Systems thinking (ST) across the various transitions of care represents a critical nurse leadership skill in the increasingly complex care service systems. As a term, ST refers to giving due consideration to the ubiquitous interdependencies at the inter-system and intra-system levels (Arnold & Wade, 2015). The most literal but simple definition would explain ST as the set of approaches, principles, and reasoning patterns that facilitate thinking about systems and detecting systematic and predictable relational patterns in diverse activity areas. In other words, ST is a field of knowledge seeking to establish universality and anatomize every system, making the resulting takeaways applicable to any industry, including the healthcare field.
Care Transition Description
The macrosystem-level transition selected for discussion is that from hospitals to nursing homes. This care transition involves discharging hospitalized patients, typically seniors, those with cognitive issues, feeding assistance needs, partial immobility, or chronic disabling conditions, from inpatient hospitals after their condition is stabilized and initiating the process of nursing home admission to continue uninterrupted care provision based on the patient’s long-term needs (Kapoor et al., 2019). The two points of care are, therefore, the long-term care facility or the nursing home and the hospital’s discharge planning structures.
Strategies to Align Transitional Interventions with the Quadruple Aim
Two strategies that nurse leaders could implement to align transition-related interventions with the Quadruple Aim (QA) are pre-discharge continuous fall risk screening and supplementing nursing home admission documentation with such data. Successful transitions require completing the physician’s order to nursing home admission, relevant treatment/medications orders, vaccination data, and so on (Kapoor et al., 2019). The first strategy to further incorporate the QA involves implementing fall risk screening tools, for instance, the TUG test, for a few days prior to discharge to assess individual fall risk dynamics before completing the transition (Asai et al., 2018). The second strategy for nurse leaders to pursue is to process detailed fall risk reports as transition documentation and contact the accepting facility’s admissions director to ensure the adequacy of equipment, such as passive/active protective and assistive devices, to handle the patient’s injury prevention needs. Both approaches incorporate the QA’s components, including reducing costs by preventing fall-related readmissions and emphasizing population health and patient experiences by communicating the client’s measurable needs to ascertain the presence of relevant resources (Feeley, 2017). By seeking to reduce preventable workloads for both facilities, the strategies also emphasize teams’ well-being.
References
Arnold, R. D., & Wade, J. P. (2015). A definition of systems thinking: A systems approach. Procedia Computer Science, 44, 669–678. Web.
Asai, T., Oshima, K., Fukumoto, Y., Yonezawa, Y., Matsuo, A., & Misu, S. (2018). Association of fall history with the Timed Up and Go test score and the dual task cost: A cross-sectional study among independent community-dwelling older adults. Geriatrics & Gerontology International, 18(8), 1189-1193. Web.
Feeley, D. (2017). The Triple Aim or the Quadruple Aim? Four points to help set your strategy. Institute for Healthcare Improvement. Web.
Kapoor, A., Field, T., Handler, S., Fisher, K., Saphirak, C., Crawford, S., Foyazi, H., Johnson, F., Spenard, A., Zhang, N., & Gurwitz, J. H. (2019). Adverse events in long-term care residents transitioning from hospital back to nursing home. JAMA Internal Medicine, 179(9), 1254-1261. Web.