Alex Cole, Kacie Terry, Noelle Olm-Trujillo, Nikki Taylor, Tatiana Facer

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 Hospital: St. Josephs Hospital - Carondelet
Health Network

Unit: Intensive Care Unit (ICU)

o Focus: Performance Results related to Post-
Code Patient Outcomes

Institute for Healthcare Improvement.(2015). Clinical microsystem assessment tool. Retrieved from
http://www.ihi.org/resources/pages/tools/clinicalmicrosystemassessmenttool.aspx
2
 Leaders struggle to find the right balance
between reaching performance goals and
supporting and empowering the staff
Democratic Leadership
Decentralized
Charge nurse takes patients for low census
o Unable to be an effective charge nurse

Bias, B. (2017). Staffing [PowerPoint Slides]. Retrieved from

https://d2l.arizona.edu/d2l/le/content/587784/viewContent/5256081/View
Lacroix, D. (2017). Management and leadership [PowerPoint Slides]. Retrieved from
https://d2l.arizona.edu/d2l/le/content/587784/viewContent/5255971/View
Institute for Healthcare Improvement.(2015). Clinical microsystem assessment tool. Retrieved from
http://www.ihi.org/resources/pages/tools/clinicalmicrosystemassessmenttool.aspx 3
 The larger organization is inconsistent and
unpredictable in providing the recognition,
information and resources needed to enhance
my work.
Inconsistent communication with organizational
leaders
Limited finances to support safe nurse-to-patient
ratios

Institute for Healthcare Improvement.(2015). Clinical microsystem assessment tool. Retrieved from
http://www.ihi.org/resources/pages/tools/clinicalmicrosystemassessmenttool.aspx
4
 Patient Focus:
o We are actively working to provide patient centered
care and we are making progress toward more
effectively and consistently learning about what patients
want and need
o Family is involved in care
o Automony

Staff Focus:
o I am not made to feel like a valued member of the
microsystem. My orientation was incomplete. My continuing
education and professional growth needs are not being met.
o Lack of educational courses offered

Institute for Healthcare Improvement.(2015). Clinical microsystem assessment tool. Retrieved from
http://www.ihi.org/resources/pages/tools/clinicalmicrosystemassessmenttool.aspx
Elwyn, G., Dehlendorf, C., Epstein, R. M., Marrin, K., White, J., & Frosch, D. L. (2014). Shared decision
making and motivational interviewing. Shared Decision Making in Health Care, 12, 239-245.
doi:10.1093/acprof:oso/9780198723448.003.0037
5
 The care approach is interdisciplinary, but we are
not always able to work together as an effective
team

ICU team struggles to collaborate for

interdependent patient care
o Communication during codes

Institute for Healthcare Improvement.(2015). Clinical microsystem assessment tool. Retrieved from
http://www.ihi.org/resources/pages/tools/clinicalmicrosystemassessmenttool.aspx
Epstein, Nancy. (2014). Multidisciplinary in-hospital teams improve patient outcomes: A review. Surgical
Neurology International, 5 (Suppl 7), S295-S303. http://doi.org/10.4103/2152-7806.139612 6
 Integration of Information with Patients
o Patients have access to some standard
information that is available to all patients
Integration of Information with Providers and Staff
o I am always tracking down the information I need
to do my work
Integration of Information with Technology
o I have access to technology that will enhance my
work, but it is not easy to use and seems to be
cumbersome and time consuming.

Institute for Healthcare Improvement.(2015). Clinical microsystem assessment tool. Retrieved from
http://www.ihi.org/resources/pages/tools/clinicalmicrosystemassessmenttool.aspx
7
 Some resources are available to support
improvement work, but we dont use them as
often as we could. Change ideas are
implemented without much discipline.
No benchmarking
Educational material provided that encourages
improvement
o Not taken seriously

Institute for Healthcare Improvement.(2015). Clinical microsystem assessment tool. Retrieved from
http://www.ihi.org/resources/pages/tools/clinicalmicrosystemassessmenttool.aspx
8
 We dont routinely collect data on the process
or outcomes of the care we provide.
Auditing patient outcomes and avoidable costs
can lead to improved care and results.
o St. Joes does not routinely collect data
regarding performance, nor do they feedback
data to the staff

Institute for Healthcare Improvement.(2015). Clinical microsystem assessment tool. Retrieved from
http://www.ihi.org/resources/pages/tools/clinicalmicrosystemassessmenttool.aspx
Gelderen, S. C., Zegers, M., Boeijen, W., Westert, G. P., Robben, P. B., Wollersheim, H. C. (2017). Evaluation the
organization and effectiveness of internal audits to govern patient safety in hospitals: a mixed-
methods study. BMJ Open, 7,7, 1-11. doi: 10.1136/bmjopen-2016-015506 9
 Staff Performance Patterns: Introduction of
auditing/data collection combined with frequent
dissemination of the data among staff
o Leads to improved patient outcomes
Studies show:
o Helps identify patient safety problems
o Governs the improvement of staff performance
for enhancing patient outcomes/safety
o Audit feedback helps with quality improvement
Ceballos, K., Waterman, K., Hulett, T., Makic, M. B. F. (2013) Nurse-Driven Quality Improvement
Interventions to Reduce Hospital-Acquired Infection in the NICU. Advances in Neonatal
Care, 13 (3), 154-163. http://doi.org/10.1097/ANC.0b013e318285fe70
Gelderen, S. C., Zegers, M., Boeijen, W., Westert, G. P., Robben, P. B., Wollersheim, H. C. (2017). Evaluation
the organization and effectiveness of internal audits to govern patient safety in hospitals: a
mixed-methods study. BMJ Open, 7,7, 1-11. doi: 10.1136/bmjopen-2016-015506
Vijayakumar, C., Maroju, N. K., Srinivasan, K., & Reddy, K. S. (2016). Clinical audit system as a quality
improvement tool in the management of breast cancer. International Journal of Surgery, 35, 44- 10
 Unit-wide audit implementation program
Literature states: Empowering nurses to perform
audits improves patient outcomes and staff
performance
o Timeline for intervention
Implement
Intro/Prep Pilot Eval with eval
Months Months Month Month 11-12
1-3 6-9 10 and continue
indefinitely

Gelderen, S. C., Zegers, M., Boeijen, W., Westert, G. P., Robben, P. B., Wollersheim, H. C. (2017).
Evaluation the organization and effectiveness of internal audits to govern patient safety in
hospitals: a mixed-methods study. BMJ pen, 7,7, 1-11. doi: 10.1136/bmjopen-2016-
015506
11
 Bias, B. (2017). Staffing [PowerPoint Slides]. Retrieved from
https://d2l.arizona.edu/d2l/le/content/587784/viewContent/5256081/View
Ceballos, K., Waterman, K., Hulett, T., Makic, M. B. F. (2013) Nurse-Driven
Quality Improvement Interventions to Reduce Hospital-Acquired
Infection in the NICU. Advances in Neonatal Care, 13 (3), 154-163.
http://doi.org/10.1097/ANC.0b013e318285fe70
Elwyn, G., Dehlendorf, C., Epstein, R. M., Marrin, K., White, J., & Frosch,
D. L. (2014). Shared decision making and motivational
interviewing. Shared Decision Making in Health Care, 12, 239-245.
doi:10.1093/acprof:oso/9780198723448.003.0037
Epstein, Nancy. (2014). Multidisciplinary in-hospital teams improve patient
outcomes: A review. Surgical Neurology International, 5 (Suppl 7), S295-
S303. http://doi.org/10.4103/2152-7806.139612
Gelderen, S. C., Zegers, M., Boeijen, W., Westert, G. P., Robben, P. B.,
Wollersheim, H. C. (2017). Evaluation the organization and effectiveness of
internal audits to govern patient safety in hospitals: a mixed-methods study.
BMJ Open, 7,7, 1-11. doi: 10.1136/bmjopen-2016-015506
12
 Institute for Healthcare Improvement.(2015). Clinical microsystem
assessment tool. Retrieved from
http://www.ihi.org/resources/pages/tools/clinicalmicrosystemassessment
tool.aspx
Lacroix, D. (2017). Management and leadership [PowerPoint Slides].
Retrieved from
https://d2l.arizona.edu/d2l/le/content/587784/viewContent/5255971/View
Marquis, B.L., & Huston, C.J. (2015c). Leadership roles and management
functions in nursing theory and application (8th ed., pp. 260-286).
Philadelphia, PA: Wolters Kluwer health/ Lippincott Williams & Wilkins.
Vijayakumar, C., Maroju, N. K., Srinivasan, K., & Reddy, K. S. (2016).
Clinical audit system as a quality improvement tool in the management
of breast cancer. International Journal of Surgery, 35, 44-50. Retrieved
from https://doi.org/10.1016/j.ijsu.2016.09.011

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