Improving Care at the Bedside Is a Team Effort

Linda Burnes Bolton, Vice President and Chief Nursing Officer at Cedars-Sinai Medical Center, is an active participant in the RWJF/IHI initiative Transforming Care at the Bedside. She shares her experiences with testing and implementing changes at the front-line to improve care.
Q: Can you say a little about your position and your organization’s work with the Transforming Care at the Bedside project?
A: I’m Vice President of Cedars-Sinai Medical Center, a 952-bed academic medical center in Los Angeles, California. We are engaged in Transforming Care at the Bedside (TCAB) because we are on a quest to not only provide excellent care but also develop models for excellent care delivery. We are a Magnet hospital, a Leapfrog hospital, and we have been engaged in improvement work with IHI for about the last 15 years.
Q: What is the gap between the way care at the bedside is currently delivered and the way it should and could be delivered?
A: Nurses spend an extraordinary amount of time trying to get to the work of caring. They spend a large amount of time waiting, hunting and gathering for supplies, documenting, and trying to communicate to other team members (family, physicians, pharmacists, and respiratory therapists). Nurses also spend a great deal of time trying to rework the interactions that happen between other disciplines and the patient. For example, the physical therapist walks out of the room and often the patient asks, “Can you explain what he or she just said?” Their “translator” role is extremely time-consuming.
And that’s the gap. It’s frustrating, it’s redundant, and it’s not highly reliable. You can’t tell from day to day whether you’re making progress or not.
What would make the perfect day from the patient and provider perspective? Reducing the redundancy in this work is part of the answer. The ideal system is highly reliable and it is very patient centered. The ideal system is engaging for a patient and his or her family — and it’s vibrant such that staff like coming to work and being present with their colleagues. That’s where we are trying to go, and we have multiple strategies that we are testing in the IHI Transforming Care at the Bedside project to see if they actually result in improvement. We can do something about that gap by actually engaging front-line team members.
Q: Can you describe some of the most promising changes you have tested?
A: The notion of team training and teams working together has always been seen as a lever for learning and improvement. Building on this, we initiated team walking rounds. First we started with the nurse walking rounds, where the incoming nurse and the outgoing nurse go into the patient’s room together and describe what has happened in the last 12 hours, what are the plans for the next 12 hours, and what the patient would like to do. That works very well, and it helps nurses get back to the type of care that they want to deliver at the bedside. In terms of coordination of care, this eliminates the fragmentation.
Q: Who should be on that team that is walking around?   
A: It depends. At Cedars–Sinai, our surgical unit has a team participating in TCAB. For a patient who has some sort of GI surgery, the team is probably going to include the dietitian, physical therapist, and the social worker. For someone who has had a colon resection, the goal is to get this patient out of the hospital and also give them some ideas of how to modify their diet when they get home. To do that prior to the day of discharge, you want the dietitian and the nurse on the team to talk to the patient and the family together.
Q: You made reference to the “deep dive.” Can you tell me what that is?
A: The “deep dive” exercise comes from a company called IDEO. To do this, you have your team observe a specific process in your system. Following this observation, you ask them to post any half-baked idea they have about improvement on a flipchart. Our entire team generated 108 ideas of how we might improve care at the bedside and this team included doctors, nurses, respiratory therapists, residents, pharmacists, students, and patients themselves. We consolidated the ideas, categorized them, and then prioritized which ones we would do first. Out of the 108 ideas generated in June, we have implemented about 30 of them.
Q: Can you give examples of some results and what you eliminated?
A: Our first area of focus was the problem of patients sitting in the recovery room who can’t get to a bed. They can’t get into a bed because there is someone still in that bed who is waiting to go home. So, we analyzed our data and found that 70 percent of our patients were going home after 11 AM. What is important about 11 AM is that this is when the first set of surgeries are usually completed. Surgeries would be completed and patients are ready to come out, but they were staying two to four hours longer than they needed to in the recovery room because the patients who had been discharged did not go home.
For our first test of change, we developed a packet for patients that we gave to them upon admission that said, “Here is what you need to do when you are ready to go home.” So, starting from check-in, the patients and their families know what they need to do to when the patient is ready to go home. Often patients will say to us that they could go home in a cab but do not have keys to the house, or they don’t have clothes or a ride.
For cycle two of this test, we expanded our van and taxi service so we could take patients home who did not have a ride. Then, in cycle three, we told physicians to stop writing orders that told patients they could go home after 1 PM. We heard that patients didn’t want to go home and not have anything to eat, so we had our dietitians prepare nice to-go lunches. So after cycle one of our test, we went from having 80 percent or more patients going home after 11 AM to 70 percent; after cycle two we got down to 50 percent; after cycle three we got down to 40 percent; and after cycle four we had 95 percent of our patients going home before 11 AM. In cycle four, we gave patients a care pack [at check-in] so they knew what was going to happen to them each day in the medical center. The packet explains to patients that if they don’t have a ride to pick them up by 11 AM, the medical center will bring them to our discharge center and they will sit there and wait for their rides. Since we started that discharge lounge twelve months ago, we have had only two patients who needed to go there — all of sudden their rides appear.
Q: Since you are measuring the percentage of patients that go home before 11 AM, that must mean your waiting time in PACU goes way down?
A: That is correct. Our target was 100 percent of the patients from the time we get the call from PACU that says the patient has reached their appropriate Adrete score (a score that indicates whether the patient has fully recovered from anesthesia). From the time we get that call to the time the patient has reached their bed cannot exceed one hour.
Q: What results have you seen, and what barriers have you encountered to making these changes?
A: We’re at 100 percent for the pilot unit. Prior to TCAB, a team member is typically thinking about the work they have to do and not necessarily how it will impact other team members. They can’t see the distance issues and they can’t proceed because they haven’t really sat down together to ask, “Can we redesign the way we do things?” Everyone works very hard, everyone does their jobs very well, but it’s not necessarily interconnected in any way. The way around this is by doing deep dive exercises and pulling all the team members together and showing them that there are opportunities to improve. This can’t just be a unit project or a nursing project. It has to be an institutional project. The CEO needs to say, “We are going to improve care at the bedside I am committed to this.”
Q: Why is it so important for senior leaders to be engaged, and why couldn’t a unit work together to redesign care?
A: A unit actually does work together to redesign some care. To make all the system support processes willing to change requires a top organizational change. To get central supply to change the way we work, it might not happen with just a unit trying to do that. But if you set targets for improvement at the senior level and hold everyone accountable at all levels its more likely to occur than just setting targets for improvement at the unit level and hoping the unit will be able to influence enough authority.
Q: Is there a business case for improving care at the bedside?
A: Right now our business case target is decreasing errors, because there is money associated with patients involved with injury — injury related to medication error or to unanticipated death. Another target is to decrease length of stay because that leads to increased hospital efficiency. Even though we have over 900 beds at Cedars-Sinai we still have many patients that are waiting to get into our surgical schedules because we aren’t as lean as we could be. So far, we have decreased our length of stay by 1.8 days on the pilot unit, and we’ve continued to decrease our injuries in that pilot unit. The other area is reducing nurse turnover. Every time you lose a nurse it costs the hospital between $25,000 and $60,000 to replace that nurse. If you can decrease turnover you can again improve your bottom line.
Q: In your experience, what difference has it made having the Vice President for Finance involved?
A: He has benefited from the deep dive exercise. It has helped him to understand that it’s a system problem, not an individual discipline problem. Looking at the issues from a systems perspective helps to identify some opportunities for improvement.
Q: What methodologies are needed to spread changes from one unit to other units, or throughout the organization?
A: We now have 24 other units engaged in TCAB. And our goal is to have eight more engaged by the end of summer. We hope to spread effectively by shortening the time frame for the adoption of an idea, and that’s number one. Second, you need to have a champion. What we have found successful in our spread is peer-to-peer counseling and mentoring. It’s not just about the director saying to the next unit, “You need to do this.” It’s about the staff nurse talking to the staff pharmacists and convincing them that this is the best thing since sliced bread. And they are able to do that because they are engaged in designing the change, implementing the change, and evaluating the change.
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