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AJN, American Journal of Nursing:
doi: 10.1097/01.NAJ.0000398532.76047.ea
AJN Reports

The Hospital Quality Network and Regional TCAB

Jacobson, Joy

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RWJF's Aligning Forces for Quality initiative helps nurses target quality nationwide.

Several years ago Bonnie Glica, MS, RN, senior vice president of nursing at Erie County Medical Center in Buffalo, New York, began to understand why nurses at her facility weren't at the center of quality improvement efforts in areas such as pressure-ulcer reduction: they were waiting to be told what to do.

Figure. Donna Alexan...
Figure. Donna Alexan...
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"Some staff would wait to take direction from nursing administration," she said recently, "rather than ask each other, 'What are we seeing today, and what can we do to make it better?'"

That began to change when the facility embarked on Transforming Care at the Bedside (TCAB), a national initiative of the Robert Wood Johnson Foundation (RWJF) and the Institute for Healthcare Improvement that empowers nurses to create and test their own ideas for improving care quality on units. (For more on TCAB, see the November 2009 AJN supplement: Transforming Care at the Bedside: Paving the Way for Change.) TCAB is one part of the RWJF's Aligning Forces for Quality initiative—a $300 million project launched in 2006 that aims to boost the quality of health care in communities, reduce racial and ethnic disparities in care, and provide models of high-quality care for national reform.

For the past couple of years, the Erie County Medical Center has been part of the Western New York region of Aligning Forces for Quality, and it's in that capacity that it has participated in a new effort: making TCAB a regional rather than a national endeavor. Although such a move might at first seem counterintuitive, it was made last year because the costs of sending nurses to national meetings were proving prohibitive for hospitals, according to Catherine West, MS, RN, the quality improvement leader for TCAB at the Center for Health Care Quality at George Washington University Medical Center, the national program office for Aligning Forces. TCAB now links hospitals regionally, and together they share resources, meet virtually to discuss strategies, and report data.

"We go in with the training, create the agenda, bring the materials," said West. "We want to build infrastructures so that when Aligning Forces goes away they don't just stop."

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Last fall, Cathy Jaco, MSN, RN, CPHQ, executive director of quality outcomes at University of New Mexico Hospitals (UNMH), began participating in a similarly new initiative designed to reduce readmissions among patients with heart failure. The facility is one of seven in Albuquerque and one of 133 in 17 regions nationwide to join the Hospital Quality Network (HQN)—another part of the RWJF's investment in Aligning Forces for Quality.

Hospitals participating in the HQN are attempting to reduce racial and ethnic disparities and improve care quality in any of the following three areas over an 18-month period (October 2010 to March 2012).

Reducing heart failure readmissions. Unplanned rehospitalizations cost Medicare $17.4 billion in 2004, reported Jencks and colleagues in the April 2, 2009, issue of the New England Journal of Medicine, and 37% of Medicare beneficiaries with heart failure were readmitted for the same diagnosis within 30 days of discharge. To address such often unnecessary costs, hospitals involved in the HQN plan ways to

* reduce 30-day heart failure readmission rates by 20%.

* maintain 95% compliance with four heart failure measures: providing discharge instruction, assessing left ventricular systolic function, prescribing specific drugs for patients with left ventricular systolic dysfunction, and counseling patients on smoking cessation.

Increasing ED 'throughput.' When ED waiting times exceed 12 hours, patients admitted to the hospital from the ED have 12% longer inpatient stays and inpatient costs rise by 11%, according to Huang and colleagues' 2010 study in BMC Emergency Medicine. Hospitals in the HQN aim to address ED backlogs by effecting 15% reductions in

* arrival-to-departure times among patients admitted to the hospital from the ED and those discharged from the ED.

* times between the decision to admit and patient departure from the ED.

* the rate of patients who leave without being seen.

Dozens of strategies for achieving these goals are suggested, such as improved recruitment of ED nurses, better patient tracking, and streamlined triage of patients with psychiatric disorders.

Mitigating language barriers. In a November 2007 study of Asian Americans published in the Journal of General Internal Medicine, Ngo-Metzger and colleagues found that patients whose providers didn't speak their language received less health education, were less satisfied with interpersonal care, and were more likely to rate their providers as fair or poor. Aims of hospitals in the HQN seeking to improve language services include

* screening all patients for their preferred spoken and written languages.

* giving all patients whose proficiency in English is limited "language services supported by qualified language service providers."

Because the elimination of racial and ethnic disparities is a chief aim of all three tracks, hospitals report their monthly outcomes data according to patients' race and ethnicity. Also monthly, frontline workers attend one-hour educational webinars or conference calls, during which they can discuss what works and what doesn't with peers as well as with experts in the respective fields. (For more, go to

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Nearly a quarter of New Mexicans are uninsured, and in 2009 the Agency for Healthcare Research and Quality assessed the care the state's residents receive and deemed it "weak"—"very weak" when it came to acute care and heart disease care.

For years, hospitals in the state "were doing great things, but we had no vehicle for exchanging best practices in these three areas of focus," said Patricia Montoya, MPA, BSN, RN, project director of the Albuquerque Coalition for Healthcare Quality, which received nearly $1.4 million from the RWJF and through which the seven Albuquerque hospitals participate in Aligning Forces and the HQN. "The collaborative has allowed people to come to a more neutral table to share their practices."

UNMH, for example, has taken on reducing readmissions for heart failure and improving language services. The facility had already worked on improving ED waiting times, Jaco said, and while its readmission rates weren't worse than national rates, there was room for improvement. For example, of all patients discharged from UNMH in 2010, 46% were Hispanic and 27% were white, but whites had higher rates of readmission. According to Jaco, "What are these data saying, and how do they help us to help our frontline nurses?"

Several national quality improvement initiatives have been undertaken in recent years, but what sets the HQN apart for Montoya is its spotlight on nursing. "In some ways, we've arrived," she said. The RWJF "has focused on the role of nurses and invested in these strategies on the local level to assist them."

And at Erie County Medical Center, Glica can attest to the value of the regional work through her TCAB experience. In mid-January the Western New York region held a three-day TCAB training, and her facility sent 30 people from four units, including a behavioral health unit. That unit might look at the use of restraints, seclusion, and medications, she said, "but what they focus on will be up to them. The point is not to steer it. We're qualitatively addressing things differently to make longstanding change."—Joy Jacobson

© 2011 Lippincott Williams & Wilkins, Inc.


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