Continuity of Care Evaluation in Urban Settings

This assignment delves into the evaluation of continuity of care within a specific urban family physician program. It examines the viewpoints of both patients and healthcare professionals regarding this crucial aspect of healthcare delivery. The analysis draws upon research findings and aims to shed light on the experiences and perceptions surrounding continuity of care in this particular setting.

Running head: CHANGES IN HEALTHCARE
CHANGES IN HEALTHCARE
Name of the student:
Name of the university:
Author note:

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During my internship months of the university, I was appointed as a nurse manager in the
orthopedic department of the XYZ hospital. I had the duty of maintaining the team of nurses and
also to look over and provide correct guidance for effective cooperative and teamwork between
the members of the multidisciplinary teams. While I was working in the hospital in the said
ward, I gradually became accustomed with the culture and the working environment of the ward.
However, I felt, there are certain number of issues in the work culture of the orthopedic
department which were affecting the smooth flow of the workplace and were not ensuring
quality care of the patients. Therefore, a thorough research was conducted by me in order to
understand the working culture of the orthopedic ward for the last 5 to 10 years. After thorough
analysis, I developed a set of goals which were implemented by the healthcare professionals in
the ward in order to make them align with patient safety. Following such goals,
recommendations were established to maintan patent safety and smooth workflow (Townsend et
al. 2014). The following assignment will first reflect on the pattern of work which is conducted
in the hospital in the orthopedic ward for about 5 to 10 years. Then analyzing their positive and
negative aspects, a change management plan would be provided so that the gaps in the care
practices of the healthcare professionals can be identified. Proper initiatives may be taken at the
individual level, team level and organizational level to develop culture of safety in the
workplace.
After working there for 2 months, I realized that the nurses who are working in the
orthopedic wards are mostly senior nurses and very few junior nurses. From a senior nurse, I
came to know that they have all joined the ward before 5 years when the nursing leaders were
very helpful and never strict. They complained of the present nurse leader being rude and

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complicated in his approach. As a result, new nurses are not being able to survive in the ward as
they used to require more help from the nurse leader. Therefore it was seen that the new nurses
were not being able to cope up with the stress of the job as they were not strategically guided by
the leaders and more pressure was felt by them. This extreme pressure made them leave their
jobs.
Through the past few years, it was also seen that the nurses tried to avoid working with
the new technologies. The senior nurses who have been working there over 10 years are of the
opinion that although new technologies have been implemented in the orthopedic wards to
support the different injuries, surgeries and other for the treatment of patients, the nurses find it
hard to use the equipments. She has also depicted a case that took place four years ago. She said
that without giving any proper training of handling C –arm, she was instructed to handle a
patient whose bone injury was to be scanned by fluoroscopy imaging during surgery. She was
asked to read the manual and learn by herself. She got nervous and the patient was mishandled
and the machine was also not operated properly which lead to a negative situation. Proper
allocation of trainings are rarely conducted in the ward for which neither new nurses who have
no skills or old nurses who are habituated with traditional methods are comfortable with handling
of new instruments. This is indeed a negative aspect as proper use of technology makes tasks
faster and provides acute results.
Another practice that I have noticed is that the orthopedic ward has multidisciplinary
teams who handle adverse cases of patients with co-morbid diseases or those who require
rehabilitations after the primary treatments. They are practicing a habit for more than 6 years is
that each of the individual of the multidisciplinary team writes down their notes in a common
copy which is followed by other members of the team for reference before implementing their

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individual care initiatives. This practice is continuing for more than 6 years although many
adverse reactions had taken place due to absence of verbal communication and also due to
absence of team meetings. Once, a case was noted by me in the ward history where the ward
nurse has seen a patient (who had a bone surgery in his ankles) to be walking properly. She noted
it down and therefore the physiotherapy expert and the others, after providing an overall check
up, discharged him. Later that person had a fall due to imbalance as he complained that he was
never able to walk properly. All these affected the reputation of the ward, stating that there was
an urgent need of team meetings and verbal communication where all should have discussed
their concern respectively so that proper decisions could have been taken. Therefore, verbal
communication was important but the ward never arranged for such meetings due to the busy
schedules of all experts. Therefore an absence of verbal communication was present which
risked the safety of the patient to a great extent.
Another issue which was also observed was that the lack of skill seen among the present
nurses. The nurses who were attending the emergency patients visiting the wards are not skilled
enough to handle patients effectively. The notes which were documented about the patients were
incompletely done and often many of important information were absent. Such improper
documentations have brought out many uneventful experiences of the patients. There was a case
which was known by me after joining the place which showed how such a practice was noted. A
patient was admitted with joint disorders but nowhere in the document was stated that he had
diabetes. As a result of the improper documentation, no diabetes maintenance was done for the
patient, which affected his health leading to serious issues.
From the entire discussion above, it is seen that after the retirement of the old nursing
leaders, the new nursing leader who was appointed and had been conducting her leadership for

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the last 5 years was not being able to manage the teams effectively in the orthopedic wards. After
her joining in the ward, the success graph of the departmental nurses of the orthopedic ward
degraded. The new leader was providing much pressure on the team members as a result of
which the new healthcare professionals were not being successful in tackling the stress.
Therefore with the passing of time, performance of the healthcare professionals deteriorated and
also the safety of the patients were compromised again and again. Ultimately, there had been
many complaints received by the complaint cell of the hospital about the orthopedic ward but no
one was able to understand how to develop the condition by overcoming the barriers. Ultimately
I was hired as the new nurse manger cum leader to recognize the areas where changes are to be
made so that the negative alternations that had taken place due to improper leadership and
evaluation can be identified and modified for better outcomes.
The main tool that can be use to evaluate the overall care provided to the patients from
the orthopedic ward is the Primary care evaluation tool called the PCET tool which mainly

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comprises of four important domains for the evaluation. It was proposed by the world health
organization:

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Source: WHO, 2014
These are the stewardship, financing and incentives, resource generation and the delivery
of primary care. Delivery of primary care can be then divided into a number of sections which
are the accessibility, coordination of care comprehensiveness of services. The first function is the
stewardship. This mainly comprises of the policy priorities as well as different accreditations,
quality assurance mechanisms for primary care and others. It also involves human resource

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planning and involvement of professionals and patients in policy processes. It also contained
patients’ rights and complaint procedures. When this part of the tool was used, it was seen that
although the organization has published many policies over the years, but few were implemented
in the services of the professionals. Although the policy had stated the importance of continuous
professional development but rarely any initiative was taken by the orthopedic ward heads to
arrange for such trainings for the workers. As a result the old staffs were not being able to learn
the new ides and skills which are invented for better practice and care for patients (Dietz et al.
2014). Therefore they were also not able to handle technologies in a better way. Besides,
improper evaluation of the policy maintenance, the human resource section was also unable to
retain the new employees and high turnover rate was noticed. Improper guidance of the leaders,
less incentive schemes, huge work pressure and others were mainly the reason which were
resulting in burning out of the workers and lack of job satisfaction.
In the category of resource generation, first option was the workforce volume. The
volume was constantly fluctuation as the retention of the new joiners was very poor. Moreover
no retention policies were present. They were leaving due to improper guidance and workload.
The second was the professional development. No scope of professional development was
available as a result of which the care which was provided was not sufficient. Moreover their
skills and knowledge were not enhanced which affected their career development. The third was
professional morale. Although the new people joined with high enthusiasm but their excitement
lasted for a few days as the huge workplace affected their mental and physical health. They were
not being able to get motivated as they were burning out and improper guidance fueled the
condition. This impacted their enthusiasm. Moreover as the senior nurses were not getting any
chances of developing their skills and knowledge they felt stagnant at this point of their career

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which resulted in job dissatisfaction in the orthopedic ward. All these affected their professional
morale (Cornell et al. 2014). Facilities and equipments were however maintained properly as the
financial manager allocated and monitored the funds for the medical equipments and other
equipment. However due to improper training the professionals were mishandling them resulting
in breaking down of the instruments and not working properly.
The next category of the evaluation tool is the financing as well as the incentives. The
first criterion is called the healthcare and financing. From the employer and the administrative
department, there is uninterrupted flow of fund for the development of the infrastructures and the
cleanliness systems. They spend a huge amount of money on the proper allocation of the
resources for the department. New equipments are purchased on the daily basis and this is indeed
a positive aspect found by the audit. The second criteria are the financial access of the patients
which is also performed by the hospitals. They follow many health care policies and investment
returns which help the patients to afford the services of the organization. They also have many
private life insurances policies which attract patients and help them to strategically save their
money for their own primary care. However, other criterion which receives criticism is the
incentives which are received by the professionals. Researchers are of the opinions that better the
incentive structure; the more motivated will be the workers to provide more productivity and
quality work (Kilpatrick et al. 2014). However, there was no incentive slabs for the workers and
as a result they was no motivation of the workers. They were even not paid for doing extra shifts
which also prevented them from taking responsibility when other members were absent. Absence
of any incentive scheme was the main reason for the lack of excitement among the nurses to
perform beyond their duties in their profession.

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The last category of the tool is the Delivery of care. It in turn has four important sub
divisions. These are access to services, continuity, coordination and comprehensiveness. In the
first domain of access to services, it is seen that the hospital is situated within the urban regions
in the centre of the state and therefore it has a very good geographical access to primary care.
Moreover organizational access is not well narrated by the patients. They say that often the
hospitals say that they cannot send provider to homes due to their workload and do not conduct
home visits. However, one of the positive aspects stated by him is that they have proper access to
healthcare even in unofficial hours which help them to handle many adverse situations occurring
during those hours. The third one is the responsiveness which often becomes a concern as most
of the nurses are so busy on the shift that they are not able to provide the care to patients due to
multitasking and handling many patients at the same time. This is quite risky as it increases the
chances of medication errors which might prove to be harmful for the patients (Reeves et al.
2013).
The next is the continuity. Informational continuity to some extent is maintained by
proper computerization of information and proper maintenance of medical records. Yet, there are
some cases which are found where incomplete information has been provided by certain nurses
which were not checked by the nurse leaders. Although they wrote down information when a
multidisciplinary team is working but they never conduct face to face meetings which affected
many care given to patients. Longitudinal continuity was also not maintained properly as total
information about patient lists and patient habits with first contact visits were not documented.
There were also no evidences of interpersonal continuity in Patient-provider relationship as gap
in communication was observed between them.

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The next is the coordination domain where the tool evaluates the coordination among the
different team members, multidisciplinary team experts and others. It is mainly seen that
although they followed a procedure of jotting down information on a common medical document
of a patient but they never had face to face communications and as a result they were not being
able to bond and develop relationships (Brekelmans et al. 2013). Therefore a communication gap
in case of verbal communication was noted which is very important in healthcare departments
(Roberts et al. 2015).
The last criterion is the comprehensiveness. The first focus is done on practice conditions
which were found to be suitable for the health professionals to work as all resources and
infrastructures were present which could help the nurses to provide the best care. The nest focus
is service delivery which was not apt as the nurse to patient ratio was not suitable. There were
less workforce is the orthopedic department in comparison to that of the number of patients
which created work pressure and hence improper service delivery. Moreover the senior nurses
were not given scope to develop their skills which impacted on their care as the care was not
evidence based. The newer nurses were not properly guided and hence they often got confused
and scared about their approach (Liyanagunawardena and Williams 2014). For community
orientation, Practice policy Monitoring and evaluation Community links are needed to be
assessed. The employer had kept a nurse leader who was not skilled enough as a leader to take
the care of evaluation and monitoring. Apart from the leaders, there were no administrative
monitoring bodies that would monitor the activities of the ward as a whole and therefore these
issues were not primarily noted by the organization (Govranos et al. 2014).
The first recommendation that needs to be provided is the proper scope for development
of the skills and knowledge. Researchers are of the opinions that nurse nee to attend continuous

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professional development courses. These help those to be accustomed with the new practices
published in recent journals (Jahromi et al. 2017). These also help them to develop their
knowledge regarding handling if instrumental and solving of ethical dilemmas faced by nurses
during their experienced years. It provides them with an overall scope for career development
and to promote themselves in their career (Bresick et al. 2015). Secondly, the new nurses should
be guided properly by effective seniors and leaders. The seniors and leaders should be trained
well to provide guidance to the juniors in cases where they face ethical dilemma, require their
help to conduct tasks, helps them strategies their day planning, help them to learn how to
strategically take decisions and others. All these reduce their workload and help them enjoy their
jobs (Butu et al. 2014). Moreover, the account departments and employers should strategically
plan incentive schemes to keep the nurses enthusiastic about their work and motivate them to
perform beyond their expectations (Jahromi et al. 2017). Thirdly, another recommendation
would be to change the culture of the communication between the experts of the
multidisciplinary teams (Pasarin et al. 2013). Rather than jotting information, all the
professionals should be instructed to conduct meetings regarding a patients’ case and discuss
about the different aspect to reach a conclusion. Verbal communication is extremely important to
maintain safety in patients’ care and they help to point out much minute information which was
not held important by one professional (Deemeh and Rosengren 2015). These would increase
proper binding among the members and chances of blame game would also lessen. Fourthly,
proper training and workshops should be conducted in a weekly basis in order to train the
professionals about the correct handling of different equipments (Savage et al. 2014). Correct use
of tractions, diagnostic tools, equipment like different tools and all should be taught to all new
comers so that they can handle them effectively and cases of instruments breaking down would

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not rise (Ortega et al. 2014). Fifthly, leadership responsibilities would be appointed to senior
nurses who show the proper skills of leadership and management so that they can motivate the
nurses to work for betterment and help them enhance their knowledge (Denise and van Gestel
2015). These are extremely important to maintain patient safety (Munce et al. 2017).
From the entire discussion, it is seen that the condition for the organization was working
well until five years ago when a new nursing leader was introduced. Due to her incapability, a
number of issues occurred which changed the working environment. The senior nurses were
getting no scope for career development, new nurse were not guided properly and faced
workload, and miscommunication took place among the multidisciplinary team and many more.
All these resulted in huge amount of patient complaints about the orthopedic wards and therefore
there was an urgent need for change management. Hence a tool called the PCET tool proposed
by the world Health Organization was used to evaluate each and every criterion. After evaluation
of the aspects, evidence based recommendations were provided for providing high care to patient
safety and developing the reputation of the ward.

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