Healthcare Delivery Systems

Improvement Project

Dylan Carey, Kristin Gustavson, Ky Ha, Raquel Hansen, Yujie Wang

April 27, 2016

Overview of Patient Care Delivery System

MedSurg/Orthopedic
Unit
Focus: Patient Focus
related to nurse-topatient ratio
U.S Department of Veterans Affairs. (2016). I care core values.
Retrieved from http://www.va.gov/icare/

Microsystem Model:
Leadership
Effective leaders know that there is no one best
leadership style. Instead, they adapt their leadership
style to the needs of the situation (Marquis and Huston,
2014).
At the hospital:

Nurse Manager: both Authoritarian and Democratic

leadership
RN feedback is valued
Certain interventions are enforced with no
exceptions
Marquis, B.L. & Huston, C.J. (2014). Leadership roles and management functions in nursing: Theory and application (8th Edition). Lippincott
Williams and Wilkins. ISBN Number: 13: 978-1-4511-9281-0.

Microsystem Mode
Organizational Culture and Support
ICARE (Integrity, Commitment, Advocacy, Respect, and
Excellence)
The hospital provides recognition, information, and
resources that enhances, the nurses work and makes it
easier for the nurses to meet the needs of patients
(SAVAHCS, 2016).

Nurses encouraged to voice their concern

Educational support
Nurses support each other in completing duties
Protection from the unions
Institute for Healthcare Improvement.(2016). Clinical Microsystem Assessment Tool. Retrieved from
http://www.ihi.org/resources/Pages/Tools/ClinicalMicrosystemAssessmentTool.aspx
Marquis, B. L., & Huston, C. J. (2015). Leadership roles and management functions in nursing: Theory and application (8th ed.,
pp. 274-276). Philadelphia, PA: Wolter Kluwer Health.

Microsystem Model:
Patient Focus & Staff Focus
Patient Focus:
oHospital defines patient centered care as not
wasting patients time, offering easy access to care,
and meeting patients needs for information,
education, and preventive care
oDelivered by engaged, collaborative teams in an
integrated environment that supports learning,
discovery, and continuous improvement.

Staff Focus:
oContinuing education courses
oCareer development
oSafety of staff (no lifting more than 40 pounds)

Microsystem Model:
Interdependence of Care Team
Effective collaboration and teamwork among the
interdisciplinary team
The interdisciplinary team consists of physicians, charge
nurse, nurse manager, clinical nurse lead, nurses, and
nursing assistants.
Excellent communication between team members
Team structure and collaboration benefits:
o Positive environment
o Higher quality interactions
o Emphasizes patient centered care
Weinberg, D. B., Cooney-Miner, D., Perloff, J. N., Babington, L., & Avgar, A. C. (2011). Building collaborative capacity: Promoting
interdisciplinary teamwork in the absence of formal teams. Medical Care, 49, 716-723. doi: 10.1097/MLR.0b013e318215da3f

Microsystem Model:
Use of Information and Healthcare Technology
One of the first hospitals to move towards complete
electronic charting.
oHIT - staff
CPRS- documentation
BCMA- medication administration
oMy HealtheVet - patient
Issues:
oDouble charting
oLack of computers in every room
U.S. Department of Veterans Affairs. (2015) Independent Assessment of the Health Care Delivery Systems and
Management Processes of the Department of Veterans Affairs: Volume 1: Integrated report. Retrieved from:
http://www.va.gov/opa/choiceact/documents/assessments/Integrated_Report.pdf

Microsystem Model:
Process for Healthcare Delivery Improvement
Benchmarking is the process of comparing a practices
performance with an external standard (Agency for
Healthcare Research and Quality, 2016).
Improvement project implemented: Yellow Fall Blanket
o Benchmark
o Quality gap
o Resistance

Agency for Healthcare Research and Quality., (2016). Practice Facilitation Handbook. Retrieved from
http://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/pfhandbook/mod7.html
M. Neuss and M. Daly, personal communication, April 18, 2016

Microsystem Model:
Staff Performance Patterns
Staff performance models should meet the goals of the
hospitals population health focused model and ensure
all eligible veterans have access to high quality, timely
care.
Staff quality improvement measures:
oYearly performance evaluations
oMonthly peer evaluations- Daisy award
oStaff accepts feedback to improve care based on
evaluations
Patient outcomes are frequently measured.
TIPS Newsletters published quarterly
U.S. Department of Veterans Affairs [USDVA]. (2015) Independent Assessment of the Health Care Delivery Systems and
Management Processes of the Department of Veterans Affairs: Volume 1: Integrated report. Retrieved from:
http://www.va.gov/opa/choiceact/documents/assessments/Integrated_Report.pdf

Specific Aspect Targeted for Improvement

Unbalanced nurse-to-patient ratio of 1:7 on MedSurg

floor
Staff Shortage
Studies/literature states:
oIncreased mortality and poor outcomes
oIncreased length of stay and wait times
oDecreased staff satisfaction and increased burnout
G
oal: Find an optimal nurse-to-patient ratio in order to
improve care and staff satisfaction.
McGahan, M., Kucharski, G., & Coyer, F. (2012). Nurse staffing levels and the incidence of mortality and morbidity in the adult intensive care
unit: A literature review. Australian Critical Care, 25(2), 64-77. doi:10.1016/j.aucc.2012.03.00
Patterson, J. (2011). The effects of nurse to patient ratios. Nurs Times, 107(2), 22-25. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/21366010
Petrucci, C., Calandro, M. T., Lancia, L., Tresulti, F., & Baldacchini, A. (2015). Relationship between nurse staffing and nursing outcomes: a
narrative review of literature. Prof Inferm, 68(4), 195-202. doi:10.1037/e556872006-028

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Specific Aspect Targeted for Improvement

(cont.)
Arizona Nurses Association (2016) mandate that RN in Arizona
hospitals:
1:2 ratio for ICU
Other nurse staffing requirements based on an individual
patient's acuity
Hospital: nurses feel more comfortable of 1:5 ratio

Positive impact when adequate nurse patient ratio

AznA, AZHHA, AzONE Joint Statement on National Nurse Staffing Ratios. (2016). Arizona Nurses Association. Retrieved from
http://www.aznurse.org/page/AV01/Advocacy-AzNA-AzONE-AzHHA-Joint-Statement.htm
Cho, S., Kim, Y., Yeon, K. N., You, S., & Lee, I. D. (2015). Effects of increasing nurse staffing on missed nursing
care. International Nursing Review, 62(2), 267-274. doi:10.1111/inr.12173

11

Leading the Plan for Healthcare Delivery

Improvement
Nurse Reinvestment Act
Year and half timeline
o Management: hospital policy changes to determine
minimum nurse-to-patient ratio
o Better nurse staffing

Retain nurses
Prevent over fatigue
Improve recruitment
Stanton, M. W. (2004, March). Hospital Nurse Staffing and Quality of Care: AHRQ Archive. Retrieved
from http://archive.ahrq.gov/research/findings/factsheets/services/nursestaffing/nursestaff.html

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Leading the Plan for Healthcare Delivery

Improvement (cont.)
Timeline

13

References
Agency for Healthcare Research and Quality. (2016). Practice Facilitation Handbook. Retrieved from
http://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/pfhandbook/mod7.html
American Nurses Association. (2016). Nurse Reinvestment Act Background. Retrieved from
http://www.nursingworld.org/NurseReinvestmentAct.aspx
AznA, AZHHA, AzONE Joint Statement on National Nurse Staffing Ratios. (2016). Arizona Nurses Association.
Retrieved from http://www.aznurse.org/page/AV01/Advocacy-AzNA-AzONE-AzHHA-Joint-Statement.htm
Blegen, M. A., Goode, C. J., Spetz, J., Vaughn, T., & Park, S. H. (2011). Nurse staffing effects on patient outcomes:
Safety-net and non-safety-net hospitals. Medical Care, 49(4), 406-414.
doi:10.1097/MLR.0b013e318202e129
Cho, S., Kim, Y., Yeon, K. N., You, S., & Lee, I. D. (2015). Effects of increasing nurse staffing on missed nursing
care. International Nursing Review, 62(2), 267-274. doi:10.1111/inr.12173
Duffield, C., Diers, D., O'Brien-Pallas, L., Aisbett, C., Roche, M., King, M., & Aisbett, K. (2011). Nursing staffing, nursing
workload, the work environment and patient outcomes.Applied Nursing Research, 24(4), 244-255.
doi:10.1016/j.apnr.2009.12.004
Liang, Y. W., Chen, W. Y., Lee, J. L., & Huang, L. C. (2012). Nurse staffing, direct nursing care hours and patient
mortality in Taiwan: the longitudinal analysis of hospital nurse staffing and patient outcome study. BMC Health
Serv Res, 12(44). doi:10.1186/1472-6963-12-44
Marquis, B.L. & Huston, C.J. (2014). Leadership roles and management functions in nursing: Theory and application
(8th Edition). Lippincott Williams and Wilkins. ISBN Number: 13: 978-1-4511-9281-0

14

References

McGahan, M., Kucharski, G., & Coyer, F. (2012). Nurse staffing levels and the incidence of mortality and morbidity in
the adult intensive care unit: A literature review. Australian Critical Care, 25(2), 64-77.
doi:10.1016/j.aucc.2012.03.003
Patterson, J. (2011). The effects of nurse to patient ratios. Nurs Times, 107(2), 22-25. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/21366010
Petrucci, C., Calandro, M. T., Lancia, L., Tresulti, F., & Baldacchini, A. (2015). Relationship between nurse staffing and
nursing outcomes: a narrative review of literature. Prof Inferm, 68(4), 195-202. doi:10.1037/e556872006028
Stanton, M. W. (2004, March). Hospital Nurse Staffing and Quality of Care: AHRQ Archive. Retrieved from
http://archive.ahrq.gov/research/findings/factsheets/services/nursestaffing/nursestaff.html
U.S Department of Veterans Affairs. (2016). I care core values. Retrieved from http://www.va.gov/icare/
U.S. Department of Veterans Affairs. (2015). Independent Assessment of the Health Care Delivery Systems and
Management Processes of the Department of Veterans Affairs: Volume 1: Integrated report. Retrieved from:
http://www.va.gov/opa/choiceact/documents/assessments/Integrated_Report.pdf
Weinberg, D. B., Cooney-Miner, D., Perloff, J. N., Babington, L., & Avgar, A. C. (2011). Building collaborative capacity:
Promoting interdisciplinary teamwork in the absence of formal teams. Medical Care, 49, 716-723. doi:
10.1097/MLR.0b013e318215da3f

15