Healthcare)Delivery)Systems)

Improvement*Project

Victoria(Sarinana,(Maddie(Perrine,(Rachel(Godwin,(Adriana(Gamez,(&(Phoenix(Velasquez(

1
Overview'of'Patient'Care'Delivery'System

Banner&University&Medical&Center&! South
Medical!Surgical/*Telemetry*Unit/*Psychiatric*
Unit
Focus:'Provide'de'!escalation*training*of*
agitated'patients'on'the'unit

2
Microsystem+Model:
Leadership

Leadership:+“maintain+constancy+of+purpose,+
establish)clear)goals)and)expectations,)foster)
positive(culture,(and(advocate(for(the(
microsystem*in*the*larger*organization”*
o Nurse&supervisor&and&charge&nurse
o 1"charge"nurse"for"2"units"(two"floors)"
counting(55(beds(total(

Nelson,(E.,(Batalden,(P.,(Huber,(T.,(Mohr,(J.,(Godfrey,(M.,((Headrick,(L.,(&(Wasson,(J.((2002).(Microsystems(
in#health#care:#Part#1.#Learning#from#high#performing#front!line%clinical%units.%Joint&Commission&Journal&on&
Quality(and(Patient(Safety.(28(9),%472!493.%doi:10.1016/S1070!3241(02)28051!7
Marquis,)B.)L.,)&)Huston,)C.)J.)(2017).)Leadership*roles*and*management*functions*in*nursing:*Theory*and*application
(9th%ed.%p.%275%).%Philadelphia:%Wolters%Kluwer%Health/Lippincott%Williams%&%Wilkins.%
3
Microsystem+Mode
Organizational+Culture+and+Support

Organizational+culture:+“total+of+an+organization’s+
values,(language,(traditions,(customs,(and(
sacred'cows”
Rapid&Response&Team
Monthly(unit(newsletter
Change'of'shift'huddle'
Fishbowl

Marquis,)B.)L.,)&)Huston,)C.)J.)(2017).)Leadership*roles*and*management*
functions)in)nursing:)Theory)and)application (9th%ed.%p.%275).%Philadelphia:%
Wolters(Kluwer(Health/Lippincott(Williams(&(Wilkins.(
4
Microsystem+Model:
Patient'Focus'&'Staff'Focus

Patient'Focus:'
o “respectful+of+and+responsive+to+individual+

patient'preferences,'needs,'and'values,'and'
ensuring(that(patient(values(guide(all(clinical(
decisions”
Staff%Focus:
o “selective)hiring)of)the)right)kind)of)people,)
integrating(new(staff(into(culture(and(work(
roles”
o Workforce(reflects(community(diversity
Marquis,)B.)L.,)&)Huston,)C.)J.)(2017).)Leadership*roles*and*management*functions*in*nursing:*Theory*
and$application (9th%ed.%p.%327,%335).%Philadelphia:%Wolters%Kluwer%Health/Lippincott%Williams%&%
Wilkins.( 5
Microsystem+Model:
Interdependence)of)Care)Team

Interdependence)of)care)team:)“interprofessional)
teams&that&leverage&information,&experience,&
technology,+and+a+culture+of+teamwork+provide+
value&for&patients&and&families”&(Nester&2016).
o Communication*between*physicians,*nurses,*
PCTs,&pharmacy&etc.&
o Level%of%trust%between%colleagues%
• respect'for'everyone’s'role
o Consistency*in*practice*and*education*

Nestor,(J.((2016).(The(importance(of(interprofessional(practice(and(education(in(the(era(of(accountable(care.(
North&Carolina&Medical&Journal,&77(2),%128!132.%doi:10.18043/ncm.77.2.128 6
Microsystem+Model:
Use$of$Information$and$Healthcare$Technology

“Technology+as+a+tool+in+contemporary+
organizational*communication”*
Electronic*health*record*(EHR)*system*
Computer)access)in)patient)rooms)
Internet&as&information&source
o Reference'manuals'

o Evidence!based&research&

Personal)mobile)communication)devices)

Marquis,)B.)L.,)&)Huston,)C.)J.)(2017).)Leadership*roles*and*management*functions*in*nursing:*Theory*
and$application (9th%ed.%pp.%506!508).&Philadelphia:&Wolters&Kluwer&Health/Lippincott&Williams&&&
Wilkins.( 7
Microsystem+Model:
Process'for'Healthcare'Delivery'Improvement'

Routine(assessment(of(patient(care(
Use$of$benchmarking$
o Agency'for'Healthcare'Research'and'Quality'

(AHRQ)’s)Inpatient)Quality)Indicators)
Audits'as'a'measurement'of'performance'
Monthly(staff(meetings(

Agency'for'Healthcare'Research'and'Quality.'(2014).'AHRQ’s'quality'indicators'help'banner'health'
monitor'clinical'performance.'Retrieved'from'https://www.ahrq.gov/news/newsroom/case!
studies/cdom0602.html
Marquis,)B.)L.,)&)Huston,)C.)J.)(2017).)Leadership)roles)and)management)functions)in)nursing:)Theory)
and$application$(9th$ed.$p.$614).$Philadelphia:$Wolters$Kluwer$Health/Lippincott$Williams$&$Wilkins.$

8
Microsystem+Model:
Staff%Performance%Patterns

Performance*appraisals*“implies...how*well*
employees(perform(the(duties(of(their(job(as(
delineated(by(the(job(description”
Patient'outcome'statistics
o CAUTIs

o HAPs

o Patient'satisfaction

Marquis,)B.)L.,)&)Huston,)C.)J.)(2017).)Leadership*roles*and*management*
functions)in)nursing:)Theory)and)application (9th%ed.%p.%575).%Philadelphia:%
Wolters(Kluwer(Health/Lippincott(Williams(&(Wilkins.( 9
 Specific'Aspect'Targeted'for'Improvement

❏ Evidence(based:(De!escalation*training*in*the*
acute&care&setting&to&help&medical&surgical&
nurses&with&agitated&patients&
❏ Improving*techniques*to*help*nurses*de!escalate'
potential)violent)situations
❏ De!escalation*training*
❏ confidence(levels
❏ communication)skills)
❏ de!escalation*techniques*
Ferrara,&K.&L.,&Davis!Ajami,'M.'D.,'Warren,'J.'I.,''&'Murphy,'L.'S.'(2017.)'De!escalation*training*to*medical–
surgical)nurses)in)the)acute)care)setting.)Issues%in%Mental%Health%Nursing,%38(9),%742!749.%
doi:10.1080/01612840.2017.1335363
10
Specific'Aspects'Targeted'for'Improvement'
continued)

❏ Integrative*nursing*is*person!centered'and'
relationship! based&&&&
❏ Modality/Intervention:0Training0specifically0on0
therapeutic*communication,*verbal*de!
escalation,+cycle+of+aggression,+crisis+of+
violence(
❖ Three%training%days,%4%hours%each
❖ Stages'of'Change'Model'
Ferrara,&K.&L.,&Davis!Ajami,'M.'D.,'Warren,'J.'I.,''&'Murphy,'L.'S.'(2017).'De!escalation*training*to*medical–
surgical)nurses)in)the)acute)care)setting.)Issues%in%Mental%Health%Nursing,%38(9),%742!749.%
doi:10.1080/01612840.2017.1335363
Principles*of*Integrative*Nursing*(2019).*Earle&E.&Bakken.&Center&for&Spirituality&and&Wellbeing.&Retireved(from(((((((((((((((((((((
https://www.csh.umn.edu/education/focus!areas/integrative!nursing/principles!integrative!nursing
11
 Leading(the(Plan(for(Healthcare(Delivery(
Improvement
Implementation+plan:
o Presentation*of*plan*to*staff:*
• Data$on$increasing$violence$towards$medical!surgical)
nurses
o Transtheoretical-model-(TTM):-Promotes-health-behavior-
change'
o Education*provided*to*RN’s*and*PCT’s*on*de!escalation*
techniques*
o Evaluation*and*hospital!wide%implementation%
• Pre$and$post$surveys$
o Expand'to'all'units'and'more'disciplines'
Ferrara,&K.&L.,&Davis!Ajami,'M.'D.,'Warren,'J.'I.,''&'Murphy,'L.'S.'(2017).'De!escalation*training*to*
medical–surgical)nurses)in)the)acute)care)setting.)Issues%in%Mental%Health%Nursing,%38(9),%742!749.%
doi:10.1080/01612840.2017.1335363
12
Timeline'of'Events''

Root cause analysis Completion of Hospital-wide

trainings by staff on implementation
unit

1st month Months 4-6 > 1 year

Months 2-3 Months 6-12

Development of Evaluation of
education program & effectiveness throughout
cost analysis unit

13
References

Agency'for'Healthcare'Research'and'Quality.'(2014).'AHRQ’s'quality'indicators'help'''''
banner&health&monitor&clinical&performance.&Retrieved&from&
https://www.ahrq.gov/news/newsroom/case!studies/cdom0602.html
Ferrara,&K.&L.,&Davis!Ajami,'M.'D.,'Warren,'J.'I.,''&'Murphy,'L.'S.''(2017)'De!escalation*training*to*medical–
surgical)nurses)in)the)acute)care)setting.)Issues%in%Mental%Health%Nursing,%38(9),%742!749.%
doi:10.1080/01612840.2017.1335363
Marquis,)B.)L.,)&)Huston,)C.)J.)(2017).)Leadership)roles)and)management)functions)in)
nursing:(Theory(and(application((9th(ed.).(Philadelphia:(Wolters(Kluwer((
Health/Lippincott.Williams.&.Wilkins..
Nelson,(E.,(Batalden,(P.,(Huber,(T.,(Mohr,(J.,(Godfrey,(M.,((Headrick,(L.,(&(Wasson,(J.((2002).(
Microsystems+in+health+care:+Part+1.+Learning+from+high+performing+front!line%clinical%units.%
Joint&Commission&Journal&on&Quality&and&Patient&Safety.&28(9),%472!493.%doi:10.1016/S1070!
3241(02)28051!7
Nestor,(J.((2016).(The(importance(of(interprofessional(practice(and(education(in(the(
era$of$accountable$care.$North&Carolina&Medical&Journal,&77(2),%128!132.%doi:10.18043/ncm.77.2.128
Principles*of*Integrative*Nursing*(2019).*Earle&E.&Bakken.&Center&for&Spirituality&and&Wellbeing.&Retireved(from(((((((((((((((((((((
https://www.csh.umn.edu/education/focus!areas/integrative!nursing/principles!integrative!nursing

The$Joint$Commission.$(2015).$Root$cause$analysis$in$health$care$[PDF$File].$Joint&Commission&&&&&&&
Resources.)Retrieved(from(https://www.jcrinc.com/assets/1/14/EBRCA15Sample.pdf
14