In today’s complex healthcare system, healthcare providers need to think critically and make informed choices. Systems thinking is a strategy that is observed to provide a powerful language to communicate care and address complex situations (Arnold & Wade, 2015). Systems thinking is used to explore and develop effective action in complex contexts and it involves moving from observing events to surfacing underlying structures that drive those events. In healthcare, systems thinking is used as a diagnostic tool whereby it provides guidance for examining problems accurately before acting (Manuele, 2019). The approach ensures that leaders or individual healthcare workers develop the willingness to see situations more fully (Arnold & Wade, 2015). Through the application of systems thinking, healthcare professionals can see relationships between issues and acknowledge that multiple interventions can be used to solve problems.
The healthcare system is faced with numerous challenges that require employees and leaders to apply systems thinking. Most of these problems have multiple solutions that should be analyzed to ensure that implemented changes are the most appropriate. Systems thinking expands the range of solutions to address a problem by broadening the thinking of individuals (Arnold & Wade, 2015). Additionally, the application of systems thinking ensures anticipation of the impact of change and minimization of its severity. In healthcare, systems thinking can be an important solution to chronic issues like staffing and patient-related issues like readmission rates. Systems thinking ensures that providers seek evidence that accounts for unintended outcomes across service areas and levels of care (Leslie et al., 2018). During the application of this model, system thinkers consider how their actions in any component can affect the system as a whole rather than a single item.
Macro system-Level Transition
The transition of care involves a wide range of services and environments used to promote the safe passage of patients across care settings. During this transfer, high-quality care should be demonstrated to avoid errors and adverse events that can result from poor communication. The macro system-level transition that I have selected for this discussion is the transfer of patients from hospitals to nursing homes. The majority of patients transferred are the elderly with chronic conditions like dementia. Nursing home care is observed to lead to desirable patient outcomes like shorter hospital stays and it improves the patient’s quality of life. Approximately 30% of hospitalized Medicare patients are transferred to nursing homes making this care transition important. Given the importance of nursing homes, it is crucial to monitor and improve the quality of transfers to prevent readmissions and adverse patient outcomes.
Safe patient transfer from hospital to nursing homes or skilled nursing facilities is a logistically challenging problem. Better coordination with healthcare providers in nursing homes requires timely communication and successful transfer of electronic medical records of patients. Ineffective communication is a top challenge during transitions that risks the well-being of patients. Developing a hospital-to-nursing home transition should focus on the goals of efficiency, patient safety, and quality that can be achieved through systems thinking. Nurse leaders should focus on making changes based on the individual needs of patients while considering the overall impact of the process on the healthcare system.
The Institute of Healthcare Improvement (IHI) quadruple aim is a framework that describes an approach to optimizing the performance of healthcare systems. The components of the quadruple aim include improving the health of populations, enhancing patient experience, and reducing the per capita cost of health care (IHI, 2019). During the transition of patients from hospitals to nursing homes, it is important to have these goals in mind to effectively deliver quality services to patients. The first point of care that is crucial during the transition of patients is effective communication. The second point of care involved in the hospital to nursing home transition is medication reconciliation which serves to minimize medication errors.
Nurse leaders can improve the care transition process using systems thinking to ensure patient safety, enhance their experience, and reduce healthcare costs. The first strategy that the leader should use is advocating for interoperability between electronic health record systems (Mileski et al., 2017). Addressing this aspect will improve communication between the two care facilities and reduce the costs of addressing transition gaps. Additionally, improved communication and interoperability can be an effective strategy to provide better patient experiences. The second strategy that nurse leaders can use is the standardization of documentation and the use of communication tools (Mileski et al., 2017). For example, communication tools like situation, background, assessment, and recommendation (SBAR) can be crucial in transferring patient information to nursing homes and reducing medication errors. The utilization of these tools can achieve the goals of improved health of populations and reduced costs of healthcare by minimizing medication errors.
Arnold, R. D., & Wade, J. P. (2015). A definition of systems thinking: A systems approach. Procedia Computer Science, 44, 669-678.
Institute for Healthcare Improvement. (2019). The triple aim or the quadruple aim? Four points to help set your strategy. http://www.ihi.org/communities/blogs/the-triple-aim-or-the-quadruple-aim-four-points-to-help-set-your-strategy
Leslie, H. H., Hirschhorn, L. R., Marchant, T., Doubova, S. V., Gureje, O., & Kruk, M. E. (2018). Health systems thinking: A new generation of research to improve healthcare quality. PLoS Medicine, 15(10), e1002682.
Manuele, F.A. (2019). Systems/Macro Thinking: A Primer. Professional Safety, 64, 37-42. https://aeasseincludes.assp.org/professionalsafety/pastissues/064/01/F3Manuele_0119.pdf
Mileski, M., Topinka, J. B., Lee, K., Brooks, M., McNeil, C., & Jackson, J. (2017). An investigation of quality improvement initiatives in decreasing the rate of avoidable 30-day, skilled nursing facility-to-hospital readmissions: A systematic review. Clinical Interventions in Aging, 12, 213.
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