Improving Interdependence of the

Healthcare Team
Andrew Chittaphong, Marco Stevens Cota,
Michael Manns, Ella Nanci, and Troy Schmidt
December 4th, 2019
 Overview of Patient Care Delivery System
Northwest Medical Center - Tucson
• Medical-Surgical Intensive Care Unit (MSICU), a 20-bed unit
• Code team consists of respiratory therapists, staff RNs,
charge nurse, house supervisor, and unit physician.
• Focus:
• Impaired interdependence of healthcare team related to
role confusion and emotional strain due to a lack of
debriefing after codes, rapid-responses, and stroke events.

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 Microsystem Model: Leadership
MSICU Leadership
• Charge RN leads in a laissez-faire style
• “Little or no control, motivates by support… does not
criticize, disperses decision making throughout group.”
• Little direction given if protocols are followed and adverse
events are prevented; small authority-power gap
• Unit director empowers RN staff to promote autonomy
Johnson, J. K. (2001). Clinical microsystem assessment. Retrieved from
http://clinicalmicrosystem.org/uploads/documents/microsystem_assessment.pdf
Marquis, B. L., & Huston, C. J. (2017). Leadership roles and management functions in nursing: theory and application (9th
ed, pg. 76, 339). Philadelphia: Wolters Kluwer Health.
3
 Microsystem Model: Organizational Culture
and Support
Unit Management
• ICU director acts through democratic leadership
• Directed through suggestions and guidance, emphasis is on
we, constructive criticism
• Unit-wide meetings held weekly (Thursday) during day shifts
to identify needs of the unit and improve unit resources
• ICU is used as IV team, Code Team, RST team, and Float
Pool
Johnson, J. K. (2001). Clinical microsystem assessment. Retrieved from
http://clinicalmicrosystem.org/uploads/documents/microsystem_assessment.pdf
Marquis, B. L., & Huston, C. J. (2017). Leadership roles and management functions in nursing: theory and application (9th
ed, pg. 76). Philadelphia: Wolters Kluwer Health. 4
 Microsystem Model: Patient/Staff Focus of
Healthcare Delivery
Culture and Work Roles Listening and Caring
• ICU director does new hires • Unit RN organizes total care
for the unit • Education on medications, lines,
• Six months of onboarding for interventions, and plan of care
new nurses • Clear and concise handoff
• Staff required to complete • Clustered and timely care
continuing education • Medication reconciliation
• Staff ratio 2:1 Johnson, J. K. (2001). Clinical microsystem
• Bonus based on annual review assessment. Retrieved from
http://clinicalmicrosystem.org/uploads/documents/m
icrosystem_assessment.pdf
 Microsystem Model: Interdependence of Care
Team
Trust, Collaboration, and Shared Purpose
• Nurses trust each other to help with assignments
• Unit focused on interdisciplinary teamwork (RTs, chaplain,
specialty physicians, social workers, etc.)
• House supervisor and physician run all codes
• Code tasks delegated to unit RNs

Johnson, J. K. (2001). Clinical microsystem assessment. Retrieved from

http://clinicalmicrosystem.org/uploads/documents/microsystem_assessment.pdf
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 Microsystem Model: Use of Information and
Healthcare Technology
Integration of Information
• Cerner EMR
• IT support, Medication database built-in
• Auto-populating charting
• Limited WOWs located around the unit
• Facility-wide phones for all staff, number list available at all
nurse stations
• Updated alarm system (bedside monitors, bed alarms)
• Patients can ask for medical records
Johnson, J. K. (2001). Clinical microsystem assessment. Retrieved from
http://clinicalmicrosystem.org/uploads/documents/microsystem_assessment.pdf
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 Microsystem Model: Process for Healthcare
Delivery Improvement Activities
Process Improvement
• Unit nurses are encouraged to continue education
• High-skill nursing tasks require education and certification
• i.e. CRRT requires in-hospital CRRT certification before
care can be given
• Unit outcomes are audited and areas of concern are
emphasized
• Grand rounds and ICU manager huddle during day shift

Johnson, J. K. (2001). Clinical microsystem assessment. Retrieved from

http://clinicalmicrosystem.org/uploads/documents/microsystem_assessment.pdf
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 Microsystem Model: Staff Performance
Patterns
Performance Results
• Benchmarks on the unit are constantly monitored or audited
• End-of-month unit manager/charge RN meetings
• Charge RN distributes information down to unit RNs
• Benchmarks results and quality indicators posted on
information boards positioned around the unit
• Yearly peer performance reviews

Johnson, J. K. (2001). Clinical microsystem assessment. Retrieved from

http://clinicalmicrosystem.org/uploads/documents/microsystem_assessment.pdf

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 Specific Aspect Targeted for Improvement
Post-Code Debriefing
• Interdependence of healthcare team related to role confusion
and strain due to a lack of debriefing post-code, rapid-
response, and strove events.
• Reflective Learning
• The use of a debriefing tool led to more code debriefs.
• Improvement in communication during arrests fosters
interdependence of the care team
Gillen, J., et al.. (2019). The impact of a fellow-driven debriefing program after pediatric cardiac arrests. BMC Medical
Education, 19(272), doi: 10.1186/s12909-019-1711-y
Kessler, D. O., Cheng, A., & Mullan, P. C. (2015). Debriefing in the emergency department after clinical events: A practical
guide. Annals of Emergency Medicine, 65(6), 690-698.
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 Integrative Nursing Principle
Integrative Nursing Principle #6
● “Integrative nursing focuses on the
health and wellbeing of caregivers as
well as those they serve.”
● Includes reflective practices such as
journaling and debriefing

Kreitzer, M. J. (2015). Integrative nursing: Application of principles across

clinical settings. Rambam Maimonides Medical Journal, 6(2). doi:
10.5041/RMMJ.10200

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 Project Timeline
Months
0-1 1-3 3-4 4-12 12+

Project Administer Education Begin Evaluate

planning and Post-Code on debriefing intervention
goal-setting Stress Scale; debriefing intervention outcomes
assessment intervention and data and apply
of baseline collection hospital wide
scores on unit
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 References
Gillen, J., Koncicki, M. L., Hough, R. F., Palumbo, K., Choudhury,
T., Daube, A., Patel, A., Chirico, A., Lin, C., Yalamanchi, S.,
Aponte-Patel, L., & Sen, A. I. (2019). The impact of a fellow-
driven debriefing program after pediatric cardiac arrests. BMC
Medical Education, 19(272), doi: 10.1186/s12909-019-1711-y
Johnson, J. K. (2001). Clinical microsystem assessment. Retrieved
from
http://clinicalmicrosystem.org/uploads/documents/microsystem_
assessment.pdf

13
 References
Kessler, D. O., Cheng, A., & Mullan, P. C. (2015). Debriefing in the
emergency department after clinical events: A practical guide.
Annals of Emergency Medicine, 65(6), 690-698.
Kreitzer, M. J. (2015). Integrative nursing: Application of principles
across clinical settings. Rambam Maimonides Medical Journal,
6(2). doi: 10.5041/RMMJ.10200
Marquis, B. L., & Huston, C. J. (2017). Leadership roles and
management functions in nursing: theory and application (9th
ed). Philadelphia: Wolters Kluwer Health.

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