“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.
Perhaps the biggest impact was on the culture of the unit. Because identified issues had become opportunities for improvement instead of problems, a new sense of optimism prevailed. Care on one patient typified this evolving approach induced by the TCAB initiative. An 81-year-old demented man was admitted for behavioral problems because the family could no longer handle him; he appeared destined to languish in the hospital. We have all taken care of patients like this, and difficulties in their management combined with no obvious disposition usually result in prolonged hospitalizations. The staff immediately saw this patient as an opportunity to work closely with the family. Making arrangements for the wife to spend time with the patient in the hospital and aggressively devising a care plan that involved the family resulted in the patient’s return home after just 4 days. The patient’s family was delighted with the care, and everybody on the unit shared a real sense of accomplishment.
A concrete example of using the white board for communication resulted in optimization of care for another gentleman who was admitted after a complicated bowel resection with a projected length of stay of 8–10 days according to the surgeon. The Two South staff worked closely with the surgeon and placed daily goals on the white board for all to see. Additionally, the nurses and patient were actively involved in the decision-making process, particularly with regard to increasing ambulation and decreasing narcotic use. This resulted in more rapid achievement of goals and recovery by the patient, with discharge from the unit occurring after just 4 days.
With the success of phase I at Kaiser Roseville, the staff anxiously set forth to participate in Phase II. Phase II increased the number of hospital sites to 13 and increased the rapid-cycle testing module. Ten areas of focused improvement were selected, including attempts to reduce unplanned transfers to the ICU and decreasing adverse events for hospitalized patients. During Phase II, Roseville developed its own Rapid Medical Response Team (RMRT). The RMRT is composed of the charge nurse for the ICU, a respiratory therapist, and a house supervisor. This team responds emergently at the request of any Medical-Surgical nurse to evaluate any patient about whom the nurse has concerns. These patients usually have a quickly evolving medical crisis such as respiratory distress, hypotension, or an altered level of consciousness. The primary goal of the RMRT is to quickly evaluate the patient, obtain physician support if needed, and stabilize the patient promptly on the floor or transfer them in a controlled fashion to the ICU. A secondary goal pertains to another TCAB aim, staff vitality, in that the medical-surgical nurse is now placed in a safe environment where he or she interacts with peers from the RMRT and gain additional critical thinking and physical assessment skills through that interaction. It is still early, as we just started the RMRT in September 2004, but the early data suggest we have significantly decreased transfers to the ICU, Code Blues outside the ICU, and unplanned mortality on the Medical-Surgical floors.
In an effort to minimize patient falls, Roseville instituted hourly safety rounds in which a direct care provider (RN, LVN, or NA) quickly looks at all the patients and their current status and implements a fall prevention protocol as needed. Another intervention they have adopted is the use of portable bed alarms, which alerts staff that a patient is attempting to get out of bed. The net result of this has been a dramatic reduction in the fall rate on the floor from a California average of 3.1 falls/thousand patient days to 0.8 falls/ thousand patient days on Two North, demonstrating expansion of the TCAB initiative to other floors in the hospital.
When the TCAB initiative was initiated at Roseville 18 months ago with the Robert Wood Johnson Foundation and the IHI, the Roseville staff had no idea of how much could be achieved—from enhancing patient care to improving both physician and nursing satisfaction to decreasing patient mortality. Although the TCAB initiative is viewed as an ongoing journey, the staff is eagerly anticipating the remainder of the voyage.
An example of an initiative at other hospitals among the 13 includes “peace and quiet time” at Long Island Jewish/North Shore. These nursing “magnet” hospitals discovered when they surveyed their patients that noise preventing patients from resting and recuperating was a major problem. Beginning with 30 minutes of enforced quiet time in the afternoon and then expanding to an hour, patients have reportedly been delighted with this. Snacks were passed out to the patients so they would buy into the initiative and believe they were not being ignored—a floor staff suggestion!
Another hospital modified the usual “multidisciplinary rounds” into highly functional, true patient rounds. At this hospital they originally were called “discharge rounds,” with a focus on discharging the patient. Recognizing that the patient had not been involved because these occurred in a conference room, they were renamed “patient care rounds” and moved out of the conference room to round in the patients’ rooms. Following the dictum of “nothing about the patient without the patient,” these rounds include a pharmacist, a social worker, the charge nurse, a nutritionist, a case manager, and the patient in the patients’ room. This team rounds on all the patients on the unit, seeing up to 37 patients in 1 hour! After initial difficulties involving the residents, they now have “firm directors,” so a physician is now involved. Based on this experience, they proclaim that their culture has changed from “no, it won’t work” to “why not try it?”
Hospitals and staff participating in TCAB are discovering just how successful they can be in achieving enhanced communication, implementing novel interventions to improve care, and optimizing the overall hospital experience for patients.