Healthcare Delivery Systems

Improvement Project
Julia Cravens, Leah Gawin, Olivia Johnson, Anne
Skinner, & Ayla Stallworth
April 24, 2019
 Overview of Patient Care Delivery
System
- Banner University Medical Center
- 4NE: Cardiac ICU Step-Down Unit (Day shift)
- Focus: Education and training related to
preceptorships for nursing students
 Microsystem Model: Leadership
- Leadership organized in a chain of command
- 1 senior nurse manager, 3 nurse managers,
and 3 charge nurses
- Select floor nurses trained as charge, used
PRN
- Each nurse assigned to a manager
- Leadership technique is dependent on staff
member
- Laissez Faire approach with less support than
textbook definition
- Small amount of instruction and lack of
support negatively affects morale and
productivity
Marquis, B.L. & Huston, C.J. (2017). Leadership roles and
management functions in nursing: Theory and application (9th
ed, p. 47). Philadelphia, PA: Wolters Kluwer.
 Microsystem Model: Organizational
Culture and Support
• “Each unit’s care should facilitate meeting the goals
of the organization, cost-effective, satisfy the
patient, role satisfaction to nurses, allow for the
implementation of nursing process, and provide
adequate communication among health care
providers”
• The impact of the unit:
• Patients’ notice staff attitude and behavior
• Staff are exhausted, do not feel appreciated and
are burned out

Marquis, B.L. & Huston, C.J. (2017). Leadership roles and management
functions in nursing: Theory and application (9th ed, p. 330).
Philadelphia, PA: Wolters Kluwer.
 Microsystem Model: Patient Focus &
Staff Focus
- Patient focus: “Patient and family centered care is an
innovative approach to the planning, delivering, and
evaluation of healthcare grounded in mutually
beneficial partnerships between patients, families, and
staff”
- Staff focus: “Managers must consider the patient care
delivery system, education and knowledge of level of
staff, budget restraints, historical staffing needs and
availability and diversity of patient population”
- Integrative principle: “1. Human beings are whole
systems inseparable from their environment”

Marquis, B.L. & Huston, C.J. (2017). Leadership roles and management functions in
nursing: Theory and application (9th ed, p. 327-336). Philadelphia, PA: Wolters Kluwer.
Kreitzer, M. (2015). Integrative nursing: Application of principles across clinical
settings”. Rambam Maimonides Medical Journal 6(2). doi: 10.5041/RMMJ.10200
Microsystem Model: Interdependence
of Care Team

• All staff members have phones that can be

used to contact each other.
• It is often difficult to communicate with
interns so residents or attendings are usually
contacted in regards to patient’s status.
• Hospitalists are usually most responsive when
nursing staff is in need.
• Patient-centered care, “should be organized
first and foremost around the needs of
patients.”
• Care coordination meetings are used to
discuss plan of care specific to patient’s needs
Marquis, B.L. & Huston, C.J. (2017). Leadership roles and
management functions in nursing: Theory and application (9th
ed). Philadelphia, PA: Wolters Kluwer.
 Microsystem Model: Use of
Information and Healthcare
Technology
● “Technologies such as social networking, texting,
email, and the intranet are increasing the potential for
effective and efficient communication throughout the
organization”
● Cerner is beneficial when patient information needs to
be accessed in different parts of hospital.
● Charting can be done at the bedside or at any
computer on the unit.
● Phones and pagers are used for communication
● Internet is available on computers for accessing
appropriate medical information.

Marquis, B.L. & Huston, C.J. (2017). Leadership roles and management
functions in nursing: Theory and application (9th ed). Philadelphia, PA:
Wolters Kluwer.
 Microsystem Model: Process for
Healthcare Delivery Improvement
Activities
“Patients should (...) be actively involved in the
determination of an organization’s quality of
care”

- Intern interviews
- Charting of HAP bundle
- Monthly staff meetings
- Standards and data
- Four eyes

Marquis, B.L. & Huston, C.J. (2017). Leadership roles and

management functions in nursing: Theory and application (9th
ed, p. 623). Philadelphia, PA: Wolters Kluwer.
 Microsystem Model: Staff
Performance Patterns
“Information obtained during the performance
appraisal can be used to develop the employee’s
potential, to assist the employee in overcoming
difficulties that he or she has in fulfilling the job’s role,
to point out strengths of which the employee may not
be aware, and to aid the employee in setting goals”

- Performance appraisal
- Reminders
- Inter-unit focus on real-time charting amongst the
nursing staff

Marquis, B.L. & Huston, C.J. (2017). Leadership roles and management
functions in nursing: Theory and application (9th ed, p. 651).
Philadelphia, PA: Wolters Kluwer.
 Specific Aspect Targeted for
Improvement

• Short staffing leads to increased workloads & less

time to dedicate to students
• Negative impact on quality of clinical teaching &
learning
• Clinical Partnership Model
• Hospital-based clinical instructor
• University instructor
• Groups of students (~6-8)
• Clear, standardized expectations
• Increased length of preceptorship (~10-12 weeks)

Chan, A. W. K., Tang, F. W. K., Choi, K. C., Liu, T., & Taylor-Piliae, R. E.
(2018). Clinical learning experiences of nursing students using an
innovative clinical partnership model: A non-randomized controlled trial.
Nurse Education Today, 68, 121-127. doi: 10.1016/j.nedt.2018.06.001
 Specific Aspect Targeted for
Improvement
• Unreasonable to expect short staffing & heavy
patient assignments to change
• Eliminates need for unit nurses to precept students
• Proposed Intervention
• Implementation of Clinical Partnership Model
• Preceptorship length: 10 weeks
• “Integrative nursing focuses on the health and
wellbeing of caregivers, as well as those they serve.”

Chan, A. W. K., Tang, F. W. K., Choi, K. C., Liu, T., & Taylor-Piliae, R. E.
(2018). Clinical learning experiences of nursing students using an
innovative clinical partnership model: A non-randomized controlled trial.
Nurse Education Today, 68, 121-127. doi: 10.1016/j.nedt.2018.06.001
Kreitzer, M. J. (2015). Integrative nursing: Application of principles across
clinical settings. Rambam Maimonides Medical Journal, 6(2), 1-8. doi:
10.5041/RMMJ.10200
 Leading the Plan for Healthcare
Delivery Improvement
• Pre-change satisfaction surveys
• Presentation of Clinical Preceptorship Model
(rational-empirical)
• Creation of application & selection of ~2
hospital-based clinical instructors
• Cost: Salary slightly higher than average
salary for experienced RN on unit (~2
employees)
• Education provided by university instructors
(orientation, pre-preceptorship training)
• Post-change satisfaction surveys

Marquis, B. L. & Huston, C. J. (2017). Leadership roles and

management functions in nursing: Theory and application (9th
ed.). Philadelphia, PA: Wolters Kluwer.
Timeline of Events
 References

Chan, A. W. K., Tang, F. W. K., Choi, K. C., Liu, T., & Taylor-
Piliae, R. E. (2018). Clinical learning experiences of nursing
students using an innovative clinical partnership model: A non-
randomized controlled trial. Nurse Education Today, 68, 121-
127. doi: 10.1016/j.nedt.2018.06.001

Kreitzer, M. J. (2015). Integrative nursing: Application of

principles across clinical settings. Rambam Maimonides Medical
Journal, 6(2), 1-8. doi: 10.5041/RMMJ.10200

Marquis, B.L. & Huston, C.J. (2017). Leadership roles and

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