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Read three or more of your colleagues’ postings from the Discussion question (support with evidence if indicated).
Respond with a comment that asks for clarification, provides support for, or contributes additional information to three or more of your colleagues’ postings.

RE: Discussion – Week 5

We are asked to look at a scenario (scenario 1) where our for-profit nursing home is sending too many patients to the ED and seeing what we can do to prevent avoidable ED visits. And we are asked what leadership strategies we would choose to implement our changes.
It is crucial for the entire team to be involved in and care about the economics of running a healthcare facility (Yoder-Wise pg.374, 2019). Also, per Yoder-Wise (pg. 3 ,2019) there are not hard lines anymore between different styles of leadership, it is more like leaders utilize a collection of tools from different theories and styles of leadership. Yoder-Wise (pg, 79, 2019) discusses Personal Leadership as a leader not leading because they have the responsibility of the role, but rather being in the role of leader as an expression of their values and the things they care about. In any case, where I have been in a position of leadership in nursing, whether it was because I was a nurse manager at the time, charge nurse, or floor nurse, this was usually the case for me.
In the case of this scenario, I would lead from the same place, doing it because I thought it was the best thing for the patients and not because of my title. As far as leadership styles from the book, I think the best thing to do would be to utilize Gardiner’s tasks of leading and management to achieve the goal of fewer ED visits. This is because these tasks will bring a unity of purpose to everyone involved, and hopefully make everyone a leader for the right change. Gardiner’s tasks involve: “Envisioning Goals”, in this case, our shared facility goal of fewer ED visits., “Affirming values”: In this case we all care about the health of our patients and we also care about saving money so our facility can continue to serve the health of our patients. As well we all care about the emergency department and do not want to contribute to staff burnout and poor quality by overloading our ED. “Motivating” by encouraging employees to help come up with solutions and participate in solving this issue. “Managing” by taking the responsibility to support employees as they do their best to keep their patients safe and figure out how to reduce ED visits, while still caring for their patients. The other tasks involve “Achieving Workable Unity, Developing Trust, Explaining, and Serving as a Symbol. These tasks are a great choice for a leader because they can remind a leader of the many roles (both guiding roles and supporting roles) that they must take on in order to lead successfully, and if done well, bring everyone together as a team.
In the case of what to do, the first thing should a root cause analysis of what leads to the decision(s) to send a person to the ED. The resources of a nursing home are unlikely to be as good as an emergency department and in situations where a nurse does not have the assessment tools to help a patient, the ED seems like the obvious choice.
Without knowing the exact breakdown of what is leading to these decisions to send patients out, we can look at general solutions. Sathyanarayanan et al (2021) discuss how solid case management and adherence to a developed plan of care reduced ED visits in frequent users of emergency Department services. Chen et al (2018) discuss the effect of provider education and lifestyle management and psychiatric care for patients, lowered ED utilization in older patients. These might not be relevant to our situation but they do show an example of ED visits being lowered through intervention and can provide motivation for employees until our root cause analysis gives us issues to focus on specifically.

Scenario 1
The scenario chosen is in need to find the root cause of the reason too many patients are sent to the ED from the nursing home. First steps would include pulling a report of why patients were admitted. Spath (2018) tells us by asking why five times, the root cause will be determined. For example, according to Connolly et al. (2018), a common reason for nursing home residents to be admitted to the ED is infection. Asking why about the multiple aspects of how an infection occurred can quickly get to the root cause.
For example, in my own experience, nursing home patients have often been sent to the ED for a deteriorating wound infection. We have sent them back within hours and all that was done was a dressing change, a script for an antibiotic (IV or PO) and a comment to have the wound team round on the patient in the morning. All those things could have been done at the nursing home without the need to transfer, thus exposing an already frail senior with multiple co-morbidities to the infectious ED department atmosphere. Connolly et al. (2018) reported a Canadian study that nursing home residents exposed to the ED were 3 times more likely to develop a respiratory infection than those who did not visit the ED. Information such as this including evidenced-based studies and statistics regarding the repercussions of unnecessary ED visits should be given to the nursing home staff. It could be, as in this scenario, the nursing staff assumes because the ED is part of their system, there are minimal costs to transfer a patient.
After the root cause is identified, flow charts or diagrams should be developed to understand what is happening, clarify the cause, determine the frequency, and the impact on patients (Spath, 2018). After that step is completed and data analyzed, an implementation plan can be put into place. A detailed flow chart, as shown in Figure 6.9 in Spath (2018) can be implemented to assist nursing staff to decide if it is appropriate to admit the patient to the ED. Nursing home staff should be given tools to empower their critical thinking and assessment skills to determine if their patients need emergency services. Yoder-Wise (2019) emphasizes the need for management and nursing to empower their staff to use creative problem-solving techniques to increase patient safety and prevent adverse outcomes (Yoder-Wise, 2019).
In conclusion, to decrease unnecessary ED visits, leadership must embrace and emphasize the concept of organizational learning and agility, a model that continuously improves existing processes and is adaptable to change (Spath, 2018). Similarly, Yoder-Wise (2019) reminds us care is complex and follows the complexity theory. The complexity theory in nursing reminds us to find the patterns in the universe, adapt them to our individualistic case/patient, recognize effective care is not linear, but an interconnected web, and learn how all this leads to nursing providing safer, higher quality patient care (Yoder-Wise, 2019).
Connolly, W., Healy-Evans, S., McCarthy, C., Butt, H., Benicio, T., Keating, T., Power, D., Duggan, J., Wei Fan, C. (2018). What are the main reasons for hospital admissions in nursing home patients?. Clin Med (4)(1). https://clinmedjournals.org/articles/jgmg/journal-of-geriatric-medicine-and-gerontology-jgmg-4-039.php
Spath, P. (2018). Introduction to healthcare quality management (3rd ed.). Health Administration Press.
Yoder-Wise, P. S. (2019). Leading and managing in nursing (7th ed.). Mosby.

This discussion post aims to devise strategies to help the 25 “frequent flyer” patients manage their own care using a nursing leadership strategy and avoiding frequent overnight emergency room visits. Yoder-wise (2019) tells us that personal leaders lead because of their ethics and core values, not because they have been tasked with the duty. Personal style leadership leads by example because they are driven too. Overall qualities embodied by a good leader include critical thinking, integrity, communication, and professionalism (Aspen University, 2021). Personal leaders choose patients over profits, encourage open communication, and respect staff as an essential part of the team (Aspen University, 2021).
In scenario two, the patients are predominantly charity care and Medicaid patients. According to Hasegawa, et al., (2014), heart failure patients with lower socioeconomic status were associated with more frequent ER visits than those of a higher socioeconomic status. The most significant predictor of emergency room visits for those with heart failure was those of non-Hispanic black race, Hispanic, and a lower median household income (Hasegawa, et al., 2014). I think a root cause analysis approach would be best suited for this scenario.
A root cause analysis is the core issue that leads to the cause-and-effect reaction, creating the underlying problem (ASQ, 2022). The root cause is then the factor that can be eliminated through process improvement (ASQ, 2022). A root cause analysis is part of a problem-solving process focusing on continuous improvement. In scenario two, finding the underlying cause of the patient’s frequent visits to the emergency room can help facilitate a strategy for change and improvement. If the underlying cause is medication compliance, the clinic can focus on medication education and why compliance is necessary to avoid the ER. If the root cause finds that the patients need more frequent care for exacerbations, the team can work on a process where patients are seen in the outpatient clinic more often. If the root cause is poor nutritional management, the outpatient clinic can focus on diet and healthy eating for patients with heart failure. A root cause analysis will help find the core of the problem to achieve an effective resolution of patients admitted to the ER for one night stays.


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