The nonprofit Seton Family of Hospitals is a network of five adult acute care urban hospitals (another is scheduled to open in October at the time of this writing), two rural hospitals, a children's hospital, a behavioral health hospital, and several clinics. It serves an 11-county region in Central Texas. Four Seton facilities are Magnet hospitals, designated as such for excellence in nursing by the American Nurses Credentialing Center.
A medical–surgical unit at Seton Northwest Hospital in Austin was one of the original pilot sites for the Transforming Care at the Bedside (TCAB) initiative. Over the subsequent five years, we spread the TCAB model to 21 units across the Seton network. "Spreading" refers to diffusing or expanding the TCAB process to other areas of the hospital or network. According to Rogers's theory of diffusion of innovation, which is the underlying framework for spreading TCAB, diffusion occurs in a five-step process proceeding from finding out about an innovation, to learning more about it, to deciding to use it, to testing it, and finally to adopting it. Diffusion of innovation requires communication within social systems and continuous monitoring of and feedback on the spread process.1 In their how-to guide for TCAB participants, Schall and colleagues describe the principles behind spreading the program and note that what's most needed for successful spread is the commitment of the hospital and unit leaders.2
SPREAD LEADERS AT SETON
One of us (JB) is our chief nursing officer (CNO). She embraced the TCAB initiative and made it a priority among our organizational goals. The strategy for spreading TCAB from the pilot site to other Seton sites relies on the TCAB spread team, which includes the CNO; two day-to-day nurse leaders— the vice president of network services (MV) and the project coordinator (CQP), who is dedicated full-time to TCAB; the senior project coordinator (CC); part-timer Allison Martinez, who provides clerical support and assists the unit TCAB teams with measurement and communication tools, including a newsletter and a Web site that enables Seton facilities to share tools and techniques; and Maggie Huebner, a coach from our organizational development department, who meets with the spread team about every two months. The spread team supports and assists the departmental TCAB teams in progressing to meet TCAB goals and introduces newly participating departments to the TCAB model.
The spread team makes the results of TCAB measures available to the network operational leaders, including the network's chief operations officers, CNOs, and vice presidents of medical affairs, as well as the system chief operating officer for Seton's hospitals. These leaders' adoption of TCAB techniques is evident in the initiative's effect on nurses' direct care time at the bedside, which increased dramatically on several units (Figure 1).
The day-to-day spread leaders—MV and CQP—track the unit TCAB teams, which are divided according to their level of expertise.
* Novice teams meet weekly, and the manager and director of the unit attend their TCAB meetings. Novice teams participate in small tests of change using the Plan–Do–Study–Act (PDSA) format. They work on building a team culture, including encouraging engaging in tests of change as a way to learn in a safe environment and welcoming all ideas, even those that may not be accepted.
* Strong teams have all the characteristics of novice teams, and more. They have successfully implemented more than three initiatives on their units. They also submit to the day-to-day spread leader and measurement specialist data such as time spent at the bedside, voluntary turnover, and numbers of falls, pressure ulcers, and adverse drug events. These data are then posted on the Seton TCAB Web site for sharing with other units.
* Advanced teams have all the characteristics of strong teams, and they also meet or exceed TCAB performance targets. In addition, advanced teams mentor other TCAB teams.
We created a grid to track our teams' advancement in their TCAB work. Figure 2 shows a portion of the grid for seven spread units. The grid captures coverage (that is, how many units have been introduced to the TCAB process) and completeness (the progress of each team as it develops from a novice to a strong to an advanced team). The grid helps us allocate the spread team's time based on each unit's needs.
The units that are most successful in adopting and spreading TCAB share certain characteristics. Their unit leaders and staff are strongly engaged in the process. Each unit has at least one TCAB champion, who teaches front-line staff the initiative's techniques for identifying and implementing change. These staff members share what they've learned with other unit representatives in monthly or quarterly TCAB meetings.
SPREAD UNIT ACTIVITY
In addition to the pilot unit, we now have 22 units at differing levels of expertise using the TCAB process: 17 medical–surgical units, 1 mother–baby unit, 1 labor and delivery unit, 2 ICUs, and 1 ED. Seton Southwest Hospital in Austin is using TCAB strategies throughout the facility, including in departments such as pharmacy, food service, and housekeeping; we call this comprehensive coverage TCAB Plus. Seton Medical Center Williamson in Round Rock includes the TCAB model in orientation training attended by all new non-physician hospital employees.
While some units volunteered to start TCAB teams, others were late adopters. To support them all, we created a structure that helps us move teams along in the TCAB process.
One of the first steps when spreading TCAB is to determine the level of the unit leadership's support for TCAB. This is done in one-on-one meetings during which a member of the spread team and the unit leader discuss the TCAB model and their expectations. The spread team member helps the unit manager correlate the TCAB model with the improvement work the unit is already doing in such activities as patient safety, nurses' council, and performance improvement meetings.
The unit manager and director then choose the month for having a structured kickoff with the unit-based TCAB team of five to 10 staff members. The unit leader invites these staff members to be on the TCAB team. Innovators, energetic people, and original thinkers are the best types of team members. New members are asked to join from time to time to revitalize the group.
The unit TCAB team chooses an issue to work on and holds "snorkeling," or brainstorming, sessions to generate ideas for tests of change. Using the PDSA model, they choose their methodology and measurement tools and begin with a small test of change. Based on those results, they adopt, adapt, or abandon the change.
We support peer learning by holding both monthly and quarterly learning sessions for the spread units. Each learning session focuses on a particular TCAB area: transformational leadership, safe and reliable care, vitality and teamwork, patient-centered care, or value-added care processes. The learning sessions enable participants to network and share ideas and information. Teams shamelessly steal innovations from each other at these meetings.
At the monthly group learning sessions the spread unit managers and key staff members meet with the TCAB spread team. The unit teams report on their trials, successes, and failures. Training focuses on TCAB processes and skills, such as the observational skills needed for performing time and motion studies.
The quarterly sessions involve as many team members from participating units as possible. Each team brings a storyboard depicting the aims of its project, how changes are being tested, and results. This process is one of the most significant learning experiences in our meetings. We also solicit participants' comments on other teams' storyboards to get their views and ideas.
A TCAB unit at Seton Southwest Hospital had low scores on patient satisfaction surveys regarding patients' understanding of the adverse effects of medications taken while in the hospital. In response, Julie Johnson, RN, a TCAB champion on the unit, spearheaded the development of a medication adverse effects tool.
This tool had positive results on the unit. When other units in the Seton Family of Hospitals learned about it, they were interested in using it too. This innovation was developed and spread solely through discussions among front-line staff in the monthly and quarterly TCAB meetings, without the influence of any manager or director. "Worksheet for a Test of Change" (Figure 3) is the PDSA plan that Johnson presented at a TCAB meeting.
Now, the medication adverse effects tool has been successfully implemented in most Seton facilities. The tool was translated into Spanish when it was adopted for use at the University Medical Center Brackenridge in Austin.
Two other articles in this supplement to AJN describe other examples of TCAB spread in the Seton Family of Hospitals. Zant discusses "Reducing Falls Among Outpatients," and Benzel and colleagues talk about using TCAB for "Improving Mammography Screening."
Support and buy-in from the facility's executive leaders are necessary to sustain and spread the TCAB program. Other critical ingredients include strategic planning, collaborative leadership, and flexibility from department leaders. New teams meet weekly and are supported and mentored by a TCAB champion or spread leader. Monthly and quarterly learning community meetings enable teams to learn from their peers.
One of the most important lessons we have learned is that change takes time and perseverance. There is a learning curve in adopting this new way of working. Even though we can point to the achievements of earlier TCAB teams, some staff members are still resistant, especially early in the process of spreading TCAB to a new unit. Everyone who's involved needs to learn to accept failure as a positive learning opportunity. In addition, those who have authority need to learn to relinquish control to front-line staff.
The unit leaders must enthusiastically participate in TCAB and commit to a culture in which decisions are made from the bottom up instead of from the top down. Staff from all shifts must be involved to spread initiatives throughout the unit. It can be particularly challenging to sustain the TCAB effort when there are changes in management and staff. For example, during the TCAB spread a number of key unit TCAB team members transferred to a newly opened facility in the Seton Family of Hospitals. Spread team members met with the remaining unit team members and discussed how to help new champions emerge, but some teams were unable to regain their former momentum.
Other challenges relate to the TCAB processes themselves. For example, teams need to learn why and how to use the PDSA approach. They also have to remember to keep tests of change small. To assist them, TCAB spread team members are available for consultation and advice, and our communication tools, which include the Seton TCAB Web site and a monthly newsletter, also provide direction.
The meetings we have as part of the TCAB spread process have been critical for our success. But they, too, pose challenges. For example, the people running the meetings need to keep the momentum going during the session. Similarly, momentum can be lost between meetings because the units are scattered throughout the hospital and are in different hospitals. Attending the national TCAB meetings helps us in this regard, as do the monthly "virtual" meetings we are testing to save travel time.