Transforming Care at the Bedside

An RWJF National Program

Field of Work: Improving hospital patient care and the hospital work environment

Problem Synopsis: Nurses are the largest group of health care professionals providing direct patient care in hospitals, and their performance has a significant impact on patient safety and the overall patient experience. In a 2003 report, the Institute of Medicine underlined the critical link between quality of care and quality of nursing. The report called for fundamental redesign of how nurses work and the culture in which they work.

Synopsis of the Work: Developed by the Robert Wood Johnson Foundation (RWJF) in collaboration with the Institute for Healthcare Improvement (IHI), Transforming Care at the Bedside (TCAB) sought to empower front-line nurses to implement innovative new practices on their units. It emphasized a bottom-up approach to change. The goal was not only to make the hospital experience safer and more pleasant for patients but also to free up nurses to spend more time in direct patient care, thereby increasing nurse job satisfaction and retention as well as quality of care.

The TCAB program developed, tested and disseminated a structured process for empowering nurses and other front-line hospital staff to take the lead in improving the work environment and quality of patient care on medical-surgical units.

Key Findings & Results: Researchers from the University of California, Los Angeles (UCLA), School of Public Health and the RAND Corporation evaluated the TCAB pilot sites. The evaluators found that the TCAB units in 10 hospitals tested 533 changes in work processes and adopted 377 (71%) of them. A total of 210 (39%) of the changes were spread to other units.

Available data from the TCAB units showed a statistically significant reduction in harmful falls and readmissions within 30 days of discharge—two measures indicating improvements in safe and reliable care. But other TCAB outcome measures showed little movement.

TCAB initiated the TCAB model in more than 100 hospitals across the country and produced materials allowing additional hospitals to implement TCAB on their own. Thus, it laid the foundation for continued spread of the TCAB model after the RWJF-supported pilot phase of the initiative.

In a 2009 article in the American Journal of Nursing, leaders of the TCAB team at the IHI summed up the overall result of the program this way:

Through TCAB, a movement has begun to transform the care delivered on medical-surgical units to better serve patients and to transform the work environment to support professional nursing practice and collaborative teamwork at the bedside.