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Healthcare Delivery Systems

Improvement Project

Dominic Colella, Morgan Frank, Johnathan Mougin, Rachel Lima & Caroline Sethney


Overview of Patient Care Delivery System
❧ St. Joseph’s Emergency Department
❧ Demographics
o 486 bed acute care hospital
o 44 emergency department beds, including 6
advanced life support designated beds
o Ratios of 1:3 in advanced life support care area and
1:4 in all other areas
(Registered nurse, personal communication, 2016)
(Carondelet Health Network, 2016)


Microsystem Model:
❧ Leaders work to balance setting and reaching collective
goals, and use the strategies of building knowledge,
respectful action, reviewing, and reflecting to empower
individual autonomy and accountability
❧ Mixture of Authoritarian and Democratic
o Emergency Department Director
o Clinical Lead
o Clinical Educator
o Charge Nurse
(Marquis and Huston, 2015)
(Registered nurse, personal communication, 2016)

Microsystem Model:
Organizational Culture and Support
❧ The larger organization looks for ways to support the
work of the microsystem and coordinate the hand-offs
between microsystems
❧ Organizational Structure
o Organization undergoing numerous budgetary
o Increased staff turnover, loss of essential support
staff, lack of updated equipment
(Marquis and Huston, 2015)
(Registered nurse, personal communication, 2016)


Microsystem Model:
Patient/Staff Focus of healthcare delivery
❧ Patient Focus: Patient centered care - Innovative
approach to planning, delivery, and evaluation
oHCAHPS (patient satisfaction survey)
❧ Staff focus
o New nurses are given six months of training in the
emergency department
o Hire new graduates
o Annual performance appraisals
(Marquis and Huston, 2016)
(Registered nurse, personal communication, 2016)

Microsystem Model:
Interdependence of Care Team
❧ Care Team Interactions
o Nurses receive report from other nurses during
change of shift
o Care team does not round on patients - should
information be required, individual consultation occurs
on a case by case basis
o Communication between providers and nurses, or
between departments, is occasionally lacking
(Registered nurse, personal communication, 2016)
(Marquis and Huston, 2015)

Microsystem Model:
Use of Information and Healthcare Technology
❧ Technology has dramatically changed how information is
transferred and accessed.
❧ Safeguards to protect the patient population.
❧ Technology used
o Cerner (some paper charting)
o No barcode drug administration used on this unit
o Internet and Intranet with access to programs such as
(Registered nurse, personal communication, 2016)
(Marquis and Huston, 2015)

Microsystem Model:
Process for Healthcare Delivery Improvement
❧ The ways in which learning is supported on the unit
o Monthly mandatory continuing education modules
o ACLS and PALS requirement-hospital provides
compensation for required classes
o Staff leaders remind staff during huddle to remain up
to date on continuing education courses
o Information on patient satisfaction and emphasis on
proper hand hygiene placed in staff breakroom
o Benchmarking

(Registered nurse, personal communication, 2016)

Microsystem Model:
Staff Performance Patterns
The ways in which the staff’s performance is measured
o Length of stay, amount of time triaged, etc.
o Performance reviews - is the nurse meeting the
requirements of the job?
o Volume of patients seen
o Assessment of patient outcomes
o Streamlining delivery
o HCAHPS (patient satisfaction survey)
(Registered nurse, personal communication, 2016)

Specific Aspect Targeted for Improvement
❧ Information and Healthcare Technology: No barcode
scanning for medication administration
❧ Barcode-assisted medication administration (BCMA)
reduces medication errors in hospitalized patients
❧ BCMA is not routinely used in emergency departments,
including St. Joseph’s ED.
❧ Research shows that EDs would benefit from the use of
BCMA because medication administration in the ED is
often complex and error-prone
(Bonkowski et al, 2013)


Leading the Plan for Healthcare Delivery
Improvement: Plan, Do, See, Act PDSA
❧ Plan: Discuss plan with Emergency Department
leadership committee and care teams
❧ Do: Adapt the barcode scanner medication
administration system already used in other units in the
❧ See: Study to see if there is a decrease in the number of
medication administration errors after implementation of
the new plan.
❧ Act: Reevaluate as necessary.
(Institute for Healthcare Improvements, 2016)


❧ Bonkowski, J., Carnes, C., Melucci, J., Mirtallo, J.,
Prier, B., Reichert, E., . . . Weber, R. (2013).
Effect of barcode-assisted medication
administration on emergency department
medication errors. Academic Emergency
Medicine : Official Journal of the Society for
Academic Emergency Medicine, 20(8), 801- 806.


❧Marquis, B. L., & Huston, C. J. (2015). Classical Views
of Leadership and Management. In Leadership
Roles and Management Functions of Nursing (8th ed.,
pp. 32-52). Philadelphia, PA: Wolters Klower.
❧Marquis, B. L., & Huston, C. J. (2015). Organizational
Structure. In Leadership Roles and Management
Functions of Nursing (8th ed., pp. 260-286).
Philadelphia, PA: Wolters Klower.


❧Marquis, B. L., & Huston, C. J. (2015). Organizational,
Interpersonal, and Group Communication. In
Leadership Roles and Management Functions of
Nursing (8th ed., pp. 436-465). Philadelphia, PA:
Wolters Klower.
❧Scientific of Improvement: Testing Changes. (2016).
Retrieved November 16, 2016, from