Transforming Care at the Bedside (TCAB) is a national initiative of the Robert Wood Johnson Foundation (RWJF) in partnership with the Institute for Healthcare Improvement (IHI). The program is designed to improve inpatient care and the hospital work environment by empowering front-line nursing staff. A basic tenet of TCAB is that front-line staff and unit nurse managers can recognize the need for change, identify innovations that will improve work processes, test these changes, and decide whether to adopt them permanently.1 The TCAB initiative also seeks to increase the vitality, teamwork, and retention of nurses.
Launched in 2003, the TCAB demonstration project had three phases (see Table 1). Phase 1 of the initiative was a one-year pilot involving one unit at each of three hospitals. In June 2004, 10 additional hospitals joined for phase 2, a two-year project. These 13 hospitals were invited to participate in TCAB based on their prior relationships with the IHI and the RWJF, the hospitals' reputations for providing high-quality care, and their work in quality improvement initiatives. Twelve of the 13 hospitals were in urban settings, four were academic medical centers, seven had more than 400 beds, and eight were part of a larger health care system. All but one, a Department of Veterans Affairs hospital, were nonprofit. At nine hospitals, one unit piloted the TCAB program; at the other four hospitals, two units piloted TCAB.
Ten of the 13 phase 2 hospitals continued into phase 3, which took place between June 2006 and May 2008. The three hospitals that ended participation cited reasons including the need to focus on other priorities and concern that the requirements for phase 3 would be different from those for phase 2. This left 13 units participating in phase 3.
The key strategy for accomplishing TCAB goals is to empower front-line staff and nurse managers by providing leader support, training, and feedback. The IHI facilitated this work by
* communicating the vision for TCAB.
* developing a taxonomy for categorizing potential changes and describing the strategies for testing and implementing improvements.
* promoting strategies for engaging front-line staff.
* developing an outcomes measurement strategy.
* providing training and consultation.
* providing mechanisms for hospitals to exchange ideas and collaborate in problem solving.
A collaborative structure helped the participating facilities develop, test, and disseminate processes to transform the experiences of both patients and health care professionals in four domains (also referred to as "aims" or "themes" by other authors in this supplement): safe and reliable care, patient-centered care, value-added processes, and vitality and teamwork. Teams from participating organizations met for training and to share ideas every three or four months during phases 2 and 3. Each meeting was hosted by one of the hospitals participating in TCAB and included a tour of the facility and the TCAB unit or units. A team from the IHI planned and led the meetings, which also included instructional sessions and group sessions in which participants planned their next steps. Among the topics were the conceptual framework of TCAB, optimal organizing to institute TCAB, tools (such as brainstorming) for identifying areas of change, and ideas for strengthening staff relationships.
To facilitate interaction among TCAB hospitals, the IHI established an online "extranet" on which hospitals posted data and other information about the changes they were testing. In addition, the IHI arranged conference calls and road trips to nonparticipating hospitals so TCAB units could study particular innovations or processes.
In this article we provide an assessment of the overall effect of TCAB, focusing on the experiences of the 10 hospitals that continued through phase 3. We explored three questions:
* How many and what kinds of innovations were tested and sustained?
* Did the outcome measures show improvement?
* What was the participants' assessment of the value of the TCAB initiative?
In companion papers in this supplement to AJN, we also examine other dimensions of the hospitals' TCAB experience: "Lessons from Nursing Leaders on Implementing TCAB" addresses the roles and experiences of chief nursing officers (CNOs) and nurse unit managers, and "Participation of Unit Nurses" looks at the ability of nursing units to implement the TCAB processes. In addition, Pat Rutherford and colleagues present results for each of the TCAB domains in "TCAB: The 'How' and the 'What.'"
METHODS
The RWJF funded our evaluation of participating hospitals' experiences with TCAB phases 2 and 3. We conducted surveys and on-site interviews with nursing staff and administrators to identify how hospitals approached the challenge of implementing the initiative, what barriers and facilitators to their work they encountered, and what factors influenced their continued participation and expansion of the initiative to additional units. We also tallied the number of innovations tested and evaluated whether these changed specific outcome measures. In addition, we assessed whether participants met IHI-established "design targets"-specific, measurable goals, such as "70% of nurses' time spent in direct patient care"-for each of the four TCAB domains.
Data came from interviews and surveys, our monitoring of all TCAB multifacility meetings and selected other meetings and phone calls, and documents and data submitted by hospitals to the IHI in connection with the TCAB initiative.
Interviews and surveys. We interviewed 150 nursing administrators, unit managers (all were RNs), front-line nursing staff, and quality improvement personnel during visits to all 13 phase 2 hospitals in spring and summer 2005. In spring 2006, we interviewed unit managers and quality improvement staff by telephone about measurement activities. In summer 2006 (after phase 2 ended), all CNOs and unit managers were again interviewed by telephone.
At both the beginning and the end of phase 3, CNOs, unit managers on pilot units and on other units to which TCAB innovations had spread, quality improvement administrators, and TCAB spread leaders at the 10 phase 3 hospitals completed Web-based questionnaires. The response rate was 100% for unit managers and quality improvement administrators, 92% for CNOs, and 88% for hospital spread leaders.
Data from hospitals. From the beginning of the TCAB initiative, the IHI required participating hospitals to measure and report data on the changes they tested and implemented. Much of this activity occurred through the extranet site, on which hospitals posted descriptions of the changes they were implementing and several sets of measures. Units also received feedback on their measurements.
Hospitals were encouraged to develop their own process and outcome measures for use in Plan-Do-Study-Act cycles, the TCAB method for rapid testing of change. Some of the standardized outcome measures they reported came from the National Quality Forum nursing-sensitive care performance measure set2 and others from the IHI.3 Data were also culled from the Healthcare Team Vitality Instrument developed for this intervention and evaluation4 as well as from patient satisfaction surveys that either were already in use at the hospitals or were used by units during the TCAB initiative.
RESULTS
Staff engagement in TCAB activities. At the end of the first year of phase 2, seven of the 13 pilot unit managers reported that less than 40% of their front-line nursing staff was actively involved in TCAB activities. Three years later, at the end of phase 3, only one manager reported staff engagement at this low level. Not only did staff engagement increase, but staff resistance also decreased. Whereas one-third of unit managers reported that at least half of the nursing staff was unsupportive at the end of the first year of phase 2, only one manager did three years later.
One measure of the perceived value of TCAB is the time that unit managers were willing to devote to the initiative. In the questionnaires administered at the end of phase 3, pilot and spread unit managers estimated that they spent an average of 4.6 hours per week on TCAB-related activities. All agreed that they would participate in the TCAB initiative again.
Volume of innovations tested and implemented. Data on innovations-defined as changes in work processes-implemented during phase 2 were reported previously.5 Here we present data on the innovations the 13 pilot units tested during the four years of phases 2 and 3.
These units tested 533 innovations. The average was 41 tests per unit, or nearly one test per unit per month, but the actual volume of testing varied substantially across units. In all, 377 innovations (71%) were adopted and sustained by the pilot units and 210 (39%) spread to other units (see Table 2).
The innovations spanned the four TCAB domains. The greatest numbers were in the patient-centered care domain and the fewest in vitality and teamwork. Table 3 presents examples of innovations that were sustained at multiple sites. Because many innovations span multiple domains, their classification was somewhat arbitrary. For example, multidisciplinary rounding, categorized in the vitality and teamwork domain, clearly can improve these factors, but it can also improve safe and reliable care and, if conducted at the bedside, enhance patient-centered care. Likewise, improved discharge procedures can improve patient-centered care and safe and reliable care while also improving efficiency, a value-added process.
Outcome measures.Figures 1 through 3 present data on seven outcome measures for which six months of data were available for each year from 2005 through 2007. The three measures of safe and reliable care-falls resulting in harm, codes, and readmissions within 30 days-were most closely related to the initiation of specific activities, and all declined substantially (see Figure 1). Although the sample size was small, the declines in falls and readmissions were statistically significant (for falls, P < 0.05 for 2006 and 2007 compared with 2005; for readmissions, P < 0.001 for 2007 compared with 2006). Most of the units instituted changes that directly sought to reduce falls and readmissions, such as special signage or safety rounds to reduce falls and revised discharge procedures to reduce readmissions. Codes were targeted indirectly by establishing initiatives such as rapid-response teams.
Of the two measures of patient-centered care (see Figure 2), time spent in direct patient care increased slightly but was basically level. The percentage of patients likely to recommend the hospital increased approximately 5%, which was not statistically significant. This latter measure was considered the best single indicator of patients' assessments of the care they received.
Highly positive staff responses to a question from the Healthcare Team Vitality Instrument about feeling part of an effective work team that continuously strives for excellence declined very slightly from 2005 to 2007 (see Figure 3). However, pilot unit managers reported on questionnaires that teamwork and vitality improved either greatly (6 of 13 units) or somewhat (7 of 13). Eight managers said that TCAB played a significant role in or was fully responsible for this change.
Another measure of vitality is staff turnover (see Figure 3). The average voluntary staff turnover on TCAB pilot units was lower than the nationwide median of 8.4%6 on medical-surgical units. Turnover declined slightly in 2006 and returned to the 2005 level in 2007.
Leaders' perceptions. At the end of phase 3, pilot and spread unit managers and CNOs were surveyed about their engagement in TCAB, the program's value, and the likelihood that their units would maintain TCAB processes and activities after their participation ended. These responses provide additional support for TCAB.
All of the managers reported that each of the four TCAB domains had improved somewhat or greatly. With the exception of the safe and reliable care domain, at least half of the pilot unit managers said that TCAB played a significant role or was fully responsible for these changes (see Table 4).
Unit managers and CNOs indicated overwhelmingly that TCAB was responsible for involving front-line staff in the improvement process and for increasing collaboration among hospital departments (see Table 5). Most leaders also expected to continue TCAB processes after the initiative ended. They disagreed that front-line staff would become less engaged in making changes on their units after their participation in TCAB ended. All said that they would participate in TCAB again.
At the end of phase 3, almost all of the hospitals were spreading TCAB processes and culture as well as specific innovations. Nearly all the unit managers and CNOs believed that most of the innovations that had been tested and adopted could be implemented as best practices on other units or spread to other hospitals. Considerably more spread unit managers than pilot unit managers stressed the importance of the nursing staff's participation in unit TCAB meetings and in assessing and revising tests of change.
Unit managers and CNOs revealed several common themes when responding to a question about what their unit or hospital had gained by participating in the TCAB initiative. They repeatedly mentioned improved teamwork, empowerment, and ownership of practice, as well as increases in concrete methods and the capacity to make change. Several survey respondents mentioned that the process improved nurses' skills for working with physicians. The following comments by three respondents summarize the gains:
* "Changed mind-set. The ability to take on processes and practice changes. Teamwork. Sense of success." -a unit manager
* "We work more closely as a team. Everyone's voice is heard. The patient as the center of care is everything."-a unit manager
* "The hospital saw such positive experiences from TCAB. It provided the framework for implementation of our shared governance model. It empowered the staff to make positive and lasting change. It improved retention rates and employee and patient satisfaction. It helped improve processes to improve our quality outcomes."-a CNO
In addition, CNOs identified "spillover effects" outside the participating units. Five CNOs cited an increase in the number of unit-initiated projects in non-TCAB units, and eight mentioned an increase in the use of rapid-cycle change methods.
When asked what they personally had gained from TCAB, CNOs and unit managers emphasized acquiring personal empowerment and new skills and learning to work with and trust front-line staff. Several emphasized the support and lessons TCAB provided for expanding shared governance. One unit manager included among her gains "the value of trust and integrity among staff nurses. The value of my time as a nurse leader and the miracles that trust brings when we allow [front-line staff] to lead."
DISCUSSION
Our review of the experiences of the 10 hospitals participating in phases 2 and 3 of the TCAB pilot found that the units engaged in 533 tests of change and adopted and spread a substantial number of them. Several patient safety indicators appeared to improve under the initiative. Unit managers felt that all four domains improved and that TCAB was an important factor in that improvement. Unit managers and CNOs reported that participation in TCAB made it more likely that unit staff would continue to initiate changes to improve patient care and that collaboration between nursing and other departments had improved. The value attributed to TCAB was reflected in the substantial amount of time that unit managers committed each week to these efforts, the increased staff engagement in TCAB, the reduced resistance of unit staff, the unanimous agreement of unit managers that they would participate in the TCAB initiative again, and the expressed commitment of most leaders to continue TCAB activities after the initiative ended.
Outcome measurement was intended to provide the RWJF with information to assess the initiative's effect, motivate units, identify problems, and test whether innovations were improving performance. Although it did serve these purposes, TCAB's flexible, autonomous approach to change and priority setting makes evaluation of a common set of outcomes across units challenging. Measurement strategies required substantial effort from units and hospitals, and as evaluators, we observed several challenges.
First and most critically, effective measurement required expertise that many units lacked in collecting, interpreting, and applying data. Hospitals were reluctant to collect data that they considered to be mainly for external assessment, with limited value to the hospital itself. The breadth of the activities the units pursued, the frequent lack of a clear causal link between changes and outcome measures, and the small sample size limit our ability to draw strong inferences from the data.
There is considerable interest in constructing a business case for quality improvement initiatives. (See "The Business Case for TCAB.") At this stage in the evaluation, the patient safety gains associated with reduced falls, codes, and readmissions are most directly measurable. Emphasizing the business case of reduced costs resulting from improvements in patient safety, however, ignores the initiative's purpose, which is to make better use of nurses' efforts, not necessarily to reduce staffing costs. Also, the effects of efforts to improve patient-centered care aren't easily quantified.
Few of the innovations tested or implemented in phases 2 and 3 were groundbreaking, but that wasn't the priority of the program. In fact, hospitals were encouraged to "steal shamelessly" from one another. The collaborative learning sessions and road trips exposed TCAB leaders to a wide range of practices that had been implemented elsewhere. The goals were to encourage the testing of changes that were aligned with a unit's needs and preferences, to adapt innovations to fit the unit's work flow and culture so they would be sustained over time, and to test the changes in a large number of settings. As a process improvement program led by front-line staff, TCAB resulted in substantial testing and implementation of changes, and in this sense it met its goals.
The hospitals engaged in the initiative were not typical. They had reputations as high-quality, innovative organizations. They maintained participation over four years and are spreading innovations and the TCAB process to other units. The results illustrate what is possible, but they may not be generalizable to a wider range of hospitals.
There was substantial variation among the hospitals' experiences and performance. Future work will explore whether these variations are associated with differences in hospital organization, hospital-specific barriers and facilitators to TCAB processes, and implementation of specific TCAB processes and activities.
VIRTUAL TCAB SITE
For a toolkit on implementing Transforming Care at the Bedside (TCAB), go to the Robert Wood Johnson Foundation's virtual TCAB site at: http://www.rwjf.org/qualityequality/product.jsp?id=30051.
REFERENCES