University of Pittsburgh Medical Center (UPMC) Implements Transforming Care at the Bedside with a Focus on Medical Errors

    • July 5, 2011

The problem. The Institute of Medicine's 1999 report To Err is Human estimated as many as 98,000 hospital patients die each year from preventable medical error. The case of Josie King put a face on that statistic—the face of an 18-month old.

Hospitalized for hot water burns, Josie was recovering nicely when her mother, Sorrel King, observed alarming changes in her daughter and sought help from the staff-ultimately to no avail. Josie died in the hospital as a result of undisputed medical error.

So it is not a theoretical problem: A family member sees something wrong and thinks the staff is not responding adequately. What to do?

The solution. UPMC Shadyside in Pittsburgh, one of three original pilot sites for Transforming Care at the Bedside (TCAB), established a rapid response hot line that family members, patients and visitors can call for immediate assistance. (UPMC is a 20-hospital system that includes 13 acute care hospitals and a psychiatric institute in Pennsylvania and additional facilities in Europe.) See Program Results for more information on the TCAB program.

UPMC had no connection with the Josie King tragedy but was moved by it-and by Sorrel King's subsequent advocacy for patient safety innovations, including an emergency lifeline for nonhospital personnel. Working with Josie's mother, Shadyside's TCAB pilot unit tested and implemented Condition H (for Help). It works like this:

A patient, family member or visitor notices a medical change and feels the situation is not being adequately addressed by the assigned care team—or that there is confusion within the team about what steps to take.

From any hospital phone, the concerned person calls the designated Condition H number (3-3131), which is answered by an operator trained to solicit the pertinent information and trigger the response team: a physician, administrative nurse coordinator, floor nurse and patient relations coordinator.

The next day a patient relations staffer asks the caller to complete a questionnaire about the incident—data that helps the hospital identify any common causes and possible interventions to prevent reoccurrence.

To publicize the system and phone number, Shadyside provided patients with a Condition H brochure, placed signs in the rooms and put stickers on the phones. Based on a positive response to the TCAB pilot, Shadyside spread the system to all of its inpatient units in 2005. Later that year UPMC began establishing Condition H in all of its acute care hospitals.

Based on Condition H questionnaires completed in 2006, the hospital reported that 69 percent of the calls "potentially may have prevented events that may have resulted in a patient incident." Of 71 Condition H calls made during 2005–2007, the largest proportion—41 percent—involved pain management/medication issues.

"Our goal is that the care patients receive will warrant this service unnecessary, but we want patients and their families to have this resource available should they need it," said Tamra E. Minnier, M.S.N., R.N., chief nurse at Shadyside when TCAB began and later chief quality officer for UPMC.

Other TCAB initiatives. Shadyside's TCAB staff tested and implemented additional innovations subsequently adopted by other UPMC units. These included:

  • Liberalized meal policy. Shadyside overhauled its menu to give patients a greater choice of what and when to eat plus information on nutrition. The goal was to increase patient autonomy and satisfaction and, thereby, encourage faster healing.

    The change sprung in part from patient dissatisfaction; interviews indicated that patients felt that they were forced to eat what staff wanted them to eat without regard to personal preferences. It also sprung from physicians' concern that patients were not eating enough of what they were served and, consequently, not receiving adequate nutrition.

    In response, physicians and nurses worked with dieticians and patient relations staff to develop a menu with an expanded set of options and symbols to educate patients on nutrition, including a symbol for foods high in fat and another for foods high in sodium.

    Patients were free to disregard the educational guidance and order what they wanted. And what they ordered is what they were served. The new policy also gave patients greater flexibility as to when their meals were served.

    The result was an increase in both food consumption and the number of patients who said the food service exceeded expectations, the hospital reported. Another result was a lesson learned: Don't expect a brief hospital stay to change the patient's dietary habits. Dietary counseling is important, but a hospital stay is not "a diet boot camp."
  • Vitality huddle. Conversion to an electronic health record system has many advantages, but Shadyside staff found it also has a negative: isolation. As nurses spent more using computers to provide and receive information, they spent less time with each other. The result was a perceived loss of collegiality.

    To build up camaraderie, a Shadyside TCAB unit inaugurated the "vitality huddle"—a brief, informal staff gathering to forge personal relationships. Signaled by the unit call system, the nurses gathered most mornings about 9:30 for 10 to 15 minutes of interaction.

    It was not a "meeting," and the topic was never clinical. Indeed, sometimes the huddle was nothing more than unstructured socializing. Other times there was a specific topic for discussion—What is your favorite movie? What is your favorite sports team? Or the huddle might be devoted to a quick game like this one: Each nurse reveals three pieces of personal information—two that are true, and one that is false. The others guess which is which.

    At one huddle, a nurse included among his three revelations that he had been a national pinball champion—a statement that his colleagues immediately identified as false. In fact, it was true. The rule: Keep it light.
  • Supplies in the room. Based on observation, Shadyside TCAB team members found that nurses were spending approximately 16 to 18 hours per week walking to and from utility rooms in search of patient care supplies.

    In response, the hospital equipped each patient room with a storage cabinet for gauze, tape, bedpans, slippers and other everyday supply items—15 to 20 in all. The move saved 832 nurse hours per year, UPMC staff told RWJF.
  • Red, yellow, green board. This simple device allowed nurses to designate their current workload status, signaling colleagues and managers when they needed help and when they could help others.

    Every two hours each nurse placed a colored dot on a central board-red meaning the nurse was swamped and needed assistance, yellow indicating the nurse needed an hour to catch up and green meaning available to help others. Use of the board spread through the UPMC system, eventually evolving into an electronic format.

In addition to specific TCAB innovations, the underlying TCAB approach spread across Shadyside, according to Minnier. Noting that in 2010 Shadyside was recognized as a Magnet® hospital by the American Nurse Credentialing Center, she says:

"They built their entire Magnet preparation journey around the methodology and approach that we used with TCAB. So [TCAB] not only sustained itself as a methodology in nursing; it really became a methodology of the organization. It's become how they do business."

Lesson learned. Shadyside differed from some of the other TCAB pilot sites in that the work was supported by two staff members from the UPMC quality improvement (QI) department. It was their job, explains Minnier, to help the TCAB unit nurses test their proposed changes and track the outcomes.

The lesson, says Minnier, is that front-line nurses are already overburdened and cannot be expected to take on the testing process without additional resources. That might be staff from the organization's QI department, or it might be a unit nurse partially relieved of regular patient responsibilities. Either way, there must be paid time devoted to the effort, says Minnier.

"You can't deliver sustainable, long-term quality improvement and safety improvement without some degree of infrastructure dedicated to the work," she says. "And the amount you have will be a very strong predictor, in my opinion, of the change and the sustainability of that change."

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 adviser 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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