Transforming Care at the Bedside is an effort to increase safe, reliable, efficient and patient-centered care to medical and surgical units of participating hospitals. According to the Institute for Healthcare Improvement, one of the program's sponsors, the work environment in hospitals' medical and surgical units is often chaotic and inefficient, contributing to high nursing turnover rates and medical errors that cause nearly 100,000 patient deaths each year. The Transforming Care program recognized that the status quo needed new models designed by those engaged in the work.
Health Progress interviewed one of the program's faculty members, Mary Viney, vice president of nursing systems and network accreditation at Seton Family of Hospitals in Austin, Texas, to learn more about how Transforming Care at the Bedside works at her hospital, Seton Northwest.
HP: Could you please briefly explain the history of Transforming Care at the Bedside?
Viney: Transforming Care at the Bedside is a project that started in 2003 with the Institute for Healthcare Improvement and the Robert Wood Johnson Foundation. It was designed to create a model, or framework, for medical and surgical nurses to improve safety, effectiveness, patient experience and teamwork vitality. We had within this project five main design themes: safe and reliable care, teamwork and vitality, patient-centered care, value-added care and transformational leadership.
The impetus was a 2001 Institute of Medicine report, Crossing the Quality Chasm, which cited the need to make care safer and more effective and patient-centered. Medical-Surgical Nursing are critical departments of every hospital, yet for decades not much technology or design work had been used to improve how care was delivered in these settings.
HP: And how did Seton Northwest Hospital get involved?
Viney: Ann Hendrich, chief nurse for Ascension Health, was in the original group from Robert Wood Johnson that formed the prototype program, and the group asked Ann if she could recommend a hospital from Ascension to be one of the pilots. The project wanted a Magnet-recognized facility. (See "Magnet Recognition: One Hospital's Journey," page 29.) Seton has four Magnet hospitals, and Joyce Batcheller, chief nursing officer for the Seton Network, selected Seton Northwest from those.
There were three hospitals in the prototype stage, which lasted about eight months: Seton Northwest in Austin, Kaiser Roseville in Sacramento, Calif., and University of Pittsburgh — Shadyside. Then 10 hospitals, including Seton Northwest, were involved at the pilot stage. Once it was established the program had merit, it expanded to a collaborative in 2005. Many more hospitals became involved.
HP: How does the collaborative work?
Viney: Once the program became an Institute for Healthcare Improvement collaborative, an invitation was extended to all hospitals that might be interested. Up to 50 hospitals joined each year. In the beginning, participants are involved in face-to-face and virtual learning aimed at skill building. The structure includes phone call-ins every month with more report-outs and skill building. Those involved in a collaborative post information on a shared website so that everyone can learn from others. Presently, two collaboratives are going on — one coordinated by the Institute for Healthcare Improvement and a second coordinated by the American Organization of Nurse Executives, both with the framework established by the Robert Wood Johnson Foundation.
So hundreds of hospitals, including all 10 Seton hospitals in Texas and many Catholic hospitals around the country, are now involved, and the program has spread to other countries such as Wales, Canada and Sweden, to name a few.
HP: How has health care changed at Seton because of its involvement in Transforming Care at the Bedside? What would I, as a patient, notice?
Viney: You would notice that the nurses are available to you. One of the most significant goals of Transforming Care at the Bedside was to increase nurses' time at the bedside. The original time studies show that medical-surgical nurses spent only 23 to 28 percent of their time at the bedside with patients, and the goal of the program was to increase that to 60 percent. The teams now check intermittently and find that our nurses consistently spend 50 to 55 percent of their time at the bedside, a nearly 30 percent improvement. So that we can make continual improvements, this is compared against other key metrics, such as patient satisfaction, how pain is managed and such outcomes as patient falls, hospital-acquired pressure ulcers and nosocomial infection rates.
HP: How do you measure the time a nurse spends at the bedside?
Viney: Each participating nurse carries a handheld personal digital assistant (PDA) with a special program installed. The PDA vibrates randomly throughout their shift and asks nurses where they are. If they are in a patient's room, it asks them to enter what they are doing, such as giving medications, hooking up an IV, doing an assessment, reviewing orders with the patient.
HP: I understand that the program encourages other kinds of personal touches that increase patient satisfaction. What are some of those?
Viney: All of the areas have a whiteboard in patients' rooms. These boards were part of our care model prior to our involvement with Transforming Care, but what is on the board now is different. Nurses will write the names of the caregivers on the board, and several units have put up photos of nurses and physicians. These also capture the anticipated date of discharge or any questions the patient might have for physicians or staff. Family members can put questions on the board as well.
Some units have developed patient journals where they can leave notes, write questions for providers and keep a journal of their care, such as tests they had done and the results, medication changes.
HP: So what is the effect of having nurses at the bedside more? What measurables can you cite as a result?
Viney: Like all hospitals across the country, we have had many initiatives over the past several years to improve our patient experience. Transforming Care at the Bedside helped more frontline staff engage in improvement work closest to the bedside. Many departments have experienced fewer patient falls, fewer pressure ulcers, patients more satisfied with their pain management and patients who feel they are well informed about their care. We have less nurse turnover when nursing shortages loom everywhere. Many improvements Seton leadership invested in, such as our nurse residency program, shared governance model and Transforming Care at the Bedside project, contribute.
HP: How do you measure patient satisfaction?
Viney: Seton sends out patient surveys, and among the questions we ask are, "Rate the communication among members of the medical team," "Did you feel your pain was managed well?" "Were you kept well informed?" Leaders watch the responses to those questions and initiate tests and trials as improvements in processes to make sure patients are safe and delighted with their care.
HP: You have been on the Transforming Care faculty since 2005. What is your role as a faculty member?
Viney: The Institute for Healthcare Improvement model is to involve persons from the field who are trying to implement changes. The institute provides expert improvement advisers and complements these experts with individuals from the hospital sites to teach the practical aspects of implementing changes and to share learning with new hospitals as they join the journey. We share through face-to-face meetings, small conferences usually involving a small team of five to six persons representing hospitals at various sites around the country. These meetings are less about hearing from experts, more about people sharing what the hospital sites have been doing and what has been successful.
Specifically, I work with another leader, Betsy Lee, on teamwork and vitality in leadership skills. We provide exercises for the members and lead discussions between the different hospitals that bring their work forward. We try to keep them on target, depending on the goal they are trying to achieve, and challenge them to keep working. It is very much a coaching role.
HP: How does a hospital go about freeing nurses up to spend more time with patients? It would seem that something would have to give.
Viney: An important part of the process is getting the nurses engaged with the work of improvement and recognizing where there are opportunities to take steps out of the work — to literally remove wasted steps. Little by little, the teams have improved such things as where supplies are located, the number of supplies available, keeping medications close to the bedside and other things that need to be close like sheets, pillows, towels, thermometers, IV poles and pumps. These things are in places that are more predictable so people do not have to spend time hunting and gathering. Another example is changes to the admitting process. Previously it would take nurses up to 55 minutes to admit a new patient because of interruptions and paperwork. Nurses would stop to answer call lights, talk to doctors, check on other patients. As a team, everyone tried, tested, different steps to come up with better ways to organize the work. The teams cut 20 minutes off the admission time, and it is safer for patients because the nurse is more focused.
HP: Any other changes you would like to mention?
Viney: Mary Johnson, RN, one of the staff nurses, instituted a new way of measuring nurses' workloads. Previously one charge nurse would go from nurse to nurse every couple of hours to ask them how busy they were and make notes to keep track. No one else saw the information. Then, Mary got the idea for using a traffic-light color rating that would be visible to everyone. Now this unit has a whiteboard in a central location with red, yellow and green magnets alongside nurses' names, indicating how busy they are. Red means "I'm swamped," green means "I'm clear." Staff members now pitch in to help those who are extra-busy.
HP: What were some of the early steps you took to implement the project at Seton?
Viney: To get started, we did a lot of brainstorming and storytelling to reach the idealized design or target we were aiming for. By the end of one day, our team had come up with 300 ideas for improving the way we do things. The idea is to start with an overall goal, with something that isn't working as well as someone had hoped — getting meds to patients on time, for instance, or discharging a patient, or teamwork with people in another department. The group then brainstorms, or snorkels, around that idea to come up with new ideas of how we might do this better, differently. The group thinks of as many ways as possible to make it a better process. Next step is to prioritize those ideas, and start very small. Rather than say we have a great idea and go change everything, the process is to take each idea and test it on different shifts. [We test] ideas one by one — even something as simple as moving some supplies to the bedside — and learn something from that. Then we try it the next day to see if we can replicate it and make it even better based on the goal or aim we have set to achieve.
HP: Has the program affected how doctors interact with patients, with nurses? With how they practice medicine?
Viney: A couple of things that have changed ... doctors check in with nurses before making rounds. This helps us be sure that everyone is on the same page, that questions are answered. We also standardized our order sets, so that physicians doing the same procedures would use the same order set.
HP: What is the end point for Transforming Care at the Bedside? Do you see it making a real difference in health care in the future?
Viney: I think the endpoint of the "project" nature of Transforming Care at the Bedside will be when it evolves into the standard practice of performance improvement for how people work together and how people approach opportunities for making improvements. The intent is that hospitals will continue to use the Transforming Care process and make it their own, and engage all members of the health care team to test and try out improvements. The main thing is staff engagement, and the process allows staff to get very involved in improvement work. I think it will look a little different at every hospital, or even in the same hospital on different floors, depending on what the goals are. What is clear is we need full engagement from every member of the health care team, and the Transforming Care at the Bedside Process is a proven way to engage every level of provider.
MARY VINEY, MSN
Viney is vice president of nursing systems and network accreditation at Seton Family of Hospitals in Austin, Texas, which serves the central part of the state. The Seton network, affiliated with St. Louis-based Ascension Health, includes eight acute care hospitals, one children's hospital, one behavioral health hospital, well-patient clinics and three primary care clinics for the un- and underinsured. Viney has worked in Seton hospitals since 1991, first as director of oncology and the medical departments at Seton Medical Center in Austin. In 1998, she was promoted to director of patient care services at Seton Northwest Hospital in Austin. The Capital Area Texas Nurse Association named her a "Fabulous Five" nurse in 2003. She also has been involved with the Transforming Care at the Bedside project sponsored by the Institute for Healthcare Improvement and the Robert Wood Johnson Foundation since its inception in 2003. She was appointed to the project's adjunct faculty in 2005.
At Seton, Viney has introduced numerous innovative programs, and as a member of the Transforming Care faculty, she has helped many other hospitals to improve experiences for both patients and staff.
Before joining Seton, Viney served in various clinical education and leadership roles at the M.D. Anderson Cancer Center in Houston, where she was an oncology nurse for 17 years. She is currently enrolled in the University of Phoenix doctoral program for health care administration.