As a nurse, I can only do so much. I know what is supposed to happen in many situations, but I can’t do anything unless the doctor orders it. I am not afraid to come to work, worried something out of my control will happen to one of my patients and cause harm. To have physicians on the ward, available if something does happen is so important to me. It’s not about one nurse, one patient or one physician, it’s about a team, and this has changed my job.

My CEO is now committed to spreading SIBR and this training module makes me certain we’ll be able to do it.

This makes us a team at the beginning so that we can all be on the same page.

My experience here, I've always felt that they were all on the same page because they're all talking to each other and including myself and my husband and my family within those conversations.

We rely on the charge nurses to be leaders, but this actually helped them become leaders.

It's not more work. All the things we do in team bedside rounds, we need to do at some point anyway. It’s one and done. When you walk away from rounds, it's done. That’s really nice.

The ACU model enables our young nurses to be empowered quickly – to use critical thinking skills at the bedside every day and be seen as the expert on their patients. For me, there is no better way to embrace our millennial nurses than to put them in an Accountable Care Unit. The unit culture and care team enables them to do their best work.

This is the ‘new way’ and the ‘old way’ just looks crude and unacceptable by comparison.

It's an all inclusive conversation, so it just feels, it really feels for a lack of a better word, really, like a family.

Two and a half months ago we implemented our first Accountable Care Unit… So far, this system has had a very positive impact on patient care. On average patients on this unit are heading home a half day earlier.

Everyone used to have their own script for handover, some were lengthy, others didn't give enough information. {The Nurses First} Bedside handover has given us structure and everyone's on the same wavelength.

We improved mortality 25 to 30 percent while reducing length of stay by 10 to 15 percent, readmissions by about 20 percent, and cost of care. So where everyone else, their metrics stayed about the same or got slightly worse, our metrics improved in every category – which said to us we were doing something right.

I’m happy here. The ACU makes it so that nurses are heard. It’s changed my job. This unit made me love nursing again.

It raises the value of what we communicate as nurses.

Yeah, how much time do we save by the SIBR model? It's considerable. So if you have a really high functioning team that is able to get everything kind of sewed up and tied up in a bow during SIBR, you don't have to contact them 15 more times during the day. It's hugely beneficial for the pharmacists and the case managers as well. So it's a time saver for everybody who's on the team because everyone's getting everything taken care of all at once.

Nurses First has been phenomenal, we need to keep that, we can't let it waver.

The care was remarkable ... We should be so lucky that this kind of care is available to more people in our community. Just to be able to meet regularly with the physician and the nurses, to know what is happening.

After a year, the Nurses First Bedside Handover that you implemented for us is still going strong, and nurses continue to use the structure.

I talk to different patients in different wards and one of the questions I often ask is 'do you feel that your whole team of of clinicians and allied health, are they all on the same page'? And sometimes the answer's not great. They'll say, well, yes, but not really, or this doctor was saying that, but then another one said this. And the Doctor would come around maybe once a day if we were lucky and didn't know what time and you always had questions for him. Where now we don't really have questions because if we do have a question, it gets answered straight away.

prior to SIBR they'll (the bedside nurse) come in and they say: so what's your goal for today? Have you got questions? What are we gonna talk about in SIBR? And then come the SIBR round, the nurse is there and she or him will pass that on during SIBR. They do that every day. They'd write it on the whiteboard in the room. So everyone who was dealing with you in that day knew your goal of the day.

{The Nurses First} Huddle is a finger on the pulse of the unit, what are the current concerns, and what do we need to do to look out for each other.

Less time in the hospital, the freeing up of beds. The care is better. The communication is better.

We recognize change fast because we're attending rounds daily, so when someone starts to do really well and maybe not do so well, it's recognized that day, not a week later.

Physicians and staff are making comments like, ‘This is what medicine is supposed to be’ or ‘This is the work environment I always envisioned working in.

Often in our medical system I think patients sometimes feel they’re left out: what’s going on with their treatment, when are they going to see their doctor next. It was incredible what I saw… Less time waiting around and chasing things, shorter hospital stays, better patient outcomes, and more satisfied patients, family, and staff.

My co-lead and I work hard to be on the same page and give consistent messages.
I’m always asking my staff, ‘What are the rocks in your shoes?’ It’s a safe place for them to bring things to our attention. We make ourselves accessible. We both believe that ‘patients come second.’ – we both put staff first. We go to bat for them, and we include them in decision-making whenever possible. As a result, we have had no sick time and minimal overtime [in six months].

I was suspicious. It sounded too good to be true… When I started working on the ACU I felt how different it was. My days used to be filled with running from floor to floor, getting paged by worried nurses to come urgently to see a patient, flipping through patient charts trying to find that important piece of nursing information that would be key to understanding. Now I’m part of a team. And with that team I go and see the patients and listen to them and find out what are their key priorities that need to be addressed… I love my job again.

When you're in SIBR every morning, you know exactly who to hand off to. You delegate those things to a reliable team member who, you know is an expert at this thing. For me, that was a huge burden lifted every single day. I know the loop will be closed at some point by my reliable team member, but it's off my plate right now.

This is by far the most efficient, effective, safest method that I've ever been part of. It's been a privilege for me to be part of this – the highlight of my career.

This is the best model for coordinating care that I’ve ever seen. Patients spend less time in the hospital, get better quicker, and don’t bounce back. Our Accountable Care Unit helped us establish a culture of safety. Now we have a unit where patients don’t die and don’t even fall.

Very much enjoying work and feel rejuvenated.

My medication list, in the last few days has actually sort of changed quite a bit. Having the SIBR rounds, the doctor's like 'okay, we can up this, we can give him this as well, that's doesn't seem to be working.' And literally you know the next lot of pills I take, they're there, they're ready to go. So it does make that difference. And on the other hand, in the UK, the nurse would have to go to the doctor and then the doctor to okay it, then they have to go to the pharmacy and it's just a long way round.

It just works really well. Everybody who was negative – they’re all on board. Patients think it’s amazing. They’ve loved it.

I am happy here. This unit made me love nursing again. The ACU makes it so that nurses are heard.

It's a great start to the shift. Everyone knows what the whole ward situation is. And people leave that huddle with a smile on their face.

Not only is it a time saver because we're getting all the people that you need to talk to you throughout the day and we're getting them all together, it's also a much more fun way to work. It's a more collaborative way to work.

Everything's laid out for you so you don't worry about missing anything.

Sometimes we're afraid of the questions patients are gonna ask, but we're more prepared to answer those questions with bedside handover report.

It’s made the new grad nurses a lot more confident ... I just can’t imagine anybody doing it any other way.

I can tell you: encouraging patients and families to be there on rounds saves tremendous downstream time.

Prescribing a therapy is the easy part. The hard part is getting a huge, complicated system to deliver that therapy to the right patient at the right time, while being alert enough to recognize-and-respond when therapy fails or patients drift off course. Traditional hospital care does none of that. But this care model does. This is the future.

There's things where you say, ‘Oh we can do this ourselves, we can figure this out ourselves.’ But sometimes you need some energy and knowing, ‘this thing has worked, that it's not complete lunacy that somebody has dreamed up.’ These are not academics sitting in a classroom saying, ‘This is how you can work at the bedside.’ I like the credibility of it coming from clinicians. It's not PI people who thought this up – it's clinicians who put this together.

It just changes that tap on the shoulder from being someone kind of haranguing you and distracting you to being something that can be done and used to your advantage in a controlled time and place and everybody benefits. Having then done the SIBR round, all of those phone calls, taps on the shoulder, forms put in front of you to sign will be less and it'll be a more structured day.

Millennials are our largest population of newly hired nurses. We know these young nurses want to practice in an environment that supports them as bedside leaders. The SIBR care model is the perfect scenario for them.

We have had consultants before, and they are just consultants. But you guys feel like family, part of our hospital family.

Efficiency-wise, it’s so much better to have everyone on one floor, so you’re not walking around everywhere. While you’re up there, if there’s an issue, I knew about it earlier, took care of it right away. It didn’t necessarily impact what time I got my notes done, but the difference was the quality interaction and the decreased amount of phone calls.

SIBR itself is not magic. Really good SIBR is not really magic either, but really good SIBR is very, very valuable. Getting people in a room and just going through a checklist and going through the script is not valuable at all. It needs to be high quality.

I would never have said three weeks ago that I would ever SIBR on delirious patient, but I absolutely see the value now. It helps so much to put the patient and family at ease. Now they know there is a process where they can hear the updates from the team. You see their concerns dissipate. And I don't get as many calls from the nurses now because we all know what the plan is and the patient’s concerns.

We had a homeless patient with dense hemiparesis from a stroke and every time I went in to see him he was just very still, not doing much. I was thinking he was going one way, but then in SIBR the therapist reported she’d had him up walking with a walker and I’m thinking to myself ‘whoa, you’ve got to be kidding me.’ I had no idea.

The Joint Commission cited us for having patients on oxygen without an order, so we added it to the checklist. Now it gets reviewed every SIBR, across 6 physician teams. I haven’t seen a simpler rollout of a QI initiative.

This is an ACU co-leadership model that we're implementing. It is not my forte speaking to physicians just as your forte is not speaking to nurses. That's why we have shared leadership model here so that you can have those challenging conversations with providers and I can have challenging conversations with nurses because that's what I do better and that's what you do better, right? We both recognize that.

The SIBR model highlights how good our nurses are. The structure enables them to be far more confident in sharing with us their expertise. And that’s enhanced the interpersonal relationships between doctors and nurses.

I was surprised by the benefit of having the family in the room exchanging nuggets of information that we may not all have known. One example: a patient who needed hospice, SIBR allowed us all to realize right there and then that nobody -- not the patient, not the family, and not me – nobody felt we should be doing anything other than hospice. So the social worker was able to jump in and set up to make the referral.

Being in SIBR and understanding what each person does, what their expertise is, what I can hand off to that expert to do themselves independently and then bring back to me as sort of an orchestrator. That was really helpful.

I am truly surprised at the buy-in that we have. The nurses are invested in this.

It helps each nurse come on their shift and hit the ground running.

I think our nurses are incredibly skilled and gifted in patient care and we knew that. But I think this SIBR model has enabled them to be far more confident in actually sharing with us their expertise. And that’s enhanced the interpersonal relationship between doctors and nurses.

I instantly fell in love with SIBR at the beginning but at that time, I had no idea how impactful it can be. This model really is amazing! You have truly brought humanity back into healthcare. I feel fortunate to participate in something that touches so many!! It is something special! Thank you for that.

It's nice to just have that one moment that we can be ‘I don't need to bother them for this, this and this’, I have SIBR, I'll make a list and then you just address it then and there and it's more compact. You're not talking to doctors constantly and bothering them when they’re trying to do stuff, too.

From my experience so far from being here, SIBR does make a difference. You get all aspects (of information) from the SIBR: you get the consultants instructions, the dietician is there, pharmacist and everybody's communicating about the same thing.

Length of Stay initiatives are just agony for everybody. So to have a major LOS initiative made much easier, where a lot of the work is done – that’s what I liked.

We're very lucky and I think the SIBR model highlights how good our nurses are. It gives them a structure and a moment where they can actually stand and deliver their expertise, and the confidence to feel a valued part of the team that is guiding and deciding patient management.

After launching our first SIBR Unit 4A, we had pretty much no turnover. Then we announced a second SIBR Unit 4B, and so many nurses applied to work there that another medicine unit 3D was short staff and we had to close 10 beds.

Excellent. A great model for our physicians to follow.

Our research found through a Difference-in-Differences analysis that our ACUs have had on average 0.679 fewer excess days per patient discharge over the past two years since implementation. This amounts to a savings of $5.4 million per year on our 6 ACU units in Excess Day Reduction compared to our non-ACU units.

It helps me be succinct and get out all the right information.

It’s faster. It’s more organized. Definitely a time saver. I think it’s cut report down by 15 minutes.

We should have done this sooner. We should have been after nurses first a year ago.

This is more than just a Unit, this is a culture change. The other floors want to look like the ACU… This is the way to do it.

Your whole treating team knows exactly what's happening, what the goals are and where you're going. It's makes you feel more important because you've got all the experts coming to you. It's an hour for them, but for us, for those five minutes, they might be with you. It makes a difference.

SIBR gets rid of the chaos and fosters teamwork with all the people providing care – and with a much-improved relationship with the patient and their families. It’s so obvious to me that this is what we’re supposed to be doing.

Everybody there seems to be on the same level. There's no real pecking order.

It doesn't have to be a long time 'cause they're all there. They all know what they wanna say. They all know what's new in the day or in the bloods. And it all just happens. They talk to the nurses too, who have got their feet on the floor, constant contact with us. And it's great.

The ACU difference is dramatic. It’s like we have twice the number of hands on deck, but we haven’t hired anyone new. We’ve just trained everyone to coordinate with each other and with greater purpose. We know we’re delivering the care we’d want for our family members or ourselves.

During my first week SIBRing, I was most surprised by how much the patients and families liked it. We had one patient, obese with obstructive sleep apnea, uncontrolled diabetes, profoundly hypothyroid – he’d stopped taking his Synthroid – he was admitted with confusion. We got him back on CPAP, got his Synthroid restarted, and started a stimulant.
I’m seeing him before SIBR one day and he says: ‘Doc, you and your team coming in every day, no one has ever done that, you guys are unbelievable, really. I’m a pretty tough guy, but I almost want to cry.’

Recommend this for all our physicians.

As a nurse leader, I want my nurses in that type of supportive {ACU} environment. And because of this, we use this model as part of our recruitment and retention strategy.

Quality improved while reducing costs by about $1,500 - $2,000 per patient per stay before versus after, and it also improved the same when we compared to a control group across the city.