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Service Delivery Innovation Profile

Nurse-Led, Unit-Based Quality Improvement Increases Amount of Time Spent With Patients, Reduces Falls and Nurse Turnover


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Snapshot

Summary

As a pilot site for the Transforming Care at the Bedside initiative, Seton Northwest Hospital continuously designs and tests nurse-led quality improvement projects at the patient's bedside using a rapid-cycle improvement process, with projects designed to meet one of four objectives: care safety/reliability, teamwork/staff vitality, waste reduction, and patient-centeredness. The hospital has undertaken more than 120 quality initiatives to date, making nurse-led performance improvement a routine part of everyday operations on the units. The program has allowed nurses to be more efficient and spend more time with patients, reduced falls and nurse turnover, accelerated patient discharge, and yielded positive feedback from staff and patients.

Evidence Rating (What is this?)

Moderate: The evidence varies by initiative, but generally consists of pre- and post-implementation comparisons of key process measures, post-implementation surveys of patients and staff, and/or anecdotal feedback from nurses.
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Developing Organizations

Institute for Healthcare Improvement; Robert Wood Johnson Foundation; Seton Healthcare Network; Seton Northwest Hospital
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Date First Implemented

2003
November

Problem Addressed

Up to 90 percent of hospital errors result from poorly designed systems,1 clearly indicating a need for fundamental process redesign. Many hospitals have focused their redesign efforts on areas such as the emergency department and the intensive care unit, while ignoring the redesign of bedside care in medical and surgical units, where much of hospital care is delivered.
  • Need for redesign of bedside care: Care process inefficiencies and health care cost cutting have resulted in high levels of employee dissatisfaction and nurse turnover. Research suggests that nurses are up to four times more likely than other United States workers to be unhappy with their jobs and that worker satisfaction and working conditions are meaningful predictors of variations in patient outcomes.2 For example, an analysis of 235 Veterans Health Administration hospitals found that those with lower nurse turnover had lower severity-adjusted length of stay, mortality, and cost per adjusted discharge, and higher levels of profitability.3 Overall, 35 to 40 percent of unexpected hospital deaths occur on medical/surgical units.1
  • Increased need in light of nursing shortages: The relationship between work environment and patient outcomes is likely to become even stronger as the nursing shortage grows.4 The number of full-time registered nurses (RNs) is projected to peak around 2010 and decline steadily thereafter; by 2020, the supply of full-time RNs will be nearly 20 percent below projected workforce requirements.5
  • Unrealized potential of nurse-led, unit-based innovation: Nurses on medical/surgical units play a central role in ensuring quality of care and have firsthand knowledge of care inefficiencies that affect patient care and staff satisfaction. Although nurse-led innovations can help to streamline processes and free up more time for patient care, nurses generally lack the organizational framework or support from leadership to develop and test new ideas on the unit.6

What They Did

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Description of the Innovative Activity

As a pilot site for the Transforming Care at the Bedside (also commonly known as TCAB) initiative, Seton Northwest Hospital continuously designs and tests nurse-led quality improvement projects at the patient's bedside using a rapid-cycle improvement process, with projects designed to meet one of four objectives: care safety/reliability, teamwork/staff vitality, waste reduction, and patient-centeredness. The hospital has undertaken more than 120 quality initiatives to date, making nurse-led performance improvement a routine part of everyday operations on the units. A brief description of the quality improvement process followed by a sample of key initiatives appears below:
  • Nurse-led quality improvement process: The specific process used for nurse-led quality improvement varies by initiative but always is based on a rapid-cycle improvement process that quickly tests, measures, and revises process changes. Process improvement teams of staff nurses identify areas for improvement in their own units/departments, set priorities for action, and then implement a five-phase process to test ideas: a planning phase in which team members brainstorm process improvement ideas; a concept design phase in which team members refine ideas with a view toward reaching the “ideal” process; prototype testing via multiple Plan-Do-Study-Act cycles; pilot testing of the prototype on a larger scale; and adaptation of the idea following lessons learned during the pilot. Sample initiatives developed via this process are described below.
  • Standardized postoperative order sets (care safety/reliability): Previously, each of the 13 gynecology surgeons admitting postoperative patients to the unit used a unique, handwritten order form, causing inefficiencies for nurses and pharmacists, and creating patient safety issues due to problems with legibility. Now surgeons use a single order set that incorporates common elements and the most frequently used best practices from the original unique forms. The order set includes basic instructions for a patient's medications, laboratory work, and recommended activity level. Preprinted forms are available in the recovery room to facilitate surgeon access. This standardization has allowed the pharmacy to create a standard record for its computer system and eliminated the need for nurses to transcribe information from the individual written forms. The success of this program has led to a similar approach being used for orthopedic surgeons who perform total knee and total hip replacement procedures.
  • Fall reduction initiative (care safety/reliability): The fall reduction initiative seeks to ensure that staff members quickly recognize patients at risk of falling and respond appropriately to them. Nurses use the Hendrich II Fall Risk Assessment Tool to determine each patient’s fall risk score. High-risk patients receive red slipper socks (in contrast to the tan socks provided to other patients) to highlight their need for extra assistance. In addition, flags placed outside the rooms and signs posted on the doors alert nurses and others to high-risk patients. Family members of high-risk patients receive information cards with instructions, such as reminding the patients to call the nurse before trying to get up. A patient contract, signed by the patient and nurse, confirms that the patient understands their risk of falling and agrees to call for help when they want to get up. All fall prevention tools come together in a single package, so that nurses can easily access them once they identify a high-risk patient.
  • Nurse status boards (teamwork/vitality): The unit experiences 15 to 20 new patient admissions daily; previously, the unit was inundated with requests to take in new patients, with a scheduler in charge of bed placement calling each nurse every 2 hours to ask whether they could accept a new patient assignment. Now, magnetic nurse status boards continually advertise nurses’ current workload, allowing staff members to assist each other during busy periods, which results in more balanced workloads and the provision of more timely care to patients. The board uses color-coded magnetic dots to reflect work intensity for each nurse, with a red dot signifying that the nurse is exceptionally busy and cannot take a new patient; a yellow dot meaning the nurse is getting caught up on work and will soon be ready for new patients or work assignments; and a green dot signaling that the nurse is available to help colleagues or accept a new patient.
  • Nurse/physician patient rounds (teamwork/vitality): Before the redesign, nurses and physicians did not have a systematic or formal way of communicating before patient rounds; as a result, the physician might leave the unit without realizing that the nurse or patient had questions, only to receive a call from the nurse later in the day. Now, a short form, included in the patient’s progress notes, reminds the physician to call the nurse before visiting the patient (the form also provides the nurse’s telephone number). The nurse rounds briefly with the physician to address all questions and problems before the physician’s visit with the patient.
  • Supply reorganization (reducing waste): To avoid situations in which nurses must roam the unit looking for basic supplies or order supplies from the central supply department, the unit now stocks frequently used supplies (e.g., oxygen tubing, suction catheters, thermometers, syringes, blood pressure cuffs, patient gowns and linens) in each patient room. In addition, intravenous poles and pumps are now located in 80 percent of the rooms; as the budget allows, this equipment will be available in all rooms. Central supply department and housekeeping staff take responsibility for stocking the rooms.
  • Smaller morphine dose packaging (reducing waste): Previously, morphine was dispensed only in 10 mg dose packages; for smaller doses, nurses had to interrupt a colleague to serve as a witness to the discarding of the residual medicine. Now the pharmacy stocks the automated dispensing machine with 2 mg and 5 mg dose packages, allowing nurses to select a dose that is much closer to what the physician orders. Since becoming aware of the smaller doses, physicians have made an effort to order doses that closely match the packaged amounts.
  • Continuity of staffing (patient-centeredness): The unit altered its scheduling process to ensure that patients receive care from fewer nurses over the course of their stay. Nurses are now assigned to the same group of rooms on the unit, thereby increasing the likelihood that they will assume care for the same patients on subsequent shifts. Some nurses also agree to be “partners,” working complementary shifts and thereby developing an ongoing professional relationship that makes patient handoffs between the nurses more efficient.
  • Patient discharge improvements (patient-centeredness): Previously, nurses and patients often remained unprepared for discharge even when the patient was clinically ready to leave the hospital. Under the new system, nurses ask physicians during their rounds about the expected date of discharge, and the clinical criteria (such as absence of fever for 24 hours or ingestion of solid food) that must be met before the patient can leave the hospital. This information allows the nurses to provide care with a view toward timely discharge; complete all administrative tasks related to discharge ahead of time; give patients and families the predicted discharge date in advance (thus allowing them to plan as well); and offer timely discharge education to patients and family members.

Context of the Innovation

Seton Healthcare Network in Austin, TX, is a not-for-profit, nine-hospital system that is part of Ascension Health, the largest Catholic and largest nonprofit health care system in the United States. In 2003, the Robert Wood Johnson Foundation and the Institute for Healthcare Improvement (IHI) developed TCAB, a 5-year national initiative designed to improve the quality and safety of patient care on medical and surgical units via nurse-initiated quality improvement activities. The initiative’s objectives include enhancing the quality of patient care and service; creating more effective care teams; improving patient and staff satisfaction; and improving staff retention.3 Leaders of Seton Northwest Hospital, a 113-bed institution, agreed to be one of three pilot sites for the initiative, as they were very interested in adopting a model that would engage staff on the medical/surgical units, where extensive innovation had not occurred in several decades. The TCAB initiative was piloted in one of Seton’s 64-bed general medical/surgical units, which had an average daily census of approximately 48 patients and a daily patient turnover rate of 30 percent.

Did It Work?

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Results

Data from Seton Northwest Hospital and other TCAB pilot sites suggest that the program has allowed nurses and other caregivers to be more efficient and spend more time with patients, reduced falls and nurse turnover, accelerated patient discharge, and yielded positive feedback from staff and patients.

Results From Seton Northwest Hospital
  • Greater caregiver efficiency: The standardized gynecology order set has saved nurses between 18 and 20 minutes per patient and the pharmacy between 7 and 8 minutes per patient.6 A pre- and post-implementation workflow analysis found that locating supplies in patient rooms saves each nurse a million steps a year. A similar analysis found that the use of smaller morphine dose packages saves each nurse approximately 25 minutes a day.
  • More nurse time spent on patient care: Seton nurses now spend 60 percent of their time on direct patient care, up from between 25 and 30 percent before implementation of the TCAB initiative.
  • Near elimination of falls: Before program implementation, between 10 and 14 falls occurred on the medical/surgical unit each month. As of August 2009, no falls had occurred in the last 16 months on the unit.
  • Positive patient and staff feedback about care continuity: Post-implementation patient/family interviews revealed overwhelmingly positive responses to the program, with patients and families being highly appreciative of having the same nurse every day. Anecdotal feedback from nurses indicates that staffing continuity leads to more efficient care, because the nurses get to know the patients they care for day after day. Nurses who are partners are also very positive about the system, noting the efficiency in patient handoffs that results from working closely with one colleague.
  • Earlier-in-day discharges: Before program implementation, the typical patient was discharged from the unit at 3 p.m. Now discharges generally occur by 1:30 p.m. Going forward, the staff would like to move the discharge time to 1 p.m. or earlier.
Results From all TCAB Hospitals1
  • More time spent on patient care: The percentage of time RNs spent on direct patient care increased from approximately 40 percent to more than 50 percent between 2004 and 2006.
  • Lower nurse turnover: Average turnover rates for RNs and advanced practice nurses fell from more than 15 percent in 2004 to less than 5 percent in 2006.

Evidence Rating (What is this?)

Moderate: The evidence varies by initiative, but generally consists of pre- and post-implementation comparisons of key process measures, post-implementation surveys of patients and staff, and/or anecdotal feedback from nurses.

How They Did It

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Planning and Development Process

Key elements of the planning and development process included the following:
  • Creating staff workgroup: Nurses and other staff volunteered to participate in the initiative; eventually, a workgroup formed that consisted of a team leader, charge nurse, nursing director, pharmacist, physician, and eight staff nurses.
  • Kickoff meeting: Members of the TCAB design team held a kickoff meeting at the hospital where workgroup participants learned about TCAB, rules for idea generation and implementation, and target processes/areas for redesign. At the design team's urging, workgroup members told both positive and negative stories about patient care and then developed as many ideas as possible related to potential process improvements. By the end of the meeting, the workgroup had generated 300 ideas and divided them into quadrants based on the difficulty and cost of making the change. As a way of prioritizing the ideas, the workgroup decided to begin redesign by testing ideas from the “easy/low cost” quadrant.
  • Implementing five-phase process: As directed by TCAB program leaders, each process improvement team uses a five-phase process to test ideas, as outlined below:
    • Planning: Planning involves selecting volunteers to join the team and ensuring that the team understands the TCAB initiative. (Workgroup members participated in the initial teams; at present any staff member can join a team.) In an initial meeting, team members first tell stories and brainstorm process improvements around the particular objective being addressed. They then pursue specific planning activities, such as articulating the objectives of the change; predicting how the change will contribute to overall redesign efforts; refining the “who, what, when, why, and how” of the prototype testing; and identifying methods for data collection and results testing.
    • Concept design: Team members refine their ideas for process improvement based on “idealized” concept design; rather than trying to fix current problems, they describe the ideal process and the design process improvements that will achieve that ideal.
    • Prototype testing: Ideas that require minimal time and resources are prioritized and implemented in rapid-cycle (Plan-Do-Study-Act) trials.
    • Pilot testing: Following the prototype testing, ideas are tested again on a larger scale with more formal measurement of the impact.
    • Adaptation: Rapid cycle testing is repeated, and program adaptations are made as needed. Once the pilot test results in a positive measurable outcome, the new process spreads to other units in the hospital and other participating TCAB sites.
  • Program expansion throughout Seton: Seton Healthcare Network has spread the TCAB program to all 22 medical/surgical units in its 9-hospital system.

Resources Used and Skills Needed

  • Staffing: The program required the hiring of one full-time staff member, a project coordinator added at the network level to facilitate skill building in hospital staff, coordinate quarterly network process improvement meetings, and facilitate the spread of successful process improvements.
  • Costs: The total cost of the initiative at Seton cannot be determined, but it consists primarily of the project coordinator’s salary and benefits and the time spent by staff planning and tracking the initiatives. Individual process improvements typically require little or no financial outlay. For example, the nurse white board cost only $5, while the initiative to provide smaller morphine doses was cost-neutral.
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Funding Sources

Robert Wood Johnson Foundation; Institute for Healthcare Improvement; Seton Healthcare Network; Seton Northwest Hospital
Seton Northwest Hospital and other participating Seton hospitals provide funding for the relatively small expenses incurred as a result of individual process improvement projects.end fs

Tools and Other Resources

Information about TCAB is available at: http://www.ihi.org/offerings/Initiatives/PastStrategicInitiatives/TCAB/Pages/default.aspx

Information about the Hendrich II Fall Risk Assessment Tool is available at: http://uprightfallprevention.com/

Adoption Considerations

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Getting Started with This Innovation

  • Ensure strong leadership: Strong nurse leaders model an openness to new ideas and trust among colleagues, provide mentoring, create supportive environments for change, and promote communication to caregivers throughout the organization.
  • Encourage innovation: Ask nurses to map out the ideal workflow on the unit and encourage them to suggest strategies that will lead to that ideal.
  • Choose pilot units with relatively stable staff: A unit with a stable staff will have trusting, positive work relationships that allow for the sharing and implementing of redesign ideas.
  • Promote rapid-cycle change: Quick, straightforward process changes are low-risk, offer an immediate reward, are easy to spread, and set the stage for testing larger ideas.
  • Divide responsibilities to speed implementation: At Seton, each staff nurse in the workgroup assumed responsibility for two or three projects, allowing several projects to progress simultaneously.

Sustaining This Innovation

  • Highlight successes to build excitement: Successful projects will encourage nurses to engage in process improvement and view the development of new innovations as part of their job.
  • Continue to motivate staff: The high energy and excitement exhibited by teams during initial projects may begin to wane over time. Leaders should continually keep staff attention on process improvement and emphasize its importance to patient care and staff satisfaction.

Spreading This Innovation

Along with Seton Northwest Hospital, other TCAB pilot sites included Shadyside, part of the University of Pittsburgh Medical Center, and Kaiser Foundation Hospital in Roseville, CA, part of Kaiser Permanente. An expanded pilot phase, implemented from June 2004 to May 2006, included 13 additional hospitals. In addition, the Robert Wood Johnson Foundation has given a grant of more than $1 million to the American Organization of Nurse Executives to spread the TCAB program to more than 50 hospitals across the country.

More Information

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Contact the Innovator

Mary A. Viney, RN, DNP, CPHQ
Vice President
Experience & Performance Improvement
1345 Philomenia
Austin, TX 78723
(512) 324-5717
E-mail: mviney@seton.org

Innovator Disclosures

Ms. Viney has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Viney M, Batcheller J, Houston S, et al. Transforming care at the bedside: designing new care systems in an age of complexity. J Nurs Care Qual. 2006;21(2):143-50. [PubMed]

Institute for Healthcare Improvement. Transforming Care at the Bedside. 2006. Available at: http://www.ihi.org/offerings/Initiatives/PastStrategicInitiatives/TCAB/Pages/default.aspx

Program enables 50 new initiatives in four months: ‘Transforming Care at the Bedside’ program. Healthcare Benchmarks Qual Improv. 2004;11(9):110-1. [PubMed]

Wood DA. Nurses transform care. NurseWeek. September 5, 2007. Available at:
http://news.nurse.com/apps/pbcs.dll/article?AID=2007309050015&template.

Robert Wood Johnson Foundation and Institute for Healthcare Improvement. A New Era in Nursing: Transforming Care at the Bedside. 2006. Available at: http://www.rwjf.org/en/research-publications/find-rwjf-research/2007/04/a-new-era-in-nursing.html

Footnotes

1 Robert Wood Johnson Foundation and Institute for Healthcare Improvement. A New Era in Nursing: Transforming Care at the Bedside. 2006. Available at: http://www.policyarchive.org/handle/10207/bitstreams/21594.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).
2 Institute for Healthcare Improvement. TCAB - Transforming Care at the Bedside Overview. Available at: http://www.ihi.org/offerings/Initiatives/PastStrategicInitiatives/TCAB/Pages/default.aspx.
3 Gelinas L, Bohlen C. Tomorrow's Work Force: A Strategic Approach. Volume 1. VHA, Inc.: VHA Research Series, 2002.
4 Buerhaus PI, Staiger DO, Auerbach DI. Implications of an aging registered nurse workforce. JAMA. 2000;283(22):2948-54. [PubMed]
5 Wood DA. Nurses transform care. NurseWeek. September 5, 2007. Available at: http://news.nurse.com/apps/pbcs.dll/article?AID=2007309050015&template.
6 Program enables 50 new initiatives in four months: ‘Transforming Care at the Bedside’ program. Healthcare Benchmarks Qual Improv. 2004;11(9):110-1. [PubMed]
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: January 27, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: June 18, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: May 21, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.