, medication room, supply room, and linen storage cart. Thus, a nurse caring for a patient in one of the rooms at either end of the hallway had to walk approximately 80 steps to retrieve linen and return to the patient's room. The effort and time involved added no value to the patient's care. In fact, it led to an ad hoc solution in which staff would stockpile linens in the patient's room, where there was no dedicated storage space. Stacks of linen would balance on a chair intended for the patient or a visitor. At the end of the shift, unused-though clean-linen was deposited in the laundry cart and rewashed.


At one of our hourly "TCAB Tuesday" meetings (the operations manager was in attendance), we decided to buy two small, wire linen carts that measured 3' x 4' x 4' x 5' to be positioned midway between the nurses' station and the ends of the hallway. The original, larger linen cart continued to be centrally located by the nurses' station and was stocked twice daily by one of the hospital's "materials management" personnel. Our unit's housekeepers and patient care associates began stocking the hallway carts at the end of their shifts.


This change was an instant success. Nurses and patient care associates are now no more than 15 steps from a linen cart when caring for patients. Spending less time hunting and gathering linens quickly became very popular with the staff, who communicated their support in conversations on the unit and at our meetings. We've also decreased the stockpiling of linen in patients' rooms and the waste of washing unused laundry. But greater efficiency wasn't the only benefit. It also encouraged the staff to become more engaged in our TCAB efforts.



Our ideas about possible changes on our unit come from various sources: brainstorming sessions, identifying best practices on other units and at other hospitals, and analyzing information from our unit's two time-study personal digital assistants (PDAs), one of which is carried by a nurse for an entire shift (while the other is charged) and rotated among the staff. The PDA data showed that staff spent a significant amount of time on documentation. Thus, the clinical nurse specialist (CNS) and I asked the staff how we could reduce the amount of time spent on documentation so that we could increase the time dedicated to direct care.


Massachusetts General Hospital is making great progress in moving to a completely electronic medical record, but this won't occur for another 18 months. Physician orders, laboratory results, and physicians' and some other health care providers' notes are electronic. Nurses, however, still document medication administration, admissions, daily assessments, and care plans on paper and flow sheets. They also write out end-of-shift notes that describe problems, nursing interventions, and outcomes-often containing data found elsewhere, such as in our computer system or on flow sheets. This time spent recording data in several locations takes away from the time we spend at the bedside. When we examined a year's worth of data from 12-hour shifts, we found that each nurse spent 17.8% to 30.4% of the shift-128 to 219 minutes-on these documenting activities; that's an average of 26.7% (192 minutes). Although this seemed to be a staggering amount of time, this finding is consistent with what is seen in the literature.2


The end-of-shift notes tend to be particularly time consuming, so our CNS led a proposed change that would decrease the amount of time nurses spent writing them. Our model called for only documenting problems, interventions, and outcomes in end-of-shift progress notes; the staff was not to document data that could be found elsewhere in the chart. This was a radical change from White 10's longstanding practice of documenting everything, even when the information was clearly and readily available elsewhere. Laboratory values, for example, are entered into our computer system directly by the laboratory, yet our staff had continued to write them in the progress notes, if they were related to the problem being discussed. The CNS set up individual and small group tutorials with all of the staff nurses; within a month, she had met with many of them. Those nurses she spoke with were supportive of this change. Unfortunately, the PDA data we collected after making this change revealed that nurses' time spent on documentation didn't decrease.


Shift notes are reflective and thoroughly written, and something in which the nurses take great pride. There is a strong sense among the staff that everything must be documented-not just the exceptions or problems-and this belief is not easily changed, despite the amount of time and effort it requires.



I am hopeful that education and newer technology can make documentation less repetitious on White 10. We'd like to see our unit preceptors instill in new nurses a different practice of note writing-emphasizing the need to document information that can't be found elsewhere. Fully electronic records will offer users access to various data simultaneously, thereby eliminating time-consuming and duplicative documentation practices that are currently the norm.


Next month I'll discuss our experience making changes to safety and reliability.




1. Institute for Healthcare Improvement. Medical-surgical care: General. 2007. [Context Link]


2. Hendrich A, et al. A 36-hospital time and motion study: How do medical-surgical nurses spend their time? Permanente Journal 2008;12(3):25-34. [Context Link]