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Case Study 6-1: The Nursing Assistant

1. Identify the facts present in this case.

The facts in this case are:

The workload on the unit is described as “heavy”

Family are turning the patient themselves

Nursing assistant Johnson told family the staff was too busy and would not be able to turn

the patient for about 4 hours.

Multiple times during the past week Johnson was observed sitting in a utility room for an

assumed long period of time.

2. State the problem.

The problem is that family feels they have to care for their loved one because they were told the

staff was too busy. The nursing assistant Johnson communicated inappropriately to the family by

telling them the staff was too busy as well as telling the family they had to turn the patient.

Another potential problem is the observation of Johnson sitting in a utility room instead of

working. Another observation that could be a problem is the workload lately on this unit.

3. Make assumptions of the three types described in the chapter. List them in order of declining

certainty.

Structural assumptions could be:

Additional resources are available to problem solve- inquire witness statements from

other staff members.

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Problem caused by uncontrollable external factors- is the department short in staffing?

Why is the workload described as heavy? What is the acuity or complexity of patients?

Personal assumptions could be:

Anchoring- Johnson was seen sitting in utility room earlier in the week, is this

assumption related to his inappropriate verbal behavior?

Escalating commitment- As manager should have inquired about Johnson sitting in utility

room during the week, could behaviors been addressed at that time to prevent this

incident?

Likely reactions- If Johnson was counseled or provided corrective action in the past he

may lie about the incident or if he has a history of poor behavior he may get angry or

defensive when manager investigates him.

Problem Centered assumptions could be:

A solution is needed urgently- family is doing the work, Johnson is inappropriate talking

to family, does the staff need help with the workload?

The problem is very important- it is impacting patient care and satisfaction.

This is a high degree of risk- patient care could be compromised, the family turning the

patient may injury the patient or themselves if they do not know what they are doing.

Degree of solution acceptance- Johnson might not be accepting workflow changes,

Johnson also may have a difficult time accepting disciplinary action.

4. Develop five solutions that should be considered. Which one should be chosen? Why?

Five solutions that should be considered are:

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A quick safety huddle of all the staff members should be done to identify possible

barriers to patient care.

A plan on how to ensure the patient will get turned every 2 hours.

Remove Johnson from his shift, send him home with suspension.

Counsel and educate the staff on the importance of patient care and turning patients every

2 hours.

Call in an extra staff member to help out.

The solution I would choose would be implementing a plan on how we are going to get this

patient turned every 2 hours. I choose this one because something has to be done immediately as

it is causing harm to the patient. Quality and safe patient care must be a priority at this moment.

Case Study 6-2: The new charge nurse

1. Describe the education and training received by nursing assistants, licensed practical nurses,

and the RNs of the various types. Referring to the discussion of nursing in Chapter 1 may be

helpful.

Registered nurses, licensed practical nurses, and nurse practitioners complete an accredited

program at an institution as well as taking a licensing examination. Nurses are classified as

having registration. Registration is noted as “qualified individuals on an official roster

maintained by a government or nongovernment body” (Longest & Darr, 2008, p. 31). In

particular to nurse midwives they achieve certification. Certification is a “process by which a

nongovernment agency or association grants recognition to someone who meets its

qualifications” (Longest & Darr, 2008, p. 31). For nurse assistants they are not necessarily

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certified but will be registered from an appropriate educational program. Education options for

registered nurses are BSN (Bachelors of Science in Nursing) which is a 4 year university degree,

a diploma which is obtained with 3 years of hospital based education, and associates degree

which is a 2 year degree from a community college. For the advanced practical nurse, they obtain

a masters degree with the option of being certified in specialties.

2. Develop a problem statement. Identify several tentative alternative solutions.

Problem statement: In what way can Sally Besnick improve on leadership skills to hold staff

accountable and improve morale.

Alternative solutions:

Help Sally identify barriers in her role, are they personal or professional barriers?

Determine what she is lacking in her skill and get her the education.

What are the barriers to holding her team accountable and get her the tools she needs to

be successful.

Implement an action plan/performance enhancement plan to Sally to meet specific

expectations in areas she is lacking.

Provide a mentor for Sally.

3. Which solution is best? Why?

The best solution would be to put her on an action plan/performance enhancement plan as well as

offer her tools/resources to be successful. This will give Sally a chance to turn her leadership

around as well as make improvements within the unit. This will determine whether she can

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manage or not. This would be better than going right to demotion. As Sally’s supervisor we

need to make every attempt to make her successful.

4. Describe how you would implement the solution chosen. How would you evaluate the results?

A structured action plan outlining her declining performance, what the expected standards are,

and ways to achieve them as well as giving additional resources/tools, for example, leadership

courses pertaining to her leadership deficits. Her action plan would list her declining

performance in leading teams, disciplining, and holding associates accountable. Weekly

meetings would be done with Sally to review her action plan progress. Sally would need to come

to meetings bringing in the actions and follow through she has done with her team for the week.

At that time Sally will be provided feedback on her progress as well as any additional coaching

needed. If Sally happens to disclose struggles in her personal life that could be having an effect

on her work due to her adopting a new baby and just moving into a house, as supervisor I would

suggest EAP (employee assistance program) to assist her.

Case study 7-2: The Carbondale Clinic

1. “For some years, the clinic as received complaints from its patients that appointment times

are not being met.” Why has no action been taken to correct the situation?

The case study states, “the clinic has felt that such delays are unavoidable” (Longest & Darr,

2008, p. 350). With the clinic assuming it is inevitable and probably cannot change or adopt

actions to improve they choose to ignore it. The clinic seems to be in denial for a possible

solution. In Chapter 7 it was stated that “managers must recognize the necessity of change if

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improvement is to occur” (Longest & Darr, 2008, p. 328). When issues present it is the due

diligence of the leadership team to attempt to resolve the issues.

2. You are a member of a QIT that was asked to evaluate the appointment/scheduling process.

Are there some “assumptions” in the narrative that you question? If data were sufficient for a

Pareto diagram of problems with the appointment/scheduling process, what do you think the

items would be? Please list them.

Using the Pareto diagram the items would be:

Annual physical exam appointments

Non emergency/routine appointments

Emergency appointments that are non life threatening

Emergency appointments that are life threatening

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3. Draw a cause-and-effect (Ishikawa) diagram of causes for patient complaints.

4. What recommendations would you make to decrease patient waiting time?

Recommendations to decrease waiting time could be:

Engage the physicians on the issues. Encourage them to not do annual physical exams

while patient is there, have them reschedule their annual exam.

Get education to schedulers on how to prioritize appointments as well as create an

algorithm for them to reference. If they do need the nurses help but they are too busy is

there a way to be creative with their schedule to be available and/or can something be

taken away from the nurses to have more time available.

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Do a time study or track on how long the time takes with routine appointments, annual

exams, emergency life threatening and non life threatening appointments, and block off

that amount of time using 15 minute increments.

Can nurse practitioners or physician assistants be incorporated to see routine

appointments to free up more physician time.

Case Study 8-4: Closing pediatrics

1. What effect would the retrenchment strategy have on City Hospital’s objectives?

Retrenchment is defined as a downsizing of services (Longest & Darr, 2008). The objectives for

City Hospital are providing a full range of pediatric services as well as a full range of graduate

medical education with pediatric residents. The effect of downsizing at City Hospital would limit

pediatric services in the hospital. The hospital would not be able to off a full range of pediatric

services. Not having full range may cause a competitor hospital to gain that lost volume. The loss

of beds during the downsizing can be converted to other areas that would be more profitable, for

example, rehabilitative care. Another effect would be the medical education with residents. If the

full services are not available for pediatrics they may lose the opportunity to partner with

residents and medical education due to lack of exposure to full range pediatric medicine.

2. Identify the stakeholders that influence the decision.

Stakeholders are “individuals, groups, or organizations affected by the HSO/HS who may seek to

influence it and its objectives and strategies” (Longest & Darr, 2008, p. 374). The stakeholders

that could influence this decision would be middle management, senior management, the CEO

and CFO, the chief of pediatrics, as well as the governing board.

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3. Are there strategies that can be considered by City Hospital?

Strategies that can be considered are:

Directional strategy- Using directional strategy will assist in keeping aligned with the

mission, values, and vision of the organization when growing services or determining the

future of continuing services.

Adaptive strategy- Using adaptive strategy will help organizations discern whether to

expand or maintain service operations.

Competitive strategy- Using competitive strategy identifies the advantages of the services

as compared to its competitors. What is its position in the community in offering its

services.

4. Argue against the closure. What reasons support your position?

Even though the hospital has seen a decline in its occupancy rate it has now stabilized at a 45%

occupancy rate. Since the objectives are to provide a full range of pediatric services as well as

provide opportunity for medical education and residents it should compete to be the organization

of choice in the community since other competitive hospitals are struggling with volume. As

other competitive hospitals struggle with volume and consider eliminating their services it would

be beneficial for the City Hospital to monopolize on their full services offered. This would be a

time to ramp up advertising to speak about the full services and recruit more volume. Eliciting

information on the demographics in area may be beneficial to maintaining pediatric services if

one can show supportive data on pediatric census.

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References

Longest Jr, B. B., & Darr, K. (2008). Managing health service organizations and systems (5th

ed.). Baltimore, MD: Health Professions Press, Inc.