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Overview of Patient Care Delivery System

St Joseph's Hospital in Tucson, Arizona
Medical Intensive Care Unit
Focus: The increase of nurse patient ratios and decline in UAPs.

Healthcare Delivery Systems

Improvement Project: Staff Focus

486 beds
3 ICU- North, West, East (biggest)
Ratio - supposed to be 1:1 or 1:2, but has been 1:3 and charge nurse also
taking on patients

Victoria Chavez, Alyssa Hall, Lauren Powell, Leah Silver, Michelle Tamayo
November 16, 2016
Tenet Health. (2015). Tenet, dignity health and ascension to form partnership to own and operate carondelet health network in arizona. Retrieved from
http://investor.tenethealth.com/press-release/acquisition-and-development/tenet-dignity-health-and-ascension-form-partnership-own-an

Microsystem Model: Leadership

Leaders often tell me how to do my job and leave little room for innovation and
autonomy. Overall they dont foster a positive culture.
Authoritarian Leadership Style:

Strong control, motivates by coercion

Lacks Staff empowerment

Chain of Command
Lack of consistent charge nurse
Or charge nurses in ratio
Marquis, B. L., & Huston, C. J. (2015a). Classical Views of Leadership and Management. In B. L. Marquis & C. J. Huston
(Eds.), Leadership roles and management functions in nursing (40). Wolters Kluwer Health/Lippincott Williams &
Wilkins.

Microsystem Model: Patient Focus & Staff

Focus
Patient Focus
We are actively working to provide patient centered care and we are making progress toward
more effectively and consistently learning about and meeting patient needs.
Patient Centered Care
Improvements based on HCAHPS

Microsystem Model: Organizational Culture and

Support
Lack of Resources and Help
Nurses utilize each other the best they can
They value extra help
Little support from upper management
Negative Vibe and Attitudes
The nurses get along with each other
o Not with upper management
Nurses want their clerks and patient care technicians back
Nurses is constantly looking for other hospitals to work
Negatively Affects Patient Outcomes
Difficult for nurses to attend to all patient needs
Higher pressure ulcer rates and higher # of CAUTIs

Marquis, B. L., & Huston, C. J. (2015c). Organizational Structure.. In B. L. Marquis & C. J. Huston (Eds.), Leadership roles and
management functions in nursing (474-476). Wolters Kluwer Health/Lippincott Williams & Wilkins.

Microsystem Model: Interdependence of

Care Team
Interdependence of Care Team
"Care is provided by an interdisciplinary team characterized by trust,
collaboration, appreciation of complementary roles, and a recognition that all
contribute individually to a shared purpose

Staff Focus
I feel like I am a valued member of the microsystem, but I dont think the microsystem is doing
all that it could to support workload
Orientation for new grads
Continuing education
Concern for increased nurse patient ratios

Effective Interdisciplinary Care Team

Daily rounds
Shift huddle

Tenet Health. (2014). Employee programs: Learning, education, and career enhancement programs. Retrieved from https://www.tenethealth.com/careers/employee-programs

Marquis, B. L., & Huston, C. J. (2015b). Organizational, interpersonal, and group communication. In B. L. Marquis & C. J. Huston (Eds.), Leadership roles and management
functions in nursing (436-465). Wolters Kluwer Health/Lippincott Williams & Wilkins.

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Microsystem Model: Use of Information and

Healthcare Technology

Microsystem Model: Process for Healthcare

Delivery Improvement
Empowering staff to have superior knowledge that enables them to make
changes that lead to:

Integration of Information with Patients

Patients have access to standard information that is available, but there are
ways to improve the information they are given to better meet their needs.
Integration of Information with Providers and Staff
The information needed to do work is available.
Integration of Information with Technology
Technology facilitates a smooth linkage between information and patient care by
providing timely, effective access to a rich information environment. The
information environment has been designed to support the work of the clinical
unit.

Better patient outcomes

Efficient system performance
Improved professional development

Quality improvement activities include:

Atmosphere
Daily shift huddle
Benchmarking

Marquis, B. L., & Huston, C. J. (2015b). Organizational, interpersonal, and group communication. In B. L. Marquis & C. J. Huston (Eds.), Leadership roles and management functions in
nursing (436-465). Wolters Kluwer Health/Lippincott Williams & Wilkins.

Institute for Healthcare Improvement. (2016). Huddles. Retrieved from http://www.ihi.org/resources/Pages/Tools/Huddles.aspx

Marquis, B. L., & Huston, C. J. (2015e). Quality Control. In B.L. Marquis & C.J. Huston (Eds.), Leadership roles and management functions in nursing (542-572). Wolters Kluwer Health/Lippincott Williams & Wilkins.
Nelson et al. (2002). Microsystems in Healthcare: Part 1. Learning from high performing frontline clinical units. Joint Commission Journal on Quality Improvement, 28 (9). 472 493. Retrieved from http://
lsatqdm.qdmnet.com/qdm/microsystems/JQIPart1.pdf

Microsystem Model: Staff Performance

Patterns
Staff performance patterns determine the employees ability to carry out
duties and responsibilities while meeting set standards of performance for
their organization.

Specific Aspect Targeted for Improvement

Affordable Care Act (ACA) Emphasizes Value-Based Healthcare
Tenet Take-Over; No Longer a Non-Profit Hospital
Reduction in Nurse Staffing and UAPs

Examples include:
o Annual evaluations/appraisals

Increased Nurse to Patient Ratios and Workload

o Patient surveys

Nurse Burnout, Poor Patient Outcomes, Increased Readmissions

Conclusion:
Increasing UAPs and RNs decreases nurse workload while improving nurse to
patient ratios and patient outcomes in the ICU.

o Patient outcome statistics

Al-Abri, R., & Al-Balushi, A. (2014). Patient Satisfaction Survey as a Tool Towards Quality Improvement. Oman Medical Journal, 29(1), 37. http://doi.org/10.5001/omj.2014.02
Marquis, B. L., & Huston, C. J. (2015d). Performance Appraisal. In B.L. Marquis & C.J. Huston (Eds.), Leadership roles and management functions in nursing (573-595). Wolters Kluwer Health/
Lippincott Williams & Wilkins.

Avalere Health LLC. (2015). Optimal nurse staffing to improve quality of care and patient outcomes: executive summary. Retrieved from American Nurses Association website: http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/State/LegislativeAgenda-Reports/State-StaffingPlansRatios/Optimal-Nurse-Staffing-ES-Sep15.pdf
Ball, J. E., Murrells, T., Rafferty, A. M., Morrow, E., & Griffiths, P. (2013). Care left undone during nursing shifts: associations with workload and perceived quality of care. British Medical Journal, 1-10. doi:10.1136/bmjqs-2012-001767
West, E., Barron, D. N., Harrison, D., Rafferty, A. M., Rowan, K., & Sanderson, C. (2014). Nurse staffing, medical staffing and mortality in Intensive Care: An observational study. International Journal of Nursing Studies, 51(5), 781-794. doi:10.1016/j.ijnurstu.
2014.02.007

Leading the Plan for Healthcare Delivery

Improvement

Leading the Plan for Healthcare Delivery

Improvement (continued)

Short Term Plan:

Organize educational session with unit manager and unit director

Long Term Plan:

Create an Arizona Staffing Law and work to pass The Registered Nurse
Staffing Act

Goals of Short Term Plan:

Hire more RNs and UAPs
Improve understanding of cost and safety implications from decreasing
staffing
Promote positive patient outcomes

Goals of Long Term Plan:

Develop a hospital staffing committee
Identify and work with local and statewide legislators to create an Arizona
staffing law.

American Nurses Association [ANA]. (2016). Nurse Staffing. Retrieved from http://www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/NurseStaffing

West, E., Barron, D. N., Harrison, D., Rafferty, A. M., Rowan, K., & Sanderson, C. (2014). Nurse staffing, medical staffing and mortality in Intensive Care: An observational study. International
Journal of Nursing Studies, 51(5), 781-794. doi:10.1016/j.ijnurstu.2014.02.007

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References
Al-Abri, R., & Al-Balushi, A. (2014). Patient Satisfaction Survey as a Tool Towards Quality Improvement. Oman Medical Journal, 29(1),
37. http://doi.org/10.5001/omj.2014.02
American Nurses Association. (2016). Nurse Staffing. Retrieved from http://www.nursingworld.org/MainMenuCategories/
ThePracticeofProfessionalNursing/NurseStaffing
Avalere Health LLC. (2015). Optimal nurse staffing to improve quality of care and patient outcomes: executive summary. Retrieved
from American Nurses Association website: http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/State/LegislativeAgenda-Reports/State-StaffingPlansRatios/Optimal-Nurse-Staffing-ES-Sep15.pdf
Ball, J. E., Murrells, T., Rafferty, A. M., Morrow, E., & Griffiths, P. (2013). Care left undone during nursing shifts: associations with
workload and perceived quality of care. British Medical Journal, 1-10. doi:10.1136/bmjqs-2012-001767
Institute for Healthcare Improvement. (2016). Huddles. Retrieved from http://www.ihi.org/resources/Pages/Tools/Huddles.aspx
Marquis, B. L., & Huston, C. J. (2015a). Classical Views of Leadership and Management. In B. L. Marquis & C. J. Huston (Eds.),
Leadership roles and management functions in nursing (40). Wolters Kluwer Health/Lippincott Williams & Wilkins.
Marquis, B. L., & Huston, C. J. (2015b). Organizational, interpersonal, and group communication. In B. L. Marquis & C. J. Huston
(Eds.), Leadership roles and management functions in nursing (436-465). Wolters Kluwer Health/Lippincott Williams & Wilkins.

References
Marquis, B. L., & Huston, C. J. (2015e). Quality Control. In B.L. Marquis & C.J. Huston (Eds.), Leadership roles and management
functions in nursing (542-572). Wolters Kluwer Health/Lippincott Williams & Wilkins.
Nelson et al. (2002). Microsystems in Healthcare: Part 1. Learning from high performing frontline clinical units. Joint Commission
Journal on Quality Improvement, 28 (9). 472 493. Retrieved from http://lsatqdm.qdmnet.com/qdm/microsystems/JQIPart1.pdf
Tenet Health. (2014). Employee programs: Learning, education, and career enhancement programs. Retrieved from https://
www.tenethealth.com/careers/employee-programs
Tenet Health. (2015). Tenet, dignity health and ascension to form partnership to own and operate carondelet health network in arizona.
Retrieved from http://investor.tenethealth.com/press-release/acquisition-and-development/tenet-dignity-health-and-ascensionform-partnership-own-an
West, E., Barron, D. N., Harrison, D., Rafferty, A. M., Rowan, K., & Sanderson, C. (2014). Nurse staffing, medical staffing and mortality
in Intensive Care: An observational study. International Journal of Nursing Studies, 51(5), 781-794. doi:10.1016/j.ijnurstu.
2014.02.007

Marquis, B. L., & Huston, C. J. (2015c). Organizational Structure.. In B. L. Marquis & C. J. Huston (Eds.), Leadership roles and
management functions in nursing (474-476). Wolters Kluwer Health/Lippincott Williams & Wilkins.
Marquis, B. L., & Huston, C. J. (2015d). Performance Appraisal. In B.L. Marquis & C.J. Huston (Eds.), Leadership roles and
management functions in nursing (573-595). Wolters Kluwer Health/Lippincott Williams & Wilkins.