NUR 530 Module 3 Milestone One Example

Milestone One: Assessing 6 South as a Clinical Microsystem Using the Five Ps

[Student Name]

Southern New Hampshire University

NUR 530: Systems Leadership and Collaborative Practice

Milestone One

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Milestone One: Assessing 6 South as a Clinical Microsystem Using the Five Ps

Nelson et al. (2002) use the term clinical microsystem for a front-line unit: a small team that works side by side every day for a defined group of patients, together with the shared information, routines and tools that let it do so. Most of the quality patients experience is produced at this level, and most improvement efforts succeed or fail there too (Mohr, 2002). This milestone assesses Tamarack Regional Medical Center's 32-bed medical floor, 6 South, using the five Ps of microsystem assessment: purpose, patients, professionals, processes and patterns. The assessment shows a capable unit whose discharge process has no single owner, so work that should happen the afternoon before a discharge is compressed into the few hours after noon.

Purpose

The unit's stated purpose, posted at the nurses' station, is to provide safe, compassionate care to adults with acute medical illness and to prepare them and their families for the next stage of recovery. Staff interviewed for this assessment described the first half of that purpose readily. Few mentioned the second. Discharge was described as an event that happens at the end of a stay rather than as work that runs through it, which matters because structured discharge planning modestly shortens length of stay and lowers readmissions among medical patients (Gonçalves-Bradley et al., 2022).

Patients

In the three months reviewed, 6 South discharged 438 patients, about 146 per month. The median age was 68. The most common reasons for admission were heart failure, pneumonia, exacerbations of chronic obstructive pulmonary disease, cellulitis and step-down care after sepsis. About 22% of patients left for a skilled nursing or rehabilitation facility and 9% went home with home health services; the remainder went home without services. Of patients discharged home, roughly four in ten depended on a family member for the ride, and many of those drivers worked until mid-afternoon. These patients are older and frailer than the hospital average, which means that the harms of waiting in a hospital bed, lost mobility and hospital-acquired infection, fall on the people least able to absorb them (Rojas-García et al., 2018).

Professionals

The unit employs 58 registered nurses, about 44 full-time equivalents, and 14 nursing assistants, with a charge nurse on every shift. Day-shift ratios are usually one nurse to five patients and one to six at night. Two hospitalist teams cover the unit, each carrying about sixteen patients, with a nocturnist overnight. One pharmacist is assigned to the unit on weekday days. Two case managers and a social worker divide the unit with a neighboring floor, and physical and occupational therapists are shared across the medical service. Transport and environmental services are central departments that serve the whole hospital.

The professionals are experienced and, by their own account, collegial. The gap is structural: of all these roles, only the charge nurse sees every patient's discharge status, and the charge nurse has no authority over the timing of any other department's work.

Processes

Table 1 follows the median discharge through its main time stamps, drawn from the electronic record for the same three months.

Table 1

Median Discharge Time Stamps on 6 South Over Three Months

Note. Composite unit data prepared for this assessment.

Two features of the process stand out. First, the decision that a patient will leave is made on the day of discharge, during morning rounds, so every step that follows starts late. Second, the steps run in sequence rather than in parallel. Medication reconciliation waits for the order, teaching waits for the reconciled list and the ride waits for a call that the patient is ready. Nothing in the current process lets a department begin its part the afternoon before.

Patterns

Only 9% of discharges left before noon over the three months, and the median departure was just before four in the afternoon. Weekend discharges ran at about 60% of the weekday volume, so Monday began with a backlog. Medicine admissions waiting in the emergency department for a 6 South bed boarded for a median of five hours and forty minutes. The unit's 30-day readmission rate was 15.8%. In an informal survey, 41 of 58 nurses agreed that discharge planning on the unit starts too late, and several described the late afternoon as the most rushed and least safe part of the day shift.

These patterns are typical rather than unusual. When one academic medical center began its own improvement work, only 7% of patients on its two medical units were leaving before noon (Wertheimer et al., 2014).

Strengths and Gaps

The assessment found real strengths. Charge nurses already keep an informal list of possible discharges, the unit pharmacist is respected and willing to change workflow, and staff want the afternoon rush to end. Nelson et al. (2002) found that high-performing microsystems used their own data routinely, and 6 South has the time stamps to do so but has never reviewed them together. The main gaps are the absence of an owner for the whole discharge process, a decision point that arrives too late in the day and handoffs that run in sequence.

Problem Statement and Draft Aim

On 6 South, discharges cluster in the late afternoon because the decision to discharge is made on the day itself and the steps that follow run in sequence across departments that do not share a plan, which delays emergency admissions and compresses discharge work into the least safe part of the shift. A draft aim for Project One is to raise the share of 6 South discharges leaving before noon from 9% to 25% within six months, without an increase in the 30-day readmission rate.

Conclusion

Assessed as a microsystem, 6 South is a capable unit caring for older, frail patients with a discharge process no one owns from end to end. The five Ps locate the problem in the timing of the discharge decision and the sequence of handoffs, not in the effort of any individual. Project One will analyze those causes in more depth and test the draft aim against a closer audit of delayed discharges.

References

Gonçalves-Bradley, D. C., Lannin, N. A., Clemson, L., Cameron, I. D., & Shepperd, S. (2022). Discharge planning from hospital. Cochrane Database of Systematic Reviews, 2022(2), Article CD000313. https://doi.org/10.1002/14651858.CD000313.pub6

Mohr, J. J. (2002). Improving safety on the front lines: The role of clinical microsystems. Quality and Safety in Health Care, 11(1), 45-50. https://doi.org/10.1136/qhc.11.1.45

Nelson, E. C., Batalden, P. B., Huber, T. P., Mohr, J. J., Godfrey, M. M., Headrick, L. A., & Wasson, J. H. (2002). Microsystems in health care: Part 1. Learning from high-performing front-line clinical units. The Joint Commission Journal on Quality Improvement, 28(9), 472-493. https://doi.org/10.1016/S1070-3241(02)28051-7

Rojas-García, A., Turner, S., Pizzo, E., Hudson, E., Thomas, J., & Raine, R. (2018). Impact and experiences of delayed discharge: A mixed-studies systematic review. Health Expectations, 21(1), 41-56. https://doi.org/10.1111/hex.12619

Wertheimer, B., Jacobs, R. E. A., Bailey, M., Holstein, S., Chatfield, S., Ohta, B., Horrocks, A., & Hochman, K. (2014). Discharge before noon: An achievable hospital goal. Journal of Hospital Medicine, 9(4), 210-214. https://doi.org/10.1002/jhm.2154