Assignment Task
Healing Haven Hospital Case Study
The following hypothetical case study has been developed in conjunction with senior healthcare executives and managers that have held and currently hold clinical, corporate and academic roles.
Introduction to Healthy Hospital (HH)
Healing Haven Hospital (HHH) is an acute public hospital located in Australia. It provides emergency, medical, and surgical services, mental health, drug treatment and community health. HHH is accredited against the National Accreditation Scheme. Comprising of 950 beds, HHH is responsible for delivering surgical, diagnostic and therapeutic procedures to a catchment area of a fast-growing population of approximately 1 million people. The original facility is over 30 years old, with several additions and upgrades over that period to accommodate the expanding demand.
The demographics includes a high proportion of Aboriginal and/or Torres Strait Islander peoples and culturally and linguistically diverse communities (CALD), including refugees. Residents live in medium and high-density housing, where there is high rental demand. New housing estates are being developed and there is a growing network of infrastructure projects including major roads, public transport and a regional airport. A university has recently opened a new campus within walking distance of HHH, with placements for medical, nursing and allied health students being offered.
The facility is one of seven that belong to a local health area (Area) and is the major referral facility for the region. The facilities general manager and leadership team report to a central administrative management system, operating within a matrix structure. Each facility is run by a General Manager (GM) that reports to a Chief Executive Officer (CEO). The Area operates under a governance scheme where there is a Board comprising of a chairperson and 15 members from the local region that represent various organisations, communities and interests.
Overview of General Ward (GW)
One of the largest department’s in HHH is the General Ward (GW). Comprising of 40 beds, the department is split into two sections with 20 beds per section. Each section has its own manager however the managers often work across both sections with staff expected to report to multiple managers. Patients present with a variety of conditions and typically stay in GW for 5 days. There are clinical placements of medical, nursing, and allied health staff in GW.
The department’s built environment is currently undergoing a redevelopment, including new patients’ beds, updating of staff desks, new paint and technology upgrades. The unit has a large kitchenette in one section and a smaller coffee/tea/water station in the other section. There are signs that these facilities are only for staff use, however patients and their visitors regularly use these. A shared tearoom for both sections is close to the elevator, however, is yet to be redeveloped, is leaking in parts and is not regularly utilised. Most staff choose to eat lunch at their desk or the HHH staff cafeteria, located two levels up. There are two meeting rooms, however the smaller room has an air-conditioning system that works sporadically, and the larger room is often booked by education convenors and other department meetings. There is a roll out of new desktop computers in the shared workspace between the two sections.
There are 120 staff that work in the GW. Of these, 65% are full time and 35% are part time or casual. The professional breakdown is as follows: 86 are nurses; 15 are allied health; 15 medical including registrars, interns and specialists; and there are 4 admin staff. Across all disciplines, 45% of staff are from a CALD background whilst the area population is 60%. Only 1.5% of staff identify as Aboriginal and/or Torres Strait Islander peoples, whilst the area population is 4.5%. Operational staff across all disciplines typically work in the GW for approximately 18 months and move to positions in other departments within HHH or to other nearby facilities. Managers in GW typically stay in their positions for 10 years or more. The average age of operational clinical staff is 26 and the average age for management staff is 56. In addition to the mandatory training required for all clinical and corporate staff under the Health Services Act (HSA) of the Region, professional development opportunities are available. An in-house leadership institute for all HHH is available for training in management and leadership skills to be able to step up into more senior roles. Additionally, tertiary opportunities in clinical, management and research training are available, however few staff from GW enrol in any of the workshops and mentorship programs. If staff do enrol, they are not supported to utilise available study leave and are told by GW management that they must use their own annual leave entitlements. If staff choose to use their own annual leave and request sign off to enrol in the Area supported courses, they are usually unable to find a manager to provide the sign off as during a shift, across all disciplines, the manager delegated changes with staff often expected to be reporting to two managers.
The increasing reports of incidences
Recently, HHH has been featured in the media with patients and anonymous staff reports about critical incidents, poor complaints handling and general cleanliness concerns. A preliminary internal investigation by the Governance Unit (GU) has flagged GW as one of the departments that have received high levels of criticism. The criticism is directed towards
incidences that have been poorly addressed. Upon review of 24 months of data from the Incident Reporting Management System (IRMS), there are red flags due to incomplete and inconsistent reporting of the incidences in the IRMS and complaints made to the GM of HHH about specific events. The GM has invited you to be a member of an independent Review Team (RT). Your expertise from a different organisation, service, or sector provides a new perspective on the management challenges which are acknowledged as common problems across all healthcare organisations. The RT has been asked to spend some time at the GW to interview staff as well as observe how the department functions.
Observation and reporting
The RT spent one month at the GW, speaking with patients and their families, staff, and contractors. Observation of interactions also took place, as well as a review of department level data including frequency and types of meetings, training sessions, logbooks, and paper/electronic patient record systems. Upon review of the data collated, several reoccurring themes emerged.
The majority of staff, including clinical and corporate, protest about the mandatory training that they need to attend. It is difficult to recruit part-time and shift workers as they are expected to complete the same amount of training as full-time workers. These part-time workers often work at several facilities in both public and private settings and are expected to complete the mandatory training at each facility. Medical staff in particular complain about the training, and the educators have shortened the sessions as a result of the feedback, however attendance and participation are still lagging behind other departments.
Several prescribing incidents have arisen with medical and nursing staff debating who should be responsible for the entry into IRMS. Approximately 15% of the IRMS over the past 12 months are medication errors relating to prescribing. The Nursing Unit Manager (NUM) on duty eventually enters the incident into IRMS, however these reports are incomplete as the NUM does not have the clinical expertise or details about specific incidents to document all the information. The NUM also cannot make any changes because the reporting and authority lines over medical staff only allow medical staff to make these changes. Food related issues are often referred onto dietitians and speech pathologists but are the responsibility of the food services. There is often tension between the dietitians and speech pathologists over scope of practice issues. The dietitians feel all dietary and nutrition referrals should be their domain, but the speech therapists feel that they can also address these concerns. The head of allied health has raised this as a concern at every weekly staff meeting for the past 14 months. Scheduled regular meetings between the Medical Head of Department (MHED), nursing unit managers, allied health and corporate management have been sporadic for 18 months.
Collection of blood samples and other diagnostics is problematic as the porters on the ward are sent from temping agencies, with large numbers of new members of staff needing to be trained. Blood samples have been frequently misplaced, and bloods need to be redone. This increases the number of invasive procedures, the risk of infection, and costs associated. Patients then remain in the ward for longer periods than initially discussed with the patient and family. These increased lengths of stays are resulting in escalating anger from patients and carers and blame is being directed towards staff. Porters are regularly sent from the imaging department to collect patients; however, the patient is often in a medical consultation, having a shower or at rehabilitation in another department.
Medical rounds occur every morning at 8 am and 7 pm at night, with doctors and nurses holding their own meetings. Allied health clinicians do not participate in or attend either of the rounds as they typically are scheduled to work between the hours of 9 am – 5 pm. There is a logbook where communication issues and other concerns can be written for staff to be aware of, however this logbook was lost when the redevelopment of the tearoom began. When clinical issues do arise, staff tend to communicate with one another using medical notes rather than also communicating verbally with each other about the issues.
Porters have identified the staff in the GW as the most difficult department personnel to interact with, and as a result it is given the lowest priority. Since the redevelopment of the department and the updating of the flooring, staff have had more workplace accidents such as there has been more frequently tripping. This is reflected in the IRMS reporting which has indicated in the increase of falls related incidents. The reporting of workplace injuries, comprising predominantly of falls, back injuries and stress leave, are increasing at a rate of 10% per year. There are 10 active workplace bullying claims that are being investigated with 8 of the cases amongst the nursing discipline. Staff across all disciplines warn new staff not to trust any of the management staff with confidential, personal issues as these are often shared amongst managers who are heard to mock staff personal circumstances during the managers meetings. Staff working in the GW have a higher-than-average sick leave rate compared to the rest of the HHH.
The majority of the IRMS (80%) in the past 12 months have been reported by nursing or allied health staff. If a medical clinician does not want to report an incident in the IRMS, then all of the medical staff form an alliance to support the doctor. When the medical staff do input into IRMS (5%), it is usually by a registrar training under the doctor in charge in the department when the incident occurred, with little detail reported and/or reported usually several days later. The nursing staff will ensure that other nurses are compliant with incident reporting, and the reports made by nursing staff heavily feature names of other staff members and use emotive language. The allied health staff usually discuss in a group why the incident occurred prior to
adding the detail of the incident to the reporting system. Overall, there is a tendency to use the ABC model in reporting of IRMS – Accuse, Blame and Criticise.
There is a divide between those in operational and management space, where each group discusses the other using less than positive terms. Those without formal management roles are excluded from any discussions and subsequent decisions about ward related changes such as staffing and resourcing requirements, training needs, redevelopment of the built environment of the ward, and end of year celebrations. When staff express dissatisfaction about this approach, managers have been heard to frequently point out all staff must go along with decisions made by management or point in the direction of the door. Additionally, there is ongoing tension between staff about professional roles and duties. The nursing and allied health staff have been debating about tasks within the department and do not always agree about professional boundaries and where tasks sit. At least 35% of patients require social work and or counselling support during their stay at GW and after discharge, however these are given a lower priority over other tasks that are considered more clinically relevant. Social workers feel that they should be contacted regarding any psychosocial issues, but clinical psychologists feel that social workers are taking over their area of expertise. The tension between these two groups is growing over professional boundaries and scope of practice. The doctors have been asked to weigh in, however they are hesitant to do so as they do not want to get involved in the disagreements about roles and tasks between other disciplines.
The junior medical staff are informally discussing feeling unsupported, isolated, and overworked. They do not, however want to lodge formal complaints for reputational fear of being labelled as being problematic. They are heeding the advice from interns who have previously worked in the GW to stay quiet, finish the rotation and move on when they can. The 4 administrative staff are all supportive of one another, often socialising outside of work hours. They have however indicated they are looking for other roles because of the tension within GW. They have also discussed their workload with other administrative staff in other similar departments and feel that the workload they are asked to undertake is not consistent with standard workload expectations or role descriptions.
Medical officers tend to organise patient discharge without consultation of the other clinical disciplines. This often leaves nursing scrambling to complete activities such as ensuring pharmacy department receives a discharge prescription in time for a pharmacist to dispense and a healthcare member of the team is available to counsel the patient in preparation o discharge them on time. It also means that allied health assessments are incomplete, or referrals come to allied health one or two days before discharge for chronic issues such as long-standing anxiety or depression. The Area has a well-developed integrated care program that has received local and international recognition about the merits of the program. However,
the managers of the GW do not feel that care beyond the ward level is within their practice and refuse to engage with the integrated care team and program. Staff are frustrated that although GW ethos claims to deliver holistic healthcare, the focus remains primarily on medical issues. The flow from ED into the ward is unpredictable and causes conflict, with bed management in the ward increasingly difficult to proactively manage. Setting up beds for new patients is often disorganised, with environmental staff complaining they are not given enough notice to clean the beds and surrounding areas.
As well as the incomplete and inconsistent entering of information in IRMS, the escalation of these issues to the GM of HHH has not occurred. Additionally, the tension between staff and lack of engagement by staff in professional development opportunities has not been flagged. When the GM asked the heads of department why the staff were not being supported to enrol in mentoring and other professional development programs, they were informed that there was not much leadership potential in the department. The heads of department have frequently been overhead stating that the newer cohorts of interns and trainees do not have the same work ethic as those in management roles and that they are lazy because they expect to be remunerated for any additional work hours and will not take additional work home to complete outside of paid hours and duties. When the GM last visited the HHH approximately five months prior to the review, they were told that aside from the need to recruit more full-time, permanent staff, things were running smoothly.
Future directions
The GM has decided that based on the initial report of the review team, that further assessment is required to address the issues occurring in GW. You are required to undertake this work. Review the three assessment tasks available in the Course Outline and on Moodle. Across the three assessments, your task will be to analyse crucial factors within the healthcare team that contribute to the internal environment (Assignment 1), critically evaluate interprofessional team collaboration (Assignment 2) and identify evidence-based recommendations for how interprofessional team practices can be improved (Assessment 3).
