Abdel latif Marini, MSN, CPHQQuality Management Specialist

Rutherford P, Lee B, Greiner A. Transforming Care at the Bedside. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2004. (Available on www.IHI.org)

As many as 90,000 people die annually from mistakes – an error rate unacceptable in any other industry.

There are more deaths due to medical errors than deaths from accidents,

breast cancer, or AIDS

(IOM Committee on Quality).

The IOM 2004 report, Keeping Patients Safe: Transforming the Work Environment for Nurses links nurses’ skill at monitoring patients’ health and symptoms to improved clinical outcomes, and suggests that their vigilance is an important defense against errors.

However, nurse turnover is typically highest on medical/surgical units, which compromises quality and increases cost.

Background

To respond to the urgent need for change on the nation’s medical/surgical units, the Institute for Healthcare Improvement (IHI), in partnership with The Robert Wood Johnson Foundation (RWJF), has launched in July 2003 an ambitious, expansive initiative to redesign medical/surgical care.

TCAB

This initiative was called Transforming Care at the Bedside (TCAB).

TCAB framework for change on medical/surgical units is built around improvements in four main categories:• Safety and Reliability • Care Team

Vitality• Patient-Centeredness • Increased Value

TCAB

TCAB is not a traditional quality improvement program; one primary characteristic that sets it apart is its focus on engaging frontline staff and unit managers.

Ideas for transforming the way care is delivered on medical/surgical units come not from the executive suite or a quality improvement department, but from the nurses and other care team members who spend the most time with patients and their families.

TCAB

In 13 pilot hospitals, change ideas within each category are being tested, refined, and implemented, many with very promising early results.

Examples include the use of Rapid Response Teams to “rescue” patients before a crisis occurs; specific communication models that support consistent and clear communication among caregivers; professional support programs such as preceptorships and educational opportunities; liberalized diet plans and meal schedules for patients; and redesigned workspace that enhances efficiency and reduces waste.

TCAB in USA

High Leverage Changes….the ―what of TCAB

1. Transformational Leadership2. Teamwork &Vitality3. Patient and Family centred care4. Value-added Care (Lean element)5. Safety &Reliability

TCAB core themes

Care for patients who are hospitalized is safe, reliable, effective and equitable.

Examples of such practices include medication system redesign, end-of-life best practices, and the use of Rapid Response Teams to “rescue” patients whose medical conditions are deteriorating before they reach a medical crisis point.

TCAB goal for safety and reliability

Ruby Red Slippersfor High Fall Risk Patients

Aim: To improve patient safety and outcomes to identify patients at high risk for falls.

Process: Upon admission, patients are

evaluated for fall risk. Fall risk is re-evaluated at least

daily by the patient’s nurse. Patient’s identified as a high risk

for a fall injury will be issued “Ruby Slippers” to alert all staff involved in the patient’s care.

  Every patient seen/screened/admitted to CCRMC will be placed on Universal Fall Precautions using the acronym N.O. F.A.L.L.S.

  N = Nearby: call light, glasses, water, all other personal belongings O = Orient patient to the environment upon admission and change in room.   F = Footwear should be non-skid and well fitting. A = Assess and assist as needed. Assess patients for mobility deficits, impaired cognition, altered elimination, high risk medication, and medical conditions that may increase fall risk. L = Low and lock beds at all times. L = Lighting should be adequate and non-glare. Use night light on evening S = Safety: A safe environment must be maintained at all times.

Safe side rail position Safe administration of medications Sensory deficits identified and compensated for

NO FALLS

SKIN bundleSurface selectionKeep turningIncontinence

mgmt.Nutrition

Six hospitals had no pressure ulcers for 1 year

“No ulcers”Nutrition and fluid statusObservation of skinUp and walking or turn and positionLift (don’t drag) skinClean skin and continence careElevate heelsRisk assessmentSupport surfaces for pressure redistribution

Within a joyful and supportive environment that nurtures professional formation and career development, effective care teams continually strive for excellence.

Eg. Based on innovative work first developed at Luther Midelfort-Mayo Health System in Eau Claire, WI, Seton Northwest nurses developed a traffic-light system to declare their availability for additional patient care.

TCAB goal for vitality

Create more time-less bell calls Pressure areas checked Position changed Pain assessment Nutrition-check (fluids

encouraged where appropriate) Obstacles & Call bells –Call

don’t fall Personal Hygiene Emotional support

TLC Rounds

Truly patient-centered care on medical and surgical units honors the whole person and family, respects individual values and choices, and ensures continuity of care.

Systems and processes are often designed to meet the needs of providers or the patients?

UPMC Shadyside, a TCAB hospital, the nutrition staff responded by creating a liberalized diet program, loosening restrictions and extending kitchen hours. An evening snack, ranging from yogurt to fruit to brownies, is also offered to all patients.

TCAB goal for patient-centeredness

All care processes are free of waste and promote continuous flow.

Eliminating waste on medical/surgical units can mean anything from redesigning work processes to redesigning physical space. Learning to think more systematically about care processes, as well as more creatively, are key steps in changing the system.

A key feature of such lean systems is that they focus on eliminating waste, or muda, which is defined as activities that absorb resources but create no value.

The TCAB goal for Value-Added Care Processes

Successful changes on the TCAB units will be adapted and spread to all medical and surgical units.

High Leverage Changes: Establish, oversee and communicate system level aims

for TCAB units and the spread of TCAB innovations Align system measures, strategy, projects and a

leadership learning system Build improvement capability at all levels of the

organization Get the right team ―on the bus—CEO, CNO, CMO, CFO,

and COO

The TCAB goal for Transformational Leadership

Innovation/ Prototype testing Ideas Generation

‘The Deep Dive’ / ‘Snorkel’/ Paddle The IHI Model for Improvement Small tests of change - PDSA

Choose “low hanging fruit” “What can you accomplish by Tuesday?”

Lean methodology Learning from Industry Local data collection Run Chart-Time series analysis Data compared ‘within’ hospitals rather than

‘between’

Improvement Methodology

Proposed Measures for TCAB • Adverse events • Unanticipated deaths • Patient falls • Unplanned returns to the ICU • Pressure ulcer prevalence • Hospital-acquired pneumonia prevalence • Care team satisfaction • Voluntary turnover • Patient and family satisfaction • Percentage of time spent in direct patient care • Percentage of time spent in documentation • Percentage of time spent in valueaddedwork

This is a story about 4 people named everybody, somebody, anybody and nobody.

There was an important job to be done and Everybody was asked to do it. Everybody was sure somebody would do it. Anybody could have done it but nobody did it. Somebody got angry about that because it was Everybody's job. Everybody thought anybody could do it, but nobody realized that everybody wouldn't do it. It ends up that everybody blames somebody when nobody did what anybody could have done!

Whose Job is it?

Transform Care at

the Bedside in two wards

sites by2012

Teamwork& vitality

Increase the percentage of time spent in direct/value-added care to 70% by:•Eliminating waste & Improve work flow processes for admissions, hand- offs an discharge•Improving work environment through physical space re-design•Enhancing efficiency with technology•Reducing duplication & time spent in documentation

Establish, oversee and communicate system levels aims for improvementAlign measures, strategy & projects and leadership learning systemChannel leadership attention to quality improvement and safetyBuild the right team Align Quality projects to Finance.Engage Physicians in improving care at all levelsBuild improvement capability

Value-Added Care

Transformational Leadership

Safety & ReliabilityReduce the adverse events rate in pilot wardsPrevent Falls by implementing falls bundlePrevent Pressure Ulcers by implementing Skin bundle

Support and involve patients and familiesEnsure patients physical comfortOptimize care transitions to home or elsewhereCreate Patient- Centred Healing EnvironmentsProvide Emotional & Spiritual SupportEnsure Patients rights to privacy & dignity is maintained

Content Area

Drivers Interventions

PatientCentred Care

Empower ward managers to create care teams with the authority to act and transform careBuild capability of front line staff and mid level managers in Innovation and ImprovementUtilize clinical micro system model & toolsEnhance physical environment for staff &prevent staff injuriesOptimize communication across the care teamDevelop staff and match roles to responsibility

Rutherford P, Lee B, Greiner A. Transforming Care at the Bedside. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2004. (Available on www.IHI.org)

Annette Bartley. Transforming Care at the Bedside. NHS North Wales (Central)

References