Cedars-Sinai Medical Center, Los Angeles, Implements Transforming Care at the Bedside with a Focus on Communication Between Nurses and Physicians

    • July 5, 2011

The problem. In any organization, there is a potential for miscommunication. Hospitals are by no means immune, and a misunderstanding between physician and nurse, the two key members of the care-giving team, can have serious consequences.

"There is a separation between physicians and nurses," says Christopher Ng, M.D., a urologic surgeon at Cedars-Sinai Medical Center, describing a common condition, one not specific to any single hospital.

"There's that stigma where the doctor is some almighty person, and the nurse is in more of a subservient role. And with that disparity…there's going to be, certainly, a lapse in communication and, potentially, a lapse in patient care, patient safety and quality outcomes."

The solution. At Cedars-Sinai, a 900-plus bed teaching hospital in Los Angeles, improving physician-nurse collaboration and communication was a key part of Transforming Care at the Bedside (TCAB). See Program Results for more information on the program.

Cedars-Sinai's effort to strengthen physician-nurse rapport was already underway in 2004 when the hospital became one of 13 TCAB pilot sites. Four years earlier it had formed an M.D.-R.N. collaborative focused on encouraging more collegial relationships between the two groups of providers.

The hospital's TCAB staff joined in and strengthened that effort. "There was tremendous synergy between our M.D.-R.N. Collaborative Committee and TCAB, such that each initiative was significantly advanced by the other," says Ng, who co-chaired the Collaborative Committee along with Peachy Hain, R.N., a TCAB nurse manager.

One initiative that TCAB helped spread was the M.D.-R.N. unit meeting—a monthly, informal get-together of nurses and doctors away from the immediate demands and pressures of patient care.

A typical session included in-service training—a physician instructing the nurses on a technical issue or a nurse instructing the doctors. The unit meeting was also an opportunity to discuss administrative and procedural issues on the unit.

For instance, Ng says, a doctor who has had trouble finding a patient chart will bring up the problem and hash out a solution. "And from that the collaboration is enhanced."

Another TCAB-backed move was initiation of joint doctor-nurse patient rounds-the matching of a nurse and a doctor to make bedside visits as a team. "So everyone involved knows what the plan of care is: the patient, the nurse and the physician," Ng explained in an interview for an RWJF video on TCAB.

"No calls need to be made to clarify the orders [and] care plans are initiated immediately. And that small change clearly has enhanced the quality of care on the unit."

In addition to physician-nurse engagement, TCAB teams tested and implemented innovations that included:

  • Joint patient rounds by the nurses going on and coming off their shifts, a step to increase information sharing
  • A falls-prevention program that provided at-risk patients with bright orange armbands and booties and an orange warning sign for the room door-all aimed at alerting staff to the patient's heightened danger of falling
  • Staff recognition programs to promote quality performance and job satisfaction, including a President's Award handed out annually to a limited number of employees, spot cash bonuses and unit-level awards Another initiative, the Safety Star Award, encourages workers to identify hospital safety hazards—anything from a frayed rug to faulty equipment. Employees reporting three real or potential dangers get a Safety Star certificate in their personnel record plus either a movie ticket or gift card to the hospital restaurant.

TCAB integration. While designed to empower nurses specifically, TCAB at Cedars-Sinai was an all-hospital endeavor, with strong backing from senior leadership.

TCAB started in one surgical unit. By the end of the pilot phases, the hospital had spread the TCAB process to all 40 inpatient units, including critical care, maternal and child health, pediatric and psychiatric.

"TCAB was thoroughly intertwined with the organization's operational and strategic policies as well as practices," says Linda Burnes Bolton, Dr.P.H., R.N., chief nursing officer and vice president of Cedars-Sinai and chair of the TCAB national advisory committee. "Transforming Care at the Bedside was owned not by nursing but by the entire organization."

In an interview in early 2011, Bolton said that integration of TCAB was so complete that achievement in meeting the TCAB outcome goals became one of the measures used by management in evaluating staff performance.

The hospital continued to track nurse time spent in direct patient care, and a majority of units were above the 70-percent TCAB target, Bolton said. The hospital's tracking also found that with increased time in patient care came higher patient satisfaction scores and lower rates of adverse events.

RWJF perspective. "Nurses are a powerful source for improving the quality of care in a hospital," says Susan B. Hassmiller, Ph.D., R.N., RWJF senior advisor for nursing and a key architect of the TCAB initiative.

"TCAB allows front-line nurses who work in a stressful environment surrounded by sick patients to become empowered to create solutions that allow them [nurses] to spend more time at the bedside."

Developed in 2003 by RWJF in collaboration with the Institute for Healthcare Improvement, TCAB had three pilot phases, the last ending in 2008. RWJF and the American Organization of Nurse Executives have since helped disseminate the TCAB model nationally. It is part of RWJF's Aligning Forces for Quality program, and a separately funded TCAB project is active in New Jersey.

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