Introduction to the Organization
Saint Mary Medical Center is a 495-bed medical center located on the near Northwest side of Chicago. Formerly known as Saint Mary of Nazareth hospital the structure located between Chicago’s Humboldt Park and Ukrainian Village, is part of the dual campus of Saints Mary and Elizabeth Medical Center and has been a presence in the community for over one hundred years. St. Mary was recently purchased by AMITA Health from the Presence health network, and this culture analysis will focus solely on the St. Mary Campus This purchase brings St. Mary into the integrated health system of AMITA Health, a joint venture between Ascension’s Alexian Brothers Health System and Adventist Midwest Health, part of the nation’s largest non-profit health system and the largest Catholic health system in the world (“Presence Health Now Part of”, 2018) In 2019 St. Mary gained American Nurse Credentialing Center (ANCC) Magnet recognition and has enjoyed recognition from The Leapfrog Group with 10 consecutive Leapfrog A’s for patient safety.
Mission and Values
As a Catholic institution St. Mary’s mission is to “extend the healing ministry of Jesus, and to embody the messages of love and compassion modeled by Christ with a legacy of healing the sick and caring for the poor and vulnerable.” (Amita Health, n.d.) This mission is manifested in the institutional values of justice, dignity, integrity, compassion and god honoring. These values are clustered around caring for the whole person, not just the physical symptoms that brought the patient in for care.
Care Delivery
The above values are executed by a care delivery model that incorporates internal and external experts as resources, partnering with patients and family, utilizing a personalized plan of care, ethical decision making and resource utilization, fiscal responsibility, and patient satisfaction. St. Mary utilizes the care model of team nursing, according to MacPhee, M., & Havei, F. (2018), team nursing utilizes a group of people led by a knowledgeable nurse, called the team leader. This model strengthens the care delivery tenets that are nurse specific including autonomy in nursing, nursing job satisfaction, and nurse sensitive indicators. The end goal of the delivery system and included in the care delivery model of St. Mary is patient satisfaction.
Delegation
When delegating tasks St. Mary utilizes the American Nurses Association and National Council on State Boards of Nursing “five rights of delegation” and their delegation decision tree, the five rights include: the right task, under the right circumstances, to the right person, with the right direction and communication, under the right supervision and evaluation. (ANA, NCSBN, 2005) At St. Mary the delegation of routinely scheduled vital sign checks on stable patients is delegated to certified nursing assistants, patient care technicians, or mental health counselors depending on the unit. This delegation is appropriate in stable patients according to the ANA and NCSBN, because “the process frequently recurs in the daily care of a client or group of clients; Is performed according to an established sequence of steps; Involves little or no modification from one client-care situation to another; May be performed with a predictable outcome.” (ANA, NCSBN, 2005) In addition, no assessment is required for daily vital sign completion, and the onus of follow-up for outside of normal limit vital signs lies not upon the unlicensed personal, but the nurse who delegated the task.
Performance Appraisal
The performance appraisal at St. Mary is a process for the employee to hold themselves accountable to the organization, the profession, and the community it serves. The hospital utilizes a three-tiered performance appraisal process. Once a year two registered nurses (RN) complete peer reviews, those peer reviews are then reviewed with the unit manager and mutual goals are set for the year based on this feedback, at the end of the year a self-evaluation process is completed. In addition, monthly clinical peer-reviews are completed on key nursing sensitive indicators on each unit such as restraints, catheter associated urinary tract infections, falls, and several other key quality indicators.
Organizational Culture
There are many aspects to analyzing a large interdisciplinary organization and the culture of an organization isn’t always easily quantifiable. A framework from which to analyze an organization must be utilized for comparison to other similarly sized organizations and to seek to understand the more abstract elements of an organization’s culture. As a recent recipient of Magnet designation, the ANCC Magnet model will be the framework from which St Mary’s organizational culture will be analyzed. This framework consists of transformational leadership, structural empowerment, exemplary professional practice, new knowledge, innovation, and improvements, and empirical quality results.
Transformational Leadership
Transformational Leadership defined by Huber (2018, pp 13) “is a leader who motivates followers to perform to their full potential over time … by providing a sense of direction. Transformational leaders grow and develop others by empowering them.” Transformational leaders create foundations that bring the mission, vision, and values to life. At St. Mary the chief nursing officer (CNO) aims to develop a work environment that encourages nursing excellence at all levels by working with staff and senior leadership to create and nurture a shared vision, challenging existing systems, and proposing strategic, creative solutions. The CNO works with staff nurses to develop a nursing strategic plan and makes sure it aligns with the organization’s strategic plan.
Formal and Informal Leadership.
As noted above the CNO plays a crucial role in motivating and leading nurses and influences the organization at large to support nursing led goals and initiatives. The CNO is charged with developing and nurturing a work environment that encourages nursing excellence and leads through planned and unplanned change. In addition to the role of the CNO, nurses hold several roles in senior leadership including but not limited to chief risk officer, director of behavioral health, and nursing innovation.
Informally nurses hold several leadership roles including chair and co-chair positions in structural empowerment councils, charge nurse, preceptor, and “unit champions.” A unit champion is an informal expert on a specific nurse-sensitive quality indicator or initiative that clinical nurses can go to for expert advice and policy and protocol questions.
Structural Empowerment
Nursing goals are used to improve clinical practice, work environment, efficiency, and improve patient outcomes, to meet these goals, nurses must advocate for resources. Structural Empowerment is utilizing programs, resources, systems, & processes to support nursing practice. Structural empowerment is achieved by utilizing multi-directional communication amongst interprofessional teams including non-clinical staff, clinical nurses, leadership, and in the community.
One of the crucial aspects of structural empowerment is professional development and ongoing education. At St Mary professional development is encouraged by strong support for certification, interdisciplinary education, skills days, and encouragement of inter-organization advancement and role transitions. In addition, St Mary has a robust Level – 2 enrichment, and mentoring program.
Exemplary Professional Practice
At St. Mary exemplary professional practice is manifested in a culture of safety both for the patient and the employee. Safety culture focuses first on meeting national patient safety goals by hospital-wide participation in constant quality (QI) and process improvements (PI) goal setting. Nurses utilize the professional practice model which is a visual representation of the philosophy nurses use to provide care. This model puts patients and staff in the middle surrounded by the guiding principals of shared governance, interprofessional team-work, holistic care, professional development, and evidenced based practice. Exemplary practice is further ensured by staff accountability, ethics, competence, and autonomy.
Knowledge, Innovation, and Improvement
At every stage of care nurses at St. Mary are encouraged to participate in research, policy improvement, and quality improvement projects to engage in best practice and expand nursing knowledge. The organizational infrastructure put in place to support nursing research and quality improvement include, but are not limited to, an in-house institutional review board, a research and evidence-based practice council, a full-time research consultant, research 101 workshops, and education funds to attend conferences.
Empirical Quality Results
According to the ANCC (n.d.), “Magnet-recognized organizations are in a unique position to become pioneers of the future and to demonstrate solutions to numerous problems inherent in our healthcare systems today.” An organization’s empirical outcomes must be specific and measurable. A current organizational initiative that reflects the operationalization of the mission and values of St Mary and reflects empirical quality results is the nurse led “zero CAUTI” initiative. The “CAUTI” (catheter associated urinary tract infection) team was created in 2015 and was tasked with decreasing the use of indwelling urinary catheter use, align clinicians and physicians with current best practices, and develop nurse led innovations to reduce CAUTI events. As a result of this nurse-led effort, an RN initiated indwelling urinary catheter (IUC) bundle was created and implemented, IUC insertion kits were upgraded, new-hire CAUTI prevention competency was created, and hospital wide CAUTI rates have declined each year since the team’s inception.
Shared Governance
Shared governance at St Mary is comprised ofcouncils at 2 levels. Unit Councils, which consist of clinical nurses at the unit level who assist coordinating council representatives in decision-making and coordinating councils and coordinating councils which consists of clinical nurses from each service line who coordinate and provide direction to unit councils. Councils at St Mary include nursing leadership coordinating council, nursing practice coordinating council, professional development council, RN level 2 council and the PI/QI coordinating council.
Several sub-committees are formed under the umbrella of each council based upon need. St Mary hospital has four floors of behavioral health so discipline specific leadership and practice coordinating councils were also created to meet the unique needs of that workforce and patient population.
Intra- and Inter-professional Communication
Communication outside of shared governance councils require the communicator to follow the chain of command. If a nurse wanted additional resources allocated for their floor; for example, a bladder scanner, the nurse or group of nurses would need to collect evidence and data supporting the need for that tool and present it to their unit manager. In instances of dispute an employee would first go to their team leader, then unit manager, then unit director and so forth up the chain of command. Unit-wide informal communication between floor staff, team leaders and unit managers is highly encouraged and unit managers as well as the chief nursing officer maintain an open door policy for acute needs.
This communication style can be effective when members of the communication line follow up to make sure their communications are received in a timely and efficient manner. This style can cause problems when policy changes are quickly created to protect patient or staff safety from leadership but are not clearly communicated to staff allowing for confusion or inaction. In addition, this communication style can cause a significant delay in decision-making that is not top priority.
Informatics
A new cardiac arrest and sepsis screening system at St. Mary was recently implemented marrying information, technology, and patient care. The electronic cardiac arrest risk triage score (eCART) system utilizes an algorithm that pulls real time data from a patient’s chart providing a percentage of risk of deterioration. This tool meets two out of three of Johnson’s Microsystem Assessment Tool “success” criteria including, integration of information and technology and integration of information with providers and staff. Once provided the risk score populated from patient vital signs, labs, and electronic medical record flowsheets, nurses can reference a decision tree if risk for deterioration is 90% or higher.
The third of Johnson’s assessment tool is integration of information with patients, the organization meets this criterion by providing patients with an after-visit summary (AVS) with embedded education that is pulled directly from the electronic medical record. Every patient is also enrolled in the patient portal so that their medical record, after visit summary, and follow up appointments can be accessed online from the privacy of their home.
Patient-Centered Care Model
At St Mary nurses are full partners with physicians and other healthcare professionals in delivering safe, efficient, cost effective, and quality care to the patient. At St Mary nurses don’t just carry out the orders of the physician, but work closely with patients and their families, respiratory therapists, dietitians, occupational therapists, specialists, activity coordinators, and physicians to develop a comprehensive plan of care that meets the needs of the patient and exceeds benchmarking data for safety and outcomes. This work is achieved while taking care to responsibly utilize resources, so the care teams can serve as many community stake-holders as possible. St Mary is a designated “safety-net” hospital which provides care to individuals regardless of their insurance status or ability to pay.
References
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American Nurses Association and The National Council on State Boards of Nursing. (2005)
Joint Statement on Delegation
. [Joint Statement]. Retrieved from https://www.ncsbn.org/Delegation_joint_statement_NCSBN-ANA.pdf. - American Nurse Credentialing Center (ANCC). (n.d) Magnet Model. Retrieved from https://www.nursingworld.org/organizational-programs/magnet/magnet-model/
- Amita Health. (n.d.). The Amita Health System mission and values. Retrieved from https://www.amitahealth.org/about-us/mission-and-values/
- Huber, D. L. (2018). Leadership and management principles. In D. Huber (Ed.), Leadership and nursing care management (6th ed., pp. 1-31). St. Louis: Elsevier
- MacPhee, M., & Havei, F. (2018). Professional practice models. In D. L. Huber (Ed.) Leadership and nursing care management. (6th ed. pp. 225- 239). St Louis: Elsevier.
- Presence Health is now part of Ascension and AMITA Health. (2018, March 02). Retrieved from https://ascension.org/News/News-Articles/2018/03/02/16/42/Presence-Health-is-now-part-of-Ascension-and-AMITA-Health
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