NURS 390

Team
Application
Project #4
Presented by Amanda Russi, Natalie
Springborn, Madeline Tapia and
Amanda Truong
Opening Mindful Moment
Presentation Objectives
1 2 3
Discuss case study and Discuss concept maps
Define related terms
background/significance and fishbone diagram

4 5 6
Introduce project, Run chart analysis and Summary and
discuss MFI and PDSA connect INPs Reflection
Useful Definitions
Complex adaptive system (CAS)
Mechanical systems thinking
Zone of complexity
A collection of individual agents that have the freedom
to act in ways that are not always predictable and
whose actions are interconnected such that one’s
agent of actions changes the context for other agents1
A form of systems thinking where we can know and
predict in detail what the each of the parts will do in
response to a given stimulus1
The area where many issues, which there are only
modest levels of certainty and agreement, of the
human systems lie1
Summary of Case Study
● Carla is a 30-year old female who has renal
failure and is going to dialysis 3 times per
week2
● She has no means of transportation but the
bus and depend on others for rides to her
appointments
● Has really high potassium and INR levels
after 3 ED visits
● Prescribed Warfarin
● Carla complaining of face tingling and nausea
● Scheduled a CT scan of Carla’s head and
found an acute subdural hematoma (a bleed
on the brain)
● Carla had a slow recovery and short-term
memory deficits and sent to long term care
facility
Background & Significance
In 2015, 40% of US hospitals adopted an online
communication portal. Online portals are aimed at
reducing cost, increasing healthcare convenience for
patients and increasing patient engagement in their care 3

Interoperability optimizes the health of individuals

and populations4

Carla’s Case Study helped us see the importance of

follow up appointments and how access to
resources can influence a patient's participation in
their care.
 Synthesis of Literature

Portal Use Convenience

Engages patients in their Able to assess from
care3,5,6,7 home or on the go5,6
Not all patients use
portals3,5,6,7

Communication Interoperability
Between patients Delivery of test/ imaging
and providers3,5,6 results5,7
Making the Connection

● Escape the fire documentary8

● Importance of communication
between different healthcare
providers
● Use of patient portal/technology
for communication with different
healthcare providers
● Healthcare providers focusing on
patients and not the
industry/money
Case Analysis
Overall Concept/Process Map2
What Contributed to the Adverse Event?
● What went wrong in Carla’s care?
○ Unwelcoming environment for both patients and employees
■ Fear of embarrassment on behalf of the patient
■ Fear from employees of consequences
● This caused health issues to be missed and for conditions to worsen
■ Ineffective communication between providers and between facilities
● This caused for important information about the patient’s care to
be missed
○ In this case, a nutritionist was never initially seen which
interfered with her pharmacological treatment and her INR
was not being checked at the dialysis facility
■ Follow through and timely care both seemed to be ineffectual by some of
the providers working with the patient
● When the dialysis nurse was going to make a call about Carla’s
missed appointment
● When care was being transferred between different providers and
units throughout the hospital
Fishbone Diagram2
Create Rules
for the
System
Rules for the System1
To help guide improvement in the system to then improve Carla’s care...
...we need to make changes to the system that are simple, based on
on the previous information we have, and are adaptable.
When there is a transfer to another facility or to another unit, a
follow up needs to be made to ensure that information and orders are
being properly communicated and adhered to for the safety and best
possible care for the patient.
Institute of Medicine, et al. (2001). Crossing the quality chasm : A new health system for the 21st century.
National Academies Press, 309-317. Retrieved from
https://arizona-primo.hosted.exlibrisgroup.com/permalink/f/1h28lag/TN_cdi_nas_primary_10027_13
 Ideal Concept/Process Map2
Follow up on the
★ appointment to the
nutritionist could
An improvement in prevent this adverse
the technology and reaction between
increased education potassium rich foods
on the use of ★ and Warfarin from
technology could occurring.
help prevent any
information from
being lost between
patient and
providers in this ★
transfer from the
hospital to dialysis.
Improving Part
of the System
Overview of Model for Improvement9
What are we trying to accomplish? Increasing patient attendance of follow up
appointments.

Is it a good change? We will look at the “S” portion of the PDSA cycle to see if our
change has been effective.

What changes did we make? Provide interdisciplinary support to our patients by having
them meet with social work to understand the features of their patient portal.
Utilization of The Patient Portal to Improve
Follow- up Adherence
Our Question: How will having social work meet
with patients to explain the features of their
patient portal affect patient adherence to follow up
appointments?
Qualitative: How will the social workers who are
teaching the patients describe their experience and
were there any facilitators or barriers that they
would like to address?
Quantitative: Will a meeting with a social worker to
learn the patient portal and its features, increase
patient attendance to subsequent appointments?
 PDSA – Plan the Test of Change
Our Test: Will meeting with a social
Barriers & Recommendations: Barriers we
worker to increase a patient’s foresee will be patient adherence to the
knowledge on their patient portal teachings and instructions on how to
increase their likelihood in showing up use their patient portal.
to future appointments? Recommendations we can expect from
the social workers will be handouts to
Who Will Collect? Outpatient office staff provide to patients prior to discharge.
will assist in collecting data. An
Interoperability specialist as well as a Expectations: We expect that we will see
quality improvement nurse. an increase in patient adherence to
follow up appointments.
Where will this take place?: We will
implement these meetings on the
Medical/Surgical Floor of the Wildcat
Hospital prior to discharge.
PDSA – Plan the Test of Change
Data Collection Plan
Our Goal: To increase patient attendance at follow up appointments post hospitalization.
Qualitative: We will look at how the social workers, who are meeting with patients feel
about this new implementation.
Quantitative: We will compare the number of follow up appointments that patients attend
and compare it to follow up attendance prior to this intervention.
When, Where, How?: We will provide social work intervention on the Medical/Surgical floor
of the Wildcat Hospital beginning on December 15th. Our study will run for 22 days and
follow patient adherence to their follow up appointments.
Who?: Data will be collected by outpatient staff and analyzed by an interoperability
specialist as well as a quality improvement nurse. The outcomes will be presented to patient
outreach decision makers within the hospital.
Data Collected
Run Chart Analysis
Run Chart What that Absent or Present in
Component component tells our run chart (if
us present, how many?)

Shift(s) There are no consecutive 0

data points that fall below
or above median line •Change is occurring but very
Trend(s) There are no sequential 0 inconsistently. As the run chart
data all going up or down
Data line crosses the
moves down, it still moves up
Number of 0
median twice for a total of
Run(s) 1 run each, which is too
to the median line. Nothing
(if any, indicate few for 10 data points
consistent enough for any runs
too many or or trends to occur.
too few status)

Astronomical There is 1 data point 1

starting from the
point(s) implementation date that
stand out from the others
PDSA - Study
In our predictions, we were expecting to see an increase
in the adherence to the follow up appointments that
patients were instructed on. However, based on our run
chart, we did not see enough change to make a
definitive conclusion about patient adherence.
Based on what we saw in this particular cycle, so far, our
proposed change will most likely not lead to an
improvement in patient adherence to follow up
appointments.
 PDSA - Act
● One obstacle that may need to tackled is the complexity and/or accessibility of the
patient portal so that patients can more easily make appointments and receive
reminders to increase likelihood they will make it to their appointment on time.
○ To overcome this, the portal, at least for the patient’s should be
modified/simplified in a way that is more tailored to the users of that
platform.
● Another obstacle may be that there is still ineffective communication between
different facilities/specialties about the needs for the patient and the need for
follow up on if appointments need to be made.
○ To combat this obstacle, a system may need to be made to have a more
effective way of making sure that everything that needs to be done up to a
certain point has been completed/verified.
 PDSA - Act
Based on our findings, in the next run cycle, we would need to (1)
increase the amount of education (and documentation of that
education) given to patients about the importance of following
through with these appointments and how it relates to their
condition and (2) we would need to increase the run cycle in order to
increase our sample size to see if adherence would directly increase
in conjunction with those two factors.
Summary, Questions
to Class, and Pearls
Summary
Process:
● Understanding course content
● Project idea was easy to understand
● IHI provided extra support

IN Principles10:
● To improve communication between healthcare
providers through patient portal for better follow up
● Future improvement:
○ Well being of patient
○ Well being of providers and nurses
 Questions to the Class

Question 1
Do you actually think that
changing complexity of the
technology/health record that
patients are using increase
their adherence to follow up
appointments?
Question 2
How do you think that
improving the communication
between facilities/units would
affect the health and wellbeing
of the caregivers, as in INP #6?
Reflection: Facilitators and Barriers

Facilitators
As our last project, we
found it easy to divide &
conquer! We are all aware
of what we need to do to
create a successful and Barriers
cohesive project. Our one and only barrier
this semester has been our
schedules. We are all very
busy and have different
class schedules & personal
lives. But, we always make it
work!
Pearls of Wisdom
A B
Teamwork makes the Utilize the tools in
dream work your toolbox
Closing Mindful Moment
 References
1. Plsek, P. (2001). Redesigning health care with insights from the science of complex adaptive systems. Institute of Medicine (US) Committee
on Quality of Health Care in America. https://www.ncbi.nlm.nih.gov/books/NBK222267/.

2. Baum, K. (n.d.). Advanced case study. Institute for Healthcare Improvement.

http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/AdvancedCaseStudy2010.aspx.

3. Holte, A. J., Molloy, I. B., Werth, P. M., et al. (2021). Do patient engagement platforms in total joint arthroplasty improve patient-reported
outcomes? Journal of Arthroplasty, 36(12), 3850–3858. https://doi-org.ezproxy4.library.arizona.edu/10.1016/j.arth.2021.08.003

4. Healthcare Information and Management Systems Society. (n.d.) Interoperability in healthcare. Healthcare Information and Management
Systems Society, Inc. https://www.himss.org/resources/interoperability-healthcare

5. Reicher, J., & Reicher, M. (2016). Implementation of certified ehr, patient portal, and “direct” messaging technology in a radiology
environment enhances communication of radiology results to both referring physicians and patients. Journal of Digital Imaging,
29(3), 337–340. https://doi-org.ezproxy4.library.arizona.edu/10.1007/s10278-015-9845-x

6. McAlearney, A. S., Sieck, C. J., Gregory, M. E., et al. (2021). Examining patients’ capacity to use patient portals: Insights for telehealth.
Medical Care, 59(12), 1067–1074. https://doi-org.ezproxy4.library.arizona.edu/10.1097/MLR.0000000000001639
 References Cont’
7. Kerner, D. E., & Knezevich, E. L. (2017). Use of communication tool within electronic medical record to improve primary nonadherence.
Journal of the American Pharmacists Association: JAPhA, 57(3), S270–S273.e2.
https://doi-org.ezproxy4.library.arizona.edu/10.1016/j.japh.2017.03.009

8. Susan Froemke, & Matthew Heineman (Producers), & Froemke, S. and Heineman, M. (Directors). (2012). Escape Fire. [Video/DVD] Ro*Co
Films. https://video.alexanderstreet.com/watch/escape-fire

9. Institute for Healthcare Improvement (n.d). How to improve. http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx

10. 10. Kreitzer, M. J., Koithan, M., & Oxford University Press. (2019). Integrative nursing (Second edition.) DOI:
10.1093/med/9780190851040.001.0001
Images Used
● Slide 2, https://www.youtube.com/watch?v=F7PxEy5IyV4
● Slide 29,
https://www.insidehighered.com/advice/2021/04/07/how-help-students-work-more
-effectively-teams-opinion
● Slide 29, https://www.digitaldealer.com/latest-news/work-smarter-not-harder/
● Slide 30,
https://www.wallpaperflare.com/rocks-stones-stacked-sunset-beach-hd-nature-wall
paper-mhzqu
Thanks
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