Frontline Teams and Patients Co-design Care to Improve Multi-level Outcomes - Transforming Care at the Bedside

Purpose:
The Transforming Care at the Bedside program, modified to embed patients in co-design of care, was implemented in 6 hospitals (2010-15), with 3 objectives: understand care through the eyes of patients/families; improve patient, staff and organizational outcomes; and increase RN time in direct care.

Relevance/Significance:
While TCAB's positively affected patient outcomes, health care team vitality and work environment, less is known about the effects on perceived team effectiveness or the impact of embedding patients in quality improvement teams. We examined dimensions of team effectiveness, and other aspects of work environment. Experience-based co-design studies, where patients/families collaborate with healthcare staff in care redesign, confirm patients valuable contribution to quality improvement initiatives.

Strategy and Implementation:
The TCAB program included 4 learning modules (12 weeks each). Workshops, combined with hands-on learning one day/week with the 19 teams, focused on developing skills in four areas: rapid cycle improvement processes (PDSA); the physical environment (Toyota Lean 5S methods); patient experience of care bundled interventions (bedside whiteboards, therapeutic questions, intentional rounds); and process mapping to improve admission/discharge processes. Unit teams of frontline staff and patient advisors, met 1 day/week throughout implementation to: identify the work processes to improve, set specific goals, make predictions, plan and take measurements, conduct simple tests of change, evaluate the results, and then adopt, adapt, or abandon each change. A facilitator provided coaching support on change management skills. Mixed measurement methods included: HCAHPS, RN time spent in direct/value-added care, work satisfaction, team effectiveness, turnover, and multiple quality measures.

Evaluation:
Outcomes: 8% increase RN time direct care; 30% increase HCAHPS; improved bedside communication, staff satisfaction, team effectiveness, turnover, overtime; reduced infections 25%; medication transcription errors 60%; new team admission process (mental health); pt-led improved test result access; redesigned space maximized efficiency; $3,000 equipment savings/unit. 2 Leading Practices. $1M grants.

Implications for Practice:
Targeting frontline managers, staff and patients to learn co-design skills in quality improvement is a worthwhile venture, with significant return on investments (improved effectiveness, efficiencies, turnover). Patient advisors bring “fresh eyes” and added value in strengthening team effectiveness.