Health System Quality

improvement
Allison Hayes, Hailey Bybee, Nicole Blackburn, Celeste Jones, and Amanda Shackelford
April 22, 2020

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 Overview of patient care delivery system
St. Joseph’s Hospital - Tucson, AZ
● Medical/Trauma Intensive Care Unit
○ 2 Units
■ ICU West: 7 beds (designated for Trauma Patients)
■ ICU East: 16 beds
○ Unit Physicians, Charge Nurse, Staff RNs, Respiratory Therapists,
Lift Coach, Nurse Manager, House Supervisor
● A good majority of nursing staff consists of travelers

Focus:
○ Develop a training program for traveling nurses, so they feel
competent, confident, and integrated into the team of core RNs
on the unit.

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 Microsystem Model: Leadership
Medical/Trauma ICU Leadership

● Charge Nurse
● Nurse Manager
● Nursing Supervisor
● MD’s
● RN’s
● Respiratory Therapists
● Lift Coaches

(Johnson, 2001) 3
 Microsystem model: leadership Cont.
Medical/Trauma ICU Leadership

● Charge Nurses
○ Three different charge nurses on days
● 1 Charge RN - Laissez-faire style leadership
○ “Permissive,...motivates by support, provides little or no
direction, places emphasis on group, does not criticize,
disperses decision making throughout group”.
● 2 Charge RN’s - Democratic style leadership
○ “Less control, awards used to motivate, ...suggestions and
guidance, communication flows up and down, decision
making involves others, and criticism is constructive”.

(Johnson, 2001)
(Marquis & Hutson, 2017)
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 Microsystem model: leadership Cont.
Medical/Trauma ICU Leadership

● Nurse Manager - Democratic style of leadership

○ “Less control, awards used to motivate,
...suggestions and guidance, communication flows
up and down, decision making involves others, and
criticism is constructive”.
○ Supportive
○ Valued teamwork

(Johnson, 2001)
(Marquis & Hutson, 2017) 5
 microsystem model: organizational culture
and support
Unit Culture:

● Culture of teamwork
● Staff Check offs for skills
○ ex. glucometer, restraint etc.

Organizational Culture

● Hand off/bed transfers - lacking

efficiency
● Different supplies between units
● Easy to contact house supervisor and
unit manager for support 6
(Johnson, 2001)
 Microsystem model: Patient/staff focus of
healthcare delivery
Patient Focus Staff Focus

● No PCTs on Unit - Lift ● Traveling Nurses > Core

coaches staff
○ Total Patient Care ● Orientation for new hires -
● Culture of caring, 4 to 5 weeks working with
listening and educating another nurse
● Clustering care ● Staff ratio 2:1
● Performance reviews

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(Johnson, 2001)
 Microsystem model: interdependence of care team

● Nurses collaborate well with each other

○ Step up and help - esp with total patient care
○ Sometimes lack of communication and role
designation in codes
● Interdisciplinary teamwork
○ Interdisciplinary rounds (Physician,
Pharmacy, RTs, Dietician, Chaplain)

(Johnson, 2001) https://www.clipart.email/clipart/healthcare-team-clipart-22760.html 8

 microsystem model: use of information and
healthcare technology
● Cerner EMR
○ IT support available
○ Lexicomp medication resource
○ Auto population charting
● Vocera
● Computers at work stations, situated throughout units
○ Only physicians get moving computers (WOW)
○ Computers in patient rooms
● Phones at work stations
○ Some were dead, not always an easily accessible list of phone
numbers near the phone

(Johnson, 2001)
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 microsystem model: process for healthcare
improvement activities
Strengths Weaknesses
● Not many quality
● Continuous
improvement
education
requirements indicators posted
○ Skill check offs ● Updates on
■ Offered on certain protocol in
dates (have to come in morning huddle -
on day off) not strictly
○ In-house trainings early in enforced or
the morning or middle of monitored
shift
(Johnson, 2001) 10
MIcrosystem Model: staff performance patterns
● Performance appraisals
○ St. Joe’s: RNs required to show
portfolio of continuing education and
accomplishments
○ Suggested tool: 360 degree method
■ Performed quarterly using scores for 30
different items
■ Success related to nurses’ participation
in appraisal process
■ Increases organizational commitment
which leads to higher quality patient care
■ (Sepahvand et al., 2020)

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 specific aspect targeted for improvement
Specific Targeted Aspect: Staff Focus
● Rationale
○ More travelers than core staff
○ Important to have competent staff
that feels confident and part of the
team
● Proposed change
○ A training program for travelers to
make them feel welcomed and
integrated into the team
● Positive Impact on patient-centered
care
○ A more coherent team of healthcare
staff works better together to care
for patients

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 Integrative Nursing Principle
Integrative Nursing Principle #4
● “Integrative nursing is person-centered
and relationship-based.”
● Elements of caring relationships: love,
warmth, trust, confidence, respect,
authenticity
● Modalities
○ intentional decision to be a warm,
inviting presence on the unit every
day
Kreitzer, M. J. (2015) Integrative
○ focuses on listening to coworkers nursing: Application of principles
across clinical settings. Rambam
and providing constructive Maimonides Medical Journal, 6(2).
doi:10.5041/RMMJ.10200
feedback 13
Leading
Leadingthe
theplan
pLanfor
forimprovement:
Improvement:Aa summary
summary
1. Innovation
a. consider current best practices
b. identify gaps in current state
c. develop measurable outcomes
2. Pilot Test
a. PDSA cycles
b. start small and grow, adjust PRN
3. Implementation
a. intertwine new process into current
ICU protocols
(IHI, 2020) 4. Spread
a. additional units in hospital 14
 Timeline for
For planned
Planned improvement
Improvement

May 2020 June - July 2020 Aug - Sept 2020 Oct - Nov 2020 Dec 2020 January 2021

Innovation Pilot Testing Pilot Testing Pilot Testing Pilot Testing Implementation
Stage 1 Stage 2 Stage 3 Stage 4
● Brainstorm
● Identify ● Continue to ● Invite core staff ● Begin stabilizing ● It is now
● Sharing
resistance support those in to participate in system change mandatory
research
● Begin resistance trainings ● Identify training for all
and data
● Offer additional ● Include core maximum # travelers
● Specify traveler
trainings for staff feedback trainings for ● Cont. progress
training and training
● PDSAs travelers travelers to reports
resources
attend

(IHI, 2020) 15
(Lewin, 1951)
 references
IHI Open School Home: IHI - Institute for Healthcare Improvement. (2020). Retrieved from

http://www.ihi.org/education/ihiopenschool/Pages/default.aspx

Johnson, J. K. (2001). Clinical microsystem assessment. Retrieved from

https://d2l.arizona.edu/d2l/le/content/854111/viewContent/8098839/View

Kreitzer, M. J. (2015) Integrative nursing: Application of principles across clinical settings. Rambam

Maimonides Medical Journal, 6(2). doi:10.5041/RMMJ.10200

Lewin, K. (1951). Field theory in social sciences: Selected theoretical papers. New York, NY: Harper & Row.

Marquis, B. L., & Huston, C. J. (2017). Leadership roles and management functions in nursing: theory and application (9th ed,

pg. 47). Philadelphia: Wolters Kluwer Health.

Sepahvand, F., Mohammadipour, F., Parvizy, S., Tafreshi, M. Z., Skerrett, V.,& Atashzadeh‐Shoorideh, F. (2020). Improving

nurses’ organizational commitment by participating in their performance appraisal process. Journal of Nursing

Management, 1(1), 1-11. https://doi.org/10.1111/jonm.12961

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