Leadership for the Clinical Context NURS5041

Case Study Information - Assessment Three

Using the case study data as a starting point, choose ONE of the issues (highlighted rows) from Table(Prefer hand hygiene compliance) Include a process or framework (prefers to use model of improvement-PDSA cycle) you could use in analysing your chosen issue, using other data from the case study that are likely connected to the issue of choice.

Introduction

You have recently been asked by your unit manager to review some of the clinical issues highlighted from a number of sources, that require attention to improve practice. As you read through the information below, refer to the highlighted rows in Table 2 and make notes related to the following points: 

1. Issues related to clinical practice that requires attention.
2. Current clinical indicators compared to National / International Benchmarks.
3. Analyse the clinical indicators to identify areas for improvement.
4. Think about how you might lead change in practices.

The Integrated Health Service (IHS)

The Integrated Health Service (IHS) was established in 2015 and provides a comprehensive, integrated health service. The service commenced as a Government commitment to improving health services covering community assessment through to acute care and back to community care. The health service achieved accreditation in 2017, having met the National Accreditation Health Standards. Recently however, there have been a number of media news reports about overcrowding in the emergency department, patients not receiving the best care, and increased waiting times for elective surgery in orthopaedics and ophthalmology.

The media reports in brief include:

1. A report in daily newspaper that mental health patients had been waiting in the Emergency Department for 3 days before a bed was available in the Mental Health Unit.
2. In August 2019 a patient had surgery on the wrong limb which resulted in an amputation
3. The infection rate within the IHS was substantially higher that of other health services within the region. This has resulted in patients cancelling their surgery, as they fear getting a severe infection
4. In September 2020 the local newspaper reported that a patient had died following cataract surgery. The newspaper alleged that the patient was given a medication after surgery that they were allergic to, which resulted in death.

The Accreditation Agency has informed the Chief Executive Officer that the health service accreditation is now under review. The accreditation agency will require a report on the Clinical Indicators for the Hospital and may decide to include a site visit. If the health service loses its accreditation,  funding from the Government and Private Health Providers will be decreased. 

Profile of the Integrated Health Service (IHS)

The IHS was established in 2015 and has the following services:

• Acute Hospital inpatients: a 650-bed hospital offering general surgery, general medicine, paediatrics, mental health, maternity services and urgent care services. The hospital has six operating rooms, a radiology and pathology department, and a speciality outpatient department.
• Ambulatory home service which provides care for patients who have been discharged from the acute service sector

The hospital has the following strategic statements:

Vision: 

To provide excellent health service to all we care for in our community.

Mission:

To provide an integrated health care service that has highly skilled clinical professional staff who provide personalised care that will allow patients to remain in their community.

Value:

• Patient centred care
• Excellence in clinical care
• Individualised care
• Open communication

Clinical Governance

The IHS has a comprehensive clinical governance framework with four main pillars:

1. Clinical Risk Management
2. Clinical Effectiveness
3. Workforce Development
4. Consumer Participation and Engagement

Clinical Services

The IHS has the following service profile:

• Acute Hospital - provides general surgery, general medicine, paediatrics, mental health, maternity services and urgent care services. The hospital has six operating rooms, a radiology and pathology department, and a speciality outpatient department. The hospital provides a community-based general health service and refers critical, complex patients to a teaching hospital for speciality services such as cardiac surgery 

• Ambulatory Home Service - established to provide a hospital in the home services. This includes nursing and allied health services. Patients who are transferred to the service have been discharged from IHS.  The IHS does not accept patients from other health services 

The Organisational Structure

The CEO and Director of Clinical Services are both medical doctors. There are nurse managers in charge of the ambulatory health service, the acute hospital service and the ambulatory home service. There is also a nurse manager overseeing staff development.  There are three support services for the clinical areas (corporate services, quality department, and cleaning and catering), with these managers reporting directly to the CEO.

The Quality Department reports directly to the CEO and has no management authority for the clinical areas.

You are one of the clinical nursing staff          working in a medical/surgical ward within the acute hospital services, and report to the nurse unit manager.

Clinical Activity

The following table indicates the clinical activity for the last three years.

Table 1: Summary of Clinical Services and status 2018 -2020 (note the impact of COVID-19*)

*Data impacted by COVID-19

The IHS service demands have increased in the areas of urgent care services, maternity and mental health.  However there have been decreases in the areas of general surgery, general medical patients and paediatric hospital admissions.

The Chief Executive is concerned about the number of the Clinical Services which are not meeting their performance requirements including:

• General Medicine has seen a decrease in the number of inpatients and this is despite a full range of general medicine being provided by IHS. The concern is why has there been this decrease, and patients from the community not wanting to be admitted to the IHS.

• A decrease in paediatric admissions despite an increase in the number of births for the area and increase in the number of births at IHS.

Clinical Indicator Data

The clinical indicator data for the hospital is provided in Table 2.

Table 2: Clinical Indicator Data for IHS 2018 - 2020

Workforce Indicators

The following are details of workforce indicators for the IHS.

Table 3: Workforce Indicators

The Quality Department

The Quality Department (QD) was established in 2015 to prepare for accreditation and to monitor clinical activities. The QD has a Manager and two Clinical Quality Offers. The manager reports directly to the Chief Executive Officer and has no management or authority for the clinical units.

The QD has the organisational responsibility for clinical goverance which includes:

• Consumer Engagement
• Clinical Risk Management
• Complaints Management and Resolution
• System-wide Quality Management
• Accreditation  

The activity within the QD has rapidly increased and has now focused on complaints management. The number of complaints has increased dramatically and the time to manage individual complaints has doubled making this outside the required Health Departments Policy of 30 days. During this busy time the Quality Department has also not convened a Consumer Engagement Committee, the Clinical Risk Management Committee or the Accreditation Committee. The next Accreditation Survey is due in six months.

The Quality Department provides administrative support to a number of quality improvement projects, for example falls management. It was noted in a Newspaper report that the IHS has not adopted a system-wide falls assessment and management approach. Individual clinical areas have varying degrees of falls identification check lists, and limited prevention programs. 

Your role in this case study

In the interim, and as preparation for the next clinical audit, your Nurse Manager has asked you to help with leading change in ONE of the two areas highlighted in Table 2. 

The assessment task/s

Choose:

Using the case study data as a starting point, choose ONE of the issues (highlighted rows) from Table

2. 

Analyse:

Include a process or framework you could use in analysing your chosen issue, using other data from the case study that are likely connected to the issue of choice. Think about ways in which you could gather accurate information (from your own area) to understand the factors impacting on the chosen clinical issue.

Recommend changes for practice:

Formulate recommendations for leading change (improvements) in clinical practices based on relevant literature, and where applicable, health policies and/or guidelines from: your own hospital or work setting, State, National or International health authorities. 

In essence, this assessment draws together the content covered in this unit and knowledge gained from your broader reading. 

Refer to the assessment rubric for further detail about the criteria.