Healthcare Delivery System Improvement Project:

Organizational Support

🙠 Angela
Ashley Baire, Micah Johnson, 🙢 Matthew, Morgan Postal,
and Abbey Spivey

December 4, 2019
1
Overview of Patient Care Delivery System

� Banner University Medical Center Tucson

� Clinical Decision Unit (CDU) - Observation
o 20 bed unit, 1:4 nurse-patient ratio (not upheld)

o 3-4 RNs including charge RN, 1-2 PCTs

o Patient base diverse

• ETOH/drug withdrawal
• PACU/pre-op/Cath-Lab overflow
• Stable chest pain
• Concussion watch for head injuries
• Psych holds for SI/HI
� Focus: Organizational support related to
mandated nurse-patient ratios
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 Microsystem Model: Leadership

� Democratic Leadership: “economic and ego awards are use to

motivate, others are directed through suggestions and guidance,
communication flows up and down...”
o Charge nurse
• Took suggestions from staff (RNs, PCTs)
• Encouraged autonomy and collaboration
� Authoritarian Leadership: “strong control is maintained over
the work group, others are motivated by coercion, others are
directed with commands, communication flows downwards…”
o Unit manager
• Asked for little feedback from staff
• Dictated unit procedures without involvement
Marquis, B. L., & Huston, C. J. (2017a). Classical views of leadership and management. In
Marquis, B. L., & Huston, C. J. (Eds). Leadership roles and management functions in
nursing: Theory and application (9th ed., pp. 47). Philadelphia, PA: Wolters Kluwer Health. 3
 Microsystem Model:
Organizational Culture and Support

� Banner has strong organizational culture/support

� “Neglected stepchild of the hospital”
o Lacking in recognition, information, and resources to
enhance work
• Charge nurse often in ratio
• New grads precept/train
• Supplies and medications in ED
• TELE boxes not readily available
• Lack of PCT when 1:1 psych patients
• No coverage available for RN leaving floor/lunch
o Lack of safe nurse-patient ratios/patient care

Institute for Healthcare Improvement. (2019). Clinical microsystem assessment tool. Retrieved from
http://www.ihi.org/resources/Pages/Tools/ClinicalMicrosystemAssessmentTool.aspx. 4
Microsystem Model:
Patient Focus & Staff Focus

Patient focus: “...philosophy… partnership that involves both the

patient and health care provider… arriving at some form of
conclusion about the care and treatment of the patient...”
� Dependent on patient severity, no real time patient assessment
charting, report not given at bedside

Staff focus: “Staffing affects the ability of all nurses to deliver

safe, quality care in all practice settings.”
� Lack of push for further education, huge push to be charge
RN, charge RN unable to make bed meetings

American Nurses Association. (2019). Nurse staffing. Retrieved from

https://www.nursingworld.org/practice-policy/nurse-staffing/
Flagg, A. J. (2015). The role of patient-centered care in nursing. Nursing Clinics of North
America, 50(1), 75-86. https://doi.org/10.1016/j.cnur.2014.10.006
5
Microsystem Model:
Interdependence of Care Team
“...interaction of staff is characterized by trust, collaboration,
willingness to help each other, appreciation of complementary
roles, respect and recognition that all contribute individually to a
shared purpose of patient care.”

� Strong Interdisciplinary Care Team

o Physicians/PCTs responsive
� Close-knit floor team
� Strong communication/report via phone when patients were
transferred to other floors
� Wait times for Pharmacy verification

Institute for Healthcare Improvement. (2019). Clinical microsystem assessment tool. Retrieved from
http://www.ihi.org/resources/Pages/Tools/ClinicalMicrosystemAssessmentTool.aspx.
6
 Microsystem Model:
Use of Information and Healthcare Technology

“Technologies such as...e-mail and the internet are

increasing the potential for effective and efficient
communication throughout the organization”
❏ Phones distributed to staff
❏ Use of EHR and IPOC
❏ Workstation on Wheels (WOWs)
❏ Pyxis downtime during night shift

Marquis, B. L., & Huston, C. J. (2017b). Organizational, interpersonal, and group communication.
In Marquis, B. L., & Huston, C. J. (Eds). Leadership roles and management functions in
nursing: Theory and application (9th ed., pp. 508). Philadelphia, PA: Wolters Kluwer
Health. 7
Microsystem Model:
Process for Healthcare Delivery Improvement

“Benchmarking is an important tool that facilitators can

use to motivate a practice to engage in improvement work
and to help members of a practice understand where their
performance falls in comparison to others”

� Benchmarking to compare with other units in the

hospital
� Random chart reviews hospital wide
� Lack of staff meetings, pre-huddle, staffing resources
Agency for Healthcare Research and Quality. (2019). Practice facilitation handbook. Retrieved from
https://www.ahrq.gov/ncepcr/tools/pf-handbook/mod7.html
8
Microsystem Model:
Staff Performance Patterns

“Performance appraisals let employees know the level

of their job performance as well as any expectations that
the organization may have of them”
o Quarterly
� Clinical ladder program
� Unit performance
o HAP bundle
o Falls
o Length of stay

Marquis, B. L., & Huston, C. J. (2017c). Performance appraisal. In Marquis, B. L., &
Huston, C. J. (Eds). Leadership roles and management functions in nursing: Theory
and application (9th ed., pp. 647). Philadelphia, PA: Wolters Kluwer Health. 9
Specific Aspect Targeted for Improvement

� “From Evidence to Practice: Developing an

Outpatient Acuity-Based Staffing Model”
� Intervention: Charge RNs will utilize a standardized
patient acuity-based assessment tool to determine
staffing for oncoming shift
� Goals:
o Adequate nurse staffing
o Reduced nurse burnout
o Increased patient safety
o Higher quality of care

Vortherms, J., Spoden, B., & Wilcken, J. (2015). From evidence to practice: Developing an
outpatient acuity-based staffing model. Clinical Journal of Oncology Nursing, 19(3), 332-
337. doi: 10.1188/15.CJON.332-337 10
Integrative Principle VI and Integrative Modality

“Integrative nursing focuses on the health and the

wellbeing of caregivers as well as those they serve”

� Nurses work in high-stress environments, making them

more vulnerable to nurse burnout and stress which
impacts their wellbeing and the care provided to their
patients.

Kreitzer M. J. (2015). Integrative nursing: application of principles across clinical settings. Rambam
Maimonides Medical Journal, 6(2), e0016. doi:10.5041/RMMJ.10200
11
 Leading the Plan for Healthcare Delivery
Improvement: Implementation of FADE Model
January 1st, 2020
o Focus: Maintaining mandated Nurse-Patient Ratios
o Analyze: An internal systems process analysis will be completed
May 1st, 2020
o Develop: Nurse Manager creates a CDU Patient Safety Acuity
Based Assessment Tool
August 1st, 2020
o Execute: Nurse Manager will educate Charge Nurses>Floor Nurses
October 1st, 2020
o Execute: Intervention will be implemented unit-wide
October 1st, 2021
o Evaluate: Impact evaluation will be performed
Agee, J. (2017). Reducing chronic obstructive pulmonary disease 30-day readmissions. JONA: The Journal of Nursing 12
Administration, 47(1), 35–40. doi: 10.1097/nna.0000000000000434
Timeline of Proposed Healthcare Delivery
Improvement & Conclusion

13
References

Agency for Healthcare Research and Quality. (2019). Practice facilitation handbook. Retrieved from

https://www.ahrq.gov/ncepcr/tools/pf-handbook/mod7.html

Agee, J. (2017). Reducing chronic obstructive pulmonary disease 30-day readmissions. JONA: The Journal of Nursing

Administration, 47(1), 35–40. doi: 10.1097/nna.0000000000000434

American Nurses Association. (2019). Nurse staffing. Retrieved from https://www.nursingworld.org/practice-policy/nurse-staffing/

Flagg, A. J. (2015). The role of patient-centered care in nursing. Nursing Clinics of North America, 50(1), 75-86.

https://doi.org/10.1016/j.cnur.2014.10.006

Institute for Healthcare Improvement. (2019). Clinical microsystem assessment tool. Retrieved from

http://www.ihi.org/resources/Pages/Tools/ClinicalMicrosystemAssessmentTool.aspx.

Kreitzer M. J. (2015). Integrative nursing: application of principles across clinical settings. Rambam Maimonides Medical Journal,

6(2), e0016. doi:10.5041/RMMJ.10200

Marquis, B. L., & Huston, C. J. (2017a). Classical views of leadership and management. In Marquis, B. L., & Huston, C. J. (Eds).

Leadership roles and management functions in nursing: Theory and application (9th ed., pp. 47). Philadelphia, PA: Wolters

Kluwer Health.

14
 References

Marquis, B. L., & Huston, C. J. (2017b). Organizational, interpersonal, and group communication. In Marquis, B. L., & Huston, C. J.

(Eds). Leadership roles and management functions in nursing: Theory and application (9th ed., pp. 508). Philadelphia, PA:

Wolters Kluwer Health.

Marquis, B. L., & Huston, C. J. (2017c). Performance appraisal. In Marquis, B. L., & Huston, C. J. (Eds). Leadership roles and

management functions in nursing: Theory and application (9th ed., pp. 647). Philadelphia, PA: Wolters Kluwer Health.

Vortherms, J., Spoden, B., & Wilcken, J. (2015). From evidence to practice: Developing an outpatient acuity-based staffing model.

Clinical Journal of Oncology Nursing, 19(3), 332-337. doi: 10.1188/15.CJON.332-337

15