“Culture trumps strategy every time”
As hospitalists attempt to improve hospital care delivery, they strive to develop strategies for successful implementation of new guidelines, order sets, and alteration of utilization patterns. Key to this success will be collaboration with staff also caring for patients in the hospital. How best to make these changes is unclear, but Kurt Swartout, a hospitalist at Kaiser Permanente’s Roseville Medical Center in California, is involved in a unique project to figure this out. Roseville is one of 13 hospitals (Figure 1) participating in the Institute for Healthcare Improvement (IHI) Transforming Care at the Bedside (TCAB) initiative.
“In July 2003, The Robert Wood Johnson Foundation awarded IHI a grant to study and develop one or more models of care at the bedside on medical and surgical units that would result in improved quality of patient care and service, more effective care teams, improved staff satisfaction and retention, and greater efficiency. Utilizing an innovative approach, IHI and select pilot organizations have been piloting new ideas based on the six Institute of Medicine dimensions of quality (safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity), plus the added dimension of vitality” (www.ihi.org).
Since joining the project in October 2003, many changes have occurred on a couple of the hospital floors at Roseville Medical Center. Dr. Swartout raves about this initiative: “TCAB significantly helped set the stage for effective communication and has helped improve the quality of care at the hospital in which I work. It is the most exciting project in which I have been involved and has done more to improve the quality of patient care than anything else I have seen as a hospitalist.”
Dr. Swartout’s hospital was selected as 1 of 3 test hospitals along with the University of Pittsburgh Medical Center at Shady Side and Seton Hospital in Austin, TX. The first phase at Kaiser Roseville started with a meeting of all employees who worked on medical floor Two South. This included the nurses, the unit assistant, respiratory and physical therapists, pharmacists, administrators, and physicians working on the unit. They had 9 areas from which to choose to study and as a group selected 3:
- Increasing patient safety;
- Improving communication among different health care providers; and
- Making care more patient oriented (patient-centered care).
Utilizing rapid-cycle testing and small tests of change, they then moved forward to improve performance with the above aims. To generate ideas, a “safe” environment was created in which no ideas were considered “bad” and everyone was encouraged to exchange suggestions freely. Administrative support was and continues to be critical to the success of TCAB, because everyone involved was given permission and in fact was empowered to develop creative testing solutions to common problems. Interventions were implemented using rapid-cycle tests and evaluated on 1 patient for 1 shift. Depending upon the outcome, these interventions were either adopted for expansion, or they were modified for further testing or abandoned if unsuccessful. This rapid-cycle testing using small tests of change appealed to everyone, generating a level of energy and enthusiasm among the entire team that had not been present among hospital staff prior to TCAB. Unique to the philosophy of the TCAB initiative, whenever an idea was being tested, the rank-and-file staff had the opportunity to stop it, no matter how enthusiastic the management staff believed in it.
During phase I, Two South rapid-cycle tested over 250 staff-generated ideas. Of note, brainstorming by the staff mainly yielded low-cost and easy-to-implement ideas. Many interventions were simple but allowed the caregiver to focus on the patient, experimenting with ideas that had previously gone unsolicited by management. For example, the staff evaluated placing white boards at the patient’s bedside on which the daily goals were outlined in collaboration with the patient, family, and caregivers. Additionally, they tried alternating midnight rounds between the hospitalist and charge nurse to proactively address issues that might otherwise result in an early, 4 a.m. phone call to the physician. These trials were successful and became permanent efforts.