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Background Information
HCA East Florida Division (HCA EFD) is a part of Health Corp. of America, which is for-profit company (HCA East Florida, 2015). This division has 13 hospitals and covers several areas from Fort Pierce to Miami Florida. The HCA’s origin can be traced back to 1960s through the works of Dr. Thomas Frist Sr. and other physicians in Nashville, Tennessee where they constructed the first hospital. Over the past four decades, physicians and nurses have worked to transform the hospital to HCA –Hospital Corporation of America.HCA is America’s leading provider of quality healthcare services. It has local facilities with nearly 191 hospitals and 82 outpatient surgery centers in 23 states and England (HCA East Florida, 2015).
A Clear Vision
HCA’s corporate mission and values statement says it best:
“Above all else, we are committed to the care and improvement of human life. In recognition of this commitment, we strive to deliver high quality, cost effective healthcare in the communities we serve” (HCA East Florida, 2015).
The health care industry and hospital environments continue to undergo significant changes. For instance, the Hospital in Dallas played an important role in putting a spotlight on the issues of communicating First Point of Contact between the nurses and Physicians. In the current society in which there has been an emergence of deadly diseases such as Ebola, the hospitals are extremely important in ensuring that the lives of the Americans are protected. Ebola is a clear case of a disease that does not only pose a threat to the affected person, but also to the medical staff and any other person who may have a direct bodily contact with the patient. This new delicate situation has complicated issues at many health care centers in the country. At the emergency department in the Dallas Hospital, the staff had to deal with these issues. The emergency department nurses have to coordinate closely with the emergency department physicians to ensure that patient management is done in an efficient and effective manner.
It is appropriate that in the modern society where technology has become a defining feature in communication that the management of HCA EFD has adopted emerging technologies in its communication system to help address the first point of contact communication. There is a notable confusion at the Dallas Hospital Emergency Department with the communication from its Triage Nurses to the ED Physicians. HCA EFD needs to improve, train and review its Electronic health records to improve communication. It needs to ensure that all First Point of Contact information is clearly communicated.
The HCA has thrived on leadership. It boasts of leadership as a benchmark for quality among its employees. These include physicians, volunteers, nurses, technicians and office clerks among others. HCA East Florida Division recognizes individual contributions in communities it serves.
HCA has received excellent ratings from the Joint Commission on Accreditation of Healthcare Organizations, 5 star ratings from Healthgrades, Inc. and recognition from the Leapfrog Group for Patient Safety (HCA East Florida, 2015). Amidst this leadership success, the hospital continues to grapple with the shortage of qualified healthcare professionals, specifically Registered Nurses. To mitigate this challenge, HCA has setup scholarship programs.
For the fiscal year 2013, the revenue increased from $33.013 billion for 2012 to $34.182 billion for 2013 (representing a growth of 3.5% and 3.1%, respectively, on a consolidated basis). At the same time, the hospital admission grew by 0.2 percent while inpatient surgical volumes increased by 0.5 percent, outpatient number increased by 0.9 percent and finally emergency room visits increased by 0.8 percent (HCA Holdings, Inc., 2013).
Problem or Business Need
When the ED Nurse documents First Point of Contact in the electronic medical record, there is poor communication with the ED Physician.
It is creating potential Patient and Caregiver safety issues if information gathered at Point of Entry is not effectively communicated to those caring for the patient when they are brought back for treatment.
It is imperative in the modern society where technology has become a defining feature in communication for the management of HCA EFD to adopt emerging technologies in its communication system to help address the First Point of Contact communication. It has been observed that there is confusion at the Dallas Hospital Emergency Department with the communication from their Triage Nurses to the ED Physicians. HCA EFD needs to improve, train and review its Electronic health records to improve communication. The hospital also needs to ensure that all First Point of Contact information is clearly communicated.
The management team has only lately started to review the issues with computerized communication between the Triage Nurse and the ED Physician since the incident in Dallas.
The observed problems in communication could affect several aspects of the hospital, including the following:
- Safety – safety can be compromised, for both the patient and healthcare personnel if communication is not clear and comprehensive. In the electronic world, where communication is reliant on documentation, poor communication can also equate to poor documentation that could lead to unsafe practices.
- Efficiency/effectiveness – lack of communication can impede the accuracy and prolong the time to treat a patient. Information that is gathered but not communicated usually results in repetitive queries from the patient.
- Cost – poor communication or lack of it at all can also affect the cost of treating a patient because patients can be misdiagnosed or key elements can be missed in the documentation and therefore affect billing as well.
- Patient Satisfaction/Marketing – if care was affected or delayed because of poor communication, it may be communicated that an organization is not cohesive or does not offer a high quality of care and therefore affect the public image and public trust.
Functional Areas
Human Resources – The staffing shortage leads to overworked nursing staff and may cause lapses in communication. This may also lead to inattentiveness from the electronic documentation triggers and cause lack of action from the staff, a situation referred to as alert fatigue.
HCA East Florida Division has noted that it has a challenge of finding highly qualified nurses (HCA East Florida, 2015). In the most basic sense, however, nursing shortage has become a global issue and generally widespread. As a result, the hospital faces a dangerous situation due to lack of adequate nurses who can run and care for patients and the public effectively. At present time, it is difficult to understand clearly the role of available nurses. Nursing, however, is a discrete field and independent profession whose members and professionals engage in saving and improving lives and patients’ health outcomes under different settings. In view of the truth, there is a growing gap between the roles of skilled nurses and their scopes of work. The fundamental aspect underlying causes of nurse shortage could be attributed to these many diverse roles and the growing gaps. As a result, there are poor working conditions, poor communication, inadequate resources and nurse training. In addition, nurse workforce is aging, new career options have emerged, the healthcare sectors has become more complex while health care technologies continue to change within short periods.
It has been illustrated that shortage of skilled nurses in any health care facility has critical negative consequences on patient care outcome. While nursing shortage interferes with effective communication among healthcare providers, it is also responsible for many deaths. At the same time, it impairs patients’ health and the public health.
There are many critical impacts associated with high nursing workload because of nurse staffing shortage. Research has demonstrated that nursing workload adversely impacts care, communication and patient safety. In addition, much nursing workload is also associated with job dissatisfaction among nurses and therefore high nurse turnover rates and subsequent shortages. High patient acuity has also contributed to high nurse workload. Patients expect much work from nurses, including other nurse professional roles such as running errands and performing ancillary roles.
Job demands have continued to increase. This is a situation, which has forced many nurses to leave their current employers.
Likewise, heavy nurse workload has led to increased nurse burnout and job dissatisfaction. This condition also leads to high nurse turnover.
The hospital nurses and physicians require adequate education and training on the use of emerging technologies for communication. In most instances, nurses may not possess the necessary skills and knowledge to help them run modern communication equipment and data management platforms. Consequently, they may offer poor services, including communication and patient information management. Generally, nurses with high qualification and good work environments have demonstrated better communication, information management and improved patient outcomes. Hence, lack of nursing empowerment, training and education could hamper communication efforts and information management.
Human resource issues will continue to affect communication in the hospital. At the same time, a lack of adequate resources to support nurse roles will also continue to deter effective communication and service provision. While the global nursing shortage challenge remains, it is imperative for HCA East Florida Division to train its workforce on the use modern technologies, effective communication, health care informatics and strive to resolve challenges related to poor communication at the workplace, particularly at the First Point of Contact to avoid alert fatigue.
Management – At some point, this project needs to be analyzed and assigned based on how important it is. The issue is a mission critical and therefore some leadership will be required to monitor the project as in the ED Director and the lead ED Physician. Monitoring of processes and compliance are necessary to provide corrective action to staff. There should be no narrow concentration on the other aspects of the facility at the expense of the effective communication, IT deployment and its application to facilitate change at the hospital. As noted as earlier, this is a mission critical project and therefore the hospital must avoid frequent leadership changes at the Department to ensure that the project is implemented and monitored effectively. It is therefore important to limit leadership changes that could influence the project negatively.
At the same time, the project requires ownership at the local levels. Responsibility and accountability should be clear for nurses and physicians at the local levels to facilitate implementation of the IT project. The hospital will have to define these issues at the local levels to facilitate implementation of the project elements and realization of its functionality and subsequent benefits. The Chief Executives and other senior executives have clear roles to play in this project. At the same time, the hospital should engage all stakeholders, including patients and support staff during the project implementation. These actions could facilitate information sharing and opinion gathering.
Leadership is critical for any change management process. The project should not fail because of a lack of a committed CEO and leadership from senior managers to lead hospital in the project implementation and monitoring. Leadership should focus on the culture change. In most cases, culture could hinder any change efforts. Physicians and nurses could have developed a culture of resisting changes and preferred to maintain the status quo. However, the process of assessing and addressing culture explicitly requires adequate time. At the same time, the project initiatives should not fail because of a lack of adequate time to communicate issues and address any concerns from various stakeholders.
Leaders must prepare for any potential outcomes during change management process. Change initiatives cannot always run as planned. There are various reactions from different stakeholders, external environments, and other shortfalls, which may affect the entire program. The project therefore will require constant monitoring and assessment of the overall outcomes and the ability of nurses and physicians to embrace change.
In case of any resistance, it is imperative to identify individuals who may influence change in either positive or negative manner. Such people require personal attention and persuasion to allow them to support the desired change. Leaders must get supports from such influential people in an organization. It would require building of confidence and trust in an organization. For any project implementation process to be successful, the hospital should offer rewards, promotions and any forms of recognition to project supporters.
Senior executives should focus on the project because of practical insights it provides on factors that affect strategic leadership and strategic planning, including resistance among physicians and nurses. The case is also relevant to middle level managers and subordinates who may need to understand role changes and support expected from them during the communication and information management projects. Effective monitoring and evaluation of the project will ensure that HCA East Florida Division achieves its desired outcomes in improving the First Point of Contact.
Information Technology – The First Point of Contact information is currently sent to multiple files that are on the Physicians’ side of the medical record. This information needs to available in one central location for the ED Physicians to review and any editing made to the information should be reflected to the section of the health record for easy access by the ED Physicians. Currently, there is not a central place for documenting the FPOC. It would be good if both nursing and providers have access to the screens directly from the EDM module.
The Point of Contact for communication could be a complicated system, particularly if it must be centralized. That implies that only a single entity is required to run it. Thus, IT system integrator should attempt to develop a single system need, manage development, integration and associated risks. In addition, the developer must also ensure coordination of schedules, efforts and contracting of procurement and development. That is, the system integrator would provide flexibility and acquisition of adaptable elements for Point of Contact at the hospital. The system should be integrated depending on the program under implementation. Nurse and physicians, however, should not view an integrated system as a means of losing control, creating conflict of interest and source of competition.
Currently, the hospital can modify its IT system to provide the necessary support for a centralized Point of Contact. This process may involve introducing the platform at an early stage or during modification as an architecture principle to ensure effective implementation. The current IT system should be able to support the First Point of Contact platform, but this should be done through conducting compatibility assessment in the early stages. This provides the rationale for the adoption of the First Point of Contact platform. Thus, modification must take place at the points of nurse and physician contacts, patient engagement, organizational structure and the governance. The First Point of Contact platform may not be suitable for addressing the entire IT communication system in the hospital. Instead, the hospital must only restrict the First Point of Contact platform to its intended purposes. Any system that depends on the First Point of Contact platform must ensure compatibility and any deviation must result into appropriate changes as corrective measures. The hospital IT system should offer a standardized framework for the First Point of Contact platform. This implies that the system can have a model of how the First Point of Contact platform governance works and supports both enterprise architecture and IT governance at the hospital.
The adoption of the new IT infrastructure will allow the hospital to utilize its resources effectively. For instance, costs saved from effective management of information and communication could be diverted to other projects. While HCA East Florida Division recognizes that the proposed system could experience drawbacks from other IT issues, management and human resource challenges, it should help in reducing operational costs, enhancing efficiency and improving patient health outcomes. Therefore, it is a viable option that can reduce operational redundancies and enhance information sharing across the organization for improved patient health.
Recommend Solution for Functional Areas
Human Resources – The staffing shortage leads to overworked Nursing staff and may cause lapses in communication, inattentiveness from the electronic documentation triggers and cause lack of action from the staff (alert fatigue). HCA East Florida Division requires good nurse staffing ratio. The significance of nurse staffing to the delivery of quality health care to patients cannot be understated. It has been showed that adequate nurse ratio was a critical factor in determining the quality of care in hospitals and the nature of patient outcomes (Stanton, 2004). Hence, ensuring adequate nurse staffing ratio is fundamental for the hospital and management of human resource issues.
Nurse-to-patient ratio is a critical issue within the healthcare sector. It is necessary for patient safety and quality of care. Generally, healthcare stakeholders have expressed their concerns about inappropriate nurse-to-patient ratios and staffing issues, but the issue of ratio requires input from individual hospitals and nurse unions. Several studies have indicated that nurses influence quality difference for patients in hospitals (Stanton, 2004). Insufficient number of nurses in hospitals compromises quality of care and patient safety with risks associated with poor health outcomes, costs, morbidity and mortality. Nurse-to-patient ratios demonstrate nurse leadership and its ability to promote quality care, protect nurses and patients from unsafe practices. The ratio creates a favorable working environment and enhances recruitment and retention of nurses. In addition, it is a strategy of mitigating effects of nurse shortage globally.
Physicians and nurses must focus on patient safety. Stakeholders in hospitals have regarded patient safety as prevention of any possible danger or harm to the patient. On this note, various complementary methods have been adopted to focus on patient. These methods of patient care also include electronic health information management. The focus on patient safety has been the prevention of errors and reduction of recurrence of errors. This approach has accounted for health care professionals, institutions, and patients. Moreover, patient safety approaches must also ensure that patients are free from accidents, avoidable injuries during medical care, poor communication, data management and transmission among others.
The IOM report recommends further nurse education and seamless academic progression for nurses and physicians (Institute of Medicine, 2011). It recommends that nurses should achieve bachelor’s degree and doctorate degree in the coming years. Nurse education requires support from both private and public sectors. Nurses should progress academically from diplomas to doctorate for nursing practice (DNP). The focus is to ensure that nurses have the highest qualifications for the profession.
Nurses should specialize in specific areas, develop their skills, knowledge and focus on continued training to enhance the quality of care.
There are however several impediments to nurse progression. Nurses continue to face regulatory and institutional challenges as they seek for further training, education and practice. HCA East Florida Division and nurse leaders must advocate for the removal of such barriers. For instance, advanced practice registered nurses (APRNs) have high-levels of qualification but cannot practices in some areas because of such barriers. APRNs have opportunities to improve the quality of healthcare if they are given chances to practice and embrace IT in their roles. Besides, APRNs roles and responsibilities have given them opportunities to acquire necessary skills and knowledge. HCA East Florida Division should implement the best methods to overcome nurse shortage challenges and improve their quality of health care through the First Point of Contact. The fundamental goal of nursing education therefore is to equip nurses with highest qualification so that they can practice effectively and deliver quality health care for patients as they embrace modern technologies in communication to facilitate their roles.
Management – it has been established that the project will require effective leadership at some point for effective implementation, monitoring and evaluation. Leadership, however, could be a major challenge for HCA East Florida Division, particularly when change is involved. Hence, the ED Director and the lead ED Physician must understand their leadership roles in this project. The IOM report recommends effective nurse leadership in the healthcare sector. Nurse leaders must strive to ensure improved practices with positive healthcare outcomes and information management and communication is equally important. Nurses can demonstrate their leadership abilities in decision-making processes, advocacy and take part in healthcare reforms, which also involve transition to adoption of IT for communication. These roles require competency and problem-solving abilities to overcome multifaceted challenges in the healthcare sector.
As healthcare reforms continue in the US, nurse leaders must participate at all levels and work with various stakeholders to redesign the system for solving contemporary challenges. Nurses understand current challenges in the healthcare system. Therefore, they can focus on enhancing quality of care and reducing costs of healthcare delivery. They must serve in advisory boards and influence policymaking. The IOM report has recognized the diverse American population, which requires healthcare services. Consequently, nurse leaders must understand such characteristics and prepare their teams to work in diverse environments. Nurses must work in collaboration with other healthcare stakeholders to optimize healthcare delivery, implement changes and ensure continued support from relevant bodies.
Nurse leadership must be full partners in the healthcare system so that they can take responsibilities in their areas of operations, patient management and reforms in the industry. Still, nurses require education to prepare them for leadership positions and service provision, for instance, in managing IT systems. Leadership nurturing, development and mentoring programs are imperative for potential nurse leaders. They also require a culture that promotes and values leadership development (Institute of Medicine, 2011). Nurse leadership requires nurses to take personal and professional responsibilities for their growth by developing competencies and applying them in different areas. For instance, nurse leaders must understand fundamentals of planning in wide-ranging dynamics noted in practices, education and resources deployment.
Leaders must also show their commitments to IT governance through constant communication and support. This shall also apply to the manager who would own IT governance in the hospital. Effective communication enhances IT governance in organizations. Formal ways of communication are effective than other informal channels and effective documentation of IT governance is useful in implementing a workable IT governance. Senior executives who shall demonstrate a clear lack of understanding of IT governance may show their objections to the IT governance. Thus, organizations must review their approaches and reinforce them using communication and education.
Organizations fail to include IT governance ownership and accountability in the implementation process. HCA East Florida Division should avoid this problem by ensuring project ownership and accountability at every stage of implementation. While the IT department may have the overall ownership and accountability of the system, it might delegate some roles like design, implementation and performance to other individuals for effective implementation and accountability of the process. This process requires some consideration. First, IT governance requires collaboration with other departments such as finance, human resources and other business units. This is an enterprise-wide approach to IT governance. Second, implementation of IT governance requires participation of all managers for its success, particularly the ED Director and the lead ED Physician. Third, IT implementation is an expensive process and therefore, the hospital will require reliable, compliant, cost-effective, secure and strategic IT governance for performance. This implies that the team must comprehend what IT can perform and cannot perform to the hospital mainly in relation to its First Point of Contact roles and other ancillary services. Thus, leaders who own IT governance must take responsibility and provide accountability of processes that appeal to all hospital units. In some instances, most organizations leave accountability of IT governance to their CIOs. CIOs also delegate these processes to business units and other relevant departments to ensure efficient design and implementation of IT governance. This approach could lead to implementation failure, lack of monitoring and evaluation and collapse of the entire project.
Information Technology – The First Point of Contact information is currently sent to multiple files that are on the Physicians’ side of the medical record. However, there is a need to create a single, central location for the ED Physicians to review and any edit made to the information and enhance accessibility of available patient data. On this note, the IT department has a critical role to play to ensure smooth implementation of the project.
The IT department will have to ensure that the project is implemented effectively to its completion because the success of this project will change information management and have positive impacts on the entire hospital. On the other hand, the project failure could affect the hospital negatively and lead to losses and therefore, the IT department must ensure the success of the project. The project elements will affect the IT department, innovation and training required and the need to enhance efficiency in information sharing across the company.
The IT manager, the ED Director and the lead ED Physician must ensure that the technology upgrade project is successful. The IT manager must continue to coordinate all communication activities; offer expert support when needed for IT troubleshooting; build and maintain suppliers’ relationships; manage the hospital’s database; supervise training program development; and lead the planning and implementation of all additions and modifications to the IT infrastructure to accommodate all elements of the First Point of Contact. In all these roles, the IT department must embrace change and support the whole organization to adopt the proposed communication upgrade.
A large organization like HCA East Florida Division should have IT governance at different levels of operations management. This must ensure that IT governance is an enterprise-wide strategy that depends of different units of the hospital for strategic goals of First Point of Contact to be achieved. An organization with a national presence and different IT functions in relation to departments, divisions, and geographies need different but linked form of IT governance. The hospital should derive both autonomy and synergy from these different units. Hospital units create synergy whereas top executives create autonomy through IT governance. However, top executives’ decisions regarding IT governance affect lower level of an organization. Thus, effective IT governance should focus on enterprise-wide governance due to its effects on other levels of the hospital.
Effective IT governance also depends on education and transparent processes, which should be demonstrated by employees. Employees usually have confidence in transparent governance processes.
Organizations that have effective IT governance have actively involved their top executives. Chief Information Officers (CIOs) must participate in IT governance. Other executives must also support processes and performance reviews. As a result, the hospital will accurately rely on management committees to enhance IT governance to achieve improved synergies across the entire organization. It is the role of top management to support IT governance decisions. Top management usually assists in such decisions because they are strategic goals that organizations need to deliver value to stakeholders. Thus, such decisions become strategic choices to the CEO and other senior executives.
The company should also be able to make choices among conflicting goals in IT governance. Conflicting goals need clear business principles. Conflicting goals come from different units of the business. They can lead to confusion and complex processes. This process requires involvement of key stakeholders to make appropriate choices for business goals.
Effective IT governance requires clarification of some exceptional processes. Exceptional cases challenge the status quo of the system. These requests may aim at meeting needs of the business. The hospital must develop exceptional procedures that guide requests for exceptions. The organization ensures that exception processes be clear to all stakeholders. The process is linear and eliminates all stages that can lead to delays. These exceptional requests also serve as learning points to the organization in the enterprise architecture.
Recommend Implementation Resources
Timeline for Solution Implementation
Analyze Long-term Financial and Organizational Impact
Financial Impact
By having the appropriate resources available, this will positively affect cost-effectiveness and the quality of care. The financial impacts of the project would be noted in reduced nurse and physicians’ turnover and burnout rates. For instance, it is projected that organizations can realize reduction in turnover and burnout at the rate of 18.3% per year. This is a direct cost-saving to the hospital when costs for new hires and training are considered.
There would be reduction in medical errors associated with poor communication.
At the same time, direct costs may be realized in terms of human resource compensation. If the First Point of Contact may reduce data input processes to three employees per day instead of five employees, then the hospital would cut costs on hiring more workers.
Savings realized could be estimated per hour as:
$40*2 = $ 80.
Costs saved could be directed to other important needs of the hospital.
Organizational Impact
HCA East Florida Division would develop and establish a strict guideline or a checklist to ensure that all pertinent information is communicated to all members of the healthcare team. Specific questions regarding travel, fever, and exposure need to be gathered at First Point of Contact for all patients coming to the facility for any treatment. Patients that meet these conditions need to be quickly isolated to prevent potential exposure to other patients and caregivers.
This would reduce errors, save time and costs and reduce employee burnout. Still, “pertinent information” in the documentation would enhance ease of isolation precautions, code status and possible sepsis among others.
The hospital will have appropriate tools to gather the information at the right time. At the same time, employees will receive education on communication and information management. Training of how to ask the First Point of Contact questions in a manner that is non-threatening to ensure they elicit accurate information from the patient is key to identifying the potential patients. Additional training on how to communicate effectively to the next provider(s) of care is essential to begin early diagnosis and care. Properly isolating and applying personal protection equipment (PPE) is significant in preventing the spread of diseases once identified. The above-mentioned elements are some of the few impacts that HCA East Florida Division is most likely to realize after implementing the project.
References
HCA East Florida. (2015). About HCA East Florida. Web.
HCA Holdings, Inc. (2013). HCA Holdings, Inc. – Form 10-K. Web.
Institute of Medicine. (2011). The Future of Nursing: LEADING CHANGE, ADVANCING HEALTH. Washington, D.C. The National Academies Press.
Stanton, M. (2004). Hospital Nurse Staffing and Quality of Care. Research in Action, 14, 1-12.
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