Healthcare Delivery Systems

Improvement Project

Dylan Carey, Kristin Gustavson, Ky Ha, Raquel Hansen, Yujie Wang

April 27, 2016

Overview of Patient Care Delivery System

MedSurg/Orthopedic
Unit
Focus: Patient Focus
related to nurse-topatient ratio

Microsystem Model:
Leadership
Effective leaders know that there is no one best
leadership style. Instead, they adapt their leadership
style to the needs of the situation (Marquis and Huston,
2014).
Nurse Manager: both Authoritarian and Democratic
leadership
RN feedback is valued
Certain interventions are enforced with no
exceptions
Marquis, B.L. & Huston, C.J. (2014). Leadership roles and management functions in nursing: Theory and application (8th Edition). Lippincott
Williams and Wilkins. ISBN Number: 13: 978-1-4511-9281-0.

Microsystem Mode
Organizational Culture and Support
ICARE (Integrity, Commitment, Advocacy, Respect, and
Excellence)
provides recognition, information, and resources that
enhances, the nurses work and makes it easier for the
nurses to meet the needs of patients
Nurses encouraged to voice their concern
Educational support
Nurses support each other in completing duties
Protection from the unions
Institute for Healthcare Improvement.(2016). Clinical Microsystem Assessment Tool. Retrieved from
http://www.ihi.org/resources/Pages/Tools/ClinicalMicrosystemAssessmentTool.aspx
Marquis, B. L., & Huston, C. J. (2015). Leadership roles and management functions in nursing: Theory and application (8th ed.,
pp. 274-276). Philadelphia, PA: Wolter Kluwer Health.
U.S Department of Veterans Affairs. (2016). I care core values. Retrieved from http://www.va.gov/icare/

Microsystem Model:
Patient Focus & Staff Focus
Patient Focus:
oVA defines patient centered care as not wasting
patients time, offering easy access to care, and
meeting patients needs for information, education,
and preventive care
oDelivered by engaged, collaborative teams in an
integrated environment that supports learning,
discovery, and continuous improvement.
Staff Focus:
oContinuing education courses
oCareer development
oSafety of staff (no lifting more than 40 pounds)
U.S Department of Veterans Affairs. (2016). I care core values. Retrieved from http://www.va.gov/icare

Microsystem Model:
Interdependence of Care Team
Effective collaboration and teamwork among the
interdisciplinary team
The interdisciplinary team consists of physicians, charge
nurse, nurse manager, clinical nurse lead, nurses, and
nursing assistants.
Excellent communication between team members
Team structure and collaboration benefits:
o Positive environment
o Higher quality interactions
o Emphasizes patient centered care
Weinberg, D. B., Cooney-Miner, D., Perloff, J. N., Babington, L., & Avgar, A. C. (2011). Building collaborative capacity: Promoting
interdisciplinary teamwork in the absence of formal teams. Medical Care, 49, 716-723. doi: 10.1097/MLR.0b013e318215da3f

Microsystem Model:
Use of Information and Healthcare Technology
One of the first hospitals to move towards complete
electronic charting.
oHIT - staff
CPRS- documentation
BCMA- medication administration
oMy HealtheVet - patient
Issues:
oDouble charting
oLack of computers in every room
U.S. Department of Veterans Affairs. (2015) Independent Assessment of the Health Care Delivery Systems and
Management Processes of the Department of Veterans Affairs: Volume 1: Integrated report. Retrieved from:
http://www.va.gov/opa/choiceact/documents/assessments/Integrated_Report.pdf

Microsystem Model:
Process for Healthcare Delivery Improvement
Benchmarking is the process of comparing a practices
performance with an external standard (Agency for
Healthcare Research and Quality, 2016).
Improvement project implemented: Yellow Fall Blanket
o Benchmark
o Quality gap
o Resistance

Agency for Healthcare Research and Quality., (2016). Practice Facilitation Handbook. Retrieved from
http://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/pfhandbook/mod7.html
M. Neuss and M. Daly, personal communication, April 18, 2016

Microsystem Model:
Staff Performance Patterns
Staff performance models should meet the goals of the
VAs population health focused model and ensure all
eligible veterans have access to high quality, timely
care. (USDVA, 2015, p. 116)
Staff quality improvement measures:
oYearly performance evaluations
oMonthly peer evaluations- Daisy award
oStaff accepts feedback to improve care based on
evaluations
Patient outcomes are frequently measured.
TIPS Newsletters published quarterly
U.S. Department of Veterans Affairs [USDVA]. (2015) Independent Assessment of the Health Care Delivery Systems and
Management Processes of the Department of Veterans Affairs: Volume 1: Integrated report. Retrieved from:
http://www.va.gov/opa/choiceact/documents/assessments/Integrated_Report.pdf

Specific Aspect Targeted for Improvement

Unbalanced nurse-to-patient ratio of 1:7 on MedSurg

floor
Staff Shortage
Studies/literature states:
oIncreased mortality and poor outcomes
oIncreased length of stay and wait times
oDecreased staff satisfaction and increased burnout
Goal: Find an optimal nurse-to-patient ratio in order to
improve care and staff satisfaction.
McGahan, M., Kucharski, G., & Coyer, F. (2012). Nurse staffing levels and the incidence of mortality and morbidity in the adult intensive care
unit: A literature review. Australian Critical Care, 25(2), 64-77. doi:10.1016/j.aucc.2012.03.00
Patterson, J. (2011). The effects of nurse to patient ratios. Nurs Times, 107(2), 22-25. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/21366010
Petrucci, C., Calandro, M. T., Lancia, L., Tresulti, F., & Baldacchini, A. (2015). Relationship between nurse staffing and nursing outcomes: a

narrative review of literature. Prof Inferm, 68(4), 195-202. doi:10.1037/e556872006-028

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Specific Aspect Targeted for Improvement

(cont.)
Arizona Nurses Association (2016) mandate that RN in Arizona
hospitals:
1:2 ratio for ICU
Other nurse staffing requirements based on an individual
patient's acuity
VA: nurses feel more comfortable of 1:5 ratio
Positive impact when adequate nurse patient ratio
AznA, AZHHA, AzONE Joint Statement on National Nurse Staffing Ratios. (2016). Arizona Nurses Association. Retrieved from
http://www.aznurse.org/page/AV01/Advocacy-AzNA-AzONE-AzHHA-Joint-Statement.htm
Cho, S., Kim, Y., Yeon, K. N., You, S., & Lee, I. D. (2015). Effects of increasing nurse staffing on missed nursing
care. International Nursing Review, 62(2), 267-274. doi:10.1111/inr.12173

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Leading the Plan for Healthcare Delivery

Improvement
Nurse Reinvestment Act
Year and half timeline
o Management: hospital policy changes to determine
minimum nurse-to-patient ratio
o Better nurse staffing
Retain nurses
Prevent over fatigue
Improve recruitment
Stanton, M. W. (2004, March). Hospital Nurse Staffing and Quality of Care: AHRQ Archive. Retrieved
from http://archive.ahrq.gov/research/findings/factsheets/services/nursestaffing/nursestaff.html

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Leading the Plan for Healthcare Delivery

Improvement (cont.)
Timeline

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References

Agency for Healthcare Research and Quality. (2016). Practice Facilitation Handbook. Retrieved from
http://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/pfhandbook/mod7.html

American Nurses Association. (2016). Nurse Reinvestment Act Background. Retrieved from
http://www.nursingworld.org/NurseReinvestmentAct.aspx

AznA, AZHHA, AzONE Joint Statement on National Nurse Staffing Ratios. (2016). Arizona Nurses Association.
Retrieved from http://www.aznurse.org/page/AV01/Advocacy-AzNA-AzONE-AzHHA-Joint-Statement.htm

Blegen, M. A., Goode, C. J., Spetz, J., Vaughn, T., & Park, S. H. (2011). Nurse staffing effects on patient
outcomes: Safety-net and non-safety-net hospitals. Medical Care, 49(4), 406-414.
doi:10.1097/MLR.0b013e318202e129

Cho, S., Kim, Y., Yeon, K. N., You, S., & Lee, I. D. (2015). Effects of increasing nurse staffing on missed nursing
care. International Nursing Review, 62(2), 267-274. doi:10.1111/inr.12173

Duffield, C., Diers, D., O'Brien-Pallas, L., Aisbett, C., Roche, M., King, M., & Aisbett, K. (2011). Nursing staffing,
nursing workload, the work environment and patient outcomes.Applied Nursing Research, 24(4), 244-255.
doi:10.1016/j.apnr.2009.12.004

Liang, Y. W., Chen, W. Y., Lee, J. L., & Huang, L. C. (2012). Nurse staffing, direct nursing care hours and patient
mortality in Taiwan: the longitudinal analysis of hospital nurse staffing and patient outcome study. BMC
Health Serv Res, 12(44). doi:10.1186/1472-6963-12-44

Marquis, B.L. & Huston, C.J. (2014). Leadership roles and management functions in nursing: Theory and
application (8th Edition). Lippincott Williams and Wilkins. ISBN Number: 13: 978-1-4511-9281-0

14

References

McGahan, M., Kucharski, G., & Coyer, F. (2012). Nurse staffing levels and the incidence of mortality and morbidity
in the adult intensive care unit: A literature review. Australian Critical Care, 25(2), 64-77.
doi:10.1016/j.aucc.2012.03.003

Patterson, J. (2011). The effects of nurse to patient ratios. Nurs Times, 107(2), 22-25. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/21366010

Petrucci, C., Calandro, M. T., Lancia, L., Tresulti, F., & Baldacchini, A. (2015). Relationship between nurse staffing
and nursing outcomes: a narrative review of literature. Prof Inferm, 68(4), 195-202.
doi:10.1037/e556872006-028

Stanton, M. W. (2004, March). Hospital Nurse Staffing and Quality of Care: AHRQ Archive. Retrieved from
http://archive.ahrq.gov/research/findings/factsheets/services/nursestaffing/nursestaff.html

U.S Department of Veterans Affairs. (2016). I care core values. Retrieved from http://www.va.gov/icare/

U.S. Department of Veterans Affairs. (2015). Independent Assessment of the Health Care Delivery Systems and

Management Processes of the Department of Veterans Affairs: Volume 1: Integrated report. Retrieved from:
http://www.va.gov/opa/choiceact/documents/assessments/Integrated_Report.pdf

Weinberg, D. B., Cooney-Miner, D., Perloff, J. N., Babington, L., & Avgar, A. C. (2011). Building collaborative
capacity: Promoting interdisciplinary teamwork in the absence of formal teams. Medical Care, 49, 716723. doi: 10.1097/MLR.0b013e318215da3f

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