Identify a unit to serve as the hospital's pilot for TCAB—one that can learn from the process, be a model for other units hospitalwide and includes nurses who can become champions for quality improvement.
Once a hospital decides to embark on the TCAB journey, a key step is to select the pilot unit or units. Nursing leaders might be tempted to choose units that require the greatest changes to achieve high retention, positive patient satisfaction scores and improvements in quality, safety and efficiency. However, it is best to select a unit with a strong nursing manager and a relatively stable staff to act as the pilot unit. Picking the unit with the greatest likelihood of early successes will generate positive stories about the experience and help your organization build internal mentors. This facilitates more rapid spread of the interventions after the initial pilot phase.
Transformation of the care environment requires active participation from a cohesive team of leaders, nurses, physicians and other staff. The culture of both the organization and the unit must support involvement from everyone—clinical and nonclinical staff—to engage the best ideas for innovation and change. A core innovation team—a multidisciplinary group committed to implementing tests of change across the unit, must lead the process.
1. Build a core TCAB team composed of a multidisciplinary group of dynamic individuals.Staff nurses, physicians and unit-level ancillary staff (such as respiratory therapists and pharmacists), often comprise the members of the core team. Include staff nurses who represent a range of personalities, including creative thinkers as well as a few naysayers. If possible, include patient volunteers or family members on your TCAB team. Nursing students and residents are also great sources of new ideas. They see things that regular staff sometimes overlook.
2. Target units with frontline managers who are intuitively curious and are risk-takers.These managers will help show early success with TCAB, making it easier to spread to other units. More conventional and controlling managers are not as good to start with when forming one of the first TCAB teams.
3. Pay special attention to the frontline manager who is typically the personality and key to a unit's success.Help him or her understand why TCAB is an effective, rewarding way to improve quality.
4. Establish a regular meeting time and hold frequent huddles to build the team.It is important that the participants know that TCAB is being taken seriously at the hospital, and a consistent meeting time with specific agendas and roles helps accomplish this. In addition, less formal but frequent huddles with team members to discuss a potential change or to share perspectives on how a change under development is proceeding creates synergy among the members and keeps TCAB in the forefront of their minds. The best results occur when regular meeting times occur every one to two weeks.
5. Periodically involve high-level nurse leaders as needed.Participation of the chief nursing officer and (more frequently) the nurse leader for the unit enhances the likelihood of success. These leaders can help identify and remove operational barriers to change, address interdepartmental challenges and model strong leadership for TCAB nurses. Supportive CNOs are more likely to report successes to the CEO and the board of trustees, engendering even more support.
6. Periodically open meetings to other staff in order to enhance idea generation and support for the tests of change.This will not only increase the range of perspectives that the team has to consider, but make others who are not actively involved in TCAB feel a part of its process and assist with its eventual spread.
June 2008. Interview with Peachy Hain, RN, nurse manager, Cedars-Sinai Medical Center. You need the support of top management to successfully implement the Transforming Care at the Bedside (TCAB) methodology.