case study


Discuss potential complications in a clinical scenario at an out-patient family practice. Explore potential effects on patient outcomes and implications for members of the health care team as a result of conflict among the healthcare team.  Students will develop strategies that result in prevention of untoward outcomes that result in a positive practice culture.

You are a family nurse practitioner working in an outpatient primary care office of a large hospital system. The practice has been operating for over 15 years, and many of the administrative and clinical staff were hired when the practice opened. You have been in the practice for less than 3 months. In that short amount of time, you have witnessed several of the clinical staff engaging in heated arguments with each other, sometimes in patient areas. You overhear an argument occurring today between two staff. You pick up a patient’s chart and notice a very low blood pressure that the medical assistant failed to notify you about. When you confront the MA, she states that she was going to report the vital signs to you when she became engaged in the heated argument you overheard and forgot to notify you.
Unfortunately, this pattern of behavior is not unusual in this practice. Working with staff who cannot cooperate effectively can negatively influence your ability to spend time with patients, can impede the flow of patients through the office, and could impact patient safety.

Case Study Responses:
1.    Analyze the case study for potential issues for members of the healthcare team from office conflict. Contrast the potential effects for each member of the healthcare team based upon the components below. Discuss the potential ethical and legal implications for each of the following practice members:
o    Medical assistant
o    Nurse Practitioner
o    Medical Director
o    Practice
2.    What strategies would you implement to prevent further episodes of potentially dangerous patient outcomes?
3.    What leadership qualities would you apply to effect positive change in the practice? Focus on the culture of the practice.
4.    A scholarly resource must be used for EACH discussion question each week.


In order to engage in quality improvement, one must develop an ongoing quality improvement mindset. This is the single most effective way to ultimately create a culture of patient safety. Although the nursing literature abounds with evidence regarding the implementation of the Plan-Do-Study-Act (PDSA) model in clinical practice and nursing administration, with the exception of a patient education focused study, no literature currently exists regarding application of the PDSA model to drive APN healthcare improvements.
The 4 phases of the PDSA model begin with planning.
    During the planning phase, the focus is on planning for structure, process, and outcomes. In this phase, one would implement a pilot test.
    In the next phase of doing, the focus is on implementation and assessment.
    Through the third phase of studying, the focus is on analysis of pre-intervention and post-intervention aspects of the plan, with an eye toward redesign for quality improvement.
    Across the final phase of acting, the focus is on planning closure of the feedback loop with a repeat trial.


Example costs of scientific/classical management approach:
    Potential lost revenue from downtime related to employee intervention
    Potential lost revenue from downtime related to needing to recoup dissatisfaction multiplier from an unhappy employee
    Potential lost revenue from increased turnover resulting in need to conduct search for new employee
    Potential lost revenue from increased turnover resulting in need to orient/train new employee
    Potential cost of litigation resulting from separated employee
    Potential lost revenue from decreased job satisfaction and/or decreased morale from unhappy employee(s)

Example benefits of human-relations/quality management approach
    Potential increased revenue resulting from increased job satisfaction and/or increased morale from happy employee(s)
    Potential increased revenue from decreased turnover
    Potential increased revenue from increased organization commitment
    Potential increased revenue from interprofessional problem solving
    Potential increased revenue from interprofessional decision making
    Potential cost savings from decreased potential litigation

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