Ekici D, Cerit K, Gür E, Mert T, Türkmen S (2016) Analysis of Managerial Insufficiency in Healthcare (Sağlık Hizmetinde Yönetsel Sorunların Analizi) ISBN- 978-605-86352-2-7 (In Turkish)
The authors were prepared almost 58 case studies that based on their true stories (but changed personal names and wards etc.), analyzed and published them in a book (in Turkish Language) for education of nursing management topics such as medication error, standards of care, organizational structure, performance appraisal etc. One of these case studies is “Ignorance of the patients” which was published in this book (in Turkish language) under the page of 222-225. Until this time, we analyzed much more case studies and after analyzing all these case studies, we realized that the most important part of nursing management is the internal control step which is not using efficiently in our countries’ hospitals. On the other hand the event used as case study in this manuscript was similar with the BBC news (http://www.bbc.com/news/uk-northern-ireland-36200808).
The total quality of health care can be ensured if knowledgeable management and organizational learning can be developed. Organizational learning, the most important part of the case study, is when knowledge is shared among the staff members and the necessary interventions are made in order to solve and prevent similar problems in the hospital.
A case study which uses as an education technique, and it is a written account that gives detailed information about the real life. It is practiced on analyzing, determining and solving the problems which is adapted from the real life. Therefore, we generally utilize the case studies for nursing management education in our courses.
Importance of Internal Audits in Nursing Services: A case study (Ignorance of the Patients)
Prof. Dr. Dilek Ekici, RN, MSc, PhD
Dr. Kamuran Cerit, RN, MSc
Emel Gür, RN, MSc
Tuğba Mert, RN, MSc
Sultan Türkmen Keskin, RN, MSc
Aim: The aim is to show the importance of the kinds of controls in nursing practices with the following case study
Background: The control is the evaluation and comparison of the ongoing nursing services and their outcomes with the predetermined aims, purposes, rules, and standards of the nursing services. There are different types of internal controls, such as preventive, concurrent, and detective controls.
Methods: In this case study 5 W’s 1 H were used as a problem analysis technique
Conclusion: Nursing managers should try to analyze the problems or errors in healthcare and rectify them instead of blaming and punishing someone else. Errors in the work process can be identified, prevented, or at least remedied before causing irreprehensible harm.
Relevance to clinical practice: Nursing managers should develop effective internal control systems, including preventive, concurrent, and detective controls, in order to observe ongoing nursing activities and rectify healthcare errors or problems in the workflow.
Key words: nursing case study, nurse manager, audit, quality of care
Review of the Literature
One of the basic tasks of nursing managers is directing and controlling the nursing services of the hospital. Thus, control of the internal audits provides nursing managers with an understanding of the possible mistakes, identifies risky conditions, generalizes good practices, and enhances the management system and processes. The purpose of the control is the evaluation and comparison of the ongoing nursing services and their outcomes with the predetermined aims, purposes, rules, and standards of the nursing services (Gardner et al.2013; Ekici 2013; p:156, Donabedian 1966). There are different types of internal controls, such as preventive, concurrent, and detective controls. Preventive control is taking precautionary measures before any nursing mistakes emerge or develop. Hospitals generally use the definitions and performance standards of the nursing jobs; rules, processes, and standards of the nursing activities; distributional standards of the available resources; and recruitment, orientation, training, and developing standards of the nursing staff in order to provide preventive control. Concurrent control is periodically monitoring the ongoing nursing activities to ensure the consistency of those activities with the quality standards. These controls depend on nursing tasks and activity rules, processes, and standards. The purpose of the concurrent control is to secure the desired standards in nursing service outcomes. Although concurrent control is the precaution of possible mistakes or errors in nursing services, it also has a corrective role for the prevention of developing negative results or behaviors in nursing care. Detective control is an evaluation of the nursing services’ outcomes to confirm whether the performance meets the established standards. Detective control relies on patient care outcomes, such as patient satisfaction, the number of falls and injuries, medication errors, decubitus, extravasations, and urinary catheter infections, etc., or nursing staff outcomes, such as nurse satisfaction, the number of staff complaints or conflicts and bullying, intention to leave, turnover, etc (Ekici 2013, p:156-159).
Quality in health care can be described as fulfilling the patients’ requirements depending on previously identified standards and reaching the intentional outcomes. Written standards identify the rules, behaviors, and situations related to healthcare. Furthermore, it shows the measurable performance stage related to healthcare. Thus, all staff can provide the same quality the first time and every time at the hospital while they are delivering health services according to the identified standards, which prevents malfunctions or defaults in patient care. However, having written standards in health care does not mean that every staff member will adhere to them.
Instead of blaming the staff for not adhering to the standards, determining the reasons why individuals are practicing other workflows, interrogation of the upper and middle level managers for not concurrently and periodically controlling the processes, and evaluation of the organizational culture is advisable to shed light on the issue. For these reasons, it is important that nursing managers observe, correct, and control clinical nurses while they are delivering patient care and give feedback on their activities to identify the risks in healthcare in order to prevent mistakes. Thus, errors in the work process can be identified, prevented, or at least remedied before causing irreprehensible harm.
In the literature, there have been many studies presented about detective control in nursing services (Heslop and Lu 2014; WHO Patient Safety Research 2012; Montalvo 2007). However, many nursing managers in Turkey still do not regularly control nursing services in order to assess the deliverance of nursing care and evaluate the outcomes (Ekici et al. 2016). Hence, they are unable to realize errors in the workflow and process (Ekici et al. 2016). Therefore, here, the aim is to show the importance of the kinds of controls in nursing practices with the following case study. The total quality of health care can be ensured if knowledgeable management and organizational learning can be developed. Organizational learning, the most important part of the case study, is when knowledge is shared among the staff members and the necessary interventions are made in order to solve and prevent similar problems in the hospital.
Study Design and Methods
In this study a case study was discussed and analyzed with 5 W’s 1 H as a problem analyze technique. Thus there is not needed any approval from intuitional review board.
Ignorance of the Patients
Nurse E was promoted to the position of nurse supervisor after working as a clinical nurse in a hospital for four years. While one of the nurse supervisors accompanied her and gave an orientation during the first four weeks in her new position, she continued her work alone after that. There were 28 clinics in the hospital and each of the nurses worked an 8-hour day shifts and a-16 hour night shift. When nurse E came on duty for one of her 16-hour night shifts, her manager said that the clinics had been very busy and they had had a hectic shift that day. Thus, she started her visits to the clinics early in order to plan support for the clinics sufficiently. When she arrived at the neurology ward, she saw that the corridor of the ward was very crowded. The crowd consisted of patients who were waiting to be admitted to the neurology clinic and the relatives of the patients who were waiting to be discharged. She looked for the clinic’s nurses among the crowds but was unable to find them. After searching for the nurses in the patients’ rooms, she finally found them in the medication preparation room. They were preparing the medication for the upcoming shifts. Supervisor nurse E asked them what they were doing and one of them replied that because the shift felt so long, they were preparing the medication in advance (12 and 16 hours) to make the upcoming shifts easier. Nurse E asked them if they were aware that there were patients who were waiting in the corridor and why they were left waiting there. One of the nurses, F, replied, stating that they were not able to manage their admission to the ward because the beds had been occupied by patients needing to be discharged. Supervisor nurse E asked them why the patients had not yet been discharged, to which nurse F replied that the pharmacy accounts of the discharging patients had not yet been closed so the hospital’s information system would not allow them to be discharged from the hospital. Therefore, they have been occupying their beds and waiting for the finalization of the discharge process. Supervisor nurse E asked them if they had discussed this situation with the pharmacy department and had the doctors informed their patients of the situation. She asked which of them was responsible for the patients who were waiting to be admitted. The nurses replied that the situation was not their concern and that the clinic’s doctor was responsible for the patients. Supervisor nurse E angrily informed them that there were some patients in the corridor who had serious illnesses, yet there the three of them were, unnecessarily preparing medications in advance of the upcoming shifts, which did not comply with medication safety standards. In the meantime, the clinic’s doctor arrived and said that he had called the pharmacy department and they were unable to find the discharge patients’ drugs, which had been sent by the clinic nurses. They were waiting for the remaining unused drugs from the nurses in order to credit them to the pharmacy account. Nurse F told the doctor that they had been informed by the day shift nurses that all of the discharged patients’ drugs had been sent to the pharmacy and all of the processes connected to the nurses were completed. Supervisor nurse E then instructed one of the nurses to phone someone on the day shift and inquire about the situation. Nurse F called a staff member who was responsible for running errands in the ward and asked if he had delivered the remaining discharge patients’ drugs to the pharmacy. First, he stated that he had returned the drugs to the pharmacy department, but then he immediately changed his statement and said that while leaving the clinic on his way to return the drugs, a relative of a patient asked him for a clean bed sheet, because the patient had thrown up in her bed and the sheets needed changing. Hence, he thought that he might have forgotten the drug box in the sheet storage room. At the same time, a relative of a patient who had been in the corridor waiting to be admitted shouted for help because he felt that his father was dying. The clinic’s doctor and nurses ran through the corridor to find a patient who was suffering from a cerebral vascular obstruction. The patient had lost consciousness and his condition was quickly becoming much worse. After taking his vital signs, it was concluded that he had lost consciousness due to hypertension and medical intervention was started immediately, with the patient being transferred to the intensive care unit (ICU). Meanwhile, Nurse F retrieved the drug box, which had in fact been left behind by the staff member in the sheet storage room, and gave it to another staff member for immediate delivery to the pharmacy department.
The condition of the patient who had lost consciousness and had been transferred to the ICU had worsened, and his relatives, who had been waiting in front of the ICU, were very anxious and nervous. When the doctor came to check on the patient, the relatives angrily informed him that they had been waiting for admittance since morning, and that if anything more serious should happen to the patient they would sue him. The doctor replied that admittance had been delayed not because of him, but due to the clinic’s nurses and their failure to return the remaining unused discharge patients’ drugs to the pharmacy department. Hence, he felt that he held no responsibility in this situation. After hearing the doctor, the crowd waiting in the corridor angrily headed towards the clinic’s nurses and started to shout at them, asking why they had not done their jobs correctly, as they had neither taken care of the relatives nor the patients. The nurses were nonplussed and tried to defend themselves. When Supervisor nurse E saw that the nurses’ responses were making the situation worse, she introduced herself to the crowd, gave an apology, and tried her best to calm them. She assured them that she would personally be informing the chief nursing officer of the problem in the morning and that the nurses responsible for the situation would absolutely be reprimanded as soon as possible.
Diagnoses of this problem: Since the discharge and admission process had not been completed in a timely manner, a patient who had been waiting in the corridor had to be admitted to the ICU because he had lost consciousness and his condition worsened.
Problem analysis technique: 5 W’s 1 H
While a staff member was in the process of transporting the remaining discharge patients’ drugs to the pharmacy department, a patient’s bed sheet needed to be changed so he went to the sheet storage room and then accidentally forgot the drugs there. Therefore, because the discharge patients’ remaining drugs had not been sent to the pharmacy department when they should have been, the patient discharge process had not been finished in a timely manner. The nurses who had been working on the day shift had not realized this, so they continued on with the discharge process, thinking that the drugs had been delivered as usual, causing them to relay incorrect information about it to the nurses who would be working the night shift. When the clinic’s doctor could not complete the patients’ discharge process on the hospital information system, he called the pharmacy department. The staff member who was working at the pharmacy department checked the records and informed him that they had not received the remaining drugs so they would not have completed the discharge process steps. The doctor then found the nurses and informed them that the remaining drugs had not been returned to the pharmacy department so the discharge process wouldn’t have been completed. The nurses finally learned the truth about the drugs after calling a member of the day staff, but by that time, one of patients who had been waiting for admission had a worsening change in his condition, so he was sent to the ICU. After an explanation about the situation was given to the patient’s relatives, they started to accuse the clinic’s nurses of being responsible for the poor care their relative had received.
When did it take place?
After changing shifts at the clinic, from the day shift (from 8:00 am to 4:00 pm) to the night shift (from 4:00 pm to 8:00 am).
Where did it take place?
In the clinics’ corridor.
Who was involved?
The clinic’s doctor, the clinic’s nurses, the staff member who was responsible for errands at the clinic, the staff members who were working in the pharmacy department, and the patients and their relatives.
How did it happen?
- With the use of functional nursing at the clinic as the nursing care delivery model, nobody has responsibility to follow and complete the discharge process steps. Therefore, nobody realized that the pharmacy department had not received the discharge patients’ unused drugs so it was impossible for them to promptly complete the process steps.
- The night shift nurses did not feel any responsibility for either the patients waiting to be discharged or those waiting to be admitted, so they simply ignored them.
- They did not have any discharge workflow so they could not follow the process. It is understood from this case that neither the upper level nor middle level managers (including the supervisor) monitor or control adherence to the process in the hospital.
- The night shift nurses were preparing medication for the upcoming shift, during their shift, to make the upcoming shift easier. We can infer that the hospital has not had a medicine preparation standard as a preventive control. Or, neither the upper level nor middle level nursing managers monitor or control adherence to the standards in the hospital beforehand as a concurrent control.
- It was understood that the nursing managers had not measured the outcomes of nursing care, such as medicine errors and patient satisfaction, with nursing care as detective control. At no level had any of the nursing managers felt any responsibility to identify the problems of nursing care and make necessary preventive intervention for the problem.
- The middle level nurse manager (supervisor) and the clinic’s doctor started to look for a fall guy for the problem they experienced instead of analyzing and identifying the main reasons for the problem. It can be inferred that if there was a problem or trouble with the workflow, the staff look for someone to blame because of the hospital’s culture.
Solving of the problem
- Instead of functional nursing care, holistic nursing care must be used as the nursing delivery model so every patient in the ward has a nurse who is responsible for their care. The patients’ workflow can be followed strictly by their nurse who is responsible for their care on that shift.
- The discharge workflow steps must be defined in the hospital as preventive control in order to follow and identify the obstruction of the process easily.
- The most important risks involved with the preparation of medications for upcoming shifts, 12 or 16 hours in advance, is that the nurses are using valuable time, and mixing the patients’ medicine and tainting the diluted medicine contentment. In order to prevent the risks and reduce medicine errors in the hospital, a medicine preparation standard must be defined as a preventive control and nursing managers should monitor the nurses’ adherence of the standards periodically as a concurrent control.
- An assessment of the nursing managers’ performance connected with the outcomes of the nursing care is necessary as a detective control for the upper level hospital manager. The nursing managers have not measured the outcomes of nursing care because they have not had an assessment of their job performance by their bosses. A performance appraisal system could be designed for nursing managers and nursing service in the hospital according to nursing care.
- When experiencing any problem or trouble with the workflow the reasons for the problems should be analyzed and identified. Next, necessary preventive interventions should be implemented so as to not experience similar problems with the workflow in future, instead of blaming someone. Therefore, it is necessary to change the culture of the hospital to identify the reasons for the problem instead of finding someone to blame.
It is important to use a holistic nursing care delivery method instead of functional nursing at a hospital to prevent nursing care errors and problems. Nursing managers can identify and decide which nursing care delivery models will be performed in the clinics, so holistic nursing care methods should be the preferred choice. Moreover, hospital managers should develop effective internal control systems, including preventive, concurrent, and detective controls, in order to observe ongoing nursing activities and rectify healthcare errors or problems in the workflow. Nursing managers’ performance appraisal should be measured according to the concurrent and detective controls of nursing service and new performance goals must be identified according to the performance results. Thus, nursing managers should try to analyze the problems or errors in healthcare and rectify them instead of blaming and punishing someone else.
Implications for Practice
Finally, regarding the above case, the hospital managers and staff members developed and refined analytical skills for solving similar problems in their work or workflow errors. The total quality of health care can be ensured if knowledgeable management and organizational learning can be developed.
- Ekici D, Cerit K, Gür E, Mert T, Türkmen S (2016) Analysis of Managerial Failures in Healthcare (Sağlık Hizmetinde Yönetsel Sorunların Analizi), Sim Press, Ankara.( in Turkish)
- Ekici D (2013) Total Quality Management of Health Service (Sağlık Hizmetinde Toplam Kalite Yönetimi), Sim Press, Ankara (in Turkish)
- Donabedian A (1988) The Quality of Care: How can it be assessed? JAMA 260 (12): 1743-1748.
- Heslop L and Lu S (2014) Nursing sensitive indicators: a concept analysis, J Adv. Nurs. Nov70 (11): 2469-2482.
- Mert T, Ekici D(2015) Development of an Assessment Model for Evaluating the Performance of Nursing Services, International Journal of Hospital Research, 4(1), 9-14. click here for details
- Montalvo I (2007) The National Database of Nursing Quality IndicatorsTM(NDNQI®)” OJIN: The Online Journal of Issues in Nursing 12 (3), Manuscript 2.
- World health Organization (WHO) Patient Safety Research, A guide for developing training programmes, retrieved March 25, 2016 from http://apps.who.int/iris/bitstream/10665/75359/1/9789241503440_eng.pdf