Working together to transform care (TCAB)

Photo on top of page: Mina De Palma, Assistant Nurse Manager and Bruno Iannuzzi, a patient attendant on the Montreal General Hospital’s in-patient psychiatric unit. Middle photo: Proud members of the TCAB team on the Montreal General Hospital’s in-patient psychiatric unit. Bottom photo: Patty O’Connor, MUHC Director of Nursing and Chief Nursing Officer.

What has car manufacturing have to do with patient care? Quite a lot actually. Manufacturers like automotive giant Toyota have pioneered quality improvement techniques such as Toyota Lean Process which is now an industry standard. Last year, the MUHC launched a quality improvement initiative, in collaboration with the Institute for Healthcare Improvement, based on Toyota Lean. The initiative is called Transforming Care At the Bedside (TCAB) and it aims to radically change the way patient care is delivered at MUHC hospitals.

“The healthcare sector has now started to adopt quality improvement methods from the private sector – and where we have, it has been a great success,” says Patty O’Connor, MUHC Director of Nursing and Chief Nursing Officer. “At the MUHC, we took a unique step by involving patients in the process, right from the start, so we could understand what improvements were needed from their perspective. Over a dozen patient representatives recruited from the MUHC Patient Committees now work with the clinical teams on the TCAB units, meeting weekly to test improvements.”

Five wards were chosen as pilot sites for TCAB. One of these, the Montreal General Hospital’s in-patient psychiatric unit, was included despite the challenges of quantifying results on a mental health unit because staff there was so enthusiastic about the TCAB concept.

“One key aim was to help nurses on TCAB pilot sites spend more time actually delivering care,” O’Connor explains. “Studies of major hospitals found nurses often spend only a fraction of their precious time at patients’ bedsides.”

The problem? Antiquated design of facilities and outmoded ways of doing things. Environments where medication and supply rooms are centralized in only one location on inpatient units require staff to waste time walking long distances for equipment or supplies. Often, however, simple changes can result in measurable improvements.

Rapid cycle improvements are key to process

At the heart of the TCAB initiative is the concept of rapid cycle improvements – small, quickly adopted changes in process, executed and assessed using a methodology known as PDSA (Plan-Do-Study-Act). Using the PDSA approach, staff set measurable goals, define the changes they want to make, implement them and then measure the results. Process changes are then adopted, modified or discarded. The approach is both simple and powerful.

“Our ‘favourite’ PDSA cycle involved development of an interprofessional admission process for patients,” says Mina De Palma, Assistant Nurse Manager on the Montreal General Hospital’s in-patient psychiatric unit. “In the past, on admission, patients were interviewed one-on-one by a physician, then by a social worker, an occupational therapist and a nurse. Not surprisingly, from the patient’s perspective there was a lot of wasted time and repetition. Also, information was not necessarily shared among all the caregivers. We decided to change the admission process so that patients met with all their caregivers at once. “

Results were phenomenal. Time required for admission dropped from over four hours to one hour. Team communication improved significantly and most importantly, patient satisfaction doubled, as patients felt that they received more complete information regarding the interdisciplinary care plan.

Other PDSA cycles involved relocation of linen and centralizing equipment storage. “We found we could save significant time by making simple changes in where laundry or equipment was kept,” says Bruno Iannuzzi, a patient attendant on the Montreal General Hospital’s in-patient psychiatric unit. “Staff had shorter distances to walk, and everyone knew exactly where equipment was. It made a great difference.”

Results from all five units were positive, and phase two of the initiative is now underway. “Our overall aim was to redesign care processes to respond better to the real needs of patients and families,” says O’Connor. “We are steadily moving towards that goal.”