Vol. 35 No.

2 March/April 2013

Do Lean Practices Lead to More Time

at the Bedside?
Tiffany Brackett, Linda Comer, Ramona Whichello

Introduction
More than ever before, healthcare professionals are struggling with the provision of safe and
competent care while simultaneously utilizing
fewer resources. Unfortunately, this effort has
resulted in an undesired consequence in which
nurses are progressively spending more time
away from their patients. According to the Institute for Healthcare Improvement (IHI), nurses
spend less than half of their worked hours providing direct patient care (Rutherford, Lee, &
Greiner, 2004). Additionally, consumers have
indicated that too little time spent at the bedside is one of the most important issues affecting medical care (Snyder & McDermott, 2009).
In an effort to improve patient outcomes, many
leaders have turned to Lean and TCAB, hoping to increase nursing time spent at the bedside. These methods, which are meant to add
value and eliminate wasteful processes and activities, may not be as beneficial to nursing sensitive outcomes as they appear at first glance.
At a time in which many healthcare organizations are striving to become lean, the authors
questioned whether or not the elimination of
nonvalue-added activities would actually have a
positive effect on direct care and lead to more
time at the bedside. The following review seeks
to answer this question through an evaluation
of the effects of Lean and TCAB methodologies
on bedside nursing.

Background
Lean Methodology
A focus on removing waste and adding value
through Lean management has been successful in the manufacturing industry for many
years. Lean thinking has its roots in the Toyota Production System (TPS), which has been
in place at Toyota Motor Company since
the 1950s. This system has been effective in
reducing cost while increasing quality (NelsonPeterson & Leppa, 2007). The Lean management strategy eliminates waste and positively
transforms inefficient processes through a set
of well-defined principles, along with the implementation of standardized work (DelliFraine,
Langabeer, & Nembhard, 2010). According to

Abstract: The aim of this review is to evaluate the application of

value-added processes in healthcare, with an emphasis on their
effects on bedside nursing. Literature relevant to Lean methodology and inpatient care was reviewed, excluding all research
related to other service lines (i.e., surgical services, emergency
services, laboratory, radiology, etc.). Increased value is also an
important tenet of transforming care at the bedside (TCAB), an
initiative launched by the Institute for Healthcare Improvement
(IHI) and the Robert Wood Johnson Foundation (RWJF). Therefore,
articles concerning TCAB were also included in this review. A systematic study of the literature revealed varied applications of Lean
principles in practice, ranging from the implementation of a single tool, to full organizational restructuring. All articles reviewed
reported positive results, although the majority lacked strong supporting evidence for claims of improvement. Even though there is
some indication that the application of Lean principles to nursing
processes is successful in improving specific outcomes, the authors cannot conclude that the implementation of Lean methodology or TCAB greatly influences direct patient care, or increases
time spent at the bedside.

Kim, Spahlinger, and Billi (2009), standard

work allows staff to immediately recognize deviations from normal process, and make real-time
corrections. Lean thinking discourages the use
of the process workaround, and encourages
resolution at the root of the problem (Braaten
& Bellhouse, 2007; Spear, 2005). Organizations
that have embraced Lean concepts promise to
deliver a customized and defect-free product
(Collins & Muthusamy, 2007). The IHI believes
that when Lean strategies are applied to an entire organization, gains can be made in the way
of improved productivity, quality, finances, and
satisfaction (IHI, 2005).

Keywords
acute
improvement
nursing
quality
research evaluation
six sigma/Lean

Transforming Care at the Bedside

The IHI and the Robert Wood Johnson Foundation (RWJF) launched transforming care at
the bedside (TCAB) in 2003 as a way to improve care on medical/surgical units. The aim
of this national initiative is to promote change
and improvement in the areas of safety and reliability, care team vitality, patient centeredness,
and increased value (Rutherford et al., 2004).
TCAB aims to engage and empower front-line
nurses in order to improve the care of their

Journal for Healthcare Quality

Journal for Healthcare Quality

Vol. 35, No. 2, pp. 714

C 2011 National Association for
Healthcare Quality

Journal for Healthcare Quality

Table 1. TCAB Participating Hospitals

Phase 1 hospitals
Seton Northwest Hospital, Austin, TX (part of Ascension Health System)
UPMC Shadyside, Pittsburgh, PA (part of University of Pittsburgh Medical Center)
Kaiser Foundation Hospital, Roseville, CA (part of Kaiser Permanente)
Phase 2 hospitals
Brigham & Womens Hospital, Boston, MA
Bronson Healthcare Group, Kalamazoo, MI
Cedars-Sinai Medical Center, Los Angeles, CA
Childrens Memorial Hospital, Chicago, IL
James A. Haley VA Hospital, Tampa, FL
Kaiser Foundation Hospital, Roseville, CA (part of Kaiser Permanente)
North Shore-Long Island Jewish Health System, Great Neck, NJ
Northwestern Memorial Hospital, Chicago, IL
Prairie Lakes Hospital, Prairie Lakes Healthcare System, Watertown, SD
Seton Northwest Hospital, Austin, TX (part of Ascension Health System)
ThedaCare (Appleton Medical Center and ThedaClark), Appleton, WI
UPMC Shadyside, Pittsburgh, PA (part of University of Pittsburgh Medical Center)
University of Texas MD Anderson Cancer Center, Houston, TX
TCAB, transforming care at the bedside.

patients. A total of 13 hospitals participated

in the multiphased process of TCAB implementation, which concluded in May 2008 (see
Table 1). Since that time, impressive claims
of improvement have been made by each of
the participating organizations (Rutherford,
Moen, & Taylor, 2009). TCAB units strive not
only to transform care, but to improve teamwork, nurse and patient satisfaction, nurse retention, and the overall experience of care
for patients and their families. According to
Rutherford and colleagues (2009), TCAB is
transformative not only through the results
achieved for patients and their families, but
also through an improved work environment
for nurses.

Value as a Core Precept

Lean and TCAB share a core preceptthe
importance of value. Both strategies seek to
eliminate waste and add value to all processes,
thereby improving the end product. The literature offers several varied definitions of value.
Despite the difference in definition, the focus
on the customer remains the same. Many organizations choose to adopt Lean strategies on
the premise that the implementation of valueadded processes will achieve more nursing time
at the bedside. However, the literature shows
that such interventions may not necessarily result in the desired outcome.

Methodology and Criteria for Analysis

Methodology
Research articles used in this analysis were chosen through a search of computer databases.
The searched databases included: the Cumulative Index for Nursing and Allied Health
Literature (CINAHL); the Cochrane Database
of Systematic Reviews; Health Source: Nursing/Academic Edition; and Medline. Search
terms included combinations of the following key words and phrases: lean, nursing, and
practice; TCAB and lean; and added value and
nursing. This comprehensive search yielded
2,105 articles. Exclusion criteria were applied,
specifically, non-English language articles; articles that addressed studies outside the United
States; articles that did not address inpatient
bedside nursing (i.e., emergency department,
surgical services, laboratory, radiology, etc.);
and articles published greater than 10 years
ago. In order to be included in the review, an
article must focus on either Lean or TCAB with
results applicable to direct patient care or bedside nursing. A search of the included articles
revealed additional articles that were utilized
for review. A total of 34 articles were found to
meet the aforementioned criteria.

Criteria for Analysis

The body of research was analyzed to determine the distribution of article types, project

Vol. 35 No. 2 March/April 2013

foci, applied principles, and reported results.

The included articles were placed in three article types, which were inspired by Poksinskas
(2010) categorization of articles. The three article types are as follows: (1) articles that discuss
the application of Lean principles or TCAB and
are based only on the experience or general
knowledge of the authors, (2) articles based on
actual case studies or research related to the application of Lean principles or TCAB, and (3)
literature reviews related to Lean processes or
TCAB.
Articles related to the Lean management system were analyzed according to area of project
focus, principles and techniques, and reported
outcomes. TCAB articles were evaluated according to project focus and outcomes as they
related to the four transformative aims, in addition to the techniques used to gain results.
The four TCAB transformative aims, as defined
in 2004 are as follows: (1) safety and reliability, Care for patients who are hospitalized is
safe, reliable, effective, and equitable (p. 5);
(2) care team vitality, Within a joyful and supportive environment that nurtures professional
formation and career development, effective
care teams continually strive for excellence
(p. 7); (3) patient centeredness, Truly patientcentered care on medical and surgical units
honors the whole person and family, respects
individual values and choices, and ensures continuity of care (p. 9); and (4) increasing value,

All care processes are free of waste and promote continuous flow (Rutherford et al., 2004,
p. 13).
The guidelines for article critique included
the potential for influence on bedside nursing, the strength of the presented evidence, and
the generalizability and sustainability of the reported results. Analysis and critique of the articles in this way allowed the authors to realize
common themes through categorization, and
surmise the potential impact of Lean and TCAB
processes on direct patient care and time spent
at the bedside.

Analysis of Body of Research

Article Types
The reviewed articles were categorized into
three types for the purpose of distinguishing
the actual evidence from rhetoric based on
general experience and knowledge (see Table 2). Thirteen articles included in the review
discussed the application of Lean principles
or TCAB based on the experience or general
knowledge of the authors (Type 1). Sixteen of
the articles were based on either case studies or
actual research related to Lean processes and
TCAB implementation (Type 2). Four articles
were comprehensive literature reviews (Type
3), included as a comparative to the results of
this study. Although the Type 1 articles do not
offer any empirical evidence on the application

Table 2. Distribution of Article Types

Type 1. Articles that discuss the Collins and Muthusamy (2007), Grigg, Garrett, and Miller (2009),
application of Lean principles
Heatherington and Herzfeldt (2008), Holmes and Chamberlain
or TCAB based on the
(2010), Kim, Spahlinger, and Billi (2009), Pocha (2010), Popkin,
experience or general
Callahan, Scanlon, and White (2007), Slunecka and Farris (2008);
knowledge of the authors
implementing TCAB (Stefancyk, 2009a); improving processes
(Stefancyk, 2009b); transforming care (Stefancyk, 2009b;
Toussaint, 2009; Viney, Batcheller, Houston, & Belcik, 2006)
Type 2. Articles based on actual Braaten and Bellhouse (2007), Furman (2005), Furman and Caplan
case studies or research
(2007), Jimmerson, Weber, and Sobek (2005), LaRocco and Brient
related to the application of
(2010), Needleman et al. (2009), Nelson-Peterson and Leppa
Lean principles or TCAB
(2007), Rutherford, Lee, and Greiner (2004), Rutherford, Moen,
and Taylor (2009), Shannon et al. (2006), Snyder and McDermott
(2009), Spear (2005), Stefancyk (2009a), Storfjell, Ohlson,
Omoike, Fitzpatrick, and Wetasin (2009), Upenieks, Akhavan, and
Kolterman (2008)
Type 3. Literature reviews related DelliFraine, Langabeer, and Nembhard (2010), Mazzocato, Savage,
to Lean processes or TCAB
Brommels, Aronsson, and Thor (2010), Poksinska (2010), Vest and
Gamm (2009)
TCAB, transforming care at the bedside.

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Journal for Healthcare Quality

of Lean and TCAB processes, they are helpful resources for those seeking general information related to the implementation of these
strategies.

Lean Articles
Project focus
Through a review of the literature, it was found
that Lean projects related to bedside nursing
had many different foci (see Table 3). The majority of projects identified within the literature
were focused on moving or reorganizing supplies and equipment. For example, Slunecka
and Farris (2008) noted that in an effort to increase efficiency and productivity, 91% of nursing supplies were moved to the point of care in

patient rooms at Avera McKennan Hospital in

South Dakota. Similarly, nurse servers full of
high-use supplies were implemented as the result of a lean project at Appleton Medical Center in Wisconsin (Heatherington & Herzfeldt,
2008). Despite the reported success of these
projects, there was no evidence that their implementation led to increased time at the bedside.
Lean techniques
The most common techniques cited for use
in Lean projects were value-stream mapping
and Kaizen teams (see Table 3), with other
Lean principles mentioned only briefly in the
literature. A value stream can be defined as
the sequence of events needed to perform a

Table 3. Focus, Techniques, and Reported Outcomes of Lean Articles

Lean Articles
Project Focus
Braaten and Bellhouse (2007), Heatherington and Herzfeldt (2008),
Jimmerson, Weber, and Sobek (2005), Nelson-Peterson and Leppa
(2007), Slunecka and Farris (2008), Snyder and McDermott (2009),
Spear (2005)
Redesign of work flow (travel, Braaten and Bellhouse (2007), Grigg, Garrett, and Miller (2009),
steps, rounding, etc.)
Nelson-Peterson and Leppa (2007), Snyder and McDermott (2009),
Toussaint (2009), Upenieks, Akhavan, and Kolterman (2008)
Redesign of work area or
Grigg, Garrett, and Miller (2009), Heatherington and Herzfeldt (2008),
environment
Snyder and McDermott (2009), Toussaint (2009)
Patient safety
Furman (2005), Furman and Caplan (2007), Shannon et al. (2006),
Spear (2005)
Redefinition of nursing role
Heatherington and Herzfeldt (2008), Toussaint (2009)
Reduction in error
Heatherington and Herzfeldt (2008), Toussaint (2009)
Improved communication
Grigg, Garrett, and Miller (2009), Heatherington and Herzfeldt (2008)
Techniques used
Value-stream mapping
Heatherington and Herzfeldt (2008), Jimmerson, Weber, and Sobek
(2005), LaRocco and Brient (2010), Nelson-Peterson and Leppa
(2007), Toussaint (2009)
Kaizen teams/continuous
Heatherington and Herzfeldt (2008), LaRocco and Brient (2010),
improvement
Nelson-Peterson and Leppa (2007), Toussaint (2009)
Reported outcomes
Improved patient safety
Furman (2005), Furman and Caplan (2007), Heatherington and
Herzfeldt (2008), LaRocco and Brient (2010), Nelson-Peterson and
Leppa (2007), Shannon et al. (2006), Spear (2005), Toussaint (2009)
Increased
Braaten and Bellhouse (2007), Grigg, Garret, and Miller (2009),
efficiency/productivity
Heatherington and Herzfeldt (2008), Nelson-Peterson and Leppa
(2007), Slunecka and Farris (2008), Snyder and McDermott (2009),
Spear (2005), Toussaint (2009)
Improved quality of care
Braaten and Bellhouse (2007), Heatherington and Herzfeldt (2008),
Nelson-Peterson and Leppa (2007), Toussaint (2009)
Financial gains
Braaten and Bellhouse (2007), Nelson-Peterson and Leppa (2007),
Slunecka and Farris (2008), Toussaint (2009)
Increased patient satisfaction Braaten and Bellhouse (2007), Heatherington and Herzfeldt (2008),
Nelson-Peterson and Leppa (2007), Toussaint (2009)
Increased staff satisfaction
Braaten and Bellhouse (2007), Nelson-Peterson and Leppa (2007)
Supplies and equipment
(moving or reorganizing)

Vol. 35 No. 2 March/April 2013

process or provide a service (Nelson-Peterson &

Leppa, 2007). Value-stream mapping is the detailed evaluation of a process that is undertaken
in order to distinguish between value-added
steps and wasteful steps (Jimmerson, Weber, &
Sobek, 2005). At St. Lukes Episcopal Hospital in Houston, Texas, teams used value-stream
mapping to improve the process of blood product transport and administration, streamlining
patient identification with the addition of barcodes and bedside scanners (LaRocco & Brient,
2010). The IHI (2005) defines Kaizen as continuous improvement of an activity to create more
value with less waste. Although Kaizen teams
can have many members, most teams discussed
in the literature were made up of small groups
of staff working to make small improvements in
processes related to their specific work areas.
At ThedaCare Health System in Wisconsin, intense work in Kaizen teams has been credited
with improvements in many areas, including increased productivity and the complete elimination of medication reconciliation errors on
some units (Toussaint, 2009).
Outcomes
There are many reported outcomes related to
the implementation of Lean processes (see Table 3). Authors most frequently claimed improvements in the areas of patient safety and increased efficiency or productivity. At Allegheny
General Hospital, ICU staff applied Lean techniques to central line placement and maintenance. As a result of the project, the authors
claimed a dramatic decrease in central lineassociated blood stream infections, from 49
to 6 within 1 year of implementation (Shannon et al., 2006). Cannon Memorial Hospital in South Carolina used Lean Methodology
to complete a workflow analysis and redesign.
As a result of a nursing station redesign, four
workstations were converted to seven, improv-

ing workflow and efficiency (Grigg, Garrett, &

Miller, 2009). The least reported outcome was
found to be increased staff satisfaction. Even
though increased efficiency and productivity
were commonly reported outcomes, there were
no reports related to increased time at the
bedside.

Transforming Care at the Bedside

TCAB techniques
Techniques most commonly cited with implementation of TCAB projects were the plando-study-act (PDSA) model for improvement,
snorkeling, and deep dives (see Table 4). Authors most frequently referred to the use of
the PDSA cycle, which allows users to make
small tests of change. Seton Health Network in
Texas utilized the PDSA model to implement a
nurse status board (Viney, Batcheller, Houston,
& Belcik, 2006). The status board allows nurses
to evaluate the workload intensity of their
team members and offer support as needed.
Snorkeling and deep diving are brainstorming
techniques developed by IDEO, a design and
innovation consulting company (Stefancyk,
2008b).
Focus and outcomes
The focus of all TCAB projects is to improve
care, improve the experience of care, improve
teamwork, improve nurse satisfaction, nurse retention, and add value. The project focus and
reported outcomes of TCAB implementation
were categorized according to the four aims
of safety and reliability, care team vitality, patient centeredness, and increasing value (see
Table 5). The most commonly cited area
of improvement was safety and reliability,
with patient centeredness being the least
cited. Collectively, TCAB units have reportedly
seen improvement in the area of safety and

Table 4. TCAB Techniques

PDSA/test-of-change

Snorkel

Deep dive

Holmes and Chamberlain (2010), Popkin, Callahan, Scanlon, and White

(2007), Rutherford, Moen, and Taylor (2009); high-use supplies (Stefancyk,
2009a); implementing TCAB (Stefancyk, 2008a; Viney, Batcheller, Houston,
& Belcik, 2006)
Holmes and Chamberlain (2010), Popkin, Callahan, Scanlon, and White
(2007), Rutherford, Moen, and Taylor (2009); implementing TCAB
(Stefancyk, 2008a); transforming care (Stefancyk, 2008b)
Implementing TCAB (Stefancyk, 2008a); transforming care (Stefancyk, 2008b;
Viney, Batcheller, Houston, & Belcik, 2006)

TCAB, transforming care at the bedside; PDSA, plan-do-study-act.

11

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Journal for Healthcare Quality

Table 5. TCAB Aims and Reported Results

Safety and reliability: Care for
patients who are hospitalized
is safe, reliable, effective, and
equitable
Care team vitality: Within a joyful
and supportive environment
that nurtures professional
formation and career
development, effective care
teams continually strive for
excellence
Patient centeredness: Truly
patient-centered care on
medical and surgical units
honors the whole person and
family, respects individual
values and choices, and
ensures continuity of care
Increasing value: All care processes
are free of waste and promote
continuous flow

Needleman et al. (2009), Popkin, Callahan, Scanlon, and White

(2007), Rutherford, Moen, and Taylor (2009); high-use supplies
(Stefancyk, 2009a; Viney, Batcheller, Houston, & Belcik, 2006)
Popkin, Callahan, Scanlon, and White (2007), Rutherford, Moen,
and Taylor (2009); high-use supplies (Stefancyk, 2009a; Viney,
Batcheller, Houston, & Belcik, 2006)

Popkin, Callahan, Scanlon, and White (2007), Rutherford, Moen,

and Taylor (2009), Viney, Batcheller, Houston, and Belcik (2006)

Popkin, Callahan, Scanlon, and White (2007), Rutherford, Moen,

and Taylor (2009); high-use supplies (Stefancyk, 2009a);
improving processes (Stefancyk, 2009b)

TCAB, transforming care at the bedside.

reliability through a decrease in harm from

falls, a decrease in code events, and decreased
admissions (Needleman et al., 2009). No evidence was presented to support the idea that
TCAB projects have led to increased time at
the bedside.

Critique
Influence on Bedside Nursing
Although many authors have noted success in
Lean projects implemented in different environments, this review has revealed very limited
applications of the Lean management strategy
to bedside nursing (Mazzaocato, Savage, Brommels, Aronsson, & Thor, 2010). The literature
has shown that although TCAB and Lean appear to have some effect on outcomes related
to patient safety, these strategies have not been
proven to positively affect patient care processes
or increase nursing time at the bedside. According to the literature, efforts to add value
to nursing processes and increase time with patients through Lean and TCAB implementation
appear to achieve only minimal success.
A medical/surgical unit at Massachusetts
General Hospital utilized TCAB to implement
a move of high-use supplies to the point of care
in the patients room (Stefancyk, 2009a). Although a goal of this project was to increase
time at the bedside, the author writes that only

small changes were noted in the amount of

time nurses reported spending in patient care
activities (Stefancyk, 2009a). Another project
on this unit focused on changing the end of
shift documentation process to exclude information, which could be found elsewhere in
the medical record. Despite this modification,
there was no evidence of an actual decrease in
documentation (Stefancyk, 2009b).
In an effort to gain a true picture of TCAB
implementation, Rutherford and colleagues
(2009) summarized the results reported by
the initial participating hospitals. The authors
point out that although 6 of the 10 hospitals
met a goal for reduction of harm from falls,
only 1 of 10 hospitals met a goal for 70% of nursing time spent in direct patient care (Rutherford et al., 2009). These results are consistent
with the prior analyses that found that improvements were most often reported in the area of
safety and reliability.
Additionally, North Shore Long Island Jewish Health System credits Lean and TCAB for a
decreased fall rate, 100% compliance with core
measures, a decreased pressure ulcer rate, and
a decreased restraint rate (Popkin, Callahan,
Scanlon, & White, 2007). The authors write,
It is evident that our success is a result of the
nurses being at the bedside, caring and interacting with patients and using the principles of
Lean (Popkin et al., 2007, p. 53). Even though

Vol. 35 No. 2 March/April 2013

these are impressive results, the authors offer

no evidence to support these claims.

Strength of the Evidence

The majority of the articles reviewed are similar in that the authors provided very weak evidence to back up their claims of success. Very
few articles included statistical analysis of results
or controls to ensure the efficacy of interventions. Most studies included only self-reported
results that were not based on empirical evidence. Additionally, the literature failed to
rule out alternative hypothesis (Vest & Gamm,
2009). Although VMMC claims to have had
stunning success with increased time for direct patient care, the authors offer no evidence
to support this declaration (Nelson-Peterson &
Leppa, 2007).
Authors Furman and Caplan (2007) wrote of
VMMCs success in the implementation of a patient safety alert (PSA) system (Furman, 2005).
This PSA system requires any staff member that
encounters an unsafe situation to report it immediately and cease any activity that could result in harm. It is clear from the article that
the implementation of the PSA has dramatically improved reporting of safety issues, but
it is questionable as to whether or not it has
actually improved safety. Although the authors
claim that the PSA is an important tool, which
makes care safer, no evidence on quality outcomes and patient safety indicators is provided
to support this argument.
Moreover, all articles reviewed reported only
positive results in the application of Lean and
TCAB strategies. This apparent one-sidedness
was also noted by DelliFraine and colleagues
(2010). The absence of research on failed initiatives may suggest a publication bias.

Generalizability and Sustainability

The generalizability and sustainability of Lean
and TCAB processes were rarely mentioned in
the literature. In the instance that these areas were addressed, the authors offered little
evidence related to their affirmations, as in
the case of Nelson-Peterson and Leppa (2007).
Furthermore, the Lean and TCAB hospitals
mentioned in the literature were already highperforming organizations prior to implementation of these strategies. It could be argued
that average or low-performing organizations
would be unable to implement these strategies
with the same degree of success.

Conclusion and Recommendations

In conclusion, the body of research has shown
that although Lean and TCAB processes may
be effective in the improvement of specific outcomes, there is no direct relationship with the
implementation of these processes and time
spent at the bedside. Furthermore, it is evident that organizations must be in a position to
commit valuable time and resources to the implementation of these strategies. Most authors,
including Pocha (2010), reported that a major
culture change is necessary in order for successful implementation of TCAB and Lean strategies. In addition to a change in culture, Holmes
and Chamberlain (2010) suggest that major
strategic changes must be undertaken at the
organizational level. Given the weakness of the
current body of evidence, one must consider
whether or not the investment necessary for
successful implementation of Lean and TCAB
strategies is worth the potential benefit.
Clearly, more research is needed regarding
the application of Lean processes at the bedside
and their influence on time spent in direct patient care. Because the strength of the present
evidence is generally weak, researchers should
take care to ensure the statistical significance of
their results. Additionally, future studies need
to address the generalizability and sustainability of Lean and TCAB processes, and include an
evaluation of failed initiatives. As a result of this
review, the authors conclude that more extensive and statistically sound research is needed
regarding the application of Lean processes as
they relate to direct patient care and increased
time at the bedside.

Acknowledgments
The authors would specially like to thank
Dwayne Hooks, MN, RN, FNP-BC, SVP/Chief
Clinical Officer of MedWest Health System for
his valuable editorial contributions.

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Authors Biographies
Tiffany Brackett, MSN, RN, is currently employed as Core
Measures Coordinator at MedWest-Haywood, part of MedWest Health System in Western North Carolina.
Linda Comer, PhD, RN, LPC, CNE, is currently on faculty at Western Carolina University in Cullowhee, North
Carolina. She serves as the associate director of Graduate
Nursing Programs, coordinator of the Nurse Educator Program, and coordinator of RN to MSN program.
Ramona Whichello, MN, RN, NEA-BC, is currently on faculty at Western Carolina University in Cullowhee, North
Carolina. She serves as the coordinator for the RN to BSN
program, as well as the coordinator for the MSN Nursing
Administration track.
For more information on this article, contact Tiffany Brackett at tiffanyb367@yahoo.com.