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Program enables 50 new initiatives in four months
Transforming Care at the Bedside’
Seton Northwest Hospital in Austin, TX, launched nearly 50 new quality initiatives in a single four-month period after deciding to participate in the "Transforming Care at the Bedside" (TCAB) program, which was launched by the Robert Wood Johnson Foundation (RWJF) in Princeton, NJ, and the Boston-based Institute for Healthcare Improvement (IHI).
The program, which targets bedside care on a standard hospital medical or surgical unit, aims to enhance the quality of patient care and service, create more effective care teams, improve patient and staff satisfaction, and improve staff retention.
Seton Northwest joined the program in November 2003, recalls Mary Viney, MSN, RN, director of patient care services. "The process we used is what allowed us to complete nearly 50 initiatives in about four months," she says.
And just what did that process involve? First, she notes, having a large number of staff nurses on the core team was critical. Other members included pharmacists, two clinical managers, Viney, and a physician consultant. "Each one of the staff nurses took on two or three projects and led the changes, so we were able to work on several of them at one time," Viney explains.
It might seem that four months is not a lot of time to make significant changes, but she says several of the projects were quite successful.
Perhaps the most impressive project involved standardization of the post-op order sets. "Our gynecological surgeons took what they thought were our highest volume of cases and looked at their order sets as they came up to the med-surg floor," Viney notes. "Each of the 13 surgeons had their own hand-written post-op order sets." One of the nurses then took this on as a project, gathering all the different order sets, noting the common elements and the most frequently used best practices.
Once that was done, it was time to sell the new form to the staff. "We went to one of the physician champions," she recalls. "We told him it was more difficult for the pharmacy and nurses [to use the different handwritten forms] and noted the safety issue of legibility. He agreed to pilot the new form on one of his post-op patients."
All of this happened within two weeks, Viney adds. "The physician was quite open and used the form. Then we asked him to use it again the following day with two more patients. He said he had absolutely no concerns, that there were no changes needed on the new order set."
The team then asked the physician to go to the group in which he practiced and asked them to try the form. "They did so, and then he went to the whole OB/GYN section meeting and led a discussion about the need for change," she explains. "Within a month, we got 12 of the 13 docs to do it."
The new forms now are available in the recovery room, "all preprinted, so they are legible, and all consistent," Viney notes. This, in turn, allowed the pharmacy to create a standard record that could be entered into their computer. "And the nurses did not have to spend as much time transcribing," she says.
Viney notes that the new form has saved nurses between 18 and 20 minutes per patient — and has saved the pharmacy close to seven or eight minutes per patient. "It was safer, took variation out of the practice, and we were able to get more than 90% of the docs to use it in one month."
Subsequently, the same process was tried with total knee and total hip replacement surgeries. "We had two large surgical groups; we went to one surgeon, he tested the form, and it began to spread," Viney reports. In this case, 100% physician participation was achieved, as were similar time savings.
What was the key to success in this initiative? "We laid the issue out, gave examples of how the new forms looked and how similar they were to the old forms," she says. "We had to go through the process, but they saw that we only changed maybe two or three things on the form, so they all agreed to it. Plus, this was a real predictable population, and they understood that. And in terms of staff, it’s been a huge satisfier all around."
In addition, Viney says she was not required to wait for 100% buy-in before proceeding with the new process. "Before, we had to. Now, we can progress by little steps — that’s part of TCAB."