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Transforming Care at Mass General

Stefancyk, Amanda L. MSN, MBA, RN

AJN, American Journal of Nursing: September 2008 - Volume 108 - Issue 9 - p 71–72
doi: 10.1097/01.NAJ.0000334978.12855.59
DEPARTMENT: Transforming Care at the Bedside

Introducing TCAB at a Massachusetts hospital.

Amanda L. Stefancyk is nursing director of a general medical unit at Massachusetts General Hospital in Boston.

She also coordinates Transforming Care at the Bedside:

Editor's note: Recognizing that medical–surgical units are among the busiest and most challenging areas of many hospitals, the Robert Wood Johnson Foundation sought to find ways to retain bedside nurses by empowering them to make the changes needed to improve care and teamwork on the unit. It developed and funded an initiative called Transforming Care at the Bedside (TCAB—pronounced "tee-cab"). The Institute for Healthcare Improvement led the first phase of this work with 10 hospitals that had agreed to test a new role for nurses and other team members who are on the front line of care.

TCAB focuses on making improvements in four areas:

  • the safety and reliability of patient care
  • team vitality and teamwork
  • patient- and family-centered care
  • adding value to care processes (for example, by increasing the time that nurses spend in direct contact with patients)

These aims are achieved by providing frontline staff with the authority and tools needed to make such changes. For example, staff members engage in brainstorming exercises called "snorkels" and "deep dives" to identify barriers and possible solutions. Using the plan–do–study–act, or PDSA, method, staff members test, evaluate, and tweak their ideas as needed and then spread their use.

Taking off from the success of the initial 10 hospitals, the American Organization of Nurse Executives is leading a second phase of TCAB that involves more than 60 hospitals. Additional TCAB initiatives are expected from the Robert Wood Johnson Foundation. A virtual TCAB learning center (see, provides more information about TCAB as well as guides and tools that others can use to transform care in hospitals and other settings. Additional information and resources are available at

Massachusetts General Hospital, a 908-bed academic medical center in Boston, is a fast-paced, high-volume work environment, with a rich history and very high standards. The nursing staff at this Magnet-designated facility is dedicated to providing excellent clinical care, advancing research and education, and serving the community. Last year, when Mass General joined the Transforming Care at the Bedside (TCAB) initiative, AJN asked me, as a nursing director of a 20-bed general medical unit, to provide my view of our successes, as well as lessons learned, in a monthly column. This is the first installment.

I learned of the TCAB initiative in March 2007 from Theresa Gallivan, MS, RN, associate chief nurse for general medical, emergency, and heart center nursing. She asked that our unit, White 10, serve as the TCAB pilot unit at Mass General. I'd been the nursing director for about a year and a half, and I knew the unit was a great choice. On our unit we see a wide array of diagnoses and comorbidities and a broad range of acuity; often patients have significant psychological and social challenges and have had little or no prehospital care.

The staff members are an energetic group, committed to their patients and to one another. Their experience levels range from recent graduates to nurses with more than 20 years of practice; most have been in practice for less than five years. Many are pursuing graduate studies and specialty certifications in medical–surgical and geriatric nursing. The unit is fully staffed and, according to our most recent staff survey, all agreed or strongly agreed that they are satisfied with the unit's work environment.

We're fortunate to have Susan Kilroy, MS, RN, a unit-dedicated clinical nurse specialist, to provide additional guidance in this initiative. The Department of Nursing also has a solid infrastructure in place that can support a project of this kind, including a recently launched Center for Innovations in Care Delivery, designed to bring multidisciplinary teams together to identify opportunities to enhance practice, estimate the impact that external changes might have on practice (including workforce demographics, new technologies, and regulatory change), and promote innovative approaches to nursing practice. This center is cosponsoring TCAB at Mass General with the Division of Medical Nursing.



As we assembled a TCAB steering committee, we asked ourselves several questions: How would TCAB fit into our institution, and how would patients and the health care team benefit? We thought that the initiative, if successful, could help us improve care on the unit, engage providers and leaders on the unit, and develop nurse leaders.

We submitted our application in March 2007; in May we learned we'd been selected as one of more than 60 hospitals nationwide. The news spread quickly throughout the hospital.

The challenge of TCAB. I was fully aware that this would be a lot of work. Before becoming a nursing director, I worked for eight years in various roles: medical–surgical and critical care nurse, researcher, and nursing instructor. The change to administrative practice was more than challenging, but I loved every minute of it. I was starting to develop a routine and rhythm that increased both my confidence and comfort in my role, and I was looking for challenges when TCAB came along.

I could see that it would be a high-visibility, high-stakes venture for us and a larger project than any I had managed previously—larger in size, duration, and scope. But I was excited. I knew that TCAB would challenge us to think differently about how we cared for patients, to act quickly on an innovative idea, and to spread our success to other units. The staff felt privileged to be part of the program, and my nursing colleagues were extremely supportive of the idea and curious about the work.

I felt overwhelmed—in a good way—to be in the spotlight. Our performance would have important implications for the future of our unit and hospital. I asked myself many questions: How would the staff respond? Would we be able to sustain the momentum throughout the TCAB process? Even more pressing: Would I have to speak in public? That was something I was not looking forward to doing. (When I raised this concern with my chief nursing officer, Jeanette Ives Erickson, MS, RN, FAAN, she was ready with resources, introducing me to an executive coach to help me "find my voice" and learn additional presentation skills.) As it turned out, I did more public speaking in the first months of TCAB than I had ever imagined I would. I'm happy to say that it does become a little easier each time—just a little.

Next month: how we brought TCAB back to the unit—and what exactly do snorkeling and deep diving exercises have to do with nursing?

© 2008 Lippincott Williams & Wilkins, Inc.