Case Studies

Intermediate Cardiac Care Unit (ICCU)

To better inform the team improvement activities, the ICCU lead improvement team began the assessment of the system's 5 P's at its first microsystem learning sessions. Team members reviewed available data, determined they needed to gather more information on the ICCU, and developed a plan to evaluate staff satisfaction in the workplace and to collect staff assessments of core and supporting processes. The team actively reviewed and adapted the many forms and methods in the Improving Care Within Your Inpatient Units workbook (Godfrey et al., 2005c) to inform their work. They put up a large poster containing the core and supporting processes assessment tool so all staff could rank how well the various ICCU processes were working. After much discussion among team members and with the broader ICCU staff, the team drafted this purpose statement for the ICCU:

The ICCU will create an environment in which cardiac patients and their families can receive excellent, comprehensive, specialized state of the art quality care. This will be accomplished by caring, competent professional staff that has the support and resources to do their best work to promote the emotional, physical and intellectual well-being of patients, families and caregivers.

Figure 13.2 is an example of the microsystem wall poster the ICCU lead improvement team used after initiating its 5 P's assessment.

Plastic Surgery Section

Through the ten-week course the lead improvement team was able to gain deeper insight into its microsystem's 5 P's. Team members created a microsystem wall poster to display their findings and engage other staff members' interest and curiosity. They discussed and identified their purpose: "Partner with our customers to improve form and function for better living."

They became more mindful of their patients and patient populations: pedi-atric, cosmetic, and reconstructive. A patient satisfaction survey revealed low patient satisfaction scores in the following areas:

• Ease of coordinating care

• Wait in waiting or exam room

• Wait for appointment

The section's professionals included six surgeons, three residents, three registered nurses, one registered nurse first assistant, one licensed practical nurse, two licensed nurse assistants, one physician assistant, two certified medical assistant, five secretaries, a half-time practice manager, a lead registered nurse, and an administrative supervisor. Through their improvement journey team members realized there were many opportunities to optimize the roles of their professionals


People with health care needs

Dartmouth-Hitchcock Medical Center ICCU

The ICCU will create an environment in which cardiac patients and their families can receive excellent, comprehensive, specialized state of the art quality care.




High risk

LOS: 5 days = 1,838 6-10 days = 257 11-20 days = 72 21-50 days = 14 51+ days = 1

Top Diagnoses

1. Athrosclerosis = 464

2. AMI, subendocardial = 517

3. AMI, inferior wall = 101

5. Fibrillation, atrial = 110

6. Heart Failure = 120

8. Dysrhythmias = 31

9. Tachycardia = 48

Discharge Disposition

Against Medical Advice = 11 Custodial Care = 10 Died = 63

Federal Hospital = 10 Home = 1638 Home with IV drug = 2 Home with VNA = 323 Short Term General Hospital = 7 Rehab Center in acute facility = 10

Skilled Nursing Facility = 93

Admission Source

Acute Care Hospital = 739 Clinic = 409 Clinic Emergency = 103 ED = 406 Nursing Home = 1 Referring Physicians = 523 Skilled Nursing Facility = 1

Patient Satisfaction

The nurses are the best ever. The wrist band and the staff scanner left you feeling very secure for all tests and pills.

Patient Age

ICCU had 10,546 patient days FY 2005 (volume)

51-64 =556

® ® © © © (Prevention (Acute) (Chronic) (Palliative^ (Educate)

High Risk


People with health care needs met

Functional & risks

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Med admin


Cardiac rehab

Care management

Cath lab





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ven everything I nee

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make my work mean

ngful to my life.


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gree Strongly Agree

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RN = 35.9 FTEs

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PCT/LNA 16.4 FTEs Secretaries = 4 FTEs Nursing Director


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ICCU Admission to Discharge

Access RN Identifies Appropriate Personnel

ICCU Charge Assigns a Bed

Report Received







• Weekly Wednesday 1:30-2:30 Lead Improvement Team meetings.

• Cardiac Services previously part of large improvement initiative 8 years ago, but many members have changed.

• Most proud of patient report of caring staff.

Admission Day of the Week Monday = 376 Tuesday = 360 Wednesday = 364 Thursday = 357 Friday = 303 Saturday = 188 Sunday = 234

ICCU staff rating: core & supporting processes results ranked most "broken" 1) Discharge planning 2) Communication of discharge 3) Coordination of discharge



Patient Professionals

Arrives Admit Patient


Plan and increase staff morale. The initial staff satisfaction survey showed a high level of work unhappiness.

The processes they gained insight into included the scheduling systems for outpatient appointments and inpatient surgeries. They realized the system of care extended beyond their four walls. They measured cycle time in the clinic for new patient visits and minor surgical procedures and uncovered a great deal of variation in practice.

The lead improvement team members also realized there were patterns of access within their plastic surgery system that they needed to know more about before they could improve total system access to care, including outpatient visits, minor surgeries, and inpatient surgical procedures; this is shown in Figure 13.3. Team members began to discuss and observe the patterns in their practice. They uncovered measures specific to appointment scheduling, including poor access to appointments for new patients. A pattern of undesired variation was discovered in the way physicians scheduled follow-up visits for patients. Follow-up volumes varied significantly across the physicians.

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