Introduction
The healthcare environment is complex and rapidly evolving fueled by health technology and knowledge. Change is a transformation of delivery processes to address access problems, higher costs, poor outcomes, and inequalities (Wheeler, 2017). Steps towards improved quality, accessibility, and affordability require a move from episodic management of conditions to comprehensive patient-centered care. With their education and training as change agents, nurses are well-positioned to lead change in healthcare organizations.
Purpose of Consultation
This paper evaluates and identifies a consultative change for Mercy Hospital, Allina Health. The purpose of the consultation (interview) was to assess the facility and its systems to determine the safety and quality levels of patient care. The organization’s strengths and weaknesses, as well as its mission, values, policies, and processes, were analyzed along with interview data. The analysis relied on quality indicators, including HCAHPS scores and hospital performance metrics. In this paper, a consultative change recommendation is proposed to the hospital’s management for action.
Overview of the Consultation Process
A face-to-face interview was conducted with Karla, an MSN nurse manager in the oncology unit at Mercy Hospital, Allina. For this consultation, the areas discussed included Karla’s role within Mercy Hospital, quality improvement initiatives at the facility, staff training and resources, and hospital policies. The interview took place on 2nd August 2018 and lasted for about one hour. Data on the health needs of the local community were obtained during the consultation as well as from the hospital’s website, and community health needs assessment (CHNA). The main indicators analyzed were healthcare access and health status. Additional data sources included CHNAs conducted by other hospitals in the area.
Organizational Analysis
Description of Organization
Type and location of the organization
Mercy Hospital is a short-term acute care facility in Minnesota. This nonprofit facility is a part of the Allina Health System. The hospital has been dedicated to serving the North Metro residents and communities from the surrounding areas for the past 50 years through its Mercy (271 beds) and Unity (273 beds) campuses that operated independently until 2017 when they were merged and renamed Mercy Hospital (Allina Health, 2019). The two are located in Coon Rapids and Fridley, respectively.
Several employees and patient encounters
Mercy Hospital staff includes a team of experienced administrators, caregivers, physicians and specialists, therapists, and RNs. In 2018, Allina Health had about 26,292 employees (Allina Health, 2019a). The number of staff at Mercy Hospital was not available on its website or other sites. Annually, the number of patient encounters is about 155,000 (29,000 admissions, 108,000 ER visits, and 18,000 surgical procedures) (Allina Health, 2019a). The hospital had over 165,000 inpatient admissions in 2018 at its two campuses, implying that the total patient encounters are increasing.
Departmental map, organizational chart, or leadership structure
Mercy Hospital has a vertical leadership structure with many levels of management. The facility’s organogram ensures optimal functioning of the hospital with staff working in “specific, narrow, and low-authority roles” (Allina Health, 2019b, para. 5). Since Mercy Hospital is a nonprofit facility, it is run by the board of directors that comprises the president and six vice presidents overseeing different functions such as medical affairs, clinical operations, patient care, cardiovascular services, and finance. It also includes the president of the hospital’s foundation and the directors of human resources and planning.
The second layer of management comprises the executive leadership team. Its role is to monitor performance and supervise operations in the facility. The executives are also the implementers of board decisions and hospital policies (Feigenbaum, 2019). The system’s executive leadership comprises the Chief Executive Officer (Penny Wheeler) and other executives, including the Chief Financial Officer, Chief Operating Officer, and Chief Information Officer (Allina Health, 2019b). The facility’s department administrators are in charge of different practices and clinical departments.
The third tier of the facility’s leadership team includes patient care managers who are responsible for hands-on patient care. An example is the nurse manager in charge of the oncology department who was interviewed for this paper. The last layer in the leadership structure comprises service providers, such as nurses and physicians. They are the professionals who interact and care for the patient.
Service area
Mercy Hospital comprises a system of clinics and departments on its two campuses. According to Allina Health (2014), the hospital’s service area includes the Northwest Metro area (twin cities region of Minnesota) and a part of Wisconsin. Its primary clientele comes from Anoka County’s population of 330,844 with a large proportion of it being aged 20-44 (>115,000) and 45-64 (>100,000).
Demographically, gender distribution varies across the age range. Females constitute 47%, 54%, and 65% of the people within the ages of 15-24, 65-84, and 85 years and above, respectively (Allina Health, 2014). Overall, 51% of the community served by the hospital is male. In terms of race/ethnicity, the population is not very diverse compared to national figures. About 14% of the residents are people of color, primarily blacks, Asians, and Hispanics (Allina Health, 2014). Over one-third of the minority population is foreign-born.
Services provided
Mercy Hospital is a high-performing facility with a range of adult specialty services. They include cancer care, heart, and vascular services, emergency and trauma care, orthopedics, cardiology, mental health, surgical services, and women’s and children’s services (Allina Health, 2014). Other specialties are nephrology, diabetes clinic, and urology. It also offers many procedures, including knee and hip replacement.
Primary Needs of Population Served by this Organization
The region associated with Mercy Hospital includes 17 ZIP codes in Anoka and areas outside the twin cities region, namely, Ramsey and Hennepin counties and River Falls in Wisconsin. Based on a recent CHNA report, the total population of this community served by Mercy is about two million, 14% of it being minority ethnic groups, including Latinos and American Indians (Allina Health, 2014). Multiple primary health risks impact this community. In Anoka County, socioeconomic status (SES) is relatively low. The median household income is a paltry $67,000 and many people are uninsured. Wide racial disparities exist concerning access to healthcare.
According to Allina Health (2014), a large proportion of the uninsured are of the Hispanic/Latino ethnicity. Poverty status is rising in Minnesota due to low household incomes. Thus, chronic stress linked to lower SES in this population can lead to higher morbidity attributed to an elevated cardiovascular risk. Other health risks impacting this community include obesity and diabetes. Additionally, accessibility and utilization of preventive care are limited. The health risks of this population have affected Mercy Hospital in two ways: increased costs of care for chronic conditions and the lack of culturally appropriate outreach programs for minority populations.
The risk factors identified have impacted the low-income groups and minorities being served by Mercy Hospital. The most affected are residents of the twin cities, where more than 7% of the population is categorized as disadvantaged and at risk of unhealthy lifestyles (Allina Health, 2014).
The uninsured comprise Hispanics and American Indians, at 30% and 23%, respectively (Allina Health, 2014). Thus, the most critical community health needs are medical coverage and access to care. In addition to low SES and financial hardships, the minority also grapple with a high chronic disease burden related to poor lifestyle choices. They are at a higher risk of being overweight or obese due to chronic drinking and the lack of exercise and support than white populations (Allina Health, 2014). Cultural barriers to care access impact their healthcare-seeking behavior and outcomes.
Nurse Leader Interview Summary
Nurse Leader Role
A face-to-face interview was conducted with Karla, Mercy Hospital’s nurse manager on the oncology unit. She indicated that leadership is a critical role of nurses who are viewed as change agents. The primary domain of Karla’s influence is the oncology unit, which is dedicated to caring for the complex needs of cancer patients to improve their outcomes and comfort. One base of her delegated authority and influence on staff nurses is her position as the nurse manager. On her formal roles, she intimated that she assigns tasks to staff, monitors performance, and implements the hospital’s policies and procedures to ensure higher patient safety outcomes.
When asked about her informal roles, Karla stated that she has been offering expert coaching and guidance to nurses in addition to patient/family support for over 15 years. Therefore, another domain of her influence is clinical practice.
Karla is an experienced nurse manager with in-depth knowledge and skills, thus, nurses seek her advice on clinical matters. In this view, she uses expert power to influence others in the facility. Another base of Karla’s informal influence is reward power – recognition of top-performing staff. As a result, she commands respect from staff nurses at the oncology unit. She also stated that she encourages staff to continue with their education to enhance their clinical decision-making and critical care skills.
To be an effective leader, Karla added that ensuring a safe practice environment for staff is crucial. She emphasized the significance of communication in enhancing the safety and quality of patient care. This nursing role aligns with MSN Essential IX, number three, namely, advocacy for patients, families, and caregivers (American Association of Colleges of Nursing (AACN), 2011). In Karla’s opinion, nursing is a holistic, patient-centered care role.
It encompasses the assessment and monitoring of patient health and collaborative development of care plans, evidence-based treatments, and self-management support. Consistent with MSN Essential IX, number 7, in-depth training and expertise allow RNs to apply their knowledge of disease management to offer evidence-based care to patient groups. Therefore, they are critical to efficient healthcare delivery.
According to Karla, nurse leadership is a role of paramount importance at Mercy Hospital. It helps define the strategic direction the hospital will take and the process changes required to improve population outcomes based on data obtained through CHNAs. This aspect aligns with the MSN Essentials IX, number 9, which demands that nurses apply “advanced knowledge of the effects of the global, individual, and population characteristics” to design, implement, and evaluate care (AACN, 2011, p. 3). Karla also stated that nurses were aware of the challenges encountered when working with the local community, a reflection of the essentials of an MSN program.
Several factors affect the performance of the health care system. Nurses have a role in developing clinical interventions to overcome these challenges and improve patient outcomes. They are at the forefront of designing and implementing innovative models of care. Karla indicated that, as the nurse manager, she has built strong professional relationships within Mercy Hospital that have led to improved communication at the oncology unit and facility.
Additionally, she has also created effective alliances with families, patients, government agencies, and academicians that have helped in the coordination and evaluation of care. To Karla, such partnerships have been vital in the development and execution of new models of care at Mercy Hospital. In concluding the interview, she noted that she ensured adequate nurse to patient ratio, high-quality patient care, and an optimal nursing work environment to promote safety outcomes at the oncology unit.
Characteristics of the Organization
Strengths
From the interview, currently, nurses at Mercy Hospital perform administrative and clinical roles. They are critical professionals to patient care delivery and collaborate across different acute care specialties and units, including geriatrics, orthopedics, and oncology. According to Karla, nurses lead evidence-based interventions at the facility to improve patient care across practices, which helps strengthen patient care services. She noted that they have high visibility and influence across different sectors of the organization. Their roles are interrelated, which helps in quality improvement and care coordination.
Weaknesses
Karla stated that nurses at the mental health and hospice care are not as visible as those in other specialties. Perhaps, more resources and engagement are needed to strengthen these services at the hospital. She further noted that unified processes are required to facilitate the transition of staff nurses from Mercy and Unity hospitals to a single facility and increase their visibility. Another problem identified was the persistent catheter-acquired urinary tract infections (CAUTIs) in critical care units. A recommended organizational change based on the PDSA model is CAUTI gap analysis to enable the facility to assess its prevention capacities and develop an action plan, adopt standard transmission precautions, analyze the results, and refine these efforts.
Evidence-based practice activities
Mercy Hospital’s CHNA identified a range of issues affecting the local community based on the Minnesota Department of Health Indicators. Key among them is access to care, alcohol, chronic disease, obesity, and maternal-infant health (Centers for Disease Control and Prevention (CDC), 2016). The hospital has prioritized chronic disease management. It provides outreach education and screening of at-risk groups such as the uninsured and low SES individuals. The programs focus on chronic conditions such as diabetes and stroke.
Another evidence-based activity being undertaken by Mercy Hospital is holding community dialogues on priority areas. On childhood obesity, the facility has been able to send nutritionists to schools to support healthy lunches, meal preparation, and physical activities (Wheeler, 2017).
Additionally, Mercy Hospital collaborates with community organizations involved in childhood obesity prevention to link at-risk groups to health programs. The facility also offers low-cost training on healthy cooking for children, adolescents, and families. Therefore, community dialogues and support has contributed to a reduced risk of childhood obesity in the area.
Dialogues on chronic illness prevention could play a role in reducing the disease burden in the area. Through increased education and awareness activities that bring together Mercy Hospital and community health players like the county health department, the prevalence of conditions like diabetes and cancer is likely to decline. The “Be Fit” program has been rolled out to staff and families (Wheeler, 2017). Screening programs for adults have been useful in the early detection and management of chronic conditions. Mercy Hospital has also undertaken to develop courses that advance fitness and proper nutrition.
Quality improvement projects
In the healthcare sector, improving performance is an objective shared by all hospitals. For Mercy Hospital (Allina), the aim is to deliver quality care to patients. The facility included IHI’s definition of value in its goals, which are promoting population health, creating optimal inpatient experience, and reducing per capita spending on care (Wheeler, 2017). To deliver value, the hospital adopted a quality improvement (QI) framework that scrutinizes the gaps in current processes, prioritizes improvement opportunities, takes specific actions, and evaluates the outcomes.
In response to the Centers for Medicare and Medicaid Services’ announcement of the Hospital Readmissions Reduction Program, Mercy Hospital initiated a long-term quality improvement project in 2008 to lower the 30-day readmission rate of heart failure (HF) patients (Wheeler, 2017). The program included an HF analytics dashboard for monitoring and managing episodes. The 2013 result indicated a decline in the readmission rate from 24.2% to 14.3% (Wheeler, 2017). The project was effective in overcoming barriers to care coordination that was attributed to adverse events requiring hospitalization.
Another quality improvement project implemented at Allina Health hospitals, including Mercy Hospital, is the enterprise data warehouse and analytics software to reduce the length of stay (LOS). This platform not only led to accurate LOS measurements, but it also allowed the facility to uncover opportunities for improvement, such as “discharge orders, practice pattern variation and delayed discharge” (Wheeler, 2017, para. 16). Based on the LOS data, the hospital achieved significant savings in inpatient days and costs and freed more beds for other patients.
Recommendation for Organizational Change
Recommendation
The problem that requires changing is the high CAUTI rate. The aim is to eliminate catheter-related infections using evidence-based interventions to improve patient outcomes. According to Flores-Mireles, Walker, Caparon, and Hultgren (2015), hospital-acquired infections add extra costs to hospitals due to LOS and increased morbidity rates. CAUTIs often develop because of improper insertion, utilization, and maintenance of indwelling catheters (Flores-Mireles et al., 2015).
Thus, prevention measures are needed to curb these infections. The CAUTI rate among Minnesota’s acute care hospitals, including Mercy Hospital, was 24% higher than the national average between 2013 and 2014 (CDC, 2016). Therefore, CAUTI prevention will ensure patient-centered care as the aim is to improve patient safety. For example, those requiring indwelling catheter insertion will not be at risk of CAUTI and other hospital-acquired infections (HAIs)
Various evidence-based practice (EBP) interventions have been proposed for preventing CAUTI. This paper recommends the use of chlorhexidine gluconate (CHG) wipes in addition to routine perineal care inhibits bacterial growth that causes infection. According to Flores-Mireles et al. (2015), CHG is an effective agent for preventing bacterial colonization of the perineal area due to its antimicrobial activity. Further, compared to other antibacterial agents, CHG remains potent even when there is a discharge of body fluids or blood.
Noto et al. (2015) also showed that daily CHG bathing could lower the risk of surgical site infections. Eliminating CAUTIs will improve the quality of care delivery at the facility. For example, LOS and readmissions – indicators of hospital performance – of catheter-requiring patients will be reduced significantly. Lower LOS, morbidity, and mortality will lead to improved overall patient outcomes. For example, enhanced recovery and lower hospitalization days will reduce the disease burden in the community and ensure a healthy population in Anoka County. The PDSA model will be used to implement the recommended change. The planning stage will involve the engagement of leaders, clinicians, and patients/families and obtaining leadership buy-in.
Rationale
The main weakness identified in the interview with the nurse manager is the difficulty of Mercy Hospital to reduce catheter-related infections despite adopting CAUTI bundles. Several interventions have been implemented to curb HAIs. The most common ones include proper hand hygiene, disinfecting surfaces and tools, and patient isolation (Huang, Chen, Wang, & He, 2016). However, these measures are often difficult to maintain.
The recommended change (daily bathing of the body with CHG wipes) in addition to standard care will eliminate bacterial growth that causes CAUTI (Huang et al., 2016). As a result, CAUTI-related LOS and comorbidity that contribute to higher healthcare costs at the facility will decline. Further, the Center for Medicaid and Medicare Services (CMS) started a policy of withholding reimbursements for additional medical charges for treating HAIs, including CAUTI (Calderwood, Kawai, Jin, & Lee, 2018). Thus, the change will reduce the facility’s care costs and increase its bed capacity due to lower readmissions and LOS.
The project will also address the needs of the community that Mercy Hospital serves. Better quality outcomes and reduced costs will reduce health disparities affecting the uninsured minority populations – Hispanics and American Indians – in Anoka County (Wheeler, 2017). Improved safety will also promote health-seeking behavior among residents.
Measurement of Effectiveness
Implemented improvements must be evaluated to determine the progress towards achieving a specific objective. Measuring the proposed change based on a national benchmark will indicate whether the intervention is working or not. The use of CHG to curb CAUTIs in Mercy Hospital will be assessed using the Hospital Consumer Assessment of Healthcare Provider and Systems (HCAHPS) survey.
This national benchmark is a 21-item standardized, national, and publicly accessible instrument for evaluating the performance of hospitals (HCAHPS, 2019). Three major guidelines/goals have influenced this standard. They include producing comparable data on the client’s experience of healthcare received, improving quality through public reporting, and enhancing accountability and transparency in hospitals.
The evaluation plan will involve three HCAHPS reports. The pre-implementation survey will generate baseline data that will be compared with the results during and after implementation. Comparisons will also be made with other hospitals locally and nationally. Based on HCAHPS percentiles or performance on the 21 indicators, hospitals can be grouped on the top or bottom box (HCAHPS, 2019). Therefore, it will be easier to compare the facility’s rating between any two periods.
Conclusion
Strategic nurse leadership is critical to the effective and efficient functioning of nursing departments and hospitals. It lies at the center of any healthcare system. From the interview with the nurse manager, catheter-related infections are a major problem at Mercy Hospital. The proposed evidence-based intervention (CHG) coupled with standard care will reduce the rate of CAUTI and healthcare costs, improve quality and safety, and lower health disparities in Anoka County.
References
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