Introduction

Simon Health Authority (SHA) is the pseudonym for one of the local health networks in Canada. SHA serves 1.8 million people, from Robert City to Massachusetts Bar. As a health authority, SHA provides health services across the care continuum, from hospital care to community-based residential, home health, mental health, and public health services. SHA is not only responsible for the provision of service but also acts as a regulatory body for contracted/affiliated organizations through its licensing powers.

Our focus for this chapter is SHA’s home support services. Home support services “focus on helping people with physical limitations manage activities of daily living” (Fraser Health Authority, n.d.). Activities of daily living include a person’s ability to “bathe, dress, transfer, toilet, control continence, and feed themselves” (Noelker & Browdie, 2013). SHA subscribes to a philosophy of “home is best,” and would prefer people to remain at home as long as possible, mainly if support was in place to do so.

The Canadian Institute for Health Information (CIHI)  (2017) says “within the next 20 years, growth in the older seniors population (those age 75 and older) — who rely more heavily on continuing care services — is expected to accelerate, causing that population to double in size”. The risk of developing chronic conditions increases with age (CIHI, 2011). Therefore, SHA foresees an increased demand for health services, including home support.

Brain Swarming 

We conducted brain swarming to prime our SWOT analysis. Results are below:

Figure 1

Figure 2

Figure 3

Figure 4

SWOT Analysis

The SWOT analysis is an essential tool for strategic management development (Hughes, Beatty, Dinwoodie, 2014). We want to describe the current status of all SHA implementation. Finding the strength and weaknesses present in our organization, the opportunity and threats in the external environment of the organization and use them to improve the overall operation and performance. Conducting a SWOT analysis for Home care services provides us with a detailed look at current service provision and areas for improvement. Figure 1 represents our SWOT analysis.

Figure 5.

We can identify some proficiencies and deficits. Homecare support services have strength and weaknesses. By using Lepsinger’s Bridges (2010), we came up with a new approach which does involve the translation of strategy into action. The effect of the policy is also dependent on coordination and cooperation as described below:

Strategic Initiative

The strategic initiative is to include Point of Care Testing (POCT) into the program and help senior citizen and adults who have a physical disability to continue residing in their home and remain part of their community. Point of Care Testing (POCT) (Leeds pathology, 2014) is clinical laboratory testing conducted close to the site of patient care, typically by patients or clinical personnel whose primary training is not in the clinical laboratory sciences. POCT refers to any testing performed outside of the traditional, core or central laboratory. An organization that understands customer value and focuses on its purpose and the process works towards achieving those values as “an organization’s cultural commitment to applying the scientific method to designing, performing, and continuously improving the work delivered by teams of people, leading to a measurably better value for patients and other stakeholders” (Toussaint and Berry (2013). While POCT represents an essential advance in patient care and provides decisions support interventions; however, it does not replace traditional laboratory tests. Thereby, healthcare providers must use it discerningly. The importance of point-of-care testing is to improve the safety, quality, and efficiency of care (Price, 2012).

In our POCT network with FHA, the POCT analyzer is currently used to measure glucose, electrolytes, renal function, troponin I, blood gases, ionized calcium, lactate, and activated clotting time in various clinical settings. The compliance of the POCT platform with its connectivity to the Laboratory Information System (LIS) affords many of the benefits delivered by POCT for physician, facilities, and adds value to the statewide provision of healthcare.

What strategically useful lessons could you learn from the initiative’s success?

There have been many strategic changes made in health care to address increasing cost. One successful strategy is the reduction of the patient’s length of hospital stay. POC testing provides rapid results. Francis & Martin (2010) say “benefits of rapid access to test results have been demonstrated about a patient length of stay in emergency departments, and timeliness of access to information is critical for patient care decisions – such as for therapeutic drug monitoring, and patient flow decisions.”

An outcome of early release from a hospital for some patients is they still require medical assistance. Because of this requirement and the increasing aging population, the home health-care industry has been growing. (Lehmann, 2002). Considering the objective of the strategic change is to provide “a strategic fit between a firm’s internal capabilities and shifts in the external environment involving technology, markets, industries, and the economy that require a change in the status quo of conducting business” (Bonnici & McGee, 2015). POC testing provides rapid availability of results, facilitating early clinical decisions and contributing to better patient management and outcomes.

Some instances were improvements in patient care were significantly achieved.

One instance is, “for patients newly commenced on warfarin therapy when pharmacists performed regular home testing of INR and conducted patient education during the first eight days post-discharge from the hospital” (Francis & Martin (2010). Another example is someone with a deep vein thrombosis and leg ulcer requiring regular dressings. After an initial period as an inpatient in an acute hospital bed, the patient is transferred to the Home Based Acute Care Service (HBACS) unit and is treated at home. During a single visit to the patient’s home, the home care nurse can: attend to the leg ulcer dressing; utilise the i-STAT to perform the INR test and review the results; liaise with the inpatient medical team who can order an alteration in the dose of warfarin if required; check the patient’s renal function and electrolytes; administer a dose of low molecular weight heparin appropriate for the patient’s measured renal function if required, and conduct patient education regarding warfarin, care of the leg ulcer and prevention of falls in the home” (Francis & Martin, 2010).

A common theme in a number of these studies is the broadly integrated patient care in addition to the real-time use of POCT.

Nurses and care aid providers would improve performance and reduce errors through a collaborative process with others in collective efforts and responsibilities (Hughes et al., 2014); by implementing periodic examinations, relicensing, accreditation and training sessions (Kohan, Corrigan, Donaldson, 2000). Since there is a team involvement with different backgrounds, the need for interdisciplinary training and education are the principal mechanisms for making a cultural change about quality improvement.

Increasing our organization chances for success requires an understanding of the environment in which a new strategy is to operate.

The POCT  initiative is vulnerable to error as a provision of health care support service. A consideration of the POCT process suggests it might be uniquely susceptible to failure because the testing is generally undertaken by non-laboratory clinical staff, whose primary job is the delivery of patient care rather than the analysis of fluid body samples. Even with adequate training, it is possible the pressures of a busy clinical environment might result in lapses or violations in the performance of POCT. Clinical management decisions made immediately on receipt of a POCT result may increase the risk to the patient if the conclusion is erroneous, compared to central lab testing where the time interval between results generation and reporting may allow more significant opportunity for error detection (delta checking) before clinical management or interventions have been implemented (O’Kane, McManus, McGowan, & Lynch (2011). Therefore, some preventative measures can be taken when performing POCT to eliminate such errors by repeating tests when unexpected results occur.    

SHA organizational policy on POCT is based on the Diagnostic Accreditation Program of the College of Physicians and Surgeons of British Columbia. A multidisciplinary committee, comprising senior representatives of laboratory staff, POCT users, hospital finance department, and medical laboratory director, oversee the performance of POCT. The introduction of POCT by clinical teams require approval from this committee. All users of POCT are required to undergo specific training delivered and coordinated by the central laboratory. Assign a member of senior laboratory staff as a POCT coordinator with a full-time role of supporting all POCT at all sites. The duties of the POCT coordinator included operator training, instrument troubleshooting, supervision of quality control and quality assurance, and prospective audit and quality management reviews. The POCT quality performance is subject to external scrutiny as a component of laboratory service and DAP. All POCT modules are subject to rigorous internal quality control (IQA) and external quality assurance (EQA). As part of accreditation, the central clinical laboratory service has access to acquire all reporting system for reporting and logging any defects, then, review and investigate them monthly by senior medical laboratory technologist staff.  

What kind of data would you need to collect that would be relevant to validating your experiment?

O’Kane, McManus, McGowan, Lynch (2011) studies reviewed different aspects of POCT.

The defect rate varied between test types: from 0% for blood ketone meter testing to 0.65% for HbA1c (Table 1). For the most commonly performed POCT test (blood glucose meter), the defect rate was 0.023%. Two-thirds (65.8%) of all Quality Query reports were logged by users, and the remainder by laboratory staff was supervising POCT.

Table 1.

Breakdown of POCT quality errors by test type.

Table 2

Breakdown of POCT quality errors by actual (A) and potential (P) impact on patient care.

Table 3.

Breakdown of POCT quality errors by phase in the analytical process.

 

The goal of POCT is to improve the quality and efficiency of patient care while controlling the cost in the provision of the best ideal patient care. The medical or organizational advantages of POCT is to provide the preliminary screening of patient results; thus, leverage a clinically significant strength in decision-making.

After Action Review

For the After Action Review, we reviewed the agency’s introduction of a company-wide app. This After Action Review involves the use of Change of readiness (Lepsinger, 2010). As it establishes a link with how a change can be introduced and utilized in the best possible way.

1. What was the intent?

The intent was to go paperless and create a way for seamless communication between field staff and office staff and maintain a secure method of exchanging information while not compromising confidentiality. By using this app, any employee could look up client-specific information online through the app without having to print and send/ fax reports. One of the highlights of the app was we could send info via text and email in moments to any person in the agency.

2. What happened?

The app launched, and it was chaotic. There were technical problems with the software of the app malfunctioning. The information exchange was not as secure as we thought. There were confidentiality breaches and many gaps in communication. Tasks for follow up did not get followed up. Client appointments got missed. The critical parties were the users and the software techs and manufacturers who developed the app. The essential junctures that were revealed were insecurity, and communication breaks down.

When asked for probing information we found out the app needed an employee and company password protection to enable use. We also realized there was not enough education surrounding the use of the app. Our employees were struggling to use the new technology.

1. What was learned?

Next time we take on a communication project that large we need to test and do a soft launch with a small group of people before a company-wide start. We learned the importance of a pilot project. Van Teijlingen and Hundley confirm the significance of doing a pilot study. In their article they acknowledge “Conducting a pilot study does not guarantee success, but it does increase the likelihood” (2001, p.1).

We learned we need to create a training program for all employees in a short amount of time. We discovered we need to be conscious of the information we put out and to maintain confidentiality we need strict parameters of who has access to what information and when and where they have access. We must maintain client confidentiality.

4.  What actions should be taken?

Create a Learning plan for all employees. Training of new employees into the organization as soon as they are hired. What can be done immediately is restrictions on access to information and password protecting all files.  We will complete a Plan Do Study Act cycle on this issue to make sure this does not happen again. We can run reports to see what times files were being accessed.

5.  Take Action

Moving forward, we have decided all employees will have mandatory yearly training on using the software to ensure it is used correctly. We will train all new and incoming short call staff. We will run reports daily to measure security breaches.

6.  Disseminate the findings

We have partnerships with other agencies in the field of home support. We reviewed our results and informed other agencies of the possible issues with transitioning to a mobile app. We have regular partnership meetings with these agencies and review challenges we mutually face in the field. We could use a single website instead with a two-step verification process. We realize it is crucial to our success to run a pilot project before implementing a significant change.

Risk

The risk is “anything that, if it occurs, has the potential to impact the achievement of objectives adversely.” (Fraser Health Authority, 2009).  Quality improvement always carries an element of risk (AHS Ethics Framework, 2014). However, health care services are expected to be accessible and to provide high-quality care at all times (ASC Communications, 2016). Health care organizations, then, engage in a balancing act of determining acceptable risk while seeking innovation to provide safe, effective, quality health care.

One weakness of many health care organizations, including the Simon Health Authority, is a reduced capacity of agility. Health care organizations are risk-averse because they feel they are held to a higher standard when saving lives. This more top standard results in a conservative approach to transformation, making this sector slow in adopting cutting-edge technology (Clark, 2017).

Risk management in health care was simple, with a primary focus on patient safety and medical errors. Over time, increasing technological complexity, advanced medical science, and changes to regulatory and financial paradigms have increased the complexity of risk management (NEJM Catalyst, 2018). Simon Health Authority, like all health authorities, recognizes the need for integrated risk management. As SHA “prepares to operate in an uncertain world, often with limited resources and increased demand for accountability, the importance of effective risk identification, mitigation and communication have never been greater.” (Fraser Health Authority, 2009).

SHA manages risk by first identifying the desired objectives, foreseeing possible events leading to risk, classifying the risk, assessing the level of risk, formulating control measures, and monitoring and reporting results. (Fraser Health Authority, 2009). This measured response to risks can translate into a perceived slowness. Hughes et al. (2014) have an assessment for an organization’s capacity for action. The results are below:

Table 4

Assessing Organizational Capacity for Action

Hughes et al. (2014) say if an organization has at least four of these factors, the organization should consider better agility as a strategic priority.

One possible reason for these answers is a poor understanding of managing risk. Informal interviews with frontline staff and department managers reveal a distaste in sharing information with others due to a feeling of danger. Part of this reluctance is legislated by privacy act regulations that restrict information flow. Another factor could be the organization applying the RACIN model as discussed by Lepsinger (2010); however, frontline staff may feel they should be informed.

This reluctance to share information may carry forward to interdepartmental relations – health care tends to work in silos. Health authorities have tried initiatives such as CommuniCARE to facilitate communication across teams (Findlay & Merkel, 2014). Success is limited at best due to poor communication of expectations and of understanding the rationale behind the initiatives.

Finally, working in silos leads to hyperfocus on doing the perceived best for that particular area. Employees may not grasp a benefit to the entire organization and would instead focus on meeting local leadership objectives; in other words, if the boss thinks an employee is doing well, the organization must be achieving its goals and is, therefore, doing well.

Addressing Agility Concerns

One way to address agility concerns is incremental changes through the plan-do-study-act cycle, also known as the PDSA, plan-do-check-act (PDCA), Deming, or Shewhart cycle. PDSA is a way to implemental small changes (American Society for Quality, n.d.). If the transition is not successful, the organization can implement other plans with little impact on current processes. However, if the change is successful, the organization can incorporate these new changes into base practice.

Another way to increase agility is to engage frontline staff. The Institute for Healthcare Improvement (IHI) says “Ideas for transforming the way care is delivered on medical-surgical units do not solely come from the executive suite or the quality improvement department, but heavily rely on front-line staff.” (Rutherford et al., 2008). Similarly, the Agency for Healthcare Research and Quality (2014) says “to help staff accept the new bundle of practices fully, ensure that they understand that those practices offer promising strategies for providing high-quality care for patients.”

One final way of increasing agility is to let people know when an organization is successful. Personal experience shows some staff does not see the graphs posted on the wall highlighting successes or areas of improvement, or understand those same graphs if they do. If frontline staff understood the current goals in place, they might see how their actions are helping. In health care, staff actions save lives and improve the quality of life, so we want staff to feel good about what they are doing.

Recommendation  

The following changes can be brought in:

Community Health Worker (CHW) accountability

There are numerous ways we can monitor CHW accountability in the field. One recommendation is for nursing supervisors to do random spot checks, to observe the CHW in a patient’s home. Another way to promote CHW accountability is to keep a record of good and bad behavior by making detailed notes in each employee file to document employee performance. We also recommend providing annual training on all medical competencies. Each year the training needs an expiry date for each CHW competency. Upon the expiry date, the nurses will review all skills. By regularly seeking feedback from all field staff and patients provides a detailed picture of employee conduct. All negative feedback needs immediate follow up.

Home care support services have additional problems addressable by using Lepsinger’s bridges, specifically expecting top performance, holding people accountable, and choosing the right person for making the right choices. The following remedies will help:

1. Confusion in communication due to multiple caregivers caring for one client – Providing caregivers sharing the same language of communication is better. As in elderly age group people, it would be tough for them to deal with someone who has difficulty in understanding them correctly and could turn into the opposite of what their purpose of providing care to them.
2. Caregivers who aren’t punctual – Care giver punctuality is important. This shows how much they care for their client.
3. Inconsistent quality of care – This can be improved by providing the same level of caretaker to an individual. As we know every caretaker, or the person, is not on the same page of providing care to their client which is frustrating and debilitating for handling  those situations. However, it can be improved by delivering the same caretaker or a similar caretaker having like nature and experience in dealing with clients.
4. Caregivers spending too much time on phones – Spending time on phones is a common complaint, and this could be devastating as this clearly shows non-interested in taking care of the individual and also against the will of the client.
5. Lack of caregiver training – Training is a must to deliver top performance as happier clients offer more chances of growth for the company.
6. Not being told when caregivers call in sick – An immediate arrangement of another caregiver if someone called sick is necessary, with informing the client a priority. This allows the client to mentally prepare for expecting another person.

These are some of the standard fundamental problems faced by homecare health facilities in their performance which can improve by adopting these measures.

Conclusion

1. Continue to develop the best performance and transform perspectives to encompass many facets and dimensions of the leadership process (Northouse, 2013) When all conditions come together we can create a team of high performers; a team can execute care effectively. (Lepsinger, 2010).
2. Create a supportive environment and encourage healthcare providers with trying a new approach when taking on challenges (Lepsinger, 2010), to increase chances of innovation, quality improvement, and safe patient care.
3. Continue to follow the organization’ mission, vision, and values (MVV). Hughes, Beatty, and Dinwoodie, (2014) noted MVV helps employees understand and make sense of the organization’s purpose, goals and culture to promote patient safety.
4. Promote and welcome innovation. One-person alone cant fully perceives systems (Atha, 2018). Input from team members may result in fresh insight.

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