In 1998, the clinical staff at the University of Pittsburgh Medical Center (UPMC) Shadyside spent three months taking a critical look at how nurses cared for patients. Through this process, they discovered that nurses were becoming increasingly encumbered with documentation, spending time performing tasks that took them away from providing direct patient care, and having difficulty communicating with physicians. As a result, UPMC Shadyside implemented a clinical design initiative to change both the patient experience and the caregivers' work environment for the better.
Five years later, the hospital expanded its program by becoming one of three pilot hospitals to participate inTransforming Care at the Bedside (TCAB), an initiative of the Robert Wood Johnson Foundation (RWJF) and the Institute for Healthcare Improvement (IHI) to improve care delivered at the bedside on medical-surgical units. The goals of TCAB are to enhance the quality of patient care, create more effective care teams, increase patient satisfaction and staff engagement, and improve staff retention. The program empowers nurses and other staff to develop and test solutions to problems on the unit.
According to Susan Christie Martin, R.N., M.S.N., Shadyside's director of nursing support services, TCAB was a natural extension of their existing performance improvement program.
“Joining TCAB gave us access to the resources of RWJF and IHI. It also gave us the ability to connect with nurses all over the country to learn from their experiences and possibly adopt their work at Shadyside,” Martin says.
In the three years since Shadyside introduced TCAB on one med-surg unit, the program has spread to another med-surg unit at Shadyside and to a unit at another hospital in the UPMC system. Martin says that the program's success can be attributed to the commitment of nursing at all levels, with engaged staff, managers, improvement specialists and executives as the real “horsepower” behind TCAB. The results are two-fold: improved quality of care and a more empowered nursing workforce.
Innovations on 4 East
One of the UPMC med-surg units adopting the TCAB process is 4 East, a 24-bed unit. A small change the unit has implemented through TCAB is to keep supplies such as gauze, tape, bedpans, slippers and nasal cannulas in a patient's room in a locked cabinet, rather than in a central supply room. Recent studies show this change is saving 700 to 800 trips to the supply room each week, translating into 17.5 to 20 hours of nurses' time. Further time studies are under way to determine how much of this time is being spent at the patients' bedsides.
Each room now has a whiteboard that can be easily seen by the patient. At the beginning of each shift, nurses write down their name, the name of the nursing assistant, the date, and a goal for the day. The goal can be challenging—like reducing pain—or simple, like watching a favorite television program. The nurse and patient work together to identify a goal; the care team then develops a plan to achieve that goal.
There are now two patient care coordinators on the unit who meet with all patients within 24 hours of admission and begin discharge planning immediately. These coordinators see patients daily throughout their hospital stay and are able to provide information to physicians about a patient's condition.
Another innovation first tested through TCAB on 4 East and now being spread to other UPMC hospitals is known as Condition H, or Condition Help. When patients or family members feel that a change is occurring in the patient that is not being appropriately recognized by the care team, or when there is confusion about how care is being delivered to the patient, they can call the Condition H hotline number. A team of clinicians is then dispatched to assess the situation and provide the necessary support. UPMC Shadyside worked on the development of Condition H, the first program of its kind in the country, with Sorrel King, whose 18-month-old daughter Josie died in another hospital facility as a result of poor communication and hospital errors.
Patients on 4 East and other med-surg units at Shadyside also benefit from a Patient Controlled Liberalized Diet Program (recently featured inFood Management magazine), providing them with meal choices similar to what they would eat at home. The menu contains a variety of foods that are lower in fat, cholesterol and sodium, and lists the carbohydrate content of all foods. Patients whose food preferences may be contributing to their poor health are offered counseling to make wiser selections. Another improvement, suggested by a patient, is the addition of moist towelettes on all trays.
Following 4 East's biweekly TCAB meeting, the team conducts interviews with patients on the unit, asking them about their experience at Shadyside. The feedback provided can lead to new TCAB innovations. For example, a patient suggested making snacks available to patients in the evening hours when the cafeteria is closed; as a result, a snack cart filled with healthy choices is now available to patients before bedtime.
Empowering Nurses, Revitalizing the Profession
Improving the patient experience is only part of the TCAB story at UPMC Shadyside. TCAB is creating excitement for the nurses caring for patients on the med-surg units, empowering them to become true leaders in the delivery of high-quality patient care.
Jessica Laratonda, R.N., B.S.N., has been working on 4 East for three years. After spending one year as a staff nurse and a second year as a charge nurse, Laratonda was promoted to unit director. She credits her involvement with TCAB as a reason for her move to management. She took the lead on many TCAB projects and worked closely with her former manager on the initiative.
“I had never thought of the big picture, but being involved with TCAB made me see that we could change the way we do things,” Laratonda says. “I really blossomed as a nurse when I was able to give input and have it considered. I had a voice at the bedside—something I never knew I could have before TCAB.”
A staff nurse on 4 East, Jessica Carter, R.N., B.S.N., never imagined that she would have taken on a leadership role when she joined the staff of 4 East three years ago. She now leads many of the TCAB projects on her med-surg unit.
“Nurses here feel so much more empowered over their environment,” she says. “The leaders of our clinical design initiative are always willing to take ideas that our team comes up with and try them. We are spoiled. We have the resources behind us to get what we need done.”
TCAB recently spread to the med-surg unit where Cindy Hostetler, R.N., practices. Earlier this year, she attended a conference to learn about TCAB principles and processes, and in just a few months, the program has rejuvenated her and her love for nursing.
“The TCAB meeting was an eye opener,” she says. “I was astounded by the different ideas that hospitals have for improving patient care. I saw nursing through a different perspective. I felt so much better about being a nurse. I know we are going to make a difference.”