System Change Case Study Analysis Paper
Part One: Description of Case
Part one of the paper should use the format for a case study analysis (can be a combination of analytic and problem case study methods), with the case presented in 6-8 pages using topical headings to organize the case study.
Objectively describe the project – do not analyze or critique in this section.
• Background and Significance/Purpose of the project
o Goals and objectives
o Primary and any secondary outcomes
• Planning activities including:
o People involved
o How the approach/strategies were developed
o Challenges in planning stage and how they were addressed (e.g. resistance from administration)
• Pre-implementation data collection
o What data was collected, by whom, for how long, etc.
• Implementation of Project
o People involved
o How intended changes were communicated to key stakeholders
o Any educational needs addressed
o How implementation proceeded
o Barriers and facilitators
o Any changes made along the way
• Outcome data collected
• Results
Part Two: Case Analysis
Part two of the paper is a critical analysis of the use of leadership principles and theory, communication plan, change theory, selection of measures and outcomes identified at this stage of the change project (4-6 pages). Reference list and appendices (only as needed) are not included in the page count.
The organization of this part of the paper is up to you. The following are some of the important things to consider (this is not comprehensive):
What leadership principles and theories were demonstrated and how effective were they? Include how leadership built on strengths (facilitators) and responded to barriers
What change theory was used for the project and was it appropriate? If no change theory was used, identify an applicable theory and discuss how it would be applied and potential benefits of doing so.
Was the team composed of all the people needed to effectively and successfully implement the project?
How well was the practice change communicated?
Was the intervention likely to meet the purpose and achieve the goals and aims of the project?
Were the metrics used to determine the outcomes appropriate?
Were appropriate data collected before and after implementation of the project?
Were there any unintended consequences?
Were evaluation methods appropriate? Would they allow the team to determine if the goals or aims were met?
What about sustainability?
**Note: use the attached project topic and reference and apply the above instructions. Though this project topic is not a completed project; part of this assignment is reviewing the outcome analysis. when you read this topic you can determine how the outcomes can be measured and discuss that.
*The project topic is “Actualizing Better Health and Health Care for Older Adults.â€
Reference:
Fulmer, T., Reuben, D. B., Auerbach, J., Fick, D. M., Galambos, C., & Johnson, K. S. (2021). Actualizing better health and health care for older adults. Health Affairs, 40(2), 219–225. https://doi.org/10.1377/hlthaff.2020.01470
System Change Case Study Analysis Paper
Part One: Description of Case
Background and Significance
Falls are among the adverse events that are most commonly reported in hospitals, especially among the elderly. Approximately 800,000 falls incidences are reported in United States hospitals annually (Agency for Healthcare Research and Quality, 2019). Falls are associated with negative quality and safety outcomes as they cause patients to sustain different types of physical injuries such as head trauma, bone fractures, and broken limbs. Other negative impacts of falls include a prolonged length of hospital stay, increased healthcare costs, and psychological issues such as anxiety and depression (Seow et al., 2021). Increased incidences of falls are usually reported at the bedside inside patient wards. Patients most commonly fall when they try to leave their beds either to have a rest or to use the washrooms. Innovative strategies that provide alerts to nurses when patients try to leave their beds have been helpful in reducing incidences of patient falls. There is a rising trend in the use of alarm devices across healthcare organizations to prevent incidences of patient falls (Okumoto et al., 2020). Healthcare organizations that are recording high incidences of patient falls can use bed alarms to prevent patient falls.
Purpose/Goals/Objectives of the Project and Outcomes
The aim of the change project is to assess the effectiveness of an integrated three-mode bed exit alarm system in preventing incidences of falls within a Singapore-based acute care setting. The acute care setting has been recording high rates of patient falls per 1,000 patient days (Seow et al., 2021). The results of the study will fill a gap in the literature concerning the effectiveness of bed alarms in preventing fall events at the bedside. The project only intends to measure one primary outcome. The specific primary outcome is the presence of falls at the bedside during every hospital stay recorded as either yes or no. This is the dependent variable that was measured after the implementation of the intervention.
Planning Activities
Proper planning was done before the project was implemented. Precisely, the investigators put in place the right people, developed the right strategies to use in the planning, and effectively addressed challenges in the planning stage. The people involved include the researchers, the nurses, the patients, and the hospital administration including the unit managers and quality control officers.
The intervention strategy or approach was developed by reviewing the literature to understand what is known and what is not known regarding the effectiveness of bed alarms in preventing falls in hospital settings. For example, the choice of bed alarms as a prevention strategy for patient falls in the study was influenced by published evidence indicating that most falls events that are reported in healthcare settings usually occur when patients are alone and without the knowledge of the nurses (Kisacik & Cigerci, 2019). The investigators in the current project believed that bed alarms can alert nurses when patients want to leave their beds.
Evidence from the literature regarding the effectiveness of bed alarms in reducing patient falls further motivated the investigators to settle on the chosen intervention. For example, Albuquerque et al. (2020) conducted a study to assess the impact of an educational program aimed at increasing nurses’ knowledge regarding the use of the Hill-Rom bed exit alarm system to reduce rates of falls among at-risk patients. Findings from the study revealed that the use of the Hill-Rom bed exit alarm system coupled with an education program for the nurses was effective in reducing rates of falls among at-risk patients. Based on this evidence, the researchers resorted to testing the effectiveness of an integrated bed exit alarm system coupled with nurse training to reduce patient falls events in the practice setting.
Some challenges were experienced during the planning stage. These include resistance from the administration and the nurses, limited funds to acquire beds already fitted with alarm systems, and limited knowledge and skills among the nurses to use the beds and set the alarms (Seow et al., 2021). The investigators taught the nurses and the administration about the benefits of using the bed alarm system. It also sourced sufficient funding to purchase beds fitted with alarm systems and trained the nurses on how to set and use the bed alarms before the implementation of the intervention.
Pre-implementation Data Collection
The investigators collected pre-implementation to be able to understand rates of patient falls in the acute care setting before any action is done to address the situation. Pre-intervention data were collected by the investigators themselves. The data was collected between October 2015 and June 2016. This period had a total of 9 months (Seow et al., 2021). The data collected during pre-intervention was on patient fall rates before bed exit alarms were used. The beds in the acute care setting during the pre-implementation phase had similar specifications to the beds used during the implementation and post-implementation phases. However, the only difference between them is that those used during the intervention and post-implementation phases had bed exit alarms installed in them. The data captured rates of patient falls in three different wards within the acute care setting. Data for patients who were hospitalized in the three wards were reviewed retrospectively. This data was obtained from the electronic databases of the hospital (Seow et al., 2021).
Implementation of Project
The primary investigators and the nurses deployed in the three wards of the acute care setting were involved in the implementation of the project and in data collection during implementation. The intended changes were communicated to the key stakeholders during the implementation phase. However, the channel of communication used is not mentioned in the article. Nurses in the wards received training on how to set and use bed exit alarms to monitor the movement of patients on and out of the bed.
The implementation proceeded with the execution of the intervention. The investigators used the Hill-Rom 1000 Medical-Surgical bed to complete the project. These types of beds have a bed exit alarm system already in-built into them. The alarm system in them can detect three different types of movements that can be made by the patient who is lying on the bed (Seow et al., 2021). One of the modes of detection is for slight changes in movement that are detected by bed pressure sensors. When the nurse activates this detection, the alarm produces alerts when the patient moves slightly on the bed such as when movement occurs from a lying to a sitting position. The other type of detection occurs when the patient changes position from one side of the bed to another side. Alert sounds are created that require the nurse to check whether the patient is likely to fall from the bed. In the third form of detection, alert sounds are produced when a patient who is seated on the edge of the bed, leaves the bed and stands next to the bed. The implementation proceeded after the investigators ensured that the nurses could effectively activate the three modes of alarm systems. During implementation, the nurses were allowed the freedom to assess patients’ needs and determine the most appropriate activation to make to prevent falls (Seow et al., 2021).
The main facilitator that enhanced the implementation of the project was the availability of enough beds to be used with all hospitalized patients. After seeking other sources of funding, the acute care setting was able to acquire enough beds to use for the project. The main barrier to project implementation was limited knowledge among the nurses deployed in the wards regarding how to activate alarm systems and use them to prevent patient falls. Although nurses were taught to enhance their competence, the process was slow because the nurses could not master concepts at the same pace (Seow et al, 2021). The project’s limitations that should be addressed by similar studies conducted in the future include the inability to monitor nurses’ compliance to respond to alarm calls, and the challenge of aligning the choice of alarm modes with patients’ profiles. No major changes were made along the way.
Outcome Data Collected
The outcome measure for the project was the presence of falls at the bedside during every hospital stay. This was recorded as either yes or no to denote the presence of falls or absence of falls respectively. The outcome data were collected from the electronic database of the hospital. The researchers considered other patient-related variables when measuring outcomes. The variables include the age of patients, the presence or absence of comorbidities, and the patient’s length of stay. The Charlson Comorbidity Index (CCI) was used to measure patients’ comorbidities (Seow et al., 2021). The post-implementation data was collected for a period of 12 months between July 2016 and June 2017. The collected data was analyzed using statistical approaches. The dependent or outcome variable was tested using a multivariable logistic generalized linear mixed-effects model.
Results
The investigators used a sample size of 17,398 from three wards of the acute care hospital. This number was arrived at after 187 patients were excluded from the study because they were present in the wards during the pre- and post-implementation phases and their data could have been captured twice. The average age of participants was 63 years. Males comprised 52% of the sample whereas females comprised 48%. High incidences of falls were recorded among elderly patients with higher CCI when compared to younger patients with low CCI (Seow et al., 2021).
A total of 45 fall incidences were reported between October 2015 and June 2017. The key results indicate that there was a direct relationship between the bed exit alarm intervention and a reduction in fall rates. By July 2016 at the time when the intervention was introduced, the incidence of falls was at 0.23%. This improved to 0.11% by December 2016, 6 months after the implementation of the intervention (Seow et al., 2021). These results indicate that there was a 0.12% reduction in fall incidences following the successful implementation of the intervention. They indicate that an integrated three-mode bed exit alarm system is effective in preventing incidences of falls within a Singapore-based acute care setting.
Part Two: Case Analysis
Leadership Principles and Theories
Leadership principles and theories were demonstrated in the project, and they were effective in helping the project team to meet its goals and objectives. The specific leadership principles that were applied to the project include effective communication, team-building, and decisiveness (Manzano & Vose, 2021). Effective communication was demonstrated when key messages related to the project were successfully exchanged between the hospital’s leadership and the protect team and among the project team members themselves. The project leader demonstrated the team-building principle of leadership by bringing together all the stakeholders involved in the project. The principle of decisiveness was evident when the project leader was able to make crucial decisions during the project to ensure the successful implementation of the integrated bed exit alarm system (Seow et al., 2021). The leadership theory that was demonstrated in the project is transformational leadership style. Transformational leadership theory assumes that an effective leader should have the capacity to build strong relationships with employees and inspire them through a meaningful change initiative (Saleem et al., 2022). This theory was evident when the project leader was able to design a change project and build a strong relationship with the project team and other stakeholders to successfully implement the proposed change. The named leadership principles and transformational leadership theory were effective in helping the leader to build on the project’s facilitators and allowed an effective response to the barriers encountered along the way.
Change Theory and Its Potential Benefits
The researchers did not clearly explain the use of a change theory in the project. The change theory that is applicable to the project is Kurt Lewin’s theory of change. Lewin’s change theory assumes that change in an organization usually occurs in three stages namely; unfreeze, change, and refreeze. The unfreeze phase entails informing stakeholders that a problem exists and explaining the action that will solve the existing problem. The ‘change’ phase entails executing the actual reform to bring about change and the ‘re-freeze’ phase is where the proposed change is integrated into the organization’s guidelines and policy to bring about sustainable change (Mitchell et al., 2022). Kurt Lewin’s change theory would be applied in the given project. Guided by the three phases of change, the project team would begin by informing stakeholders about the rising incidences of patient falls and the need to implement an integrated three-mode bed exit alarm system to reduce rates of patient falls (unfreeze). In the ‘change’ phase, the project team would implement the bed alarms system to reduce rates of patient falls in the wards. In the refreeze phase, the acute care setting would integrate the three-mode bed exit alarm system into the healthcare delivery processes of the organization (Parker et al., 2022). The potential benefits of using Kurt Lewin’s change theory to drive change in the acute care setting would provide a clear framework for the project team to ensure that it successfully implements the intervention in the facility to reduce incidences of patient falls.
Teamwork and Collaboration
There was evidence of teamwork in the project. The people involved include the researchers, the nurses, the patients, and the hospital administration including the unit managers and quality control officers. The team was composed of the people that the project leader needed to effectively and successfully implement the project. However, the addition a nurse informaticist or a health information technology professional and a finance manager to the team could have enhanced the project’s success (Staggs et al., 2020). The researchers or the project team played a key role in completing specific tasks that led to the completion of the project. Patients are a crucial component of the team because they are the focus of the project on which the impacts of the intervention are measured. The project team teams nurses to activate the alarm systems and use them to monitor patients’ movements and incidences of patient falls. The hospital administration including the unit managers and quality control officers offered the support that the project team needed to successfully implement the intervention in the acute care setting. According to Gabutti et al. (2022), multidisciplinary collaboration is among the factors that organizations need to successfully implement change It is important to note that including a nurse informaticist in the team would be helpful in that the incumbent would assess the performance of the bed exit alarm systems throughout the project as support its integration into the healthcare delivery process of the acute care setting. Additionally, involving a finance manager in the project would have helped the project team with budget development and the acquisition of funds to facilitate project implementation.
Practice Change Communication
The practice change was well communicated with the stakeholders. The stakeholders were informed about the change and its intended benefits. According to Rasheed et al. (2021), effective communication is a crucial element in supporting practice change initiatives in healthcare settings. The reason is that it allows members of a group to engage in shared decision-making and completion of tasks thereby enhancing the realization of the desired goals. The authors further assert that effective communication serves four major functions in a practice change initiative. The specific functions include controlling the behaviors of members, motivating team members to complete tasks, providing room for emotional expression, and providing information to guide decision-making (Rasheed et al., 2021). According to Jankelová and Joniaková (2021), healthcare organizations and project teams utilize communication as a management tool to allow sharing of crucial information. This helps to create a comfortable work environment for all and helps to streamline processes and operations. Effective communication of the practice change to stakeholders is among the factors that contributed to the success of the bed alarms project.
Intervention
Since the project was successfully implemented, the intervention successfully met the purpose and achieved the goals as well as the aims of the project. The purpose/goal of the project, which also serves as its objective and aim, was to assess the effectiveness of an integrated three-mode bed exit alarm system in preventing incidences of falls within a Singapore-based acute care setting (Seow et al., 2021). 6 months after the implementation of the intervention, incidences of patient falls had reduced by 0.12% from a value of 0.23% to 0.11% (Seow et al., 2021). A total of 45 fall incidences were reported between October 2015 and June 2017. From these findings, it is evident that there was a direct relationship between the bed exit alarm intervention and a reduction in fall rates.
Appropriateness of the Metrics
In practice change projects, a measure is a parameter that is used to determine the impacts of an intervention. The specific metric in the case study is the presence of falls at the bedside during every hospital stay recorded as either yes or no. This is the dependent variable that was measured after the implementation of the intervention. According to Seligman et al. (2021), outcome measures vary depending on the practice problem that a given intervention is meant to address. In the given project, the three-mode bed exit alarm system (intervention) is meant to reduce incidences of patient falls in the acute care setting. Therefore, the chosen metric was appropriate in determining the impacts of the three-mode bed exit alarm system on incidences of patient falls.
Appropriateness of the Data that was Collected During Pre-Implementation and Post-Implementation
The data that was collected during the pre-implementation and post-implementation phases were appropriate. Considering the nature of the project, it was imperative to know the incidences of patient falls in the three wards before and after the implementation of the project (Kisacik & Cigerci, 2019). The data collected during pre-intervention was on patient fall rates before bed exit alarms were implemented. Data for patients who were hospitalized in the three wards were reviewed retrospectively, a factor that enabled the project team to understand the situations in the wards regarding rates of patient falls when no bed alarms are used (Seow et al., 2021). Besides, the data that was collected during the post-intervention phase was appropriate in that it generated insights regarding rates of patient falls in the wards after bed alarms were used to alert nurses about patients’ movements.
Unintended Consequences
Unintended consequences in a project might affect the investigator’s ability to establish the actual association between a practice change and the outcome. In this respect, it is imperative that a change team understands how to differentiate between the intended impacts and unintended effects of an practice change intervention (Zhang et al., 2022). One intended effect encountered in the project was that there would be variations in the rates of falls among patients of different age groups. It was expected that changes in rates of falls would be uniform across patients of different age groups irrespective of whether one was an adult or an elderly. However, Seow et al. (2021) indicate that high incidences of falls were recorded among elderly patients with higher CCI when compared to younger patients with low CCI.
Appropriateness of the Evaluation Methods and Sustainability Issues
The evaluation methods used in the project were appropriate considering the nature of the project. The reason is that they would allow the project team to determine if the goals or aims of the project were met. The researchers evaluated the intervention based on the aim of the study and the outcome measure (Shepherd et al., 2022). The aim of the change project is to assess the effectiveness of an integrated three-mode bed exit alarm system in preventing incidences of falls within a Singapore-based acute care setting (Seow et al., 2021). By using the named evaluation method, the investigators found that an integrated three-mode bed exit alarm system is effective in reducing incidences of falls in the acute care setting. To ensure sustainability, it is important that the organization addresses issues related to “alarm fatigue”, the possibility of non-compliance by the nurses when activating and using the alarm system, and the nurse’s ability to respond quickly to alarm calls (Seow et al., 2021). Generally, effective implementation of a practice change required effective leadership, effective communication, appropriate selection of intervention and associated metrics, and appropriate choice of evaluation and sustainability approaches.
References
Agency for Healthcare Research and Quality. (2019). Falls. https://www.ahrq.gov/topics/falls.html
Albuquerque, L. H., Jacob, B., & Mahon, E. H. (2020). Hill-Rom’s bed exit system with audible alarm, used in conjunction with falls protocol: Reduces falls on a medical-surgical inpatient unit: A process improvement project. Journal of Comprehensive Nursing Research and Care, 5(1), 159. https://doi.org/10.33790/jcnrc1100159.
Gabutti, I., Colizzi, C., & Sanna, T. (2022). Assessing organizational readiness to change through a framework applied to hospitals. Public Organization Review, 1–22. Advance online publication. https://doi.org/10.1007/s11115-022-00628-7
Jankelová, N., & Joniaková, Z. (2021). Communication skills and transformational leadership style of first-line nurse managers in relation to job satisfaction of nurses and moderators of this relationship. Healthcare (Basel, Switzerland), 9(3), 346. https://doi.org/10.3390/healthcare9030346
Kisacik, O. G. & Cigerci, Y. (2019). Characteristics of inpatient falls in a hospital setting: A retrospective study from Turkey. International Journal of Caring Sciences, 12(2), 768. http://www.internationaljournalofcaringsciences.org/docs/18_gurlek_original_12_2.pdf
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Mitchell, S., Harrison, M., Oliver, P., Gardiner, C., Chapman, H., Khan, D., Boyd, K., Dale, J., Barclay, S., & Mayland, C. R. (2022). Service change and innovation in community end-of-life care during the COVID-19 pandemic: Qualitative analysis of a nationwide primary care survey. Palliative Medicine, 36(1), 161–170. https://doi.org/10.1177/02692163211049311
Parker, G., Shahid, N., Rappon, T., Kastner, M., Born, K., & Berta, W. (2022). Using theories and frameworks to understand how to reduce low-value healthcare: a scoping review. Implementation Science: IS, 17(1), 6. https://doi.org/10.1186/s13012-021-01177-1
Okumoto, A., Miyata, C., Yoneyama, S., & Kinoshita, A. (2020). Nurses’ Perception of the Bed Alarm System in Acute-Care Hospitals. SAGE Open Nursing, 6, 2377960820916252. https://doi.org/10.1177/2377960820916252
Rasheed, M. A., Hookmani, A. A., Waleed, S., Fatima, H. S., Siddiqui, S., Khurram, M., & Hasan, B. S. (2021). Implementation and evaluation of a social media-based communication strategy to enhance employee engagement: Experiences from a children’s hospital, Pakistan. Frontiers in Public Health, 9, 584179. https://doi.org/10.3389/fpubh.2021.584179
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Seow, J. P., Chua, T. L., Aloweni, F., Lim, S. H., & Ang, S. (2021). Effectiveness of an integrated three-mode bed exit alarm system in reducing inpatient falls within an acute care setting. Japan Journal of Nursing Science, 19 (1), e12446. https://doi.org/101111/jjns.12446.
Shepherd, V., Islam, I., Wood, F., Williamson, P. R., Goodman, C., Bath, P. M., Thompson, C., Knapp, M., Gordon, A. L., & Hood, K. (2022). Development of a core outcome set for the evaluation of interventions to prevent COVID-19 in care homes (COS-COVID-PCARE Study). BMC Geriatrics, 22(1), 710. https://doi.org/10.1186/s12877-022-03395-8
Staggs, V. S., Turner, K., Potter, C., Cramer, E., Dunton, N., Mion, L. C., & Shorr, R. I. (2020). Unit-level variation in bed alarm use in US hospitals. Research in Nursing & Health, 43(4), 365–372. https://doi.org/10.1002/nur.22049
Zhang, T., Liu, J., Lu, B., Yan, Z., Huang, X., & Lu, W. (2022). Intended and unintended impacts of the comprehensive reform of urban public hospitals: A mixed-method study in Hangzhou, China. Frontiers in Public Health, 10, 979455. https://doi.org/10.3389/fpubh.2022.979455