Sometimes perfect compliance on a quality measure is only as far away as a store-bought shower caddy and a bit of MacGyver ingenuity. That’s how an Erie County Medical Center unit lifted nurse compliance with its IV-tube labeling measure out of the 20 percent to 30 percent range to 100 percent.
This creative solution was just one outcome of the hospital’s Transforming Care at the Bedside (TCAB) project. Erie County Medical Center embarked on the initiative after it was selected in 2009 to participate in Aligning Forces for Quality’s (AF4Q) TCAB collaborative.
TCAB’s primary focus is to engage nurses and other frontline staff to develop and lead quality improvement efforts on medical-surgical units, where an estimated 35 percent to 40 percent of unexpected hospital deaths occur annually. Five units at the Erie County Medical Center are using the model, which was developed by the Robert Wood Johnson Foundation and the Institute for Healthcare Improvement.
Staff members were trained in the “plan, do, study, act” method and then encouraged to “snorkel,” or brainstorm to come up with ideas for change that could improve patient care or their work environment, explained Karen Ziemianski, RN, acting director of nursing. The medical-surgical unit that Patty Kiblin manages settled on IV-tube labeling as one target because it had been striving to improve compliance but was falling short.
The nurses decided that poor access to the labels was the main barrier. Nurses had to walk to a medication room to get the labels, which indicate when IV tubing must be changed. Changing tubing at appropriate intervals helps prevent bloodstream infections, and nurses realized they needed to have the labels in patient rooms. The medication carts were too small to carry the necessary seven rolls of labels, color-coded to represent each day of the week.
Nurses began visiting retail stores to find a product that would meet their needs. Kiblin took to carrying seven label rolls with her wherever she went. That’s how she happened upon the shower caddy. “I opened up the seven rolls, shoved them in there, and thought, ‘Oh my gosh, it works,’” she said. The unit charge nurse’s father adapted it by adding a spindle with caps on the ends so nurses could hang the rolls in the caddy and easily replace them when they ran out. The unit bought enough labels and caddies for each patient room.
“It’s amazing what a change it made just to have the accessibility for the nurses,” Kiblin said. Not only did the unit’s compliance jump to 100 percent and stay there, but the hospital saved $5,000 in seven months on IV tubing and solution. Before the project, if a nurse found tubing that wasn’t labeled, she had to discard it and the IV solution, which led to waste.
The shower caddy idea spread, not just to other Erie County Medical Center units but also to other hospitals participating in TCAB. The program promotes the concept of “shamelessly stealing” successful ideas from others.
Erie County Medical Center’s new family activated rapid response initiative is an example of how shameless stealing works. Staff learned about the concept at a national TCAB meeting, which featured a heart-wrenching video by the mother of Lewis Blackman. The 15-year-old died in 2000 from internal bleeding after elective surgery, even though his mother repeatedly brought concerns about his deteriorating condition to the hospital staff.
“Based on that, we decided at our hospital that our families really need to become part of our team,” Kiblin said. The staff engaged patient families in the effort by asking them to review and give input on informational materials that explain to families they have the right to call a rapid response if they believe their loved one’s condition is worsening and the staff isn’t listening to their concerns. Several units have implemented the rapid-response program, and it is being rolled out to the entire hospital.
When the medical center first started its TCAB journey, nurses were doubtful it would have that kind of success. “They thought, ‘Nobody is going to listen to us,’ or ‘We’re not going to be able to do anything about it,’” Kiblin said. “But as they saw that people were listening and changes were happening—and they’re changes that make their job easier or help patient care—they really had buy-in.” Now Kiblin’s nurses routinely walk up to her in the hall to propose ideas. Ziemianski said staff members slip notes under her door about products that might improve patient safety or grants they want the hospital to seek.
To win nurses over, it helps to start small, Kiblin said. She hung a poster board on a wall in her unit where nurses could write down their ideas. They worked on the easiest ones with the highest impact first. “You want the staff in the beginning to say, ‘That was super easy. We could have done that years ago.’”
One simple project that had a big impact was getting a discharge board for the unit. The nurses and discharge planners weren’t communicating well. “All of the sudden, an ambulance would show up for Mr. Smith, and he wouldn’t be ready,” Kiblin said. The board posts patients’ room numbers, the time they’re leaving, where they’re being discharged to, and how they’re getting there. The discharge planner loves it because she was tired of trying to track down nurses to discharge a patient. The board’s success spurred other units to shamelessly steal the idea, Kiblin said.
Other projects have been large, multipronged efforts. For example, the hospital revamped its heart failure treatment program using TCAB principles, Ziemianski said. “I brought the frontline staff in, and we looked at what we were doing. Was it patient-centric? Was it really adding value to the patients? What we found out was that it really wasn’t.”
Admitting when a practice isn’t working is an essential part of TCAB, Ziemianski said. “You can never acknowledge different challenges that are holding you back if you always say that you’re 100 percent correct.” The heart failure effort resulted in the change of myriad processes and implementation of new ideas. The hospital used the American Heart Association’s “Get with the Guidelines” program and received the Gold Quality Achievement Award. The heart failure program includes quality improvement measures, discharge protocols, standing orders, and measurement tools. The staff reworked all the patient education materials. They collaborated with the informatics staff to change the electronic medical record so nurses conducting patient education could see what the patient had already learned about and what his or her struggles still were.
Nurses introduced a calendar that tracks heart failure patients’ weight and how they feel that day using red, yellow, and green as indicators. The patients take the calendar home and then bring it to their outpatient hospital or primary care physician visits, Ziemianski said. The staff also initiated a post-discharge callback program through which they check on such items as whether patients are taking their medications and if they’re being weighed.
TCAB’s bottom-up approach makes all the difference, Ziemianski said. “It really changes the complexion of your organization when you really listen to your front line staff who are doing the work,” she said. The hospital’s senior leadership has fully supported TCAB, Ziemianski said, and has provided funds when they’re needed. “To be honest, the nurses are very frugal,” she added. “Many of their ideas don’t cost a lot of money at all and really increase patient safety or really try to change that experience for the patient.”
The program’s biggest challenge has been time constraints, especially when the TCAB units have high caseloads, Ziemianski said. Nurses need time to test their ideas to see if they should be adapted, adopted, or abandoned, she said.
But Ziemianski added: “You have to continue to break down your challenges and work around them. You have to keep saying to yourself that this is the best opportunity that the front line staff has right now to get their voice heard in an organization.”
Listen to your frontline staff. Nurses are very creative and patient centered. They should be at the forefront of the quality improvement process because their position at the bedside enables them to see where change is needed.
Empower patients and their families. One of the program’s pillars is to improve patients’ and family members’ experience of care. Don’t be afraid to ask for their input when creating education materials or embarking on projects such as family-activated rapid response.
Create opportunities for staff to “shamelessly steal” successful ideas from other units within the hospital and from other hospitals so that positive changes spread.