Case Story

When patients are ready to be discharged from the hospital, their patient files—stuffed with patient histories and edged with a rainbow of colored section tabs—have a “discharge face sheet” attached to their fronts. This face sheet outlines the patient’s discharge medications, treatments, and future appointments. In the past, face sheets were scribbled quickly by the physicians who used medical abbreviations which parents wouldn’t understand. The nurses then recopied the sheets into plain English, so that both the patients and their families could understand them. Recopying was a lengthy process, sometimes taking up to 25 minutes for each face sheet. For Leslie, these sheets represented an inefficient, time-consuming task.

Leadership from Within:
Nurse Leslie and the Face Sheet

Leslie is a registered nurse in the bustling pediatric ward at Heuristic Hospital. She has a solid reputation as a nurse who provides excellent patient care and as a person who cares about her patients, their families, and her co-workers. Because she has worked on the ward for the past 10 years, Leslie knows all of the system intricacies, including which processes don’t work optimally. Often Leslie sat at the nurses’ work station filling out paperwork for patient discharges and thought to herself, “Why am I spending twenty minutes filling out this form, ‘patient discharge instructions,’ when the resident physicians just filled out a similar form, the ‘discharge face sheet,’ for the patient chart?”

Engaging her Colleagues

This thought stuck in Leslie’s mind, and prompted her to talk with her colleagues and co-workers. After discussing her concern about the time being used on the patient discharge instructions, Leslie found that her nursing colleagues felt the same. Why spend time filling out paperwork when they could spend this time with their patients?

Leslie realized that this didn’t just affect the nurses and her approach was to seek out others to work with her in correcting the system. The face sheet process also affected the pharmacists—who used the patient discharge instructions to understand the recommended medication doses and times of administration—and the resident physicians—who filled out the discharge face sheet in the first place.

Leslie then sought out Mike, an experienced pharmacist working in the Pediatrics Ward. Mike had noticed that errors sometimes crept into orders for medications. Upon hearing Leslie’s concern about the extra time taken copying the physician’s face sheet, Mike realized that copying over the medication orders was one of the places where errors could slip in. He agreed that the ward would benefit by simplifying the system.

Dr. Steve, a physician on the ward, was also asked his opinion on this proposal. He responded enthusiastically, knowing that saving nurses’ time would likely improve patient care and that minimizing medication error was of key importance. However, he expressed some reservation that certain doctors could resist if the change created too much more work for them. Therefore, Leslie chose several senior residents and the chief resident as targets of her lobbying. She asked these individuals to spread the word among the rest of the residents.

Leslie’s plan had been to garner support from as many people as possible. She had no problem gaining the support of her fellow nurses. Her peers were enthusiastic about the idea of saving anywhere from 5-25 minutes of paperwork with each discharge. The pharmacists were enthusiastic, given Leslie and Mike’s enthusiasm and the chance to decrease errors in transcription. And the physicians were generally accepting of the plan. They liked the idea of decreasing the chance of errors and increasing process efficiency, leaving more time for nurses to spend with patients.

 

Vision and Change

Leslie began to envision the new process. She thought that they could get rid of the “patient discharge instructions” sheet completely if the physician “discharge face sheet” was modified slightly and written on the new sheet legibly in plain English by the physicians. Then a single discharge sheet would suffice.

A team was developed to revise the discharge face sheet. This team included Leslie from Nursing, Mike from Pharmacy, Steve from the staff physicians, a health unit clerk, a resident physician, and the unit discharge coordinator. Leslie and the team worked well together, for they already had established trust and open communication with each other. The team pursued the idea for change with the appropriate committees at the hospital. Leslie was enthusiastic and focused throughout the process, which allowed her to communicate her ideas effectively to the committees and to her teammates. The committees were easily convinced and her new, “no copy” face sheet plan became reality. And because Leslie had gathered input from her peers and worked well with the rest of her team, the new face sheet process was implemented without a hitch.

Although she did not have any positional authority, Leslie operated as an effective leader in changing the face sheet process.

 

Things to consider about this case

There are several issues to consider about this case that demonstrate system improvement. You will explore these issues more fully in the learning activities.

• Consider changes in Leslie's behavior that may have led to a failure to change the system, such as:
•  Leslie not even thinking about change;
•  Leslie not working with her peers to ascertain whether the proposed change was a good one for all involved disciplines;
•  Leslie not taking the time to lobby several members of various disciplines;
•  Leslie making decisions unilaterally or on a uni-disciplinary basis rather than developing a multidisciplinary committee to consider the best route of change.
• If Leslie's supervisor, the clinical nurse manager, was against the proposed changes, what would have been the likely outcome?
• Consider the advantages and disadvantages if Leslie first envisions change and then carries out 90% or more of the work involved in developing a new discharge face sheet?
• Consider the advantages and disadvantages if the multidisciplinary team described in the case story shares the work of developing a new discharge face sheet.

 

What to do next

Now that you have read the case, go to the Lecture section to gain a better conceptual understanding of effective leadership.