1. Abdel latif Marini, MSN,
CPHQ
Quality Management Specialist
Rutherford P, Lee B, Greiner A. Transforming Care at the Bedside. IHI Innovation Series
white paper. Boston: Institute for Healthcare Improvement; 2004. (Available

2. As many as 90,000 people die annually
from mistakes – an error rate
unacceptable in any other industry.
There are more deaths due to medical
errors than deaths from accidents, breast
cancer, or AIDS
(IOM Committee on Quality).

3.  The IOM 2004 report, Keeping Patients
Safe: Transforming the Work Environment
for Nurses links nurses’ skill at monitoring
patients’ health and symptoms to improved
clinical outcomes, and suggests that their
vigilance is an important defense against
errors.
 However, nurse turnover is typically
highest on medical/surgical units, which
compromises quality and increases cost.
Background

4.  To respond to the urgent need for change
on the nation’s medical/surgical units, the
Institute for Healthcare Improvement (IHI),
in partnership with The Robert Wood
Johnson Foundation (RWJF), has
launched in July 2003 an ambitious,
expansive initiative to redesign
medical/surgical care.
TCAB

5. This initiative was called Transforming Care
at the Bedside (TCAB).
TCAB framework for change on
medical/surgical units is built around
improvements in four main categories:
• Safety and Reliability • Care Team
Vitality
• Patient-Centeredness • Increased Value
TCAB

6.  TCAB is not a traditional quality
improvement program; one primary
characteristic that sets it apart is its focus
on engaging frontline staff and unit
managers.
 Ideas for transforming the way care is
delivered on medical/surgical units come
not from the executive suite or a quality
improvement department, but from the
nurses and other care team members who
spend the most time with patients and
their families.
TCAB

7.  In 13 pilot hospitals, change ideas within each
category are being tested, refined, and
implemented, many with very promising early
results.
 Examples include the use of Rapid Response
Teams to “rescue” patients before a crisis occurs;
specific communication models that support
consistent and clear communication among
caregivers; professional support programs such as
preceptorships and educational opportunities;
liberalized diet plans and meal schedules for
patients; and redesigned workspace that
enhances efficiency and reduces waste.
TCAB in USA

9. High Leverage Changes….the ―what of TCAB
1. Transformational Leadership
2. Teamwork &Vitality
3. Patient and Family centred care
4. Value-added Care (Lean element)
5. Safety &Reliability
TCAB core themes

10.  Care for patients who are hospitalized is
safe, reliable, effective and equitable.
 Examples of such practices include
medication system redesign, end-of-life
best practices, and the use of Rapid
Response Teams to “rescue” patients
whose medical conditions are deteriorating
before they reach a medical crisis point.
TCAB goal for safety and reliability

11. Ruby Red Slippers
for High Fall Risk Patients
Aim: To improve patient safety and
outcomes to identify patients at high
risk for falls.
Process:
 Upon admission, patients are
evaluated for fall risk.
 Fall risk is re-evaluated at least daily by
the patient’s nurse.
 Patient’s identified as a high risk for a
fall injury will be issued “Ruby Slippers”
to alert all staff involved in the patient’s
care.

12. Every patient seen/screened/admitted to CCRMC will be
placed on Universal Fall Precautions using the acronym
N.O. F.A.L.L.S.
 N = Nearby: call light, glasses, water, all other personal belongings
 O = Orient patient to the environment upon admission and change in
room.

 F = Footwear should be non-skid and well fitting.
 A = Assess and assist as needed. Assess patients for mobility deficits,
 impaired cognition, altered elimination, high risk medication, and
 medical conditions that may increase fall risk.
 L = Low and lock beds at all times.
 L = Lighting should be adequate and non-glare. Use night light on
evening
 S = Safety: A safe environment must be maintained at all times.
 Safe side rail position
 Safe administration of medications
 Sensory deficits identified and compensated for
NO FALLS

13. SKIN bundle
Surface selection
Keep turning
Incontinence mgmt.
Nutrition
Six hospitals had no pressure ulcers for 1 year
“No ulcers”
Nutrition and fluid status
Observation of skin
Up and walking or turn and
position
Lift (don’t drag) skin
Clean skin and continence care
Elevate heels
Risk assessment
Support surfaces for pressure
redistribution

14.  Within a joyful and supportive environment
that nurtures professional formation and
career development, effective care teams
continually strive for excellence.
 Eg. Based on innovative work first
developed at Luther Midelfort-Mayo Health
System in Eau Claire, WI, Seton
Northwest nurses developed a traffic-light
system to declare their availability for
additional patient care.
TCAB goal for vitality

16.  Create more time-less bell calls
 Pressure areas checked
 Position changed
 Pain assessment
 Nutrition-check (fluids encouraged
where appropriate)
 Obstacles & Call bells –Call don’t
fall
 Personal Hygiene
 Emotional support
TLC Rounds

17.  Truly patient-centered care on medical and
surgical units honors the whole person and family,
respects individual values and choices, and
ensures continuity of care.
 Systems and processes are often designed to
meet the needs of providers or the patients?
 UPMC Shadyside, a TCAB hospital, the nutrition
staff responded by creating a liberalized diet
program, loosening restrictions and extending
kitchen hours. An evening snack, ranging from
yogurt to fruit to brownies, is also offered to all
patients.
TCAB goal for patient-
centeredness

20.  All care processes are free of waste and promote
continuous flow.
 Eliminating waste on medical/surgical units can
mean anything from redesigning work processes
to redesigning physical space. Learning to think
more systematically about care processes, as well
as more creatively, are key steps in changing the
system.
 A key feature of such lean systems is that they
focus on eliminating waste, or muda, which is
defined as activities that absorb resources but
create no value.
The TCAB goal for Value-Added Care
Processes

21.  Successful changes on the TCAB units will be
adapted and spread to all medical and surgical
units.
High Leverage Changes:
 Establish, oversee and communicate system level
aims for TCAB units and the spread of TCAB
innovations
 Align system measures, strategy, projects and a
leadership learning system
 Build improvement capability at all levels of the
organization
 Get the right team ―on the bus—CEO, CNO,
CMO, CFO, and COO
The TCAB goal for Transformational
Leadership

22.  Innovation/ Prototype testing
 Ideas Generation
 ‘The Deep Dive’ / ‘Snorkel’/ Paddle
 The IHI Model for Improvement
 Small tests of change - PDSA
 Choose “low hanging fruit”
 “What can you accomplish by Tuesday?”
 Lean methodology
 Learning from Industry
 Local data collection
 Run Chart-Time series analysis
 Data compared ‘within’ hospitals rather than
‘between’
Improvement Methodology

23. Proposed Measures for TCAB
 • Adverse events
 • Unanticipated deaths
 • Patient falls
 • Unplanned returns to the ICU
 • Pressure ulcer prevalence
 • Hospital-acquired pneumonia prevalence
 • Care team satisfaction
 • Voluntary turnover
 • Patient and family satisfaction
 • Percentage of time spent in direct patient care
 • Percentage of time spent in documentation
 • Percentage of time spent in valueaddedwork

25.  This is a story about 4 people named
everybody, somebody, anybody and nobody.
 There was an important job to be done and
Everybody was asked to do it. Everybody was
sure somebody would do it. Anybody could have
done it but nobody did it. Somebody got angry
about that because it was Everybody's job.
Everybody thought anybody could do it, but
nobody realized that everybody wouldn't do it.
It ends up that everybody blames somebody
when nobody did what anybody could have done!
Whose Job is it?

26. Transform
Care at the
Bedside in
two wards
sites by
2012
Teamwork
& vitality
Increase the percentage of time spent in direct/value-added care
to 70% by:
•Eliminating waste & Improve work flow processes for admissions,
hand-
offs an discharge
•Improving work environment through physical space re-design
•Enhancing efficiency with technology
•Reducing duplication & time spent in documentation
Establish, oversee and communicate system levels aims for
improvement
Align measures, strategy & projects and leadership learning
system
Channel leadership attention to quality improvement and safety
Build the right team
Align Quality projects to Finance.
Engage Physicians in improving care at all levels
Build improvement capability
Value-Added Care
Transformational
Leadership
Safety & Reliability
Reduce the adverse events rate in pilot wards
Prevent Falls by implementing falls bundle
Prevent Pressure Ulcers by implementing Skin bundle
Support and involve patients and families
Ensure patients physical comfort
Optimize care transitions to home or elsewhere
Create Patient- Centred Healing Environments
Provide Emotional & Spiritual Support
Ensure Patients rights to privacy & dignity is maintained
Content Area Drivers Interventions
Patient
Centred Care
Empower ward managers to create care teams with the authority
to act and transform care
Build capability of front line staff and mid level managers in
Innovation and Improvement
Utilize clinical micro system model & tools
Enhance physical environment for staff &prevent staff injuries
Optimize communication across the care team
Develop staff and match roles to responsibility

27.  Rutherford P, Lee B, Greiner
A. Transforming Care at the Bedside. IHI
Innovation Series white paper. Boston:
Institute for Healthcare Improvement;
2004. (Available on www.IHI.org)
 Annette Bartley. Transforming Care at the
Bedside. NHS North Wales (Central)
References