Read a selection of your colleagues’ responses and respond to at least two of your colleagues on two different days. Provide feedback explaining insights you gained about the potential use of systems thinking by registered nurse leaders at the macrosystem level to meet IHI’s Quadruple Aim. Use your Resources and outside literature to support your response. WRITE A RESPONSE
Week 3 DB
Systems thinking, in my own words, is a system in which all the variables come together in an interconnected manner to achieve the system’s goal. It is a system of identifying a goal, finding its parts, and exposing the interconnections between them. Arnold & Wade (2015) describes system thinking as a “set of synergistic analytic skills used to improve the capability of identifying and understanding systems, predicting their behaviors, and devising modifications to them to produce desired effects. The skills work together as a system”.
Macrosystem-level Transition of Care
The transition from hospital to nursing home is a macro-system level transition of care that many people experience when they have been admitted to the hospital. Hospitals transition people to nursing homes because these patients aren’t back to their baseline and would not be able to support themselves at home. The goal is in the name: Nursing home. Nursing homes are set up like homes but provide 24/7 nursing care. It is the transition from the hospital to the patient’s home. The patients going to nursing homes are still ill, however, and without careful treatment and monitoring will end up back in the hospital. Caruso, Thwin & Brandeis (2014) identified barriers to the transition. The hospital provider’s recommendations were not followed when the patient was transitioned, resulting in higher readmission rates for the patient and the hospital. Two points of the continuum in this transition are discharged from the hospital and the nursing home receiving the patient with discharge instructions. Britton et al. (2017) identified barriers to an uncomplicated seamless transition to skilled nursing facilities. Four themes emerged from the study: increasing patient complexity, determining an optimal care setting, rising financial pressure, and barriers to effective communication. Patients come from the hospital to nursing homes sicker than they were years ago, on multiple medications and specialized medical equipment, constantly teetering on needing hospitalization. This is very challenging for nursing home staff and requires more technical and time-consuming care for the patient.
The quadruple aim focuses on improving the health of populations, enhancing the experience of care for individuals, reducing the per capita cost of healthcare, and finding joy in work (Institute for Healthcare Improvement, 2019). Transitioning from a hospital to a nursing home can be complex, with many breakdowns that negatively impact the patient and healthcare. Nurse leaders in both facilities need to focus on improving communication. Local hospitals should help invest in electronic health records (EHR) for nursing home facilities. A compatible EHR between the two entities will enhance communication, and healthcare providers between the two organizations can share essential information about the patient. Investing in a compatible EHR will reduce the per capita cost of healthcare and make nursing care more efficient and individualized. Another measure to improve the transition to nursing home care is a tighter integration of social work and general medicine services to address better the patients’ needs (Britton et al., 2017). Increased support from adjunctive disciplines will help transition the patients from the hospital to the nursing home.
Arnold, R. D., & Wade, J. P. (2015). A definition of systems thinking: A systems approach.
Procedia Computer Science, 44, 669-678.
Britton, M. C., Ouellet, G. M., Minges, K. E., Gawel, M., Hodshon, B., & Chaudhry, S. I.
(2017). Care transitions between hospitals and skilled nursing facilities: Perspectives of
sending and receiving providers. Joint Commission Journal on Quality and Patient
Safety, 43(11), 565–572. https://doi.org/10.1016/j.jcjq.2017.06.004
Caruso, L.B., Thwin, S. S. & Brandeis, G.H. (2014). Following up on clinical recommendations
in transitions from hospital to nursing home. Journal of Aging Research, 2014.
Institute for Healthcare Improvement. (2019). The triple aim or the quadruple aim? Four points
to help set your strategy. Retrieved from https://www.ihi.org/communities/blogs/the-