Healthcare Delivery Systems

Improvement Project

Sophie Griswold, Wendy Bertoglio, Jeremiah Palicka, Jacky Fuentes, Mack Flaherty
April 26, 2017

1
Overview of Patient Care Delivery System

VA Hospital
3N Telemetry Unit
Focus: Telemetry Monitoring Discontinuation
Protocol

2
Microsystem Model:
Leadership

Leaders struggle to find the right balance

between reaching performance goals and
supporting and empowering the staff
Mix between authoritarian and democratic
leadership
o The overall system favors and enables
authoritarian leadership
o The individual nurse managers try to use
economic and ego awards along with
communication to motivate staff
Marquis, B.L. & Huston, C.J. (2015a). Leadership roles and management functions in nursing: Theory and application (8th ed., pp.
40-41).Lippincott Williams and Wilkins. ISBN Number: 13: 978-1-4511-9281-0.
Johnson, J.K. (2003). Clinical microsystem assessment tool. 2nd ed. Lebanon, NH: Dartmouth College. Retrieved from 3
http://dms.dartmouth.edu/cms
Microsystem Model:
Organizational Culture and Support

The larger organization is inconsistent and

unpredictable in providing the recognition,
information, and resources needed to enhance
my work.

Notable influencing factors

o Little communication between upper management
and floor nurses
o Some awards (Daisy Award, 5/10 year pins) given out

Marquis, B.L. & Huston, C.J. (2015b). Leadership roles and management functions in nursing: Theory and application (8th ed., pp.
264-265).Lippincott Williams and Wilkins. ISBN Number: 13: 978-1-4511-9281-0.
Johnson, J.K. (2003). Clinical microsystem assessment tool. 2nd ed. Lebanon, NH: Dartmouth College. Retrieved from 4
http://dms.dartmouth.edu/cms
Microsystem Model:
Patient Focus & Staff Focus

Patient Focus
o By and large, [we] are effective in learning about and meeting patient
needs: caring, listening, educating, and responding to special requests
and smooth service flow.
o Volunteer support staff, and ancillary support staff on unit allows for
effective completion of nursing tasks and meeting specific patient needs
Staff Focus
o Nurses report feeling like they are a valued member of the
microsystem, and what [they] say matters. This is evident through
staffing, education and training, workload, and professional growth.
o Nurses report 4:1 or 5:1 patient/nurse ratios, sufficient UAP staffing,
Black Belt Program

Marquis, B.L. & Huston, C.J. (2015c). Leadership roles and management functions in nursing: Theory and application (8th ed., pp.
365-366).Lippincott Williams and Wilkins. ISBN Number: 13: 978-1-4511-9281-0.
Johnson, J.K. (2003). Clinical microsystem assessment tool. 2nd ed. Lebanon, NH: Dartmouth College. Retrieved from 5
http://dms.dartmouth.edu/cms
Microsystem Model:
Interdependence of Care Team

The care approach is interdisciplinary, but we

are not always able to work together as an
effective team

Notable influencing factors

o Delay of care related to placing orders
o Delay in discharge, related to poor
communication between disciplines
o Inefficiency and miscommunication with
laboratory
Marquis, B.L. & Huston, C.J. (2015d). Leadership roles and management functions in nursing: Theory and application (8th ed., pp.
321).Lippincott Williams and Wilkins. ISBN Number: 13: 978-1-4511-9281-0.
Johnson, J.K. (2003). Clinical microsystem assessment tool. 2nd ed. Lebanon, NH: Dartmouth College. Retrieved from 6
http://dms.dartmouth.edu/cms
Microsystem Model:
Use of Information and Healthcare Technology

Integration of Information with Patients

o Patients have access to standard information that is available to all
patients. Weve started to think about how to improve the
information they are given to better meet their needs.
o Medication and discharge education provided by nursing staff
Integration of Information with Providers and Staff
o The information I need to do my work is available when I need it
o Information from providers and staff typically available via patient
chart or through direct contact with individual
Integration of Information with Technology
o I have access to technology that will enhance my work, but is not
easy to use, and seems to be cumbersome and time-consuming
o First national EMR program still in use, non-intuitive and requires
extensive training for appropriate utilization

Marquis, B.L. & Huston, C.J. (2015e). Leadership roles and management functions in nursing: Theory and application (8th ed., pp.
452-456).Lippincott Williams and Wilkins. ISBN Number: 13: 978-1-4511-9281-0.
Johnson, J.K. (2003). Clinical microsystem assessment tool. 2nd ed. Lebanon, NH: Dartmouth College. Retrieved from 7
http://dms.dartmouth.edu/cms
Microsystem Model:
Process for Healthcare Delivery Improvement

Some resources are available to support

improvement work, but we dont use them as
often as we could. Change ideas are
implemented without much discipline.

Notable influencing factors

o Black Belt Program, lack of time while on the floor to
engage in additional improvement activities

Johnson, J.K. (2003). Clinical microsystem assessment tool. 2nd ed. Lebanon, NH: Dartmouth College. Retrieved from
http://dms.dartmouth.edu/cms 8
Microsystem Model:
Staff Performance Patterns

We often collect data on the outcomes of the

care we provide and on some processes of care

Tracked outcome data

o Readmission rates
o Nursing hours per patient
o Falls
o CHG bath protocol/ CAUTI prevention

Johnson, J.K. (2003). Clinical microsystem assessment tool. 2nd ed. Lebanon, NH: Dartmouth College. Retrieved from
http://dms.dartmouth.edu/cms 9
 Specific Aspect Targeted for Improvement

Telemetry orders in EMR non-standardized

o D/C orders embedded in telemetry order form
o Current practice requires a separate D/C telemetry
order
o Telemetry technician will not D/C if MD does not D/C
all redundant telemetry orders
Studies found: unnecessary telemetry monitoring
increased alarm fatigue, length of stay and expense, did
not improve patient outcomes
Goal: Standardize telemetry ordering protocol with
automatic discontinuation with inaction
Cantillon, D. J., Loy, M., Burkle, A., Pengel, S., Brosovich, D., Hamilton, A., . . . Lindsay, B. D. (2016). Association between off-site central monitoring using standardized
cardiac telemetry and clinical outcomes among non-critically ill patients. Jama, 316(5), 519-524.
Chambrin, M. C., Ravaux, P., Calvelo-Aros, D., Jaborska, A., Chopin, C., & Boniface, B. (1999). Multicentric study of monitoring alarms in the adult intensive care unit
(ICU): A descriptive analysis. Intensive Care Medicine, 25(12), 1360-1366.
Dressler, R., Dryer, M. M., Coletti, C., Mahoney, D., & Doorey, A. J. (2014). Altering overuse of cardiac telemetry in non-intensive care unit settings by hardwiring the use of
american heart association guidelines. JAMA Internal Medicine, 174(11), 1852-1854.
Sendelbach, S., & Funk, M. (2013). Alarm fatigue: A patient safety concern. AACN Advanced Critical Care, 24(4), 378-86; quiz 387-8.
10
Specific Aspect Targeted for Improvement
(cont.)

Process improvement: MDs are required to

place telemetry orders with an available template
in the EMR
Upon expiration of the order, the MD will be
flagged to renew or discontinue the monitoring
order
The EMR will automatically expire the telemetry
order 24 hours after listed expiration time, should
no action be taken by the physician
Nurses and telemetry technicians should use
clinical judgement to advocate for patients
continued use of telemetry, if indicated 11
Leading the Plan for Healthcare Delivery
Improvement

Joint Commission National Patient Safety Goal

o Improve the safety of clinical alarm systems
o whether specific alarm signals are needed or
contribute to alarm noise and alarm fatigue
Nurses will have decrease in telemetry
monitoring-related work
Eight month timeline

Cantillon, D. J., Loy, M., Burkle, A., Pengel, S., Brosovich, D., Hamilton, A., . . . Lindsay, B. D. (2016). Association between off-site central monitoring
using standardized cardiac telemetry and clinical outcomes among non-critically ill patients. Jama, 316(5), 519-524.
Marquis, B.L. & Huston, C.J. (2015f). Leadership roles and management functions in nursing: Theory and application (8th ed., pp.8-9). Lippincott 12
Williams and Wilkins.
 References

Cantillon, D. J., Loy, M., Burkle, A., Pengel, S., Brosovich, D., Hamilton, A., . . .
Lindsay, B. D. (2016). Association between off-site central monitoring using
standardized cardiac telemetry and clinical outcomes among non-critically ill
patients. Jama, 316(5), 519-524.
Chambrin, M. C., Ravaux, P., Calvelo-Aros, D., Jaborska, A., Chopin, C., &
Boniface, B. (1999). Multicentric study of monitoring alarms in the adult intensive
care unit (ICU): A descriptive analysis. Intensive Care Medicine, 25(12),
1360-1366.
Dressler, R., Dryer, M. M., Coletti, C., Mahoney, D., & Doorey, A. J. (2014).
Altering overuse of cardiac telemetry in non-intensive care unit settings by
hardwiring the use of american heart association guidelines. JAMA Internal
Medicine, 174(11), 1852-1854.
Johnson, J.K. (2003). Clinical microsystem assessment tool. 2nd ed. Lebanon, NH:
Dartmouth College. Retrieved
from http://dms.dartmouth.edu/cms
Marquis, B.L. & Huston, C.J. (2015a). Leadership roles and management functions
in nursing: Theory and application (8th ed., pp. 40-41).Lippincott Williams and
Wilkins.
13
References

Marquis, B.L. & Huston, C.J. (2015b). Leadership roles and management functions
in nursing: Theory and application (8th ed., pp. 264-265).Lippincott Williams and
Wilkins.
Marquis, B.L. & Huston, C.J. (2015c). Leadership roles and management functions
in nursing: Theory and application (8th ed., pp. 365-366).Lippincott Williams and
Wilkins.
Marquis, B.L. & Huston, C.J. (2015d). Leadership roles and management functions
in nursing: Theory and application (8th ed., pp. 321).Lippincott Williams and
Wilkins.
Marquis, B.L. & Huston, C.J. (2015e). Leadership roles and management functions
in nursing: Theory and application (8th ed., pp. 452-456).Lippincott Williams and
Wilkins.
Sendelbach, S., & Funk, M. (2013). Alarm fatigue: A patient safety concern. AACN
Advanced Critical Care, 24(4), 378-86; quiz 387-8.
Society of Hospital Medicine (2013). Continuous telemetry monitoring outside
ICU. Retrieved from
http://www.choosingwisely.org/clinician-lists/society-hospital-medicine-adult-conti
nuous-telemetry-monitoring-outside-icu/
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