Qip Project

Improving Interdependence of the
Healthcare Team
Andrew Chittaphong, Marco Stevens Cota,
Michael Manns, Ella Nanci, and Troy Schmidt
December 4th, 2019
Overview of Patient Care Delivery System
Northwest Medical Center - Tucson
• Medical-Surgical Intensive Care Unit (MSICU), a 20-bed unit
• Code team consists of respiratory therapists, staff RNs,
charge nurse, house supervisor, and unit physician.
• Focus:
• Impaired interdependence of healthcare team related to
role confusion and emotional strain due to a lack of
debriefing after codes, rapid-responses, and stroke events.
Microsystem Model: Leadership
MSICU Leadership
• Charge RN leads in a laissez-faire style
• “Little or no control, motivates by support… does not
criticize, disperses decision making throughout
group.”
• Little direction as long as protocols are followed and
adverse events prevented
• Unit director empowers RN staff to promote autonomy
Johnson, J. K. (2001). Clinical microsystem assessment. Retrieved from
http://clinicalmicrosystem.org/uploads/documents/microsystem_assessment.pdf
Microsystem Model: Organizational Culture
and Support
Unit Management
• ICU director acts through democratic leadership
• Directed through suggestions and guidance, emphasis is on we,
constructive criticism
• Unit-wide meetings held weekly during day shifts to identify
needs of the unit and improve unit resources
• ICU is used as IV team, Code Team, RST team, and Float Pool

Microsystem Model: Patient/Staff Focus of
Healthcare Delivery
Culture and Work Roles Listening and Caring
• ICU director does new hires • Unit RN organizes care
for the unit • Education on medications, lines,
• Six months of onboarding for interventions, and plan of care
new nurses • Clear and concise bedside handoff
• Staff required to complete • Clustered and timely care
continuing education • Medication reconciliation
• Staff ratio 2:1
• Bonus based on annual review
Microsystem Model: Interdependence of Care Team
Trust, Collaboration, and Shared Purpose
• Nurses trust each other to help with assignments
• Unit focused on interdisciplinary teamwork (RSTs,
chaplain, ENTs, social workers, etc.)
• House supervisor and physician run all codes
• Code tasks delegated to unit RNs

Microsystem Model: Use of Information and
Healthcare Technology
Integration of Information
• Cerner EMR
• IT support, Medication database built-in
• Auto-populating charting
• Patients can ask for medical records
• Limited workstation-on-wheels located around the unit
• Facility-wide phones for all staff, number list available at all
nurse stations
• Updated alarm system (bedside monitors, bed alarms)
Microsystem Model: Process for Healthcare
Delivery Improvement Activities
Process Improvement
• Unit nurses are encouraged to continue education
• High-skill nursing tasks require education and certification
• i.e. CRRT requires in-hospital CRRT certification before
care can be given
• Unit outcomes are audited and areas of concern are
emphasized
• Grand rounds and ICU manager huddle during day shift
Microsystem Model: Staff Performance
Patterns
Performance Results
• Benchmarks on the unit are constantly monitored or audited
• End-of-month unit manager/charge RN meetings
• Charge RN distributes information down to unit RNs
• Benchmark results and quality indicators posted on information
boards positioned around the unit
• Yearly peer performance reviews

Specific Aspect Targeted for Improvement
Post-Code Debriefing
• Interdependence of healthcare team related to role
confusion and strain due to a lack of debriefing
post-code, rapid-response, and stroke events
• The use of a debriefing tool led to more code debriefs
• Reflective learning
Gillen, J., et al.. (2019). The impact of a fellow-driven debriefing program after pediatric cardiac
arrests. BMC Medical Education, 19(272), doi: 10.1186/s12909-019-1711-y
Kessler, D. O., Cheng, A., & Mullan, P. C. (2015). Debriefing in the emergency department after
clinical events: A practical guide. Annals of Emergency Medicine, 65(6), 690-698.
Integrative Nursing Principle
Integrative Nursing Principle #6
● “Integrative nursing focuses on the
health and wellbeing of caregivers
as well as those they serve.”
● Includes reflective practices such
as journaling and debriefing
Kreitzer, M. J. (2015). Integrative nursing: Application of principles across

clinical settings. Rambam Maimonides Medical Journal, 6(2). doi:
10.5041/RMMJ.10200
Project Timeline
Months
0-1 1-3 3-4 4-12 12+
Project Administer Education Begin Evaluate

planning and Post-Code on debriefing intervention
goal-setting Stress Scale; debriefing intervention outcomes
assessment intervention and data and apply
of baseline collection hospital wide
scores on unit
References
Gillen, J., Koncicki, M. L., Hough, R. F., Palumbo, K., Choudhury,
T., Daube, A., Patel, A., Chirico, A., Lin, C., Yalamanchi, S.,
Aponte-Patel, L., & Sen, A. I. (2019). The impact of a fellow-driven
debriefing program after pediatric cardiac arrests. BMC Medical
Education, 19(272), doi: 10.1186/s12909-019-1711-y
Johnson, J. K. (2001). Clinical microsystem assessment. Retrieved
from
http://clinicalmicrosystem.org/uploads/documents/microsystem_asse
ssment.pdf
References
Kessler, D. O., Cheng, A., & Mullan, P. C. (2015). Debriefing in the
emergency department after clinical events: A practical guide.
Annals of Emergency Medicine, 65(6), 690-698.
Kreitzer, M. J. (2015). Integrative nursing: Application of principles
across clinical settings. Rambam Maimonides Medical Journal,
6(2). doi: 10.5041/RMMJ.10200
Marquis, B. L., & Huston, C. J. (2017). Leadership roles and
management functions in nursing: theory and application (9th ed).
Philadelphia: Wolters Kluwer Health.

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What is the leadership style of the ICU director and charge nurse?

What aspects of care does the microsystem focus on?

Improving Interdependence of the

Johnson, J. K. (2001). Clinical microsystem assessment. Retrieved from

Johnson, J. K. (2001). Clinical microsystem assessment. Retrieved from

Johnson, J. K. (2001). Clinical microsystem assessment. Retrieved from

Kreitzer, M. J. (2015). Integrative nursing: Application of principles across

Project Administer Education Begin Evaluate

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