Sparking Innovation and Excitement on the Hospital Unit

Imagine this: during a hospital stay for a routine procedure or surgery you see pictures of your nurse, physician, physical therapist, nurses’ aides — everyone on your care team — on a white board across the room. And on your bedside table you find a small notebook called “Questions about My Care” that suggests good questions to ask your doctor when she visits. And on the day you leave the hospital the nurse gives you a write-up about your hospital visit — what they did to you while you were there and why, what the tests found, what comes next, and what it all means about your health status. It’s nothing technical; more of a story about your stay in the hospital that’s simple enough to explain to your family and friends.

Such personal touches may seem a far cry from standard hospital experiences, but these are real examples of changes in patient care being implemented by a handful of progressive hospitals that are part of a national initiative called Transforming Care at the Bedside (TCAB).

New Focus on Direct Patient Care

The program was launched in July 2003 by the Institute of Healthcare Improvement (IHI), in partnership with The Robert Wood Johnson Foundation (RWJF). It is targeting one segment in the health care delivery system: bedside care on a standard hospital medical or surgical unit. The aims for TCAB are to enhance the quality of patient care and service, create more effective care teams, improve patient and staff satisfaction, and improve staff retention.

Pat Rutherford, IHI vice president overseeing TCAB, describes the program as the newest in a series of IHI redesign initiatives: “This is really the next frontier: direct patient care. We’ve already made inroads in redesigning care in the ICU, emergency departments, and the clinical office practice. Now the focus is on improving the quality of care on the standard hospital unit.”

A central principle behind the TCAB project is the link between the quality of care patients receive and the work environment in which their caregivers function. In particular, RWJF’s support for the initiative is a response to growing concerns over the crisis in nursing. The human and financial costs — to hospitals and society at large — of the high turnover and low retention rates in nursing, RWJF believes, demand bold new strategies.

More broadly, TCAB is addressing fundamental health quality issues: the need to reduce errors, enhance organizational efficiency, adapt to constant industry changes, and maintain financial viability. The initiative was designed to draw on IHI’s experience in mobilizing teams of frontline workers to make significant changes toward these goals, as well as its expertise in health system redesign.

The vision for a new model of bedside care evolved during 2003 in a series of design initiatives by a team of planners from IHI and RWJF. A key component was an intensive three-day brainstorming session, modeled on an innovation methodology led by consultants from IDEO called a “Deep Dive,” once featured on ABC’s Nightline. Through teamwork, role-playing and site visits to two Boston hospitals, the Deep Dive teams generated hundreds of ideas for how to enhance bedside care.

Field Testing the Promising Ideas

In the fall of 2003, IHI and RWJF recruited three hospitals to test the viability of the TCAB approach through a rapid prototyping process. The sites, chosen for their shared culture of innovation and strong leadership, included: Seton Northwest Hospital in Austin, Texas, part of the Ascension Health System; UPMC Shadyside, part of the University of Pittsburgh Medical Center (UPMC) in Pittsburgh, Pennsylvania; and Kaiser Foundation Hospital in Roseville, California, part of Kaiser Permanente.

Members of the TCAB design team held kick-off meetings at the three prototype sites with nurses and staff from the designated medical or surgical unit. The meetings offered background in IHI’s Idealized Design Process as well as its Collaborative learning process, which is based on the Plan-Do-Study-Act (PDSA) improvement methodology.

A focus of each meeting was brainstorming through storytelling exercises, describes Mary Viney, Director of Patient Care Services at Seton Northwest. She says: “The leaders from IHI and RWJF went around the room and asked everyone to think of examples of a patient visit they had been part of that went really well, where the patient had a really good experience. Then they asked, ‘Why was it so positive? What made it go so well?’” When they had identified the reasons, says Viney, the leaders asked them to imagine working on a unit where every patient could have that positive experience. “They said: ‘What would it take to make that happen? What would you do differently?’”

Viney says by the end of the day her TCAB team had 300 ideas. To narrow down the list, they divided the ideas into quadrants based on the difficulty of making the change and its cost. They decided to start with tests from the “easy/low cost” column, where in fact the majority of the ideas fell. After six months of testing, Viney says: “We still had 30 more ideas to test from this one category.”

According to IHI’s Rutherford, this prototype launch process reflects IHI’s overall approach to health system innovation. She describes it in a humanitarian example: “It’s the basic question, ‘Is it better to feed fish to people in a third world country, or to teach them how to fish?’ We wanted to teach the TCAB teams how to fish.”

Fresh Thinking, Simple Steps

Some of the most successful prototype tests have been simple, common sense changes in the way providers interact with patients. The personalized “discharge summary” mentioned above is a good example. Sue Martin, Director of Nursing Support Services at UPMC Shadyside Hospital, relates that this idea on her TCAB unit came from talking to patients: “We found out that what they really want to know before they leave is what happened to them in the hospital, in simple terms. Not just the generic ‘discharge instructions’ that say when to take your pills or when to schedule a follow-up appointment with the doctor.” She says: “So we write up something that tells the patient ‘You were admitted, your blood pressure was __, you had a chest x-ray, we found pneumonia, so we gave you antibiotics . . .’”

On the TCAB unit at Kaiser Roseville Hospital, a successful test grew out of an effort to help patients learn nurses’ names. Barbara Crawford, Chief Operating Officer, says her team decided to put up white boards in patients’ rooms to write names in large type. Then, she says, they decided to make it even easier: they bought a digital camera and started taking pictures of everyone — physicians, nurses, aides, respiratory therapists, everyone on the unit.