8-1 Case Study: Ladder of Influence
Mia is the oldest of six children from a two-parent family. She was diagnosed with osteosarcoma of the left leg and was experiencing intractable pain. She received her diagnosis at 15 years of age under the care of a pediatric oncologist at a local hospital. Mia underwent months of radiation and intensive chemotherapy. Mia’s community nursing team was struggling to meet her needs and referred her for palliative care services through a local home care agency.
Her parents had a complex history of substance abuse and domestic violence, and Mia had a difficult relationship with both, although recently she has become close to her mother who has attended most of her chemotherapy treatments.
During one episode of severe uncontrolled pain which required that Mia be transferred by ambulance to the emergency department, she noticed all of the nurses except for one being attentive and kind. Mia overheard the nurse saying:
“I don’t know why her parents bring her here… We can’t meet her needs and we are short-staffed…”
The conversation Mia overheard was incomplete, which left her to draw her own conclusions. The whispering nurse was actually the charge nurse who was in the midst of planning staffing for a pending snowstorm. Her complete statement is as follows:
“I don’t know why her parents bring her here. The home care nurses should be addressing pain management issues with her oncologist in a more timely manner so that Mia can remain in her home for treatment. If we had available resources to address Mia’s pain, we could plan to make her stays in the emergency room more comfortable. I wish that we could meet her needs better and in a timelier manner. I feel frustrated that once again we can’t meet her needs more effectively. We are short-staffed, and that shortchanges Mia.”
Upon Mia’s mother’s return to the bedside, Mia begs her to take her home, even though the pain medication has had little effect in relieving her pain. Throughout the ride home, Mia becomes increasingly sullen and tells her mother she doesn’t ever want to go back to the emergency room for care.
Using the Ladder of Inference Worksheet (Nelson text, page 300), fill in the information on Mia’s Ladder of Inference.
Course Objectives Met By These Cases:
1.Define, identify, and assess clinical microsystems.
2.Summarize strengths and improvement opportunities.
3.Utilize the Dartmouth microsystem Improvement Curriculum to support improvement.
4.Identify leadership actions that support front line improvement.
Program Outcomes Met by This Assignment 1.Synthesize and apply theories and conceptual models from nursing and other related disciplines to facilitate clinical practice decision-making.
2.Integrate the use of communication skills, information systems, and standardized language in relation to clinical outcomes and continuous performance measures.
3.Develop collaborative interdisciplinary relationships and partnerships to improve the health care of the cohort population.
Part 3: Using Measurement to Improve Health Care Value *Milestone Reminder:
The next step of the course project is to utilize the Clinical Value Compass (CVC) (unit of analysis is the patient or population) to describe a balanced approach to measure and display health care in the microsystem that you have designed to meet the needs of patients with a chronic care condition. For this assignment, you must include a dia-gram of Side A and Side B of the Clinical Value Compass (Nelson, et al., Chapter 4, pages 156-157) for your proposed clinical microsystem. In addition, you must complete a Balanced Scorecard, which should provide measures to assess if the system is meeting the members’ needs while matching up with the strategic plan and larger organi-zational vision. The discussion portion of this assignment should include an explanation of the four points of success including:
1.Strategic learning and innovation. To achieve your vision, how your microsystem will sustain its ability to change and improve as fast as care needs require?
2.Key processes. To satisfy healthcare consumers, what key processes must your microsystem perfect?
3.Customers’ view of goodness. How should your microsystem appear to customers? Does the microsystem instill feelings of honesty, competence, and integrity?
4.Financial Results. To succeed financially, how should your microsystem appear to shareholders and board members?
This chapter of your course project should be 4-6 pages in length and contain a minimum of 5 scholarly references that describe principles of measurement in clinical microsystems.