Healthcare Delivery Systems

Improvement Project: Staff Focus

Samantha Helms, Emily St. Germain, Holly Zuehlke-Frazelle, Jaime Varner

11.30.2016

Overview of Patient Care Delivery System

Banner

University Medical Center

Diamond

2 North (D2N)
o Adult Trauma PCU
o 24 bed unit

Focus:

Medication errors caused by

interruptions/distractions at the Pyxis.

(G.Cordova, personal communication, 2016)

Microsystem Model:
Leadership

Democratic leadership style

oShared Leadership Council

One unit manager

oFour clinical managers
oMany different nurses rotating as charge

(Marquis & Huston, 2015)

Microsystem Mode
Organizational Culture and Support
Values

at Banner Health
o People Above All by treating those we
serve with compassion, dignity and respect.
o Excellence by acting with integrity and
striving for the highest quality care and
service.
o Results by exceeding the expectations of
those we serve and those we set for
ourselves.

(Banner, 2016)

Microsystem Model:
Patient Focus & Staff Focus
Patient Focus:

Individual patient needs

Patient centered care
Culturally sensitive
Nurses as patient advocates

Staff Focus:
New graduates
Continuing education courses
Self care promotion
(Choi, 2015)

Microsystem Model:
Interdependence of Care Team
New movement in healthcare organizations is toward team
building and providing a continual supportive learning
environment
oTeams, rather than individuals function more efficiently

Unit huddle
oStaffing

Unit clerk
On call physicians
Pharmacy
SWAT

(Marquis & Huston, 2015)

Microsystem Model:
Use of Information and Healthcare Technology
How nurses communicate and perform their work has been
dramatically changed by technology because it has given
us the potential for immediate information access and
exchange.
Electronic charting system
oEpic
Communication
oASCOM mobile phone system
oIn chart messages to pharmacy
Medication barcoding
MyChart patient portal
(Marquis & Huston, 2015).

Microsystem Model:
Process for Healthcare Delivery Improvement
Shift log
oCentral lines
oFoleys
Incident reporting
oSentinel events
oCodes or rapid responses
Wound audits

(G.Cordova, personal communication, 2016)

Microsystem Model:
Staff Performance Patterns
Annual Reviews
Manager Documentation
oDiscipline
oAbsences
D2N Star of the Month
Daisy Award

(The Daisy Foundation, 2016)

(G. Cordova, personal communication, 2016)

Specific Aspect Targeted for Improvement

Staff Focus
Nurses

administering medications are

distracted and interrupted every two minutes
o The risk of medication error increases 12.7%
with each interruption
Distractions from socializing
Interruptions from environment
(Institute for Safe Medication Practices, 2012)

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Specific Aspect Targeted for Improvement

(cont.)

450,00 medication errors occur every year

No Interruption Zone
oYellow Vest/Sash
Step by Step Interruption Guide
oSituation
oSignificance
oFrequency
oTiming
oUrgency

(Lewis, Smith, & Williams-Jones, 2012)

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Leading the Plan for Healthcare Delivery

Improvement
AIM: Decrease medication errors at the Pyxis related to
interruptions and distractions by educating staff on proper
Pyxis culture.
PDSA
oPlan:
Conduct an online continuing education course
Nurses and PCTs
Complete within a 30 day period
Implement a No Interruption Zone with visual cues
oDo:
Collect data on staff compliance and medication errors
oStudy:
Analyze and compare statistics, and feedback
oAct:
Modify intervention and continue to monitor staff compliance
(IHI, 2016)

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References
Marquis, B.L. and Huston, C.J. (2015). Leadership roles
and management functions in nursing. Philadelphia, PA:
Wolters Kluwer Health
Choi, PP. (2015). Patient advocacy : the role of the
nurse. Nursing Standard 29(41), 52-58. Retrieved from
http://journals.rcni.com/doi/pdfplus/10.7748/ns.29.41.52.
e9772
The Daisy Foundation. (2016). What is the daisy award?
Retrieved from https://www.daisyfoundation.org/daisyaward

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References cont.
Lewis, T., Smith, C.B., and Williams-Jones, P. (2012).
Tips to reduce dangerous interruptions by healthcare
staff. Nursing 42(11), (65-67). doi:
10.1097/01.NURSE.0000421387.36112.e0
Institute for Safe Medication Practices. (2012). Side
tracks on the safety express. Interruptions lead to errors
and unfinished...wait, what was I doing? Retrieved from
https://www.ismp.org/newsletters/acutecare/showarticle.
aspx?id=37
Institute for Healthcare Improvement [IHI]. (2016).
Science of improvement: How to improve. Retrieved
fromhttp://www.ihi.org/resources/Pages/HowtoImprove/S
cienceofImprovementHowtoImprove.aspx
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