Healthcare Delivery Systems

Improvement Project
Date: Wednesday, April 17, 2019
🙠 🙢
Karli Basakos, Hayley Comrie, Alli Meaux,
Jennifer Stebbins, Anh Vu

1
Overview of Patient Care Delivery System

� Banner University Medical Center - Tucson

Campus
� Cardiovascular Intermediate Care Unit
� Focus: Process Improvement related to
receiving patient report from the emergency
department

2
 Microsystem Model:
Leadership

� Democratic leadership (Frandsen, 2014).

� Supportive, equals
� Shared leadership model
o “non-hierarchical leadership model that
describes leadership that emerges within a
group, depending on the context and skills
required at a given time” (Thusini & Mingay,
2019, p. 357).
Frandsen, B. (2014). Nursing leadership: Management & leadership styles [PDF file]. Retrieved from
https://www.aanac.org/docs/white-papers/2013-nursing-leadership---management-leadership-
styles.pdf?sfvrsn=4
Thusini, S. & Mingay, J. (2019). Models of leadership and their implications for nursing practice. British 3
Journal of Nursing, (28)6, 356-360. doi: 10.12968/bjon.2019.28.6.356
Microsystem Mode
Organizational Culture and Support

� Charge RN went to bed meeting at 0300

� Huddles prior to each shift, offgoing charge
nurse
� SWAT RN - relational leadership seen
� “Leadership focused solely on task completion is
insufficient to achieve optimum outcomes for the
nursing workforce” (Cummings et al., 2019, p.
19).
Cummings, G. G., Tate, K., Lee, S., Wong, C. A., Paananen, T., Micaroni, S., & Chatterjee, G. E.
(2018). Leadership styles and outcome patterns for the nursing workforce and work
environment: A systematic review. International Journal of Nursing Studies, (85), 19-60. doi:
10.1016/j.ijnurstu.2018.04.016 4
 Microsystem Model:
Patient Focus & Staff Focus
� Patient Focus
o Provide care to the patients based on their preferences,
values, and needs → patient-centered care (Marquis &
Huston, 2017).
� Staff Focus
o Need staffing policies and communication tools in both our
unit and the ED (Marquis & Huston, 2017).
→ understand the patient’s situation more accurately
→ be able to deliver continuity and quality of care
� Integrative Nursing Principle: Patient-centered and
relationship-based care
Kreitzer, M. J. (2016). Integrative nursing: Application of principle across clinical settings. Rambam Maimonides
Medical Journal, 6(2). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4422455/
Marquis, B. L., & Huston, C. J. (2017). Leadership roles and management functions in nursing: Theory and 5
application (9th ed., p. 364-366). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
 Microsystem Model:
Interdependence of Care Team

� The use of an interdisciplinary team increases the likelihood

of comprehensive and holistic care (Marquis & Huston,
2017).
o Close staff nurse relationships with attendings, residents,
charge nurses, and the nurse manager
o Nurses also work with social workers and case managers
during day shift
� Tele boxes & tele station utilized
� Lack of adequate reports from ED admitting patients

Marquis, B. L., & Huston, C. J. (2017). Leadership roles and management functions in nursing: Theory
and application (9th ed., p. 364-366). Philadelphia: Wolters Kluwer Health/Lippincott Williams &
Wilkins. 6
 Microsystem Model:
Use of Information and Healthcare Technology

� “Technology has dramatically changed how

nurses communicate and perform their work”
(Marquis & Huston, 2017).
� Electronic medical records used for consistent
patient information hospital-wide
� eMAR used to administer medications
� Patient handouts easy to print out
� Cerner charting system is not user-friendly

Marquis, B.L. & Huston C.J. (2017). Leadership and management function in nursing: Theory and
application (9th ed. p. 510). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
7
 Microsystem Model:
Process for Healthcare Delivery Improvement

� Health-care organizations can do a better job of

identifying errors by categorizing the errors and
examining and reworking the processes that led
to them (Marquis & Huston, 2017).
� Follows hospital protocol to provide quality care
� Cardiovascular champion
� Chart auditing used for process improvement
� ED handoff minimal or nonexistent

Marquis, B.L. & Huston C.J. (2017). Leadership and management function in nursing: Theory and
application (9th ed. p. 632). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. 8
 Microsystem Model:
Staff Performance Patterns

� Audits as a quality control tool: “An audit is a

systematic and official examination of a record,
process, structure, environment, or account to
evaluate performance (Marquis & Huston,
2017)”
� Hospital acquired pneumonia prevention chart
auditing
� Quarterly performance appraisals of staff
� Inter-unit focus on:
o HAP, falls

Marquis, B.L. & Huston C.J. (2017). Leadership and management function in nursing: Theory and
application (9th ed. p. 618). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
9
 Specific Aspect Targeted for Improvement and State
IN Principle & Describe IN Modality Applied

� Evidence-Based: Effects of the I-PASS Nursing

Handoff Bundle on Communication Quality and
Workflow
� Improving RN communication
during patient handoff
� Lack of report given from the ED
o Adverse and sentinel events
o Length of time before being seen
o Patient satisfaction
Collins, R. (2017). Hand-off communication: The weak link in healthcare. Becker’s Hospital Review.
Received from https://www.beckershospitalreview.com/hospital-management-
administration/hand-off-communication-the-weak-link-in-healthcare.html
Starmer, A.J., Schnock, K.O., Lyons, A., Hehn, R.S., Graham, D.A., et al. (2017). Effects of the I-
PASS nursing handoff bundle on communication quality and workflow. British Medical Journal 10
on Quality and Safety, 26 (12), 949-957. doi: 10.1136/bmjqs-2016-006224.
Specific Aspect Targeted for Improvement and State IN
Principle & Describe IN Modality Applied (cont.)

� Process Improvement
� Lacking appropriate handoff from the ED → increased risk of
adverse/sentinel events
� Unit RN relies on the EMR for patient history, admitting
diagnoses, care tasks, precautions, etc.
� Proposed intervention:
o Establish the I-PASS patient handoff system within the ED
to facilitate an organized and informative report.
o RNs on the cardiovascular intermediate care unit must
actively contact ED RNs for I-PASS report if not given.
� Integrative principle: patient-centered, relationship-based care
Starmer, A.J., Spector, N.D., Srivastava, R., West, D.C., Rosenbluth, G., et al. (2014). Changes in medical
errors after implementation of a handoff program. The New England Journal of Medicine, 371 (19), 1803-
1812. doi: 10.1056/NEJMsa1405556.
11
 Leading the Plan for Healthcare Delivery
Improvement

� Present proposed intervention to nurse manager

with key findings from Starmer et al. (2017)
o highlight benefits

o create a committee for implementation

• tech support, designated colleague educators

o integrate I-PASS into EMR as a nurses note
o reminders in pre-shift huddle
o posters in break room with example of I-PASS
Starmer, A.J., Schnock, K.O., Lyons, A., Hehn, R.S., Graham, D.A., et al. (2017). Effects of the I-
PASS nursing handoff bundle on communication quality and workflow. British Medical Journal
on Quality and Safety, 26 (12), 949-957. doi: 10.1136/bmjqs-2016-006224.
12
 Six Month Timeline

1st-2nd 3rd-4th 4th-5th 5th-6th

1st Month
Month Month Month Month

Present Root-Cause ED RN Evaluate Implement

to Nurse Analysis by committee intervention hospital-
Manager ED Nurse synthesized efficacy wide
Manager; to introduce I-PASS
Budget I-PASS and system
Analysis for train the ED
EMR staff
 References

Collins, R. (2017). Hand-off communication: The weak link in healthcare. Becker’s Hospital Review. Received
from https://www.beckershospitalreview.com/hospital-management-administration/hand-off-
communication-the-weak-link-in-healthcare.html.
Cummings, G. G., Tate, K., Lee, S., Wong, C. A., Paananen, T., Micaroni, S., & Chatterjee, G. E. (2018).
Leadership styles and outcome patterns for the nursing workforce and work environment: A systematic
review. International Journal of Nursing Studies, (85), 19-60. doi: 10.1016/j.ijnurstu.2018.04.016.
Frandsen, B. (2014). Nursing leadership: Management & leadership styles [PDF file]. Retrieved from
https://www.aanac.org/docs/white-papers/2013-nursing-leadership---management-leadership-
styles.pdf?sfvrsn=4.
Kreitzer, M. J. (2016). Integrative nursing: Application of principle across clinical settings. Rambam Maimonides
Medical Journal, 6(2). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4422455/
Marquis, B.L. & Huston C.J. (2017). Leadership and management function in nursing: Theory and application
(9th ed. p. 364-366, 618). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Starmer, A.J., Schnock, K.O., Lyons, A., Hehn, R.S., Graham, D.A., et al. (2017). Effects of the I-PASS nursing
handoff bundle on communication quality and workflow. British Medical Journal on Quality and Safety, 26
(12), 949-957. doi: 10.1136/bmjqs-2016-006224.
Starmer, A.J., Spector, N.D., Srivastava, R., West, D.C., Rosenbluth, G., et al. (2014). Changes in medical errors
after implementation of a handoff program. The New England Journal of Medicine, 371 (19), 1803-1812.
doi: 10.1056/NEJMsa1405556.
Thusini, S. & Mingay, J. (2019). Models of leadership and their implications for nursing practice. British Journal of
Nursing, (28)6, 356-360. doi: 10.12968/bjon.2019.28.6.356.

14