Amanda Stefancyk is the nurse manager of White 10, a general medical unit at Massachusetts General Hospital, and the author of a series of articles launched in our September issue describing the unit's involvement in Transforming Care at the Bedside. Also known as TCAB, it's a process by which clinical staff are given the power to institute "rapid-cycle change," small and quick tests of ideas for improving patient outcomes, patient and family satisfaction, team work, and the use of resources.
The nurses use the plan-do- study-act model: plan the change, do carry it out, study its impact, and act to modify, discard, or implement it. Sometimes the changes seem quite straightforward but may be more challenging than anticipated: this month Stefancyk describes the unit's experience with nurses, instead of interns, presenting patients on morning rounds (see page 70). At other times the changes require significant resources: as Rick Homola and Jill Fuller write on page 35, Prairie Lakes Healthcare, one of the original TCAB sites, created an admissions team to shorten a patient's time from ED to inpatient bed.
Such quality improvement (QI) efforts have been criticized in recent years for failing to ensure that the changes institutions are making are the right ones. For example, a lack of rigor in many QI studies has resulted in few being published in leading biomedical journals, the studies often lack sufficient detail, making it hard for institutions to determine whether they should consider adopting similar changes. And yet how are we to improve health care without every institution testing every new idea and making the same mistakes in designing and using them?
In a 2006 article in Quality and Safety in Health Care, Pronovost and Wachter write that "arguments to relax traditional evidence based medicine standards for QI research and publication [horizontal ellipsis] would be detrimental to the field, waste essential and scarce resources, and lead providers and organizations down too many blind alleys." For instance, perhaps improvements are seen on rounds when a nurse rather than an intern presents the patient because the staff is aware that they're being studied. But are the improvements sustained when no one is measuring the outcomes?
On the other side of the debate is Donald Berwick, founder of the Institute for Healthcare Improvement, which led the original TCAB initiative. He writes in the March 12 issue of JAMA that we can't afford to wait to improve care until we have the resources to carry out randomized clinical trials. In fact, he notes that too often rigorous clinical trials fail to account for the real world of health care.
In April 2007 I was invited to participate in a two-day meeting of 30 "stakeholders," including journal editors and clinicians engaged in major QI initiatives (including Pronovost and Berwick). The purpose of the meeting was to assist in revising the SQUIRE guidelines-Standards for QUality Improvement Reporting Excellence-that were first published in 2005 in Quality and Safety in Health Care. If used by authors and journals, the guidelines can increase the likelihood that reports of QI studies will have sufficient detail to be included in systematic reviews, provide a basis for editors and peer reviewers in evaluating manuscripts, and perhaps result in better-designed QI projects. (See the revised guidelines on page 80.) I urge readers to read the discussion of the new guidelines in the October issue of Quality and Safety in Health Care (http://qshc.bmj.com%2fcontent%2fvol17%2fSuppl%26%2395%3b1). Manuscripts on QI projects submitted to AJN must now reflect these standards.
As nurses become more engaged in QI, it's important to strengthen these efforts. In the meantime, nurses on White 10 and at Prairie Lakes Healthcare are focused on improving how care is delivered. As Stefancyk noted in her first report for AJN, "TCAB would challenge us to think differently about how we cared for patients, to act quickly on an innovative idea, and to spread our success to other units." And that alone may qualify as "better."