NURS 6201 Week 3 Quiz Question 4 Which of the following best describes Transforming Care at the Bedside (TCAB)?
NURS 6201 Week 3 Quiz Question 4 Which of the following best describes Transforming Care at the Bedside (TCAB)?
Transforming Care at the Bedside (TCAB) is one of those transforming innovations that will have a significant impact on the environment in hospitals and healthcare organizations. TCAB was originally launched in July 2003 by the Institute of Healthcare Improvement in partnership with the Robert Wood Johnson Foundation (RWJF). It targeted bedside care on a standard hospital medical-surgical unit and aimed to enhance the quality of patient care and service, create more effective care teams, improve patient and staff satisfaction, and improve staff retention.
TCAB focuses on four areas:
care for hospitalized patients is safe, reliable, effective, and equitable
effective care teams continually strive for excellence when they work in a joyful and supportive environment that nurtures professional training and career development
patient-centered care honors the whole person and family, respects individual values and choices, and ensures continuity of care
all care processes are free of waste and promote continuous flow.3
In mid-2009, the RWJF funded an initiative of the New Jersey Hospital Association’s Institute for Quality and Patient Safety to implement TCAB in 50 healthcare organizations in New Jersey. Half of the organizations underwent 3 days of training in November 2009, and the other half went through their training in March 2010. Using a quality improvement collaborative methodology, all organizations sent a team from their pilot unit to the training, where the teams learned and practiced performance improvement techniques to identify areas for change and possible strategies, how to test them, and how to decide whether they should be maintained. “Adopt, adapt, or abandon” became the teams’ mantra as they began their work and implemented changes on their units.
All of the organizations are supported in this work both internally and externally. Each team has to have a senior leader, generally the CNO, and all teams must have the support of their CEO. Teams need the support of governing bodies and medical staff, and commitments are made by all the organizations’ leadership to support the work through resources and time for improvement activities. The Institute sponsors monthly conference calls and content webinars, a dedicated electronic mailing list and website, and site visits by the program manager. Teams share their tests of change during the monthly calls, thereby capitalizing on the learning and improvement strategies of all to redesign processes and systems.
As the teams began their journeys to transform care on their units, it became clear that by giving frontline staff members the skills they need and the permission to innovate and make improvements in their work, new energy and enthusiasm has emerged. After learning how to utilize “snorkeling,” teams used storytelling and brainstorming to generate new ideas and engage all the staff on their units. Of utmost importance is that ideas and concepts must come from frontline staff, not the nurse manager or the CNO. Teams are encouraged to use strategies from other industries to generate new ideas; for example, the body of manufacturing knowledge on lean thinking and eliminating waste. Concepts from the airline industry might include crew resource management techniques or structured communication such as SBAR (Situation-Background-Assessment-Recommendations); concepts from athletics might include the implementation of huddles, used to keep teams informed during the game, review the effectiveness of changes, and rapidly make changes as necessary.
After the teams select ideas to develop, they create action plans for testing, measuring, and implementing new change ideas. They’re encouraged to perform small tests of change, such as one nurse, one patient, one shift. Utilizing PDSA (Plan-Do-Study-Act) cycles, staff members can try out different changes and rapidly make determinations as to whether they should adopt, adapt, or abandon them. Measurement helps teams decide whether the changes are impacting on the desired outcome.
The CNO’s role
The roles of nursing management and the CNO are critical to the success of the teams’ work. Many of them find their biggest challenge is learning how to step back and not say anything! Managers must adopt a style that delegates authority to their staff to learn new skills and try new things, not try to dictate the work. Managers must encourage staff autonomy and acknowledge that in order for transformational changes to care to succeed, they must be driven by frontline staff. The CNO may also want to direct the activities of the team, but she must step back and let the staff drive the process.
In one of our hospitals, the CNO related that she was less than enthusiastic when her unit’s team decided to try having three nurses do patient admissions—one for the orders and chart processes, one for the physical exam, and one for the verbal communication necessary to complete the admission—fearing a loss of continuity in care. But she “sat on her hands” and let them try it out, and was surprised when the time for a routine admission dropped from 1 hour to around 20 minutes. It was a huge staff satisfier and, even more important, the patients loved it. For those who had been admitted to the hospital before, it was quicker, more organized, and avoided a lot of duplication of effort. In the first 3 months of this test of change, the unit’s Hospital Consumer Assessment of Healthcare Providers and Systems score went up by nine points. The unit’s success was rewarded with a party.
TCAB teams must understand that they can expect successes, but that it’s also alright to have failures because the learning will be just as valuable. The teams need to have the support of the CNO that failures are acceptable, and the CNO must acknowledge this, not taking the position of “I told you this wasn’t going to work” or “This was a bad idea.” The motto “share everything, steal shamelessly” is paramount to this work, so learning from other teams is expected. We’ve had a major teaching hospital adopt an idea from a small community hospital with great success. Rapid cycle improvement theory and small tests of change aren’t always showstoppers, but it’s the way to get buy-in and participation from all staff.
The CNO must also anticipate and plan for the training, support, and time needed for this work, which may include ensuring that ancillary departments know that things may be done a little differently on the TCAB unit. If unit staff members want to reorganize supplies to eliminate “hunting and gathering,” central supply should be part of that work. If staff members want to work on medication administration, the CNO should ensure that the pharmacy department is part of the team. Many of the teams have included key members of the medical staff as physician champions. The CNO and CEO should make sure to take every opportunity to ensure the work of the TCAB unit is visible to the organization and to their governing boards.
For those organizations pursuing Magnet® recognition, TCAB is a valuable tool. Two of the Model Components are Transformational Leadership and Structural Empowerment. TCAB teaches nurse managers the leadership skills necessary to facilitate innovation. It also develops frontline staff and empowers them to find the best ways to improve their work environment, thereby providing the best care to their patients and accomplishing the organization’s goals. TCAB strengthens professional nursing practice and creates a framework for new ideas and partnerships in care. Finally, TCAB will assist the CNO in creating the vision for and leading the organization through the coming healthcare reform.
Commit to change
In summary, the nurse manager and the CNO must be committed to developing the skill set necessary for frontline staff to engage in performance improvement activities on their unit if the primary goal is to transition staff from working around problems in the delivery of care to solving them, transforming their unit to one where highly reliable, effective, efficient, and safe patient care is provided.
REFERENCES
1. Buerhaus PI, Staiger DO, Auerback DI. The Future of the Nursing Workforce in the United States: Data, Trends and Implications. Boston, MA: Jones & Bartlett Publishers; 2008.
Cited Here
2. Christensen C. The Innovator’s Prescription. New York, NY: McGraw Hill; 2009.
Cited Here
3. Robert Wood Johnson Foundation. The Transforming Care At The Bedside (TCAB) toolkit . http://www.rwjf.org/pr/product.jsp?id=30057&parentid=30052&grparentid=30051.
