Case Study and Clinical Microsystem Assessment

Hospitals and health care facilities are often plagued with the tension of balancing many components of health care. From managing the morale and empowerment of health care employees and nurses, to addressing funding, patient advocacy, and communication issues, there is always something to work on and improve. Despite the large-scale problems that cannot be addressed overnight, such as nurse or funding shortages, adequate training for staff must be a priority. Patient consideration and bedside manners are important to quality outcomes and should not be overlooked or disregarded. The following will discuss a patient’s letter regarding his hospital stay experience and provide an analysis of the microsystem in place. Members of the hospital quality improvement council as well as the nurse manager will be able to use the following outlined framework to manage improvement of the issues outlined in the patient’s letter. Although the patient’s letter highlights multiple areas for priority change, this document will focus on one topic with which to develop an improvement plan. While there are some high-level issues that cannot be immediately addressed, many issues in the patient’s letter can be managed by stressing the importance of clear communication and standardized practices within the hospital facility.

Analysis of the Microsystem

The microsystem of the hospital is plagued with a miscommunication, inconsistency, and inconsideration. Despite the target clinical and business goals as well as the interconnected and linked processes, the shared environment has not created steady and consistent practices. As nursing managers focus on working to meet staff needs and maintain a clinical unit, managing the cohesiveness of a microsystem can be a true challenge. The microsystem described by the patient reflected a very disconnected team. Studies show miscommunication or lack of communication between care staff occurs often (Kripalani et. Al., 2007).There were many examples of miscommunication which could have had very damaging consequences for the patient and for the hospital. The first series of examples centered on medication errors and potential medication errors that could have had detrimental implications for the patient’s surgery. A nurse failed to report for her evening administration of medication, leaving the patient one dose short of the doctor recommended dosage. In addition, the patient had to specifically ask for medication that subsequently went missing. This scenario is particularly concerning because it highlights the need for intense accountability of nurses and their use and distribution of medication. Analyzing this scenario reveals the potential for a nurse to steal medication without consequence. The nurse either did not check the chart or was attempting to act unethically. In either case, as strong system of communication and accountability would have flagged the issue to someone on the medical team instead of the customer having to address it.

The miscommunication points to exhaustion or carelessness. While exhaustion can be addressed by managing nursing hours and providing a sufficient balance of patient schedules, carelessness is a trait that cannot be a part of nurses’ characteristics. The patient’s poor reaction to surgery tape should have prompted action on behalf of the nursing staff, instead the patient’s wife was forced to pull her weight and inquire multiple times for a flag to be added to the file. Worse, the patient was told to remember to advise nursing staff rather than taking ownership of the problem him or herself. This reveals low levels of initiative and empowerment and reflects a clinical microsystem that is not working in unison.

Managing informed consent is an essential part of running a clinical microsystem in a hospital. Many lawsuits have occurred related to informed consent and the patient’s right to understand the surgery and extent of surgery being performed (Joffe, et al., 2001). Asking a patient to sign an informed consent form and filling in the details later lacks integrity and opens the hospital up to a significant amount of liability and lawsuits, not to mention a significant ethical conflict on the part of the nursing staff. As the informed consent form is the facilities primary source of communication to reflect its discussions with the patient regarding surgery, attempting to circumvent the documentation process is inadmissible.

The miscommunication issue was apparent on multiple levels. From failing to record instances in the patient’s chart to some nurses advising the patient to stay while others were congratulating them on going home. It is clear that training related to medical communication as well as patient and interpersonal communication is necessary in order to improve this clinical microsystem to make sure quality, reliable, and safe care is provided.

Action Plan

In case it has not already been shared with staff this letter needs to be shared with the nursing staff immediately. The root causes of miscommunication must be addressed in order to highlight the issue. A mandatory training will be developed which will highlight the multiple areas of miscommunication and what can be done to eliminate inconsistencies. On the priority list is discussing who is empowered to add to a patient’s chart. Some nurses may not have been previously empowered by supervisors to add things to the charts, making them unsure about adding updates. The training will identify the special circumstances in which nurses and staff should update the chart.  The importance of checking the paper chart as well as the patient’s digital records will also be stressed in training. This will become part of a best practice that will be required of all nurses before they interact with patients or provide them with any medication. Failure to do this will result in disciplinary action after an initial warning.

A legal analyst will be brought in to discuss the issue of informed consent and the liability of the hospital relating to consent forms. He or she will discuss what is mandatory to address with the patient and the responsibility staff has in maintaining consistency when describing surgical procedures and post and pre-operative processes (Alfidi, 1971). In addition, any staff member caught advising patients to sign informed consent forms without the information filled in will be immediately put on a written warning.  As the education and information increases, so must the potential consequences. This will help to weed out the staff that is careless and insensitive to patient needs, allowing the nursing manager to hire conciencious and alert staff to the team.

The patient also highlighted immense areas of improvement for discharge communication. This communication barrier must be addressed sufficiently in order to manage low return and rates after a patient is discharged. Case study from Key-Solle (2010) shows that educational interventions that are brief and low in intensity can significantly improve discharge communication quality. As a result, it is recommended that current nurses and nurses in residency be mandated to attend a course. Checklists can also be implemented to help nurses manage time and responsibilities. As nurses often have multiple responsibilities and ever-changing roles and patient rotations, they can become overwhelmed and forget important aspects of patient care. Electronic templates can be used to provide them with standards to check and review periodically in order to help them operate more efficiently.

This improvement plan will have a foundation in training, advising staff of what needs to change and providing an outlet for questions and support. A code of conduct will be presented as well as a written version of the standards which will be signed and initialed by everyone on staff.  Team members will be encouraged to support their team members and help keep one another accountable. In addition, a time for individual feedback will be provided in order for staff to understand the perspectives and outlooks of the staff. It is essential that nurse management take this time in order to record ideas and issues that may be the underlying cause of the miscommunication.

Competing priorities, inadequate coordination and lack of standardization all contribute to poor communication with the patient and among the health care team. By establishing a training which will communicate clear standards, hospitals can improve poor communication and establish accountability in best practices (Greysen, 2012). While the patient’s letter was unsolicited, it provided authentic feedback for improvement. The hospital will need to increase its patient post-survey frequency. This will allow patients to provide clear feedback on their experiences and create data for a quality control metric system from the customer’s point of view. This increased survey process along with the digital checklists can be used to manage accountability and improve miscommunication. The checklist will help overwhelmed nurses to remember to address certain tasks and will provide a standard for what is to be discussed and communicated to the customer. These aspects will contribute a measurable component to the priority area of managing communication within the hospital’s microsystem. It will result in an intended goal increased communication which will decrease mistakes and mortality and return rates. These data sources will be continuously reviewed and measured in order to provide valuable team feedback.

Conclusion

In conclusion, training and one on one feedback will help hospital staff to increase their ability to relate to patients and communicate with colleagues. It is absolutely necessary to maintain open communication with staff in order to address the underlying issues which negatively impact patients. Managing this with training and measurable aspects will lead to improved relations between hospital staff and the patients who rely on them.

References

Alfidi, R. MD (1971). Informed Consent A Study of Patient Reaction. JAMA. 216(8): 1325-1329. doi:10.1001/jama.1971.03180340045010.

Greysen SR, Schiliro D, Horwitz LI, Curry L, Bradley EH. (2012)"Out of sight, out of mind": housestaff perceptions of quality-limiting factors in discharge care at teaching hospitals. J. Hosp. Med. 7(5): 376-81. doi: 10.1002/jhm.1928.

Joffe S, Cook EF, Cleary PD, Clark JW, Weeks JC. (2001). Quality of informed consent: a new measure of understanding among research subjects. J. Natl. Cancer Inst. (2001)

Key-Solle M, Paulk E, Bradford K, Skinner AC, Lewis MC, Shomaker K. (2010) Improving the quality of discharge communication with an educational intervention. Carolina’s medical center.126(4):734-9. doi: 10.1542/peds.2010-0884

Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. (2007) Deficits in Communication and Information Transfer Between Hospital-Based and Primary Care Physicians: Implications for Patient Safety and Continuity of Care. JAMA; 297(8): 831-841. doi:10.1001/jama.297.8.831.