Since 2009, Transforming Care at the Bedside (TCAB) has been an integral component of nursing practice at Eastern Maine Medical Center (EMMC). Selected to participate in a nationwide collaborative sponsored by the Robert Wood Johnson Foundation (RWJF) and George Washington University, staff nurses on Grant 6 Oncology and Grant 6 Respiratory have used TCAB tools to improve the quality and safety of care with the ultimate goal of increasing time at the bedside.
What is TCAB?
TCABÂ is a staff nurse driving quality improvement program designed for medical/surgical units. Innovations come from a brainstorming activity called Snorkeling. Staff nurses then vote on the idea that is most important to them. Using the Plan, Do, Study, Act model of process improvement, conducting rapid tests of change, and developing associated measurements, ideas are quickly adapted, adopted, or abandoned.
It is important to know that the innovations developed through TCAB are staff nurse driven through a bottom-up rather than top-down process. Nurse managers and other members of the leadership team provide guidance, support and access to the necessary tools to conduct the tests of change. TCAB can only be successful if nursing leaders understand this crucial concept.
The Grant 6 Journey and Time Savings Innovations
The Grant 6 staff attended a 3-day training session with 13 other hospitals from around the country. It was during this teaching that these nurses learned that the nationwide average of time at the bedside is between 30 and 40%. The six members of this team embraced this challenge and selected what seemed to be a lofty goal, to increase time at the bedside to 70% by 2012. They then focused on choosing innovations that could be adapted and adopted quickly, engage staff in the process, and demonstrate positive results of increased time at the bedside.
The first innovation was improving the location of supplies. Outside each set of four rooms on this unit is a supply closet, referred to at EMMC as a nurse server. Using the PDSA process and rapid tests of change, closets were set up in an organized standard fashion for frequently used supplies.
To measure the success of this innovation, steps saved were calculated. It was determined that each nurse saved 4318 steps per week equaling over 88 miles per year. This group then calculated the indirect cost savings through the elimination of non-value added process by converting the 4318 steps into minutes. This equaled 43 minutes per week or 37 hours per year. Then, using an average salary of $35.00 per hour, staff found that indirect cost savings per nurse equaled $1295.00 per year.
Keeping the focus of increasing time at the bedside, the next innovation focused on was the creation of geographical assignment regions. The TCAB team took a copy of the floor layout and created blocks of rooms using a staffing pattern of two RNs and a nursing technician (CNA) per 10 rooms. Patient acuity and RN skill set determined the actual patient assignment within the block. To dispel previous negative connotation around block assignments, the TCAB team selected the term “districts” as the naming convention for these groups of rooms.
Staff satisfaction with district assignments, which demonstrated positive results, was the catalyst of the creation of Buddy Huddles. Buddy Huddles improve communication between care team members. Around 8:30 each morning, the two RNs and the nursing tech assigned to each district gather in a designate area and share a brief report on their patients and interventions required during the shift.
Measuring Time at the Bedside
During the TCAB training session, RWJF provided each TCAB team an evidence-based time study tool created by the Institute for Healthcare Improvement (IHI). The Grant 6 team, through trial and error, established an ongoing system of ensuring measurement of time at the bedside each quarter. Using the national benchmark of 30%, the Grant 6 team maintained an average of around 65% for about 15 months. Slippage occurred in July of 2013. The TCAB team refocused their work efforts and as of April 2014 had returned to a rate of 50%.
Since 2009, the Grant 6 nurses at EMMC have adapted, adopted or abandoned over 100 staff-driven innovations. Not only have they increased the time spent at the bedside, they have improved the quality and safety of care, patient and family participation, and staff engagement.
Healthcare organizations that embrace and promote TCAB provide staff nurses a unique approach to quality. The empowerment of front-line staff in work redesign is essential in the continued improvement of clinical outcomes and quality of patient care.
Jennifer Fogel is director of Nursing Systems at Eastern Maine Medical Center, Bangor, Maine.
