DNP 805 Module 7 Spreading a Unit Practice Across a System Example

From One Unit to Forty-One: Spreading Bedside Shift Report Across a Health System

Student Name

Doctor of Nursing Practice Program, Aspen University

DNP 805: Organizational and Systems Leadership

Instructor Name

Month Day, Year

From One Unit to Forty-One: Spreading Bedside Shift Report Across a Health System

Health systems are full of successful pilots that never spread. A unit improves a practice, measures good results, presents a poster, and a year later the rest of the system works the same way it always did. Spread requires a deliberate plan, because the conditions that made the pilot succeed, a committed manager, an enthusiastic team, extra attention, are not automatically present elsewhere. This paper describes how a composite five-hospital system spread bedside shift report from one orthopedic unit to 41 adult inpatient units, using a framework for spread and evidence from research on the diffusion of innovations in health care.

The Practice and the Pilot

In bedside shift report, the outgoing and incoming nurses exchange information at the patient's bedside, involving the patient and family, checking safety items such as lines, drains and fall risk together, and confirming the plan for the shift. A systematic review of 41 articles on bedside shift-to-shift handoffs reported that the practice was associated with improvements in patient satisfaction, nurse satisfaction and some safety and efficiency outcomes, though most studies were small, single-site evaluations (Mardis et al., 2016). On the system's orthopedic pilot unit, bedside report was adopted over three months. Patient experience scores for nurse communication rose, overtime at shift change fell, and nurses reported that they caught several safety issues, such as an infusion running at the wrong rate, during report.

A Framework for Spread

The Institute for Healthcare Improvement's framework for spread identifies components that leaders must address to move an improvement from a pilot to a whole organization. Leadership must make spread a strategic priority and assign responsibility. There must be a better idea, a change with clear evidence of benefit that others can understand. Set-up includes identifying target units, adopter groups and the sequence of spread. Communication must make the idea and its benefits known through multiple channels. Social systems, the relationships through which people learn from peers, must be used deliberately. And measurement and feedback must track adoption and results so that the spread team can adjust (Massoud et al., 2006).

What Diffusion Research Adds

A comprehensive systematic review of diffusion of innovations in health service organizations identified attributes that make innovations more likely to be adopted: a relative advantage that users can see, compatibility with their values and ways of working, low complexity, trialability, observability of results and the possibility of reinvention, that is, adapting the innovation to local needs. It also emphasized the role of opinion leaders and champions, the importance of an organization's readiness and absorptive capacity, and the need for ongoing support rather than a one-time launch (Greenhalgh et al., 2004). These findings shaped how the system presented bedside report and supported units through adoption.

The Spread Plan

The chief nursing officer made spread a system nursing priority, with an executive sponsor and a spread lead, a nurse from the pilot unit released half time. Set-up placed units in three waves. The first wave included units whose managers volunteered and one unit at each hospital, so that every hospital had a local example. The second and third waves followed at three-month intervals. Each unit identified two nurse champions, trained by pilot unit nurses rather than educators, because peers are more credible than managers when a change affects daily work.

The practice was presented with its relative advantage in terms nurses valued: fewer surprises at the start of a shift, fewer late handoffs and a chance to meet the patient with the previous nurse present. Units were encouraged to adapt the script and timing while keeping core elements: report at the bedside, patient invited to participate, safety checks performed together, and sensitive information shared away from the bedside. Communication included short videos filmed on the pilot unit, stories at nursing councils and a monthly spread newsletter.

Patients and families were prepared as well. A short card explained that the nurses would talk at the bedside, that the patient was welcome to join in or correct anything, and that private matters would be discussed elsewhere if the patient preferred. Early concerns from nurses, especially about sleeping patients and roommates overhearing, were resolved by agreed rules rather than by abandoning the practice: sleeping patients were not woken for report unless a safety check required it, and sensitive details were written or shared at the door.

Measurement and Results

The spread team tracked adoption with monthly observation audits of ten shift changes per unit, measuring the percentage of reports done at the bedside with the core elements. Outcome measures included patient experience scores for nurse communication, overtime at shift change and nurse-reported safety catches. By 12 months, 36 of the 41 units had reached at least 80% bedside report. The second hospital adopted in about half the time of the first, which the team attributed to having local champions who had seen the practice work nearby. Five units had not reached the target; all had new managers or high vacancy rates, and the spread lead worked with them individually.

Lessons for System Leaders

Several lessons stand out. Spread needs dedicated leadership and time; asking a pilot team to spread in their spare time rarely works. Peers teach peers better than formal education. Allowing adaptation of the form while protecting the core helps units adopt the change as their own. Measuring adoption, not only outcomes, shows where support is needed. And units under strain, with vacancies or leadership changes, need to be supported first or sequenced later rather than pushed.

Conclusion

Spreading a successful practice across a system is a leadership task distinct from designing it. Using a framework for spread, informed by research on what makes innovations travel, the composite system moved bedside shift report from one unit to most of its 41 units in a year. Dedicated leadership, peer champions, adaptation within core elements and measurement of adoption made the difference between a pilot and a system practice.

The same approach can carry the system's next improvements.

References

Greenhalgh, T., Robert, G., Macfarlane, F., Bate, P., & Kyriakidou, O. (2004). Diffusion of innovations in service organizations: Systematic review and recommendations. The Milbank Quarterly, 82(4), 581-629. https://doi.org/10.1111/j.0887-378X.2004.00325.x

Mardis, T., Mardis, M., Davis, J., Justice, E. M., Riley Holdinsky, S., Donnelly, J., Ragozine-Bush, H., & Riesenberg, L. A. (2016). Bedside shift-to-shift handoffs: A systematic review of the literature. Journal of Nursing Care Quality, 31(1), 54-60. https://doi.org/10.1097/NCQ.0000000000000142

Massoud, M. R., Nielsen, G. A., Nolan, K., Schall, M. W., & Sevin, C. (2006). A framework for spread: From local improvements to system-wide change (IHI Innovation Series white paper). Institute for Healthcare Improvement. https://www.ihi.org/resources/white-papers/framework-spread-local-improvements-system-wide-change