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.
© 2009 Lippincott Williams & Wilkins, Inc.
1. Rogers EM. Diffusion of innovations
. 5th ed. New York: Free Press; 2003.