Transforming Care at the Bedside: Developing a M/S Bedside Care Model

Abstract
In 2003, the Institute for Healthcare Improvement (IHI), through a grant from the Robert Wood Johnson Foundation (RWJF), launched an investigation to study and develop one or more bedside care models to be used on medical and surgical units, labeled the “Transforming Care at the Bedside” (TCAB) project.   Using methodologies such as idealized design, brainstorming, small tests of change, rapid cycle change processes, as well as design themes, 13 pilot sites are testing, adapting, adopting, or abandoning a multitude of new design components for delivering patient care. The purpose of this article is to share our experiences associated with the TCAB innovative process.

Special Acknowledgments
Robert Wood Johnson Foundation and Institute for Healthcare Improvement

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     In 2003, the Robert Wood Johnson Foundation (RWJF) recognized the need to focus patient care improvement on the delivery of one of the largest aspects of hospital care: Medical –Surgical Nursing. In a partnership with the Institute for Healthcare Improvement (IHI), small pilot groups from thirteen healthcare institutions from across the U.S. were selected to participate. Seton Northwest Hospital in Austin and MD Anderson Cancer Center, Houston are the only 2 pilot project sites in Texas. 
Seton NW, my hospital, is the site being discussed.  The direction of the work was centered on the Institute of Medicines’ six aims for health care improvement from a patient perspective. The Institute aggregated those aims into 4 key design themes. These design themes are:
Reliability - Care for moderately sick patients who are hospitalized as safe, reliable, effective and equitable.
Vitality - Within a joyful and supportive environment that nurtures professional formation and career development; effective care teams continually strive for excellence.
Patient-Centeredness - Truly patient-centered care on M/S units honors the whole person and family, respects individual values and choices, and ensures continuity of care.
Increased Value - All care processes are free of waste and promote continuous flow.

     All sites used a 5-phase process to generate design components (innovations). The first four phases are storytelling, idea generation, priority setting, and small tests of change, called rapid-cycling.  If the innovation did what we expected, then the 5th phase, adaptation was initiated and more nurses and patients would experience the innovation.  In the phase of storytelling, staff recounts actual experiences when care was less than optimal.  More stories were shared when care was exceptional. Then, nurses were asked what it would take for every patient to have that experience. [This exercise helped to create the vision for possibility thinking.] The idea generation was a rapid-fire brainstorming event with active participation using sticky notes and big flip charts. The many ideas generated were then prioritized into categories based on level of impact and complexity for the micro system to test. A staff member owns each idea.  That member will develop a small test involving 1 patient, 1 nurse and trialing the ideas. This trial is then evaluated.  Did it do what we expected? If so, expand to more patients or more nurses. If not, adapt or change it. If this is not going to work at all!  Abandon the idea. The unique phase of this implementation is the every day small tests. Test the idea, evaluate and adapt; then, test again the next day rather than waiting an entire cycle of monthly meetings.

        One of our most successful designs was toward the design target of “vitality in the workplace; i.e., the Nurse Status Board. The idea is that each nurse is able to self-declare their own workload status every two hours throughout the shift. The hypothesis was this would give each nurse a sense of control over their workload and a sense of support from the team and Team Leader. Prior to the Nurse Status Board, this level of inquiry was done only when there was a new patient to assign.  In the prospective plan, the nurse declares their status every two hours so ALL team members can help each other “get to green”.  
     Modeled after a traffic light, the magnetic board reflects staff names and uses color coated magnetic dots to reflect each person's level of work intensity. Red dots indicate that the staff member is exceptionally busy and could use some help getting caught up.   Yellow dots reflect that the staff member is getting caught up and will be ready for new assignment(s) or patient admission/transfer.  Green dots reflect everything is in control and nurse available to help co-workers. This innovation supported the key design theme of vitality and the accompanying target of promoting effective, supportive patient care teams.  The emerging results are very promising with higher vitality scores within the team, reduced turnover, nurses spending more time at the bedside, higher patient satisfaction scores and less emergency codes in our Med-Surg units. Phase 3 will continue through June 2008. Its’ goal is to pursue achieving the highest level of movement toward our targets.  There is a core team of 8-10 staff nurses, who impact the entire staff on all shifts.

Mary A Viney RN MSN CNAA
Vice President Nursing Systems
SETON Family of Hospitals
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References:
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