Health Care System "In Pursuit of Excellence" Case Example

Franciscan Services Corporation, Sylvania, Ohio

October 2008

The Organization

St. Joseph Health System, located in Bryan, Texas, is part of Franciscan Services Corporation, the healthcare ministry of the Sisters of St. Francis of Sylvania, Ohio.  Since the St. Joseph health ministry began in 1936, governance members, leadership and staff have exercised effective stewardship in working with the community to address its health needs.  A significant measure of that stewardship was the growth of St. Joseph from a single hospital to a health system with locations in six counties.  Communities and individuals throughout the Brazos Valley are touched by the benefits of the system's more than twenty locations, including primary, ambulatory, acute and long-term care.  The health system views the effective planning and delivery of care to local residents as the individual and collective responsibility of more than 2,600 staff, volunteers, governance members and physicians throughout the health system.

St. Joseph Health System's mission is expressed in the following words, "In the Franciscan tradition, out of reverence for the dignity of every person, the mission of St. Joseph Health System is to provide excellent healthcare and to promote wellness throughout the Brazos Valley".

The Initiative

In December 2006 a representative from Madison St. Joseph Health Center, a critical access hospital, that is part of St. Joseph Health System, attended a conference providing information about the Institute for Healthcare Improvement's (IHI) "Transforming Care at the Bedside" (TCAB) model.  While Franciscan Services Corporation uses the same quality metrics and benchmarks for all organizations within the system, individual systems are encouraged to add additional quality metrics.   St. Joseph Health System decided to begin implementing the Transforming Care at the Bedside model in early 2007, beginning with Madison St. Joseph Health Center.  Once the model was successfully implemented at this critical access hospital, St. Joseph Health System began implementing the concept at its two other rural hospitals.  Although still in the early stages, St. Joseph Health System is already experiencing positive results, including an increased amount of nurse time at the bedside, the identification of and reduction of medication errors and a reduction in patient falls.

The IHI Model. With an estimated 35 to 40 percent of unexpected hospital deaths occurring in hospital medical/surgical units, The Robert Wood Johnson Foundation and IHI agreed to work together to create, test, and implement changes that will dramatically improve care on medical/surgical units and improve staff satisfaction.  In 2003, through Transforming Care at the Bedside, Robert Wood Johnson Foundation and IHI created a framework for change on medical/surgical units built around improvements in four main categories: 1) safe and reliable care; 2) vitality and teamwork; 3) patient-centered care; and 4) value-added care processes.  The Transforming Care at the Bedside initiative consists of ten participating hospitals that are testing, refining, and implementing change ideas within each category, many with promising early results. Examples include the use of Rapid Response Teams to "rescue" patients before a crisis occurs and specific communication models that support consistent and clear communication among caregivers.

Implementing the Concept at Madison St. Joseph Health Center. Madison St. Joseph Health Center was the first hospital in St. Joseph Health System to implement the Transforming Care at the Bedside model.  The hospital's primary goal was to increase the amount of time that nurses spend at the bedside, citing studies that showed a direct correlation between an increase in nursing hours per patient day and a reduction in patient morbidity, such as urinary tract infections and pneumonia.  According to Robert Wood Johnson, studies of hospitals participating in TCAB showed that system failures, inefficiencies and distractions allow nurses to spend only about 30 percent of their time at the patient's bedside.  The TCAB goal is to increase nurse time at the bedside to 70 percent.

In addition to increasing the amount of time that each nurse spends at the bedside, Madison St. Joseph Health Center also sought to reduce provider distractions, allow nurses to try their own ideas for improving patient care, and make the best use of technology.  In each step along the way the hospital implemented a trial using a small number of providers for approximately two weeks.  Trials that were successful were then implemented throughout the facility over a one-month period.

Increasing Nurse Time at the Bedside and Improving Communication.  St. Joseph Health System believes that communication among the patient, nurse, physician, family and other health care workers is essential to preventing medical errors.  According to The Joint Commission, 70 percent of reported sentinel events cite communication as the root cause.  In order to improve communication and increase the amount of time nurses spend at the bedside, Madison St. Joseph Health Center implemented a number of initiatives:

  • Bedside reporting;
  • Bedside documentation;
  • Structured rounds with physicians;
  • One-hour nurse bedside checks;
  • Communication boards that that are reset with each shift by changing magnetic pieces that ensure patients know the name of their nurse, doctor, housekeeper, social worker, and others caring for them;
  • Rapid Response Teams that "rescue" patients before a crisis occurs; and
  • Electronic medication administration record and bedside medication verification.

Implementing New Technology.  When Madison St. Joseph Health Center began implementing the TCAB model the hospital was still using paper records.  They began the process of implementing an electronic health record, conducting bedside documentation on paper until the electronic health record was fully implemented.  Once the system was in place, the Computers on Wheels System (COWS) facilitated the documentation at the bedside, using the computers during physician rounds.

The hospital also implemented an electronic medication administration record (eMAR) and bedside medication verification system.  The system immediately highlighted vulnerable process points, and since the implementation there has been a dramatic reduction in the medication errors that reach patients.

Governance Support. Patient safety is a top priority for Franciscan Services Corporation board of trustees.  Although no adverse event had occurred, based on research the board had reviewed, they decided to invest in an information technology system to prevent the potential for medical errors in the future.  The board recognized that medication errors may be occurring that they weren't aware of because of the lack of technology. 

To determine the need, each hospital system in Franciscan Services Corporation was asked to submit a detailed report of the resources necessary to implement a bedside medication verification system.  The board awarded each health system the full amount each requested, with the grant totaling $3.2 million system-wide.  $1.54 million of the funding was for St. Joseph Health System, and approximately $51,000 was awarded specifically to Madison St. Joseph Health Center.

Each hospital's individual governance monitors progress as the medication verification systems are implemented.

Staff Changes.  Implementing the electronic medication administration record and bedside medication verification slowed nurse productivity slightly because the new process was more detailed.  The technology changes combined with increasing the amount of time nurses spend at the bedside required changes in staffing ratios.  At Madison St. Joseph Health Center, nurse-to-patient ratios were reduced from 6-7 patients per nurse to 4-5 patients per nurse.

Physician Involvement.  Physician support and involvement in the changes was critical to success.  At Madison St. Joseph Health Center, one physician spearheaded the efforts, primarily focusing on physician rounds and medication safety.  He was committed to ensuring the implementation was smooth, and served as an "error-check point."  In addition, an emergency room physician assisted with the implementation of the Rapid Response Teams.


Because the Transforming Care at the Bedside model was implemented at one of the system's smaller hospitals first, St. Joseph was able to ensure that every component of the program was implemented.  The small number of nurses enabled hospital leaders to measure implementation on a per-nurse basis, resulting in detailed data about compliance and the impact on pre-determined measures such as medication errors and patient falls.  Despite the level of detail required for implementation and measurement, the registered nurse turnover rate at Madison St. Joseph Health Center in 2007 was zero.

The Model Has Had a Measurable Impact on Patient Care in Madisonville.  Since the TCAB model was implemented at Madison St. Joseph Health Center, there has been a measurable reduction in medication errors, patient falls, and pressure ulcers.  In addition, patient satisfaction has improved.  Although there is no technology in place to measure nurse time at the bedside, self-reported observation documents nurses spending between 50 - 60 percent of their time at the bedside.

Challenges to Implementation.  When the Transforming Care at the Bedside model was first introduced some employees were hesitant.  Many were concerned that it was "just another program" which might require a significant amount of administrative time, and yield minimal benefit to patients.  Once the program was implemented and the hospital began collecting data that demonstrated the impact, employees became more supportive of the initiative. 
Data demonstrating the success at Madison St. Joseph Health Center also helped build employee-buy-in and willingness to participate at other St. Joseph Health System facilities.

Advice for Organizations Implementing a Similar Initiative. Start small and allow employees to take ownership in the effort.  St. Joseph selected a few nurses to start, communicating the general goals and objectives and letting the nurses work together to design a system that best fit their needs.  Once a system is in place, be persistent with follow-up and direct observation to ensure that the system is implemented properly.  Unless all of the employees commit to implementing the new model, the impact will be minimal.

Finally, measure results.  While this can be through direct observation or a more sophisticated tracking system, the key is that employees have a tangible measurement that demonstrates their success and encourages them to continue with the implementation.  As you measure results, focus on the end goal of improving patient safety. 

System Value

Individual organizations and systems that are part of Franciscan Services Corporation share their success stories at system meetings.  The success of the Transforming Care at the Bedside model at Madison St. Joseph Health Center has resulted in similar efforts at other St. Joseph Health System facilities, as well as the sharing of best practices and outcomes with other organizations in Franciscan Services Corporation.

Contact Name:  Mark Montgomery MD
Title: Vice President, Quality and Medical Affairs, St. Joseph Health System
Tel:  (979) 776-5969
Fax:  (979) 774-4590

Contact Name:  Charlotte Ferguson RN
Title: Director of Performance Improvement, St. Joseph Health System
Tel:  (979 776-2439
Fax:  (979) 776-5326

Contact Name:  Holly Meyers
Title: Vice President Quality Management, Franciscan Services Corporation
Tel:  (419) 882-8373
Fax:  (419) 882-7360



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