1. Lavizzo-Mourey, Risa MD, MBA
  2. Berwick, Donald M. MD, MPP

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Patients and their families expect to receive safe, reliable, and respectful hospital care that fits their needs. Most of the time it does; but all too often it does not. The hard reality is that deep and dangerous gaps exist between the care that patients should receive and the care they actually do receive. No one knows this better than nurses, whose vigilance at the bedside may be a patient's last line of defense against broken processes-as well as a hospital's best opportunity to improve the quality of care.


Recognizing nursing's critical but commonly overlooked role, the Robert Wood Johnson Foundation (RWJF) and the Institute for Healthcare Improvement (IHI) created an ambitious, nurse-led initiative to turn a select set of high-performing hospitals into innovative learning laboratories for real-time improvement of patient care. The program's name denotes exactly what our organizations envision nurses doing: Transforming Care at the Bedside (TCAB).

Figure. Risa Lavizzo... - Click to enlarge in new windowFigure. Risa Lavizzo-Mourey (left) and Donald M. Berwick

TCAB initially focused on improving care on medical-surgical units, where most inpatient care is delivered and where the need for improvement is greatest. It's on these units that an estimated 35% to 40% of unexpected hospital deaths occur.1


Six years of work with hundreds of front-line hospital staff has generated an evidence-based road map for hospitals to achieve safer, more reliable, patient-centered inpatient care. The resulting best-practice benchmarks are achievable, affordable, and lasting. TCAB is improving the efficiency of care processes, supporting nurse teamwork and leadership in improvement efforts, and involving patients and their families in making decisions about and managing their own care. Participating hospitals report better clinical outcomes, increased direct care time for nurses, reduced nurse turnover, and lower costs.


With TCAB, most of the ideas for transforming care come from front-line nurses, who spend the most time with patients and their families. These nurse-led teams identify where change is needed, suggest and test solutions, and decide whether and how to implement these innovations.


The ultimate success and sustainability of TCAB depend on leadership commitment at all levels: from the senior executives who set strategic priorities and ensure that good changes spread, to midlevel clinical leaders who empower staff and orchestrate change, to local leaders and staff who redesign care processes to achieve unprecedented patient outcomes.


Encouraged by successful prototypes produced in the initial TCAB experience, hospitals in the United States and abroad are applying and adapting TCAB principles and processes. The American Organization of Nurse Executives is working with the RWJF to spread TCAB's insights to hospitals nationwide. The RWJF's Aligning Forces for Quality program is engaging patients, providers, and payers to collaborate in improving overall health care quality in 15 communities, reducing disparities, and providing models for national reform.2, 3 The IHI is leading an ongoing program devoted to TCAB processes and innovations.4


With the nation's attention focused on comprehensive health care reform, now is the time for leaders and policymakers to understand and leverage the enormous energy that nurses bring to improving the quality and value of health care for every patient every day.




1. Rutherford P, et al. Transforming Care at the Bedside. Cambridge, MA: Institute for Healthcare Improvement; 2004. IHI Innovation series white paper. [Context Link]


2. Painter MW, Lavizzo-Mourey R. Aligning Forces for Quality: a program to improve health and health care in communities across the United States. Health Aff (Millwood) 2008;27(5):1461-3. [Context Link]


3. Robert Wood Johnson Foundation. Aligning Forces for Quality (AF4Q). 2009. [Context Link]


4. Institute for Healthcare Improvement. IHI Collaborative: Transforming Care at the Bedside. 2009. [Context Link]