Introduction
Change in clinical practice encompasses incremental improvement in care quality or personnel capacities by training change agents, reconfigurating clinical processes, and adopting new models of care. A renewed focus on quality and safety, an aging population, novel payment methods, and the development of innovative treatments provide an impetus for transforming healthcare. Therefore, meeting patient needs, improving outcomes, and attaining better value for patients are the key factors driving change.
Purpose of Consultation and Overview of the Consultation Process
An objective assessment of a facility’s processes and systems identifies areas that need to change. The purpose of the consultation was to determine an improvement needed within the organization (Direct Care and Treatment/Community Based Services (DCT/CBS) of Minnesota Department of Human Services (MDHS) and give a consultative change recommendation. External metrics, including patient outcomes and community needs, will inform the recommendation.
A nurse leader serving as the Health Service Director in the CBS division of the DCT was selected and interviewed to generate data for the analysis. The face-to-face interview focused on a broad range of topics, including her role in the organization and its goals and quality improvement efforts. Among other issues discussed were DCT’s mission, strength, weakness, opportunities for improvement, and initiatives to enhance patient safety. Additional data on the staff population, leadership structure, and services provided were collected from the organization’s website. Key community needs were also identified through the same process.
Organizational Analysis
Description of Organization
MDHS operates institutional services for persons living with disabilities using the community-oriented model. MDHS is a public health department that seeks to address diverse health needs across Minnesota through its many divisions and programs. MDHS has three main offices in the Twin Cities metro area but has seven other campuses in Bemidji, Duluth, Fergus Falls, Mankato, Marshall, Rochester, and St. Cloud (“2018-2020 Agencywide Strategic Plan,” 2018). These offices house the different MDHS divisions, bureaus, and programs, including the DCT/CBS.
The MDHS includes many department and county agencies involved in healthcare and social services. The estimated number of employees is 3,600 working in different divisions and programs (Minnesota Department of Human Services, 2020). The number of patient encounters is not indicated, but the agency serves all the Minnesota population. The CBS program targets persons with disabilities in the community (approximately 593,700 people) through its distinct service lines focusing on foster care, family support, residential treatment, and vocational training. The estimated number of patient encounters is not indicated on the organizational website, probably because of the multiple service lines available. The CBS comprises seventeen vocational sites, four crisis homes, nine mobile support groups, and about 120 foster care facilities (“DHS-Operated Community-Based Services,” 2018). Thus, the number of patients or communities served is quite large.
The leadership structure of MDHS recognizes four bureaus organized according to different functional lines. They involve the health protection, improvement, systems, and operations headed by assistant commissioners (Minnesota Department of Human Services, 2020). This executive leadership also includes the MDHS commissioner and his deputy, who provide oversight on all health-related issues in the state. The bureaus comprise eight divisions that are headed by directors that report directly to the assistant commissioners.
Details of the MDHS service area, such as size, age, and demographics, could not be found on its website. They may be privileged information that is not available to the public. The MDHS provides a broad range of services, including individual and family health (vaccinations and birth records), behavioral treatment, insurance, and preventive care (Minnesota Department of Human Services, 2020). Specifically, the MDHS-operated DCT/CBS program contains three service lines: community support services, intensive therapeutic homes, and residential and vocational services.
Primary Needs of Population
The MDHS, through its DCT/CBS program, serves the entire state of Minnesota. The overall size of the area served is 225,181 kilometers that comprise 87 counties and 852 incorporated cities (Minnesota State Demographic Center, 2020). Thus, MDHS serves metropolitan and rural communities throughout this area through its diverse programs. The state’s demographics include 83.3% White, 6.2% African American, 4.8% Asian, 1.1% Native American, and 0.04% Pacific Islander (Minnesota Department of Health [MDH], 2019). The elderly population is relatively high in Minnesota, presenting another public health challenge. Over a third of the people in metropolitan areas and about 6% of those in rural locations are above 50 years, and 11% of the state’s population includes persons with disabilities (Minnesota State Demographic Center, 2020). The unique needs of each population group call for tailored interventions and programs.
The primary health risks present in the population relate to ethnicity, poverty, age, substance use, and poor diet that lead to a high incidence of non-communicable diseases and disability. The minority groups – African Americans, Asians, Native Americans, and Pacific Islanders – are likely to have poor outcomes in education, socioeconomic status, and health compared to Whites (MDH, 2019). These health disparities lead to a high burden for overweight and related diseases such as cancer, diabetes, and mental illness in these communities. Minnesota obesity rate stands at 30.1% compared to a national average of 30.9%, with the low-income and minority groups experiencing the highest risk (“Obesity Quick Facts,” 2020). These communities live in poor neighborhoods with a high concentration of unhealthy food options and limited physical exercise opportunities.
The high elderly population is also another public health concern in Minnesota. Aging is a risk factor for fall-related injuries and disability in the state (Burns & Kakara, 2018). This community’s health risks impact MDHS spending in healthcare programs with a health budget for obesity standing at $3.2 billion annually (“Obesity Quick Facts,” 2020). The high demand for preventive care, mental health, and treatment and support for developmental challenges and chemical dependency increase care costs, strain healthcare resources and providers, and limit outreach services.
Nurse Leader Interview Summary
Role of the Nurse Leader
An interview with the Health Service Director was conducted for this analysis. She revealed that her role within DCT/CBS is similar to that of the Director of Nursing or Nursing Supervisor at a facility. The director has significant formal influence within DCT/CBS derived from her primary responsibilities. She supervises all staff and develops evidence-based policies and procedures that guide practitioners in providing healthcare. Her role aligns well with The Essentials of Master’s Education in Nursing. Specifically, Essential IX recognizes nursing practice at the master’s level as “interventions that influence health outcomes for individuals, populations, and systems” (American Association of Colleges of Nursing, 2011, p. 5). The integration of knowledge into practice, which is required at this level, is seen in her development and implementation of evidence-based policies and procedures. She is also responsible for designing organizational systems that meet priority population health needs supported by DCT/CBS using community resources, espoused in Essential IX.
The breadth of the director’s influence also extends to quality improvement (QI) efforts initiated under the DCT/CBS program. She ensures that all QI projects meet practice standards and include evidence-based practices informed by patient/community-oriented care. As a nurse leader, the director is well-versed with issues shaping current healthcare systems; hence, she collaborates to develop a long-term strategic plan that includes specific goals related to strategic planning and implementation. Some of these include creating safe, respective, and positive environments for staff, fostering a person-centered culture at the organization, building a shared vision with community providers to increase resources and support for people served by CBS, and merging different service-line policies (MSOCS, CSS, MLB, and MITH) into a unified system.
The director exerts some informal influence on the internal stakeholders of CBS and DCT. She encourages staff and management within the two programs and related service lines and the individuals supported to start training meant to promote patient safety. She collaboratively developed supportive measures for personnel training and health technology such as electronic records in community settings, motivational interviewing, and medication administration.
Organization’s Characteristics
Current Strengths
At the MDHS and DCT/CBS program, people are highly valued. The staff members are motivated to learn and improve their skills and competencies in their roles continually. The organization’s workforce is at the core of the delivery of diverse services, including foster care for persons with a disability, family healthcare, residential care for people exhibiting risky behaviors, rehabilitation, and vocational training (Minnesota Department of Human Services, 2020). Thus, the team is supported to explore, research, and pilot health innovations and evidence-based practices in these areas. Training opportunities on leadership, project management, and lean sigma six programs are also available for staff.
Current Weaknesses
The organization depends heavily on community providers to manage healthcare needs. As a result, project targets are rarely met because these stakeholders have capacity or resource challenges. For example, the preventive screening project in Minnesota has done tests lower than the national average because of relying on community providers to recognize the need for the screen instead of communicating to them that it is required.
Evidence-Based Practice Activities
The organization integrates evidence-based practice into its care delivery systems, policies, procedures, and day-to-day practices. Before updating or implementing a new policy, it is benchmarked, and a best practice determined to ensure that it is proven to work. Staff education about the National Patient Safety Goals is done when implementing evidence-based protocols or procedures. Examples include doing three checks before medication administration to reduce errors and an updated suicide policy that reflects community risks. The director also develops evidence-based policies and procedures for staff to deliver to the communities served.
Quality Improvement Projects
At the MDHS, quality improvement has occurred at the level of staff training to improve the skills needed to deliver the organization’s goals, among them creating a patient-centered culture and serving as a safety net provider. A 5-hour classroom Medication Administration Refresher and a one-hour Computer Based Training are offered to direct care staff to minimize medication errors. Another quality improvement project is system-wide satisfaction surveys and tools that monitor outcomes related to the quality of life, implemented evidence-based practices, and treatments. An electronic health record (AVATAR) has been piloted in residential care homes to tests its efficacy in community settings. The SBAR tool has also been adopted to improve communication within the larger DCT organization, while cognitive-behavioral training has replaced seclusion and restraint in mental health care.
Recommendation for Organization Change
Recommendation
A redesigned preventive healthcare is recommended to preserve and protect the health of Minnesotans. Using the plan-do-study-act model, the initial focus should be on educating populations to avoid health risk factors, adopt healthy lifestyles, and provide early screening and treatment. Nurses at the MDHS agencies and programs will then collaborate with providers – as the first point of contact – in a patient-centered approach to promote the community’s health through evidence-based interventions and health-seeking behavior. The providers will prioritize early disease detection (screening) and identify high-risk individuals guided by MDHS for a referral to the CBS program. Once identified, the nursing staff at the organization will work with them in community settings (their homes and foster care facilities) to decrease health risks, address social determinants, and modify specific lifestyles based on the baseline data. The recommended nurse-led preventive health model will focus on conditions with a high incidence in the community such as obesity, heart disease, cancer, mental illness, and diabetes.
Rationale
A key organizational weakness identified through the interview is over-dependence on community providers to manage most healthcare needs, resulting in suboptimal health outcomes. Stronger preventive care is needed, given the high prevalence of preventable non-communicable diseases. According to the “Obesity Quick Facts,” (2020), currently, 30.1% of Minnesota adults are obese, 9% have been diagnosed with diabetes, and the rate of psychiatric admissions stands at 7.0 per 1,000 people. Insurance coverage is low, which limits access to care.
A collaborative approach in which DCT/CBS provides guidance on risk factors to screen for and addresses preclinical diseases will help examine the gaps. It will ensure regular in-home screenings performed by community health nurses who will also serve as educators providing useful health information to promote positive behaviors (Burns & Kakara, 2018). The unique needs of the population will also be addressed through this change. They include cancer, diabetes, mental illness, age-related injuries and disabilities, and obesity attributed to unhealthy food and physical environments for minorities (“Obesity Quick Facts,” 2020). Clinical outcomes can be improved by engaging community health providers under the MDHS/DCT/CBS program to conduct regular tests to identify high-risk individuals, educate the population on risk factors and symptoms, and strengthen the emergency response.
Evaluation of Change Effectiveness
The Centers for Medicare and Medicaid Services meaningful measures will be the national benchmark for evaluating the organizational change. They cover areas critical to better patient outcomes, including the promotion of prevention and treatment of chronic disease. The specific measures for assessing the effectiveness of the change will include the percentage of the population that receive influenza immunization, and cancer, diabetes, and substance use screenings conducted, follow-ups after hospitalization for psychiatric conditions, obesity rates, and 30-day heart failure readmissions over time (“Meaningful Measures Hub,” 2019). Patient experience of preventive care – health promotion, screening, and education – will also be measured. The Hospital Consumer Assessment of Healthcare Provider and Systems (HCAPS) tool will be used for this purpose (“Hospital CAHPS,” 2020). This national, standardized survey instrument will help evaluate the community’s post-implementation perceptions and satisfaction with the preventive health project.
Conclusion
Nurse leadership is critical not only in clinical settings but also in policy development and implementation. It impacts the safety and quality of care delivered and the integration of evidence-based protocols and procedures into practice. From the interview with a nurse leader who has a strategic role at the MDHS’s DCT/CBS program, preventive health in Minnesota needs improvement to address the population’s risk factors within a systems framework. The consultative change recommendation provided aims to improve the prevention of non-communicable diseases and related outcomes in this community.
References
American Association of Colleges of Nursing. (2011). The essentials of master’s education in nursing [PDF document]. Web.
Burns, E., & Kakara, R. (2018). Deaths from falls among persons aged ≥65 years – United States, 2007–2016.Morbidity and Mortality Weekly Report, 67(18), 509–514. Web.
DHS-Operated Community-Based Services. (2018). Minnesota Department of Human Services. Web.
Hospital CAHPS. (2020). Centers for Medicare and Medicaid Services. Web.
Meaningful Measures Hub. (2019). Centers for Medicare and Medicaid Services. Web.
Minnesota Department of Health. (2019). 2017 Minnesota statewide health assessment[PDF document]. Web.
Minnesota Department of Human Services. (2020). Organization/management. Web.
Minnesota State Demographic Center. (2020). Our estimates. Web.
Obesity Quick Facts. (2020). Minnesota Department of Health. Web.
2018-2020 Agencywide Strategic Plan. (2018). Minnesota Department of Human Services. Web.