The topic of the opening conference plenary that Dr. Callis and I attended at the Master’s Education Conference in Atlanta, Georgia, was “Driving Quality Improvement in Today’s Health System.”  The speaker, Margarita Baggett, is the Chief Clinical Officer at UC, San Diego.  She reinforced that the complexity of today’s health care practice environments require nurse leaders and educators to embrace and direct quality improvement and systems thinking in the work they do.  In doing so, patient safety and quality outcomes for patients and their families are ensured. Margarita used a chaos theory approach in her presentation and provided a vision for how nurse leaders can respond to complex systems in improving practice and preparing graduates who can lead responsive and sustainable change.

THE COMPLEXITY OF HEATH CARE SYSTEMS

UC San Diego Health – Clinical Enterprise is a complex healthcare system consisting of two campus sites with over 7,500 employees, 850 physicians, 808-beds, and a $1.7 billion operating budget. As you look at these numbers, the complexity of this hospital organization is significant. Margarita began her presentation by describing the hospitals journey to Magnet status. This voluntary process occurs in conjunction with the American Nurses Credentialing Center and recognizes nursing excellence.  The achievement of Magnet status was the direct result of a strongly committed nursing leadership team and clinical nurses who focused on quality improvement and the provision of care based on research and evidence-based findings. New cultural themes and emerging patterns resulted from this journey and resulted in the structural and psychological empowerment of nursing practice and professional practice behaviors.

After this accomplishment, several changes occurred that impacted the stability of the hospital culture and included emerging patterns of new leaders, new teams, additional filled hospital beds, and the use of traveling nurses (n=200).  These changes in the system resulted in a host of missed care opportunities, failure of nurses to speak up when a possible error was about to occur, and was accompanied by an increase in hospital acquired infections. These changes caused the leadership to reflect on patient care issues through the lens of chaos theory.

CHAOS THEORY

Chaos theory is a branch of mathematics focused on the behavior of dynamical systems that are highly sensitive to initial conditions. The essence of chaos theory is that the organization is better served by looking for and responding to certain types of behavior within the organizations versus pinpointing causes. A behavior that was uncovered at that point in time was that nurses were failing to speak up; obvious barriers to speaking up were identified and recognized. We know that the consequences of nurses not speaking up are concerning.  The Agency for Healthcare Research and Quality (AHRQ), 2004] identified that 70-80% of medical mishaps are related to interpersonal interactions. Sixty-six percent of sentinel events have incomplete communications among caregivers as a root cause [The Joint Commission (TJC), 2005].

COMMITMENT TO PATIENT SAFETY

A commitment to safety was subsequently implemented hospital wide. Hospital leadership focused on what they could do to support nurses speaking up, with a vision that the hospitals true north was and remains patient and family centered care.  The campaign focused on the importance of speaking up in all environments of care with a renewed commitment to patient safety. Margarita ended her presentation with an inspirational message of never doubting the power of a dream, since a dream can result in a future that is inspirational and empowering.  Truly the journey of this hospital reflected the power associated with achieving a dream of nursing excellence. The take home messages from this session were many and can be applied in any complex organizations, including a department within a university.  I learned the importance of using a theory based approach to complex problem situations and to focus on and respond to changing patterns of behaviors in my own work setting.

Drs. Wickman and Callis on a virtual tour of the Tara Plantation (fictional plantation in the state of Georgia, in the historical novel Gone with the Wind by Margaret Mitchell).