The Case of the Warm Brownies - Case for Chapter 5

Susan Casciani

Yolanda pulled into the parking lot of North County Clinic (NCC) already dreading the upcoming day. After months of back to back meetings, the strategic plan update she had led for the development of the clinic was finally being implemented. She should be happy and enjoying some well-deserved downtime, but instead she was in the hot seat with Tom, NCC's new Administrator. As Yolanda trudged to her office, she tried to figure what had gone wrong.

NCC is a large, 30-physician primary care clinic located in the suburbs of a small metropolitan area in the Midwestern U.S. The clinic has many ancillary services on location, including laboratory, imaging, diagnostic, and pharmacy services. It was not unusual for NCC's employees to have been with the clinic for many years, and several employees have spent their entire career with NCC. NCC is patient-centric and enjoys a great reputation for quality of care in the community, but NCC's competitive advantage had always been their personal touch in everything they do. Employees are known to bring in homemade baked goods to share with patients, and the clinic sends birthday and holiday cards to patients every year. It truly seems to just about everyone that NCC takes care of patients like family.

Last year the clinic hired a new Administrator, Tom Gardner, and it didn't take long for him to fit into the family of NCC. Tom had a warm personality and was well liked by the majority of the staff. About 6 months ago, Yolanda started the annual process of updating the clinic's strategic plan; they were currently entering the last year of a 3-year plan. Tom came on board at NCC right as last year's planning cycle ended, and this year he instituted a lot of changes to how NCC normally did their planning. As an example, in the past Yolanda and her staff would meet with various clinic stakeholders on an ongoing basis to gather market information and monitor trends. This helped Yolanda ensure the clinic's strategies stayed on track and were responsive to the market and hospital resources. Tom, however, was more comfortable with getting market data from third-party companies that specialized in tracking health care data and trends and he instructed Yolanda to outsource this function this year. Although the information these companies provided seemed on target, Yolanda felt that something was missing, but she could never quite put her finger on what.

Once the external assessment was completed based on the third-party data, Tom had Yolanda present the information to the management of the clinic. This group included managers from each of the operational areas, along with the lead physician. Everyone seemed pleased with Yolanda's presentation, although few questions were asked. Yolanda found this interesting as the data pointed toward discontinuing the clinic's personal outreach services in favor of a more high-tech marketing approach. She thought for sure managers wouldn't like this trend as it would involve less time staff would spend out in the community, but most seemed excited by the prospect of being in television commercials for the clinic. Many of the managers started joking about getting asked for autographs once they became "famous."

Yolanda then worked with Jed, the clinic's financial manager, to put together the financial forecasts for the upcoming year. Tom saw to it that none of the outreach workers were laid off; most were moved to different roles and a few opted to retire. Other than the increase in funding necessary for the new outreach, the rest of what was already in the 3-year strategic plan was confirmed for going forward; there were no major changes to be executed and the clinic would hold a steady course. Yolanda expected smooth sailing.

With funding in place, a marketing firm was retained for the new outreach plan. Managers and other staff were buzzing about the new commercials that were going to be made, which were to include both television and radio ads. Most were excited to take part in what they saw as a fun opportunity to be in a commercial, although with such a large clinic the staff didn't stop to realize they couldn't all be in the commercials. It turned out not to matter anyway as the marketing firm decided to use real actors, and already had some footage and voiceovers from other projects that were merged into the clinic's new campaign. Once the commercials aired, patients who had been coming to the clinic for years asked staff why they didn't recognize anyone in the commercials. Staff didn't really have an answer, but eventually everyone seemed to forget about the new outreach efforts and went about business as usual.

A few weeks later Jed was talking to one of his financial analysts who told him he was starting to notice a decreasing trend in new patient visits. The analyst thought it was odd since it was fall and the weather was starting to turn, which meant the clinic normally would be seeing an uptick in visit volume. Jed dug into the volume data and found that returning patient volume was also starting to decrease. Since both numbers were decreasing and not just new patient volume, Jed didn't see a connection with the new outreach efforts, as those were focused only on new patients. The numbers were discouraging, however.

As several more weeks went by, visit volume continued to decrease but the more insidious nature of the matter was starting to surface. Tom had been noticing during his weekly administrative rounds that increasingly there were no baked goods at the front entrance to the clinic. Although Tom was sure his wife would be happy that he was doing better sticking to his diet, he missed the homey smell of those fresh brownies and cookies. Tom also noticed that staff did not seem as cheerful lately, but he tried to chalk that off to the decreasing hours of sunlight as winter approached. Then Tom remembered what Jed told him about the continuing decreases in visit volume, and it all started to click. There was definitely a problem, and Tom felt that he was only seeing the very beginning of what was to come. That's when he decided to call a meeting with Yolanda.

Discussion Questions

How does the planning process undertaken at NCC compare to an ideal process? Are there any steps missing? Is the level of analysis appropriate for the planning stage (last year of 3-year plan)?

What could Yolanda have done differently to effect a better outcome for the planning process?

What unintended consequences are surfacing from the decision to move the clinic's outreach plan to television and radio ads? How are these issues affecting the clinic as a whole?

How does the clinic's organizational culture play a role in this case?

PART TWO:

Implementing a Practice Change - Case for Chapters 2, 3, and 13

Jodie Bell

The Nurse Manager of a 40-bed Newborn Nursery unit attended the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) national conference. One of the conference sessions introduced the buccal administration of glucose gel as a means to treat neonatal hypoglycemia. The glucose gel treatment had been shown to decrease transfers to the Neonatal Intensive Care Unit (NICU) for intravenous glucose. It also decreased the need for formula supplements to normalize blood sugar levels, leading to improved success with breastfeeding. The Nurse Manager was very excited to implement this practice change in the Newborn Nursery unit. A decrease in transfers to NICU would improve patient satisfaction as mothers would not be separated from their babies. The lower cost of nursery care compared to care in the NICU would create a financial benefit for the hospital. By reducing formula use, the glucose gel initiative fit right in with previous projects the Newborn Nursery had successfully completed to promote exclusive breastfeeding. The Nurse Manager thought the introduction of glucose gel would be a win all around.

Resources were tight because of a high census and staff vacations. In addition, two nurses were out on prolonged medical leaves. Several staff nurses were already working on a project to address employee engagement scores, which were declining from their previously high levels. All of the nurses were scheduled for multiple educational sessions about upcoming changes to the electronic medical record system. Because of these competing priorities, the Nurse Manager began to work through the details of the glucose gel project alone. She sought approval from the Medical Director for the practice change and partnered with the pharmacy to have a protocol for specific dosing instructions. The Nurse Manager developed a policy and discussed the project details with the unit leadership team. When it was time to implement the change, the Manager presented the policy and instructions to the staff. The buccal administration of glucose gel was demonstrated through a train-the-trainer approach managed by the unit educator.

The project got off to a rocky start, with many texts flying back and forth between the nurses and the unit leadership team. The nurses complained about their unfamiliarity of the buccal administration of the gel, despite the education provided. They questioned the dosage amounts and the safety of administering the glucose product to a newborn. The administration of glucose gel caused additional work for the nurses, who said that they would rather the babies were just transferred to the NICU instead. As the project continued, individual interpretations of the protocol caused confusion, and some nurses only gave the gel if they had time. Many complaints were brought to a staff meeting held the second week of the project. Although the glucose gel project was eventually fully implemented, it continued to be a topic of discussion at subsequent staff meetings, and the overall project was perceived as a negative change that just made more work for the nurses.

Discussion Questions

What facts in this case show resistance to change?

How had the staff in this case previously dealt with change?

What factors may be influencing the unit's readiness for change?

What could have been done differently to engage the staff in the practice change?

What could the Nurse Manager have done differently to prepare the staff for change?