Transforming Care at the Bedside

Children's Memorial Hospital in Chicago empowers nurses by having them test and implement changes they think will improve patient care and enhance patient and nursing staff satisfaction.

    • June 10, 2008

The Problem: Nurses who work in hospitals often have many ideas to improve patient care and their work environment. But making changes in a hospital can be a long and drawn-out affair. Transforming Care at the Bedside (TCAB) employs a change process that rapidly allows nurses to test their ideas on a trial basis and implement successful ones, thereby offering nurses a tool to speed quality improvement innovations to the benefit of patients and staff.

Grantee Perspective: When the Pulmonary Allergy Transitional Care Unit at Children's Memorial Hospital in Chicago first started using the TCAB "Test of Change" process in 2006, Constance Hill, the unit's director, asked the nurses to brainstorm small ideas to improve patient care and enhance patient and nurse satisfaction.

"Our hospital staff tends to think of big ideas, but I wanted to give the nurses something more tangible," says Hill. "I wanted to show them that they could have high impact in short amount of time."

She asked the nurses what bothered them throughout the day; what changes could be made; and what possible solutions could be put in place and tested over two weeks instead of the customary six-to-nine month period that clinical governance committees use. Her floor tested and evaluated each idea and adapted successful ones.

The nursing floor also asked families and others who entered the unit to write down their suggestions for ways to improve their experiences on the unit. A young man who works in housekeeping suggested that the floor use a sign to identify a room where a mom was breastfeeding.

"We created a picture of a mother holding her child to be placed on the door outside to indicate that this is a breastfeeding mom," says Hill. "That was something that made sense and was easily adapted. Now it has been implemented hospital-wide."

The floor abandoned other ideas that were not beneficial. For example, one nurse suggested changing the physical location of the charts. "It caused chaos for the whole unit," says Hill. "So that was something that was aborted, and the charts were moved back to their original location."

The floor also altered its interactions with the rotating residents who train at Children's Memorial. "We introduce them to our unit, give them a brief orientation and feed them breakfast or lunch. We talk about our expectations and theirs, and how we value our patients' opinions," says Hill. Then, once a month, based on patient satisfaction surveys, the nurses vote on the resident of the month, an award replete with tiara or crown, blown-up picture prominently displayed on the unit and a gift certificate to a local business. "You would have thought we gave them an Oscar," says Hill of resident reaction to the honor. "The award is a popular initiative that helps with our staff vitality and helps build relationships and makes our lives easier."

Perhaps the most popular changes were those that improved the nurses own vitality and well-being. "Nurses get caught up in their day and constantly are on the go, often sacrificing their lunch breaks so they do not have to leave the unit," explains Hill. To help reduce nurse stress during the day, the unit brought in a massage therapist. "We wanted to provide them with an opportunity to get away for 15 minutes and go to a room on the unit where they could de-stress and rejuvenate before going back into patient care," says Hill. The massage therapist was so popular that other departments at Children's Memorial that are implementing the TCAB process now use one as well.

"The greatest thing about TCAB was that it gave nurses a sense of ownership in the decision-making process on the floor," says Hill. Participation in TCAB also helped the nurses appreciate bigger organizational changes that occurred. "There was less resistance to changes that could not be aborted. They were willing to engage in each change and take it on-whether or not they liked the change-because they understood the process of trying to implement change."

Nurses who have a connection to the institution are more likely to stay working there. Retention, which has long been a nursing issue, is also one at Children's Memorial, albeit with a twist. With an average nurse age of 28 years in Hill's unit versus 50 in a general medicine unit, the main reasons for nurse turnover are marriage and relocation or going back to school. But Hill's nurses love the teamwork and personal growth opportunities at Children's Memorial so much that many commute an hour and a half each way from the suburbs.

"TCAB gives newer nurses a sense of having ownership of what is being done on this unit, and the satisfaction that if their idea is embraced, it could be adopted throughout the institution," Hill says.

RWJF Perspective: TCAB, a major RWJF initiative, started in 2003 with 10 hospitals involved in testing, refining and implementing change ideas. The program engages leaders at all levels of an organization to improve the quality of patient-centered care; increase the vitality and retention of nurses; engage and improve the patient's and family members' experience of care; and improve the effectiveness of the entire care team.

"Nurses are a powerful source for improving the quality of care in a hospital," says Susan Hassmiller, Ph.D., R.N., F.A.A.N., TCAB senior program officer and Human Capital team leader. "TCAB allows frontline nurses who work in a stressful environment surrounded by sick patients to become empowered to create solutions that allow them to spend more time at the bedside. Instead of being given constant direction by administrators, all of a sudden, with TCAB, their work environment belongs to them. With TCAB, they are told, 'If you see things holding you back from doing your job and harming patient care, let us know; tell us a better way.' It gives power back to nurses by letting them say what they think is right and wrong."

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