Applying a Team Approach to Patient Discharge

13 Dec 2012

St. Mary’s Medical Center, a 233-bed acute care facility in Lewiston, ME, “patient-centered” is more than just a buzz word—it’s a standard of practice that’s carried out by every staff member on every shift. St. Mary’s approach to patient-centered care is clearly evident in its adoption of Transforming Care at the Bedside (TCAB), a process improvement methodology the hospital is using for discharge planning. Developed and led by the Robert Wood Johnson Foundation and the Institute for Healthcare Improvement, TCAB seeks to engage patients further and elevate the effectiveness of providers.

Working with the Robert Wood Johnson Foundation’s Aligning Forces for Quality initiative, administrative leadership, physicians, and most importantly, nurses—who are in the day-to-day trenches of patient care—St. Mary’s adopted TCAB in 2009 because of the model’s potential to improve the patient experience as well as coordination of follow-up care, boost post-discharge compliance, and reduce patient falls and hospital-acquired conditions, such as pressure ulcers. TCAB requires a multidisciplinary team of providers that include the charge nurse, the patient’s nurse, a physician, a case manager, a social worker, a physical therapist or occupational therapist, and pastoral care.
With each patient, using TCAB during discharge, the primary nurse gives a one-minute-long presentation at the bedside followed by input from the care team, including the patient. All of this takes place at the patient’s bedside right before release from the hospital, and the patient can ask questions or offer suggestions to the entire care team. This is a shift from traditional discharge planning, which typically occurs behind closed doors, away from the patient, and allows limited opportunities for shared learning among the care team.
“TCAB directly supports one of the strategic priorities of Maine Quality Counts, which is to offer quality improvement assistance to providers,” explained Lisa M. Letourneau, MD, MPH, executive director for Maine Quality Counts, a regional collaborative working with area providers and hospitals to improve health care quality. Dr. Letourneau noted the TCAB model has been useful to a number of small hospitals in Maine working to pilot the TCAB initiative to improve care. “Many quality improvement initiatives can sometimes feel like a chore for hospital staff, whereas TCAB turns that on its head and brings in frontline nurses who historically weren’t always included in these types of quality improvement initiatives. Frontline nurses know from their gut what to do and what patients need. Engaging nurses in this way creates energy and makes good use of their skills.”
Melissa Brisson, RN, a clinical resource nurse in the cardiac-pulmonary unit at St. Mary’s Medical Center, agreed. “Our unit was among the first at St. Mary’s to introduce TCAB,” she said, “and the nurses have been very excited about it. Our unit is very fast paced—we see just about every specialty, from telemetry to oncology. It’s a good unit to test the effectiveness of TCAB because we have many challenges here, like high patient turnover and high staff turnover. There’s a lot of movement.” 
TCAB appears to be good for both patients and providers. A small survey among no more than 20 patients at St. Mary’s reveals that patients’ responses to the new multidisciplinary bedside discharge model are overwhelmingly positive. When asked questions about having a role in their care, feeling their concerns were heard, and feeling the information presented was understood, the majority of patients responded “yes.” Patients also were asked if they ever felt intimidated with the number of staff visiting their bedside at once, since TCAB can involve several providers from multiple different specialties coming together at once. The majority of patients responded “no,” it was not intimidating.
TCAB also offers providers many benefits, including cultivating trust among staff, teams, and specialties, and improving dialogue between staff and upper management. Shift reports are carried out at bedside, ensuring full continuity of care, which further develops a sense of teamwork among providers.
“Before TCAB, decisions were made at the top and brought down,” said Brisson. “The action is happening at the bottom, and upper management is increasingly recognizing that. Now nurses have a voice in how care should be delivered.”
Care at St. Mary’s also has become more collaborative as a result of TCAB, added Brisson. “Everyone had their separate job. The case manager or social worker arranging for the patient’s home health care would do her bit, the nurse would do her education piece, and the physician ordered any follow-up tests or prescriptions. It was much more siloed. Now we all come together at the patient’s bedside, and we’re learning from each other.”
New payment models being supported by the current federal health care law emphasize value over volume and may give models like TCAB a platform on which to thrive. For example, a care delivery model known as an accountable care organization (ACO) relies heavily on greater coordinated care among providers to reduce hospital readmissions, which then ultimately controls costs. TCAB could have a role in this environment by controlling costs through reducing the need for repeat hospitalizations because discharge planning is now more thorough and comprehensive. Patients and their families leave the hospital with a clearer understanding of what they need to do to take better care of themselves at home and are better equipped to manage their conditions in the outpatient setting, which then hopefully reduces or eliminates the need for return hospital visits.
Implementing TCAB at St. Mary’s has had its ups and downs, and ensuring TCAB remains sustainable will require support. “Sometimes we need to rejuvenate TCAB, especially when new staff come on or there are changes in management,” said Brisson. “People also get busy, or they’re used to doing things a certain way, and so we have to constantly remind and support people about the new processes in place. I’m really a champion for TCAB because I see that it works and that the patients and staff really benefit both in the short and long term.” Brisson added that St. Mary’s Medical Center is interested in adopting the TCAB model in other units, including other medical-surgical units and possible emergency medicine.
“We want to try out some ideas with ER,” said Brisson, “such as looking at the bedside report with the ER nurse at beginning of admission, and ER nurses giving admission reports over the phone.
TCAB could change that and bring it to the patient bedside. The primary nurse who would be receiving the patient would also be there. It could really help everyone.”
Added Dr. Letourneau, “With the upcoming changes in health care reform and new payment models such as ACOs, hospitals and provider groups will increasingly be in charge of their destiny. Our hope is that hospitals will see the value of TCAB and use it as a model for improving both the quality and costs of care.”
Lessons Learned
  • Overall, maintaining data entry was a challenge. For example, turnover in nursing staff requires reminders about updating data logs and maintaining current records about inpatient stays, unit admissions, falls, falls with harm, and pressure ulcers, and then breaking down these categories by the patient’s race, ethnicity, and language.
  • The team conducted periodic progress reports about what was working and not working. For example, a vitality survey asked staff questions such as, “My ideas really seem to count on this unit” or “Essential patient care equipment is in good working condition on this unit.” However, teams did not keep up with the progress reports, making it difficult to gauge progress.
  • TCAB activities required pre- and post-measurement to evaluate how the intervention was working. For example, did implementing hourly rounding reduce call bells, which can impact a nurse’s time if call bells are being repeatedly signaled? Counting call bells is time consuming and will need to be encouraged and supported so that data are accurate.