Description of the Organization
The organization is a private academic healthcare institution with facilities for research. It has 100 inpatient beds and different specialty departments, including the accident and emergency department (ED), as well as outpatient services. With an average annual of 20,000 inpatients and 450,000 outpatients, the organization is one of the largest healthcare providers in the Northern Emirates with different branches in the other emirates.
The President of the organization, the administrative director, and the hospital director makes up the Upper Management. It has different departments with a head, operational core, and supporting staff. The organization structure is characteristic of a professional bureaucracy (Mitzbergs, 1981). The organization is the first JCIA accredited hospital in its district with over 2,200 employees around its different branches. It has special schemes to provide affordable medical care without compromising on quality. In addition, it works towards instituting controls and quality systems that meet international healthcare standards.
Its mission is to provide patients with care that is ethical and focused towards their safety at an affordable and effective rate. It achieves this by considering the latest improvements on healthcare and encompassing the new changes incorporated in the field. It strives to attain the highest quality and accreditation standards.
The Proposed Change
In the hospital, all patients with complaints of chest pain are seen in the emergency department and discharged or admitted directly to the Coronary Cardiac Unit (CCU). Due to a constant patients’ flow in the ER and bed shortages, various cases of chest pain can be missed. However, some cases are overlooked because patients are monitored at the ER for only a few hours in order to determine the presence of an evolving heart event. Other chest pain events are left out if patients fail to pay the CCU charges.
A “HEART ER Project”, also referred to as the Chest Pain Clinic, will be implemented as an attachment to the Emergency department. Patients with high suspicion of cardiac event will be observed and evaluated within twenty-four hours at the department. Therefore, the implementation of the program will be a pathway towards eliminating cardiac events. Presently, hospitals deal with chest problems as general illnesses. As a result, the effectiveness of treating cardiac illnesses is lowered significantly.
When patients visit the hospital, they are forced to queue with other patients as they wait for medical services. Consequently, their chest pains become worse with the passage of time. Such situations are discouraged because they lead to an increased morbidity that can be avoided by attending to the patient in time (Davis, 2012).
Cardiac Decision Units (CDU) or the Chest Pain Units decrease hospitalizations, as well as the mortality rate that results from outpatient care (Gaspoz et al., 1994; Goldman, 1995; Graff et al.,1995; Gibler et al., 1995). The primary goal of CDU is to create a center that exceeds the quality of the care offered to the patients with acute chest pain at the emergency department.
The following objectives are required to meet the aim of the project:
1. To enhance patient care within three months by decreasing the time interval between a cardiac event presentation and treatment to between 60 and 30 minutes
2. To identify patients with unstable angina within thirty minutes after arrival at the ED
3. To reduce the time from the onset of chest pain to arrival at the ED to less than 6 hours
4. To fully evaluate, within 24 hours, the patients with chest pains
The method meant for implementation is the HSE Change Model proposed by the Health Service Executive in Ireland (Health Services in Ireland, 2006). Evidence shows that it helps staff and teams in working towards enhancing services, as well as promoting a consistent approach to change across the system.
The model is based on an organizational development approach that focuses on the public aspect of change. Such model will help when approaching the main stakeholders in the project, which include the high-risk cardiac patients, triage nurses, the ED doctors, a cardiologist, and the director of the organization.
The Need for Change
The presentation of chest pain is a primary difficulty for various medical professionals. Moreover, it is the commonest medical reason for a patient to attending the Accident and Emergency Department (Newby et al., 1998). Establishing the cause of chest pain is crucial to the future management of patients, as well as the appropriate and efficient use of healthcare resources.
A chest pain clinic has practical benefits that help to reduce hospitalization while radically transforming the assessment and management of patients with cardiac events. The cause of the chest pain should be diagnosed in time, and proper treatment made to prevent the possible increase in morbidity and mortality.
It is essential for the community to have a center that entirely focuses on chest pain research, with qualified personnel that offer expert advice. The specialized treatment, which is offered at the center, underscores the significance of such clinics (Excellence, 2012).
These clinics will not only reduce the time taken by the patients as they wait to access treatment, but will also research on chest pains and better mechanisms of dealing with it (Gibler WB, 1995). Appendix 1 shows the force field analysis when analyzing the need for change.
The Organizational Impact and Expected Outcome(s)
The implementation of the changes will have a positive influence on the organization and contribute to its development. Having a separate clinic that is entirely dedicated to providing the best management for patients with chest pain will reduce the influx of patients in the emergency room by reducing the long queues (Tatum JL, 1997).
The organization will also benefit economically since higher profits can be reaped from offering specialized treatment. The organization will be identified as one of the very few healthcare providers with a sophisticated chest pain center in the country. Further, the provision of such services will ameliorate the organization’s goodwill and public image.
The organization will also benefit from having experts employed in the clinic because it will facilitate research on chest pain (Team, 2012). Figure 1 further describes the benefits of the clinic to the organization.
Figure 1. Benefits of the Chest Pain Center. The figure describes the various benefits linked to Chest Pain Center
The Potential Threats or Obstacles to Implementing the Change
There are various threats and obstacles that might hinder the meeting of the objectives. The first obstacle is the lack of funds to finance the setting up of the clinic. Setting up a clinic is highly expensive because it involves new amenities, new buildings, and more staff (Team, 2012). The challenge can be overcome if an area at the hospital is set aside for the clinic, and the amenities needed are available in the cardiology OPD for the initial trail. If employing a new staff is not possible, the use of a specialist B cardiologist and a well-experienced emergency nurse can be useful.
Another challenge is the denial of an operating license for not meeting certain thresholds. Such an issue may render the project useless and unviable (Vaerenbergh, 2006). Other threats include the lack of professionals experienced in chest pains, lack of proper materials, and the presence of resistance from the current staff or the public. Figure 2 highlights various forms of resistance and the means of overcoming it.
Figure 2: Actions of solving the implementation challenges. The figure describes the recommended approaches to address the implementation challenges
The Proposed Method(s) of Evaluating the Change.
There are various expected outcomes for the organization. One of the outcomes would be a reduction of the influx of patients in the cardiology clinic. Medical records will be examined to confirm the influx reduction (Richard A, 2000).
The evaluation of chest pain has been shown to be a resource intensive process and a significant economic burden (McCullough et al., 1998). The clinical evaluation will use the following methods:
- Approach that uses diagnosis codes: two cohorts of patients with chest pain will be identified retrospectively from automated data. The ninth International Classification of Diseases and Clinical Modification (ICD-9-CM) codes will be used.
- Chart review of a random patients’ specimen: ECG review and management strategies to observe the identification of patient with typical chest pain within the required period.
- Cardiac enzyme testing and electrocardiography as a proxy for a chest pain evaluation: The proxy will identify the proper management strategy of the ED patients experiencing chest pain.
- Hospitalization rates can be assessed using health system and managed care’ claims data. The hospital’s death certificates will ascertain death. Descriptive statistics will be given in means and standard deviations or count (proportions). Comparisons will be made using the chi-square test or analysis of variance as appropriate.
Another organizational benefit would be an increase in profitability due to the building of the clinic. The cost of building the clinic would initially have an adverse effect on financial statements unless a funding from external sources is received (Zalenski RJ, 1998). The income statement would be a reliable document to evaluate the business improvements.
Another avenue would involve engaging the members of the public by giving out questionnaires concerning the services offered. The filling of such questionnaires can be analyzed to determine the public perception of the business. Figure 3 shows some key performance indicators for evaluating the change project.
Figure 3: Performance Measures. The fundamental performance indicators for evaluating the change project are described in the figure
My Role in the Organization and the Change project
I am a general practitioner who has worked in the emergency department for the past six months. I have worked in the internal medicine and cardiology department for the previous five and a half years, in the same organization. I will be the project leader in the present project and will outline the methods and stages of the project’s implementation. Other members of staff have expressed interest in the project with some researching the best way to set up a chest pain clinic. Figure 4 shows a group of nine staff members involved in the plan.
Experts with technical knowledge in the field will be engaged to ensure the project succeeds. During the implementation of the proposed plan, informed consent from the participants will be sought, and the protection of individual identities ensured.
The data collected from the organization will be handled on a strict confidentiality basis. In addition, the whole process will go through an ethics committee approval in order to meet the need for the protection of the participants. Appendix 2 is a proposed Gantt chart of the project.
Figure 4: Project Team Members. The members will be involved in the change project
References/ Literature List
Davis T, B. J. 2012. Diagnosis and Treatment of Chest pain and Acute Coronary Syndrome. S.l.: Institute for Clinical Systems Improvement.
Dominic Kelly, S. C., 2011. Implementation of the new NICE guidelines for stable chest pain: likely impact on chest pain services in the UK. Available [Online] at: http://bjcardio.co.uk [Accessed 14 June 2014].
Excellence, N. I. F. H. A. C. 2012. Chest Pain of Recent Onset: Implementation Advice. London: National Institute for Health Clinical Excellence.
Gaspoz, J.M., Lee, T.H., Weinstein, M.C., Cook, E.F., Goldman, P., Komaroff, A. and Goldman, L. 1994. Cost-effectiveness of a new short-stay unit to `rule out' acute myocardial infarction in low risk patients. Journal of the American College of Cardiology, 24, pp. 1249-59.
Gibler, W.B., Runyon, J.P., Levy, R.C., Sayre, M.R., Kacich, R., Hattemer, C.R. and Hamilton, C. 1995. A rapid diagnostic and treatment center for patients with chest pain in the emergency department. Annals of Emergency Medicine, 25, pp. 1-8.
Goldman, L. 1995. Using prediction models and cost-effectiveness analysis to improve clinical decisions: emergency department patients with acute chest pain. Proceedings of the Association of American Physicians, 107, pp. 329-333.
Graff, L., Joseph, T., Andelman, R., Bahr, R., DeHart, D., Espinosa, J. and Gibler, B. 1995. American College of Emergency Physicians Information Paper: Chest pain units in emergency departments – a report from the short-term observation services section. American Journal of Cardiology, 76, pp. 1036-9.
Health Services in Ireland, 2006. Health Services in Ireland. Available [Online] at: http://www.hse.ie [Accessed 10 June 2014].
McCullough, P.A., Ayad, O., O'Neill, W.W. and Goldstein, J.A. 1998. Costs and outcomes of patients admitted with chest pain and essentially normal electrocardiograms. Clinical Cardiology, 21, pp. 22-26.
Mintzberg, H. 1981. Organization Design: fashion of Fit? Harvard Business Review (Jan-Feb).
Newby D.E, Fox K.A.A., Flint L.L, and Boon N.A., 1998. A ‘same day’ direct-access chest pain clinic: improved management and reduced hospitalization. Q J Med 91, pp 333–337.
Richard, A. S. 2000. AHA Science Advisory. Available [Online] at: http://circ.ahajournals.org [Accessed 22 June 2014].
Tatum JL, J. R. K. M., 1997. Comprehensive strategy for the evaluation and triage of the chest pain patient. Ann Emerg Med., Issue 29, pp. 116-125.
Team, C. B., 2012. Cost implications of implementing NICE guideline on chest pain in rapid access chest pain clinics: an audit and cost analysis. Available [Online] at: http://www.ncbi.nlm.nih.gov [Accessed 14 June 2014].
Varenbergh, E. M. A. C. V., 2006. Guiding change in the Irish health system. Dublin: Trinity College.
Zalenski RJ, R. R. T. S., 1998. A national survey of emergency department chest pain centers in the United States. American Journal of Cardiology, 81, pp. 1305-1309.
Appendix 1
Lewin’s Force Field Analysis
Appendix 2
Proposed Gantt chart
