1. Bolton, Linda Burnes DrPH, RN, FAAN
  2. Aronow, Harriet Udin PhD


Estimates of cost savings with sustained improvement.


Article Content

We used the Model for Improvement of the Institute for Healthcare Improvement (IHI)1 at Cedars-Sinai Medical Center (CSMC) in Los Angeles to engage front-line staff and launch more than 300 tests of change aimed at improving our performance on the Transforming Care at the Bedside (TCAB) themes of safe and reliable care, teamwork and staff vitality, patient-centered care, and value-added care processes (lean systems). The Model for Improvement asks three questions: What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? The Plan-Do-Study-Act cycle was used to test changes. These tests of change have resulted in numerous and cumulative improvements at CSMC.


We were one of the hospitals participating in phases 2 and 3 of the Robert Wood Johnson Foundation (RWJF)-IHI initiative. Over the four years of this early TCAB work, we spread the principles of the initiative and specific promising interventions across all nursing areas of our organization, including inpatient, ambulatory, procedural (for example, the gastrointestinal laboratory), and perioperative (for example, surgery and postanesthesia care unit) areas.


But what about the return on the investment? In this article we present examples illustrating the business value of launching and sustaining TCAB. We focus on the period when we initiated our TCAB work, from the baseline and pilot year (2004) through the period of implementation and spread (2005 to 2008), and relate the resulting cost savings as well as improvements in patient and organizational outcomes.



Implementation of TCAB required an infrastructure. Every week we held huddles-quick, informal meetings-on units, teaching clinics for direct care staff on TCAB principles and techniques, and operations and steering committee meetings for overall project coordination and evaluation activities. In addition, there were monthly community forums in which TCAB projects were showcased and promoted among a large audience of direct care staff and managers. We estimate the annual cost of this infrastructure-including pay for facilitators assigned to unit-based teams, pay for time nonexempt employees spent in building and maintaining the infrastructure, and support services for meetings-to be $500,000.


Some of these costs, such as those related to facilitators and trainers on units and oversight meetings with broad attendance by stakeholders, continued throughout the formal RWJF-IHI initiative. Going forward, we anticipate a consistent commitment of resources of about $50,000 a year to support ongoing quality improvement projects using the TCAB method. This amount will cover staff release time when launching projects, facilitator time, and recognition events.



Our calculations of the hospital-wide value of reducing nursing turnover and adverse patient events provide examples of the cost-saving benefits associated with TCAB.


Reduction in nursing turnover. Staff vitality interventions led by nurse and physician champions, we believe, were the reason for the reduced nurse turnover (from 7% in 2004 to 3% in 2008) at CSMC by the end of the formal RWJF-IHI initiative. Interventions included physician-nurse rounding, physician-nurse education teams, unit-based employee recognition programs, letters of excellence awarded to top performers by the chief nursing officer, and interdisciplinary service agreements (for example, our "Toes Out, Toes In" initiative, the successful coordination of nursing, environmental services, and administration to reduce the time between one patient's discharge and another's admission to the same bed).


To determine the cost savings resulting from this reduced turnover, we began with the National Quality Forum (NQF) definition of voluntary turnover.2 We applied our hospital's cost estimates for immediate filling of a nurse vacancy (overtime and temporary staff), recruitment (advertising and human resources department and nursing staff involvement), and permanent replacement with a new nurse (training and orientation). The savings realized from our reductions in nursing turnover from 7% in 2004 to 6% in 2007 were estimated at just over $509,000. Further reduction in turnover to 3% in 2008 was estimated at a savings of $5,090,909. Thus, the combined savings realized by reduced nursing turnover in 2007 and 2008 was an estimated $5.6 million.


Reduction of adverse events. We spread across the organization a bundle of improvements related to safety and reliability that had been made early in our TCAB units' participation in the initiative. These included using situation-background-assessment-recommendation communication; performing hourly and change-of-shift bedside walking rounds; establishing unit champions for fall prevention, skin assessment, and handwashing; using computer screen savers that displayed prohibited abbreviations and other safety messages; and deploying rapid-response teams.


Figure 1 shows the reductions we achieved in two nurse-sensitive adverse events: falls and stage III or IV hospital-acquired pressure ulcers. This graph was derived from our archived data submitted to the Collaborative Alliance for Nursing Outcomes (CALNOC) database ( Using measures based on the nursing consensus standards published by the NQF, CALNOC makes outcomes measures available for trend analysis, along with representative benchmarks from all CALNOC member hospitals. The incidence of both falls and stage III or IV pressure ulcers fell substantially as TCAB improvements spread throughout CSMC.

Figure 1 - Click to enlarge in new windowFigure 1. Trends in two adverse events: the number of falls resulting in moderate or worse injury and the percentage of patients with stage III or IV hospital-acquired pressure ulcers (HAPU).

To estimate the cost savings achieved with these reductions in adverse events, we used the costs identified by the Centers for Medicare and Medicaid in the Federal Register3 and the calendar year 2004 as our baseline.


Falls. A detailed analysis of patient falls from 2006 through 2008 confirmed that while patients might have experienced more than one fall during a given hospitalization, no patient had more than one fall that resulted in an injury rated as moderate or worse during a single admission. The estimated cost per hospitalization associated with moderate or worse falls was $33,894. We used our CALNOC-archived monthly counts of patient falls with moderate or worse injury to determine that the hospital-wide reduction in falls realized with the spread of TCAB resulted in cumulative cost savings of $7.9 million (see Table 1).

Table 1 - Click to enlarge in new windowTABLE 1. Estimated Cost Outcomes, Falls with Moderate or Worse Injury

Pressure ulcers. We documented trends in hospital-acquired pressure ulcers at CSMC using standardized methods for conducting regular, periodic prevalence studies. On prevalence study days, all patients in participating units were assessed for pressure ulcers, which were staged by expert raters; pressure ulcers seen upon admission were also noted.


We estimated the cost outcomes associated with reducing the incidence of stage III or IV pressure ulcers based on our CALNOC-archived prevalence study data. We applied the percentage of patients with stage III or IV pressure ulcers on the surveyed units to the total number of patients discharged from those units during the calendar year to estimate the total number of patients with this hospital-acquired condition. The cost per hospitalization associated with stage III or IV pressure ulcers was $43,180, so the estimated cumulative savings from the reduction in pressure ulcer incidence during the TCAB implementation period was $59.3 million (see Table 2).

Table 2 - Click to enlarge in new windowTABLE 2. Estimated Cost Outcomes, Stage III and IV Pressure Ulcers


In the absence of randomized controlled trials of each intervention on each nursing unit (which is both impractical and undesirable, given the demands for rapid improvement), we can only speculate on the root causes for the improved outcomes seen with TCAB. The small tests of change and the bundle of improvements that we spread throughout CSMC appear to have created a culture that emphasizes performance improvement and value-adding activities on nursing units. From nurses' feedback on the effective interventions, we know that each unit tailored its own set of activities to suit its needs.


In addition to the changed organizational culture, two other factors appeared especially instrumental in leading to improvement: reductions in practice variation and increases in the time nurses spent with patients. Figure 2 depicts the increased time nurses spent in direct care and its association with reduced patient falls on one floor (two nursing units) at a time when the nurse-patient ratio remained steady.

Figure 2 - Click to enlarge in new windowFigure 2. Association between time nurses spent in direct care and patient falls on one surgical floor.

Philosophically and logically, this association resonates. The interventions we spread during the TCAB initiative provide bedside nurses with a set of nursing activities that they trust, because they have been involved in testing them and have adopted and adapted the best interventions for their areas of care. Spreading a bundle of interventions throughout the hospital reduces variations in care and increases the efficiency of care delivery. Efficiency, combined with a culture of patient- and outcome-centered performance improvement, enables and reinforces spending more direct care time with patients. This increased time, in turn, permits nurses to critically and appropriately apply the bundle of activities to meet patient needs.


We have practice-based evidence associating the implementation of TCAB in our institution with large improvements in outcomes and reductions in costs related to adverse events and nurse turnover. The time and effort expended by the hospital's executive team, performance improvement facilitators, and human resources personnel in support of TCAB yielded significant financial and clinical outcomes.


We wonder whether we will see diminishing returns as we move forward and cost outcomes are optimized. Ongoing costs in a continuing effort to transform care at the bedside must be seen as routine costs of conducting business and delivering good outcomes. Aligning TCAB with overall organizational quality efforts is essential. The organization's chief executives must remain engaged for TCAB to be successful, and we continue to have this support at CSMC.




1. Langley GJ, et al. The improvement guide: a practical approach to enhancing organizational performance. 2nd ed. San Francisco: Jossey-Bass; 2009. [Context Link]


2. National Quality Forum. National voluntary consensus standards for nursing-sensitive care: an initial performance measure set. Washington, DC; 2004. [Context Link]


3. Centers for Medicare and Medicaid. Rules and regulations. Hospital acquired conditions. Federal Register 2008;48473-4. [Context Link]