Creative Change in Healthcare
Mary Ofili
HSC 587
May 19, 2014
Lanny A. Kope

Creative Change in Healthcare
Change in any organization, especially healthcare is a given constant, frequent and always almost inevitable. Several factors may lead to these changes and sometimes, these factors are internal and other times they are external. In the United States, the economy determines the interactions between the cost of healthcare and the way hospitals deliver care to the patients. The current persistent economic downturn continues to force Medicare to look closely at how hospitals are reimbursed and to cut reimbursement rates. With the overhaul of the healthcare system, hospitals have to evaluate how to deliver care to the patients with limited financial resources. Therefore, Medicare expects hospitals to bear the cost of any adverse outcome caused by any changes within the hospital environment. For examples, hospitals are no longer reimbursed for the cost of diabetic ulcer treatment acquired while the patient is in the hospital. The quality of the expected result is much higher while the reimbursement is much lower. Hospitals have to look closely at how the nursing staff delivers care to the patients. The traditional bedside nursing is staffed by three levels of nurses. Certified Nurse’s Assistant (CNA), Licensed Vocation Nurse (LVN), and the Registered Nurse (RN). Other levels of nurses such as Nurse Practitioners and other advanced practice nurses are not included in the bedside staffing ratios. This paper will discuss the change that occurred in a teaching hospital, in the Los Angeles area. That change took place in the 2008. CNA’s, traditionally, take the patient’s ‘vital signs’ which include temperature, blood pressure, heart rate, respirations, oxygen saturation percentage and the pain level. The CNA’s relays the information to the RNs, who use the results to develop a comprehensive treatment plan for the patients for a better result. A large teaching institution in Los Angeles changed their practice to have RNs take the first ‘vital signs’ of the day. The new practice created such conflict among RNs, management and CNAs. The results were positive and other facilities in the area shortly began to implement the new practice as the outcome became widely known within the healthcare industry and hospital environment. The change was implemented to require the RN to assess the patient at the beginning of the day, take and document the first set of ‘vital signs’ of each day. Earlier on in nursing, many of the rudimentary tasks were assigned to CNAs, for example, almost all the ‘vital signs’ were taken by the CNA at most facilities. This practice was developed from the inception of nursing practices due to the workload of the RNs. Originally, it was very helpful to the RNs for the CNA to take the ‘vital signs’ as that allowed the RN time to complete the shift change report, evaluate, and develop a plan of care for the patient prior to passing any medications the patients is scheduled to take during the day. The time was utilized effectively by RNs who didn’t have to take the initial “vital signs”, especially with the work load the RN has to complete during the day. The congestive heart failure floor (3WEST) is where the hospital admits cardiac patients with ejection fraction less than 40%. These patients are given beta blockade medications such as “Coreg” and “Metoprolol”, which unfortunately has the side effect of decreasing the blood pressure and heart rate of the patient. An audit of the Rapid Response Team (RRT) and Code Blue (cardiac arrest) time sheets revealed an unusually high number of Rapid Repose about 10am and 10pm. This is one hour after the patients receive their doses of Coreg and other beta blockers usually scheduled at 9pm. Management of the 3 West floor conducted an audit to determine why the patients were having problems at that time of day. The audit revealed ‘vital signs’ for several patients were the same between 10am and 10pm, and also in a 6 month period, no RN held any beta blocker because of low blood pressure or low hear rate. It became apparent that some of the ‘vital signs’ must not be accurate. A study was conducted on the floor (trial of RNs taking all ‘vital signs’). The results showed that RNs reported low blood pressure and heart rate frequently and held more beta blockade medications. A sharp decrease in RRTS caused by low heart rate and blood pressure was noted. Therefore the 3 West management team mandated that RNs must take all the initial ‘vital signs’. The Director of Nursing for the hospital implemented the new practice hospital wide. As we learned from Lewin’s change management model,” To begin any successful change process you must first start by understanding why the change must take place.”(Spector, 2010). The management (Nurse Manager of 3West) conducted the study in her floor. The hospital, based on the result of the study on the floor, hospital management implemented the change hospital wide without all the other nurses participating in the “unfreezing” phase. The tedious work of taking the vital signs was always done by the CNA. The RNs resisted the change as it was perceived as additional work in an already overwhelming daily assignment. During a mandatory meeting to discuss the implementation, some RNs suggested a bedside monitor that not only takes the vital signs, but also stores it, be installed at the bedside of every patient. Management quickly rejected the idea as being too costly.
The internal factor that triggered the change in the way ‘vital signs’ were taken was the adverse patient condition resulting from inaccurate vital signs. According to Lewin’s change model, the “Unfreezing, change and refreezing” (Spector 2010) are phases the organization must go through for the change to be successful. Unfreezing refers to breaking down the current situation rated just as melting down ice. This is done so the why, what and how questions are carefully answered. We implement the change and we mold the water back to the desired shape or the desired results.
In this situation, the unfreezing, change and refreezing phases took place in 3West but not the whole hospital. The statement by Lewin stated “Motivation for change must be generated before change can occur” (Spector, 2010). Whereas, the nurses in 3West were motivated, the rest of the nurses were not, hence, the conflict.

Upon implementation, weekly chart audits revealed that many patients had blood pressures and heart rate for which the beta blockers were contraindicated. These ‘vital signs’ were already too low and taking the beta blockers caused very serious adverse reaction requiring rapid response team intervention and in some cases code blue. With the nurses taking the initial ‘vital signs’, the number of these incidents greatly decreased. Fewer code blues and RRT meant decreased work load for the nurses and improved patient outcome. The Hospital days of a typical patient with a diagnosis of CHF exacerbation in 3West decreased from 5 days to 3 days. Some of the nurses remarked that the new practice gives them more confident during medication administration. They trusted the ‘vital signs’ more. “Employees require a stable psychological condition in the workplace. In instances where changes occur, issues of professional and personal insecurity are kindled primarily by lack of understanding…” (Borkowski, 2005). Management must carefully “unfreeze” the current situation, involve employees in the change process and thereby mold the employees to take the shape of the desired outcome. This was not done hospital wide during this change.
The final outcome of this change was very positive. “Management’s failure to furnish realistic information in a timely fashion further adds to an employee’s uncertainty” (Borkowski, 2005). Once the initial disruption caused by lack of clearly communicating the rational for the change was corrected, the nurses became more cooperative. All the nurses took the first set of ‘vital signs’ of the day. The initial chart audit revealed the importance of this change. More nurses held medications that were contraindicated because of the ‘vital signs’. The nurses were more comfortable with their baseline assessment at the beginning of the shift. The result was less RRTs and less code blue. Patient outcome greatly improved. In conclusion, “Health services organizations are experiencing decreased reimbursements/ revenues and increasing costs resulting in smaller profit margins, if any. Furthermore, fragmented processes do not ensure that the patients are receiving appropriate and effective services” (Borkowski, 2005). There are various types of forces that drive changes in an organization. When employees lack an understanding of rational for change, resistance may arise. This resistance may be caused by certain organizational or individual barriers. Utilizing the three phases of change as described by Lewin is critical to the success of organizational change. The nurses in the teaching hospital resisted the change because they saw taking the first ‘vital signs’ as a mere increase in their workload. Once implemented, the audit showed that this practice actually decreased the workload for the nurses and improved patient outcome. “Managers need to be aware that most organizational change efforts will be met with resistance” (Maxwell, P ….) and ensure effective planning and adequate communication.

References: 1. Spector, B (2010). Implementing Organization Change: Theory Into Practice. (2nd ed.). Upper Saddle, N J Pearson Prentice Hall 2. Maxwell, P (2009). Organizational Behavior In Healthcare: Chapter 17. (1st ed.). Retrieved from University of Phoenix eBook Collection database. 3. Borowski, N (2005). Organizational Behavior in Healthcare. Jones and Bartlette Publishers, Sudbury, Massachusetts.