The Transforming Care at the Bedside project (TCAB) was an initiative led by the Robert Wood Johnson Foundation and the Institute for Healthcare Improvement (IHI) in collaboration with hospitals across the United States. Launched in the early 2000s, the project aimed to improve the quality of patient care by engaging frontline nurses and other healthcare staff in the redesign of care processes at the bedside. The key goal was to improve patient outcomes, staff satisfaction, and the overall healthcare experience.
The project focused on several core areas:
- Improving Patient Safety and Quality: TCAB aimed to implement safer, more effective care practices at the point of care delivery, reducing preventable harm and improving patient outcomes.
- Lean Methodology: Small tests of change using PDSA cycles allowed for quick learning and adaptation. Failed tests provided valuable insights without major resource investment. Successful changes could be rapidly scaled across units. Staff became more comfortable with change through frequent small improvements. A major focus was made to increase the amount of time nurses spent at the bedside.
- Engaging Nurses and Frontline Staff: The project emphasized the importance of involving nurses, as well as other frontline healthcare providers, in decision-making and care redesign. Nurses, being directly involved in patient care, were seen as crucial in driving improvements in care delivery.
- Innovative Care Delivery: The TCAB initiative encouraged the use of innovative strategies and solutions to address challenges such as care coordination, communication, and workflow inefficiencies. Ideas like bedside report (handing off information about patients directly at the bedside) were tested and implemented.
- Creating Collaborative Environments: The project fostered collaborative environments where healthcare teams worked together to improve the patient experience, staff satisfaction, and the efficiency of healthcare delivery.
- Evidenced-Based Measurement: Time Study RN (TSRN) was developed in the pilot program to measure the impact of change on caregiver workload. Time Study RN is a work sampling program using android phones as data collection devices. This program measures where and how nurses spend their time. It also measures the time nurses spend doing work that can be done by other lower skilled resources, and it produces a model of how nurses use the workspace.
Over 200 hospitals participated in the TCAB project from 2003 through 2015 and over 600 units performed measurements with Time Study RN. The benefits reported by participants is as follows:
Leader Development and Leadership Support: Participants reported that active senior leadership engagement was essential for success. The TCAB educational plan trained senior leaders on protecting time for staff to participate in improvement work and encouraged idea creation and testing from front line staff. Leaders were encouraged to actively participate and commit resources to remove barriers and support sustainability and spread successful innovations.
Safe and Reliable Care: Participants reported reduction in patient falls and medication errors, improved handoffs and communication, enhanced early warning systems for patient deterioration, and standardization of critical processes.
Vitality and Teamwork: The TCAB teams reported Improved staff satisfaction and retention, enhanced interprofessional collaboration, reduced turnover rates, and stronger team communication.
Patient-Centered Care: Increased patient satisfaction scores, better patient-family engagement, and improved discharge planning and education were reported.
Value-Added Care Processes: The elimination of wasteful activities, streamlined documentation, better supply management, more efficient workflows, and increased time spent with patients was reported.
Evidence-Based Staffing Plans: Some TCAB teams were able to implement an improved staff planning process. In alignment with AHA’s safe and adequate staffing principles, a system to measure the effectiveness of nurse staffing plans was added to the Time Study RN National Benchmarking Database. The system uses heuristics in the database to calculate a target for Nurse utilization that is needed to achieve safe staffing. Nurse utilization is then measured in Time Study RN and compared to the target to determine if unit staffing is adequate and to determine is an adjustment to the staffing plan is needed.
Development of a Continuous Improvement Culture: All participants reported enhanced problem-solving capabilities, improved staff retention and satisfaction, better patient outcomes and satisfaction, and more efficient resource utilization.
Evidence-Based Unit Design and Architecture: A few TCAB teams who were redesigning their unitsduring the project, were able to import the Time Study RN data model into Layout-iQ and to simulate alternative ways to layout the unit and find the best way to redesign the layout and organize the nursing unit given the nurses patterns of practice.
This transformative initiative showed that engaging frontline staff in improvement work, combined with supportive leadership and systematic methodology, can create sustainable positive changes in healthcare delivery. The lessons learned continue to influence healthcare improvement efforts today.
Innovations Implemented by TCAB Teams
There were many Innovations that were born from the ideas of the participating front line nurses and were tested by a TCAB team and found to be effective. Those ideas were then shared with other TCAB teams and many were implemented widely throughout the collaborative. In the first 2 years of the program a survey was conducted among the 13 original TCAB participants that identified 533 unique innovations that were tested in the program. In another cohort, 32 participating hospital units tested over 933 unique innovations. Examples of those innovations are as follows:
- Whiteboards in Patient Rooms: Whiteboards in patient rooms were found to improve communication between patients, families, and caregiving teams. There was significant sharing and collaboration among TCAB teams to determine the information and layout of the whiteboards to get the most benefit. Updating the whiteboards during the bedside report, which was another TCAB innovation, was found to strengthen shift change communication, impact safety, and improve patient satisfaction.
2. Yellow Socks – Fall Prevention Kits: A significant effort was made early in the TCAB program to reduce falls. One of the innovations tested by a TCAB unit was to identify patients with an elevated risk for falls with yellow socks. They are a visual alert system that quickly identifies patients at higher risk of falling, allowing medical staff to take immediate preventative measures. When patients wear yellow socks, healthcare workers can:
- Quickly recognize fall-risk patients
- Implement additional safety protocols
- Provide more focused monitoring and assistance
- Use color-coded communication for patient safety
- The bright color serves as an immediate, universal signal to all hospital staff that a patient requires extra attention to prevent potential falls.
All TCAB teams that tested yellow socks found that giving fall risk patients yellow socks significantly reduced falls and this innovation was spread throughout the TCAB community. Some units were able to eliminate all falls during the study period.
3. Bedside Reporting at Shift Change:Within TCAB there were many teams that tested innovations to improve the shift change Report. Bedside reporting at shift change was widely adopted throughout the TCAB community. TCAB participants reported improvements in patient safety, the quality of communication, staff accountability, patient satisfaction, and clinical accuracy.
4. Rounding: Innovations related to Rounding became an area of interest and testing within the TCAB community early in the project. Various types of rounding were experimented with and adopted almost universally within the TCAB community. Different types of rounding that were tested are as follows:
Multi-disciplinary Rounding (MDR):One of the innovations that was tested and that has been adopted widely is multi-disciplinary rounding (MDR). Essentially all relevant members of the care team meet to review and discuss their patients. This meeting commonly called a huddle can occur in the patient room, in the hallway outside the patient room, or in meeting area on the unit. This collaboration gets everyone in the care team on the same page and ensures a consistent plan of care.
TCAB units testing MDR reported that it creates a more patient-centered environment that fosters collaboration, improves care quality, and supports better clinical outcomes. In addition, it was found that more frequent rounding significantly increases the time caregivers spend with patients.
PCA/CNA Rounding: One TCAB unit manager was concerned about the number of adverse events occurring on her unit. After studying the problem the team noticed that a high number of these events were caused by patient actions and could have been prevented with staff assistance. The unit implemented and tested PCA rounding and dramatically reduced the rate of adverse events on the unit.
More Frequent RN Rounding: Many TCAB teams tested and implemented hourly rounding to assess patients more often. Putting eyes on a patient more frequently allows the care team to catch problems and intervene earlier in the process. It also builds trust between the patient and the caregivers. More frequent RN rounding was implemented by many teams in the TCAB program.
Purposeful Rounding: High acuity patients with special needs, such as pain management or respiratory distress may need more frequent rounding beyond routine checks.
5. Connected Vitals:The impact of connecting the vitals machine directly to the EMR was tested at 3 hospital systems. Testing included comprehensive data collection using Time Study RN and direct observations of 100’s of vitals-taking events to document the time nurses spend doing vitals and entering that data into the EMR. The connected vitals system tested was provided by Welch Allen, now Baxter. Data collection was performed prior to implementing connected vitals and after implementation.
These studies showed that connecting vitals to the EMR results in the following benefits:
Streamlined Workflow and Timeliness: Automating the entry of vital signs directly into the EMR reduces the caregivers time spent taking vitals. Caregivers no longer have to transcribe and manually enter the data. It frees up time for healthcare staff to focus on other clinical tasks, enhancing workflow efficiency and reducing clinician burnout.
The study also found that if RN’s did not enter the data within 10 minutes of taking vitals, then the average delay was approximately 60 minutes. Observed errors were 14% more likely to happen when RN’s waited to enter the vitals data. If PCT’s did not enter the data within 10 minutes of taking vitals, then the average delay was approximately 30 minutes. Observed errors were 66% more likely to happen when PCT’s waited to enter the vitals data.
Reduced Risk of Errors: The connected vitals system had no errors in transferring the data into the EMR. However, the direct observation study of manual transcription and entry of vitals found high rates of errors. Observed transcription errors varied from incomplete note taking and relying on memory, basic keystroke errors, missing values, and entering the wrong patient’s data.
This study classified errors into 2 types. Entries that had significant error, including multiple values in error or major differences were Red Flagged. Entries that had multiple parameters with modest error were Yellow flagged. Entries that had small errors, (e.g. +/- 3 on a single parameter) were not flagged.
Overall, connecting vitals to the EMR enhances both the quality and safety of patient care, improves operational efficiency, and contributes to a more connected healthcare environment. By eliminating erroneous vitals data in the EMR, it also increases the confidence patients and caregivers have in the quality of care provided.
6. Prioritize Patient Education to Reduce Readmissions:A review of the data in the Time Study RN National Benchmarking database showed that nurses spend less than 1% of their time educating patients how to care for themselves after discharge. Several TCAB teams implemented projects to improve their patient education programs and prioritize this activity. TCAB units working on this problem agreed that nurses should spend at least 5% of their time on patient education to achieve a quality outcome.
7. Storing High Use Supplies at the Bedside:TCAB teams using Time Study RN noticed that nurses were spending a lot of time hunting and gathering supplies. In an effort to reduce time spent hunting and gathering, a TCAB unit at Mass General tested moving high use supplies into patient rooms. This unit experienced an 82% reduction in time spent hunting and gathering and estimated a reduction of 1,162 nursing hours per year gathering supplies. Storing high use supplies at the bedside has been tested by many TCAB units and is considered a best practice by participants.
8. Clinical Interventions to Improve Safety and Reduce Harm were tested, implemented, and spread through the community.
- Catheter-associated urinary tract infections were eliminated in a neurosurgical intensive care unit.
- Treating and preventing nosocomial pressure ulcers.
- The implementation of bedside report that contributed to a decrease in fall and pressure ulcer rates, as well as incremental overtime.
- Change in medication practices that resulted in fewer missing medications leading to a decreased amount of time nurses spent calling pharmacy for medications.
- Reducing falls by more frequent PCA rounding and daily reporting and posting.
- Changing the time of Meds Administration to a less chaotic time resulted in fewer meds errors, improved nurse satisfaction, and an increase in time spent with patients.
9. EMR Lessons Learned:The TCAB project was implemented during a time period in which some hospitals were still using paper documentation and had not implemented an electronic health record. This provided a unique opportunity to study both systems and to learn more about the process of moving from a paper health record to an EMR. In a deep dive of the Time Study RN National Benchmarking database and looking at nursing time spent in documentation we found a bi-modal dataset. What was interesting is that both the best and worst performing units have EMR’s.
The key lesson is that a shoddy implementation will result in nurses spending more time in the documentation task. Investing money on the front end on the design, workflow, implementation, and education of nurses produces significant reductions in the time nurses spend in documentation. The best performing unit measures around 8% time spent in documentation and the worst performing units are over 30% of time spent in documentation. According to the Time Study RN National Benchmarking Database, on average nurses spend 17% of their workday in documentation.
The Documentation by Exception (DBE) method reduced nurse time spent in documentation and was preferred by most nurses who participated in the survey. However, the DBE method requires a significant effort up front to design the workflow, standards, protocols, forms, and checklists.
10. Automatic Handwashing Alerts using RTLS: Testing the effectiveness of automatic handwashing alerts to improve handwashing compliance was performed at 2 hospitals. The handwash alert system could detect when a handwashing was called for and alert the caregiver if they were not in compliance. Hill-Rom, now Baxter, was the vendor of the handwashing alert system that was tested. Direct observations were performed before and after the system was installed to get a good comparison of the impact of the system on handwashing compliance. The first hospital measured an improvement of 55% from 36% compliance to 91% compliance. The second hospital measured an improvement of 15% from 60% compliance to 75% compliance. Both hospitals reported reductions in nosocomial infections.
11. Creating the Nurse Utilization Target: Unfortunately, many hospitals have difficulty adequately staffing their units leading to over-utilization and inadequate patient care. Adequate staffing implies that nurses are available when a patient needs one. In fact, we added nurse availability as a core value in the Lean framework for TCAB since we know that patients are willing to pay to have a nurse available when they need one. To support the new Lean definition we developed a calculation for target utilization. The nurse utilization target is calculated using the following formula.
Target Nurse Utilization = (# Nurses on the Unit – 1) / Number of Nurses on the Unit
Nurse utilization above this target cuts into nurse availability and is considered unsafe because it creates an environment where nurses are not available when needed.
Over-Utilization leads to burnout, stress, and potential errors in care. Nurses may feel overwhelmed and unable to perform their jobs to the best of their ability, which can compromise patient safety and care quality. Overworked nurses are more likely to make mistakes, experience physical and mental exhaustion, and leave the profession, leading to higher turnover rates.
Under-Utilization causes nurses to feel under-challenged, unfulfilled, or less engaged in their work. However, the risks associated with under-utilization are usually less severe than over-utilization, as it doesn’t stretch resources to the point of compromising patient care. Under-utilization can lead to inefficiency and wasted potential, but it doesn’t typically lead to the same safety risks or emotional exhaustion that over-utilization does.
The goal of staffing planners is to get as close to the target as possible without going over it.
12. Staffing Planners must Prioritize Nurse Utilization: The most effective way to determine whether the staffing plan is effective is to measure nurse utilization on a regular basis. In 2012, the nurse utilization metric was added to Time Study RN and nurse utilization targets were developed within the Time Study RN National Benchmarking Database for each unit. These tools allow nursing managers to measure the effectiveness of their staffing plans by comparing nurse utilization with the nurse utilization target for their unit.
Staffing planners and unit managers need to know what the nurse utilization numbers are because both over-utilization and under-utilization of nurses can have negative consequences. In fact, measuring nurse utilization is the only way to determine whether adequate staffing was provided over a given period of time.
A ProModel Simulationmodel was developed o demonstrate the impact of under-staffing on acute care nursing units for those participating in the Time Study RN National Benchmarking Database project.
This simulation model is flexible and can be used on any acute care nursing unit. The model is designed to test various staffing levels and calculate specific operating parameters of the system. The operating parameters calculated in the model include the following:
- Caregiver utilization in real time
- Summary of caregiver utilization
- The number of delayed events
- The % of events delayed
- The % of events delayed > 10 minutes
- The average delay in minutes
- The maximum delay in minutes
The results of this simulation model are available to Time Study RN users and they prove that increasing nurse utilization above the targets causes increasing rates of delays delivering care at the bedside, delays responding to nurse calls, and impacts on other quality of care metrics as found in the literature (e.g. – increasing rates of errors and omissions).
The TCAB Legacy: One of the most compelling legacies of the TCAB project was the impact it had on the frontline nurses who participated. Their unique story was captured in a series of 12 articles by Amanda Stefancyk who lead the TCAB team at Mass General hospital. These articles, published in the American Journal of Nursing, are a great representation of what participants experienced in the TCAB project. Read these articles and it may actually change your life.
1-Transforming Care at Mass General. Stefancyk, Amanda L. MSN, MBA, RN. AJN, American Journal of Nursing 108(9):p 71-72, September 2008. | DOI: 10.1097/01.NAJ.0000334978.12855.59
2-Implementing TCAB on White 10: A retreat can advance care. Stefancyk, Amanda L. MSN, MBA, RN. AJN, American Journal of Nursing 108(10): p 27-28, October 2008. | DOI: 10.1097/01.NAJ.0000337732.23365.93
3-Nurses Participate in Presenting Patients in Morning Rounds: The first test of change was more complex than was anticipated. Stefancyk, Amanda L. MSN, MBA, RN. AJN, American Journal of Nursing 108(11):p 70-72, November 2008.
4-Nurses Participate in Presenting Patients in Rounds: Part 2. Stefancyk, Amanda L. MSN, MBA, RN. AJN, American Journal of Nursing 108(12):p 30-31, December 2008. | DOI: 10.1097/01.NAJ.0000342062.46923.19
5-One-Hour, Off-Unit Meal Breaks. Stefancyk, Amanda L. MSN, MBA, RN. AJN, American Journal of Nursing 109(1):p 64-66, January 2009. | DOI: 10.1097/01.NAJ.0000344043.57392.ce
6-High-Use Supplies at the Bedside. Stefancyk, Amanda L. MSN, MBA, RN. AJN, American Journal of Nursing 109(2):p 33-35, February 2009. | DOI: 10.1097/01.NAJ.0000345427.99615.a1
7-Leading the Way. Stefancyk, Amanda L. MSN, MBA, RN. AJN, American Journal of Nursing 109(3):p 68-69, March 2009. | DOI: 10.1097/01.NAJ.0000346935.28488.5f
8-Postponing Medication Administration. Stefancyk, Amanda L. MSN, MBA, RN. AJN, American Journal of Nursing 109(4):p 21-23, April 2009. | DOI: 10.1097/01.NAJ.0000348587.04168.29. Available at.
9-Placing the Patient at the Center of Care. Stefancyk, Amanda L. MSN, MBA, RN, CNML. AJN, American Journal of Nursing 109(5):p 27-28, May 2009. | DOI: 10.1097/01.NAJ.0000351501.24262.09
10-Improving Processes of Care. Stefancyk, Amanda L. MSN, MBA, RN, CNML. AJN, American Journal of Nursing 109(6):p 36-37, June 2009.
11-Safe and Reliable Care. Stefancyk, Amanda L. MSN, MBA, RN, CNML. AJN, American Journal of Nursing 109(7):p 70-71, July 2009. | DOI: 10.1097/01.NAJ.0000357177.68581.fd
12-Vitality and Teamwork. Stefancyk, Amanda L. MSN, MBA, RN, CNML. AJN, American Journal of Nursing 109(8):p 70-71, August 2009. | DOI: 10.1097/01.NAJ.0000358507.31582.31
Conclusions
During the TCAB project it was my honor to work with over 600 nursing unit teams in a partnership with IHI, RWF, AONE, HQC and other associations who organized this work. For many of the participating nurses, the TCAB project was the first time they had been empowered to innovate and make their ideas happen. The TCAB project gave them purpose and many of them fell in love with nursing again.
The 12 innovations that I listed are a small representation of several thousand innovations that were tested throughout the TCAB community. If TCAB is measured by the number of innovations that were implemented; or the number of nurses/nursing units/hospitals that it benefited; or the number of similar programs that evolved from it, or the number of lives that have been saved… I argue that TCAB was the most successful nursing improvement project ever to be implemented in human history.
TCAB ended officially in 2015, but the spirit of the program has survived because the methods and innovations are timeless. I think it is time to re-start the program. Anybody Interested?
References
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31. Stefancyk, Amanda L. MSN, MBA, RN. Transforming Care at Mass General. AJN, American Journal of Nursing 108(9):p 71-72, September 2008. | DOI: 10.1097/01.NAJ.0000334978.12855.59
32. Stefancyk, Amanda L. MSN, MBA, RN. Implementing TCAB on White 10: A retreat can advance care. AJN, American Journal of Nursing 108(10): p 27-28, October 2008. | DOI: 10.1097/01.NAJ.0000337732.23365.93
33. Stefancyk, Amanda L. MSN, MBA, RN. Nurses Participate in Presenting Patients in Morning Rounds: The first test of change was more complex than was anticipated. AJN, American Journal of Nursing 108(11):p 70-72, November 2008.
34. Stefancyk, Amanda L. MSN, MBA, RN. Nurses Participate in Presenting Patients in Rounds: Part 2. AJN, American Journal of Nursing 108(12):p 30-31, December 2008. | DOI: 10.1097/01.NAJ.0000342062.46923.19
35. Stefancyk, Amanda L. MSN, MBA, RN. One-Hour, Off-Unit Meal Breaks. AJN, American Journal of Nursing 109(1):p 64-66, January 2009. | DOI: 10.1097/01.NAJ.0000344043.57392.ce
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