Clinical Microsystems, Essay Example

Part One: Exploring Generative Relationships through the Application of STAR for Chronic Care: Chronic Obstructive Pulmonary Disease

Frequency of condition

COPD affects over 24 million people in the United States alone, and is the third leading cause of death within this population (Heitz, 2013). This condition is comprised of two primary conditions, chronic bronchitis and emphysema (Heitz, 2013).

Age at onset

Persons over the age of 40 face the highest level of risk of developing COPD, particularly if they have smoked for a long period of time, those persons who have been exposed to irritants that impact the lungs, and those who have been previously diagnosed with HIV (Heitz, 2013).

Major symptoms

The primary symptoms associated with COPD include shortness of breath, an ongoing and persistent cough, tightness in the chest, wheezing, and the development of respiratory infections on a frequent basis (Heitz, 2013). These symptoms may present differently in patients; therefore, an examination of the challenges associated with patient care and wellbeing must be addressed (Heitz, 2013).

Care needs

For patients with COPD, there are considerable challenges that require ongoing care and treatment for patients, particularly as the condition worsens and symptoms become more frequent. For patients in the early stages of COPD, lifestyle changes are essential, including quitting smoking through cessation efforts, increased levels of mild to moderate exercise, and improved nutrition, all of which support greater quality of life for these patients who require specialized care and treatment to improve symptom management and outcomes for COPD (Heitz, 2013).

Key relationships in providing care for COPD

In caring for and treating patients with COPD, it is important to identify the specific relationships that are required to ensure that patients receive the level and quality of care that they deserve in order to manage the disease and its symptoms more effectively.

Nurses

Nurses play a critical role in the care and treatment of patients with COPD, particularly as patients face unique challenges regarding the disease that must be addressed on a regular basis. Nurses who specialize in respiratory care are likely to be effective in providing a high level of care and treatment that supports a continuum of care over time, rather than using nurses with limited knowledge of COPD management (Vrijhoef et.al, 2000). In accordance with existing strategies, specific nursing-based knowledge regarding COPD care and treatment must be considered for its value and contribution to symptom management and improving quality of life (Fletcher & Dahl, 2013). To be specific, “Nurses have consistently shown a positive contribution in delivering the hospital-at-home and early discharge schemes for COPD. Under these schemes, patients with acute exacerbations are cared for at home by a specialist respiratory nurse with the support of a hospital-based multidisciplinary team” (Fletcher & Dahl, 2013, p. 2). Under these conditions, nurses provide a framework for patients to gain comfort and a greater understanding of the challenges that are associated with effective nursing practice and the achievement of high quality care and treatment for this patient population, particularly when symptoms are exacerbated and are difficult to overcome for this group of chronically ill patients (Fletcher & Dahl, 2013).

Physicians

Physicians are responsible for confirming diagnoses, identifying and ordering treatments, and governing the overall level of care that patients require. Physicians are invaluable to the COPD management team because they support a greater understanding of the challenges associated with treating the disease and the steps that are required to support an effective understanding of the condition on a comprehensive basis. This process supports an effective strategy for improving patient care outcomes and for developing new approaches to care and treatment that will improve quality of life, while working in conjunction with the entire COPD team of experts in this process in a leadership role.

Respiratory Therapists

In managing the symptoms of COPD, respiratory therapists play an essential role in this process, as they support the course of action by administering specific treatments in the required intervals of time. This process is essential to the process, as it supports the development of new factors that will be effective in providing greater quality of care for patients and for supporting a new framework that will govern the treatment plan. Respiratory therapists assume a leadership role in this process, as they are experts in providing different types of treatments with the anticipated belief that they will alleviate some of the most important symptoms associated with the COPD condition in its current state. These treatments must be administered expertly and efficiently at all times in order to accomplish these objectives and to recognize the value of this role in the ongoing treatment of COPD.

Family members

Family members of COPD patients must be active participants in the care and treatment plan, as they are responsible for providing support, guidance, and decision-making in cases where the disease is of a terminal nature. Family members must actively communicate with the care team and provide their input as necessary in order to guide the treatment plan in the appropriate direction. In addition, family members must serve as key supporters of patients when COPD symptoms are exacerbated and additional treatments are required. Family members may often find it difficult to manage their emotions when observing their family members with COPD; therefore, the entire team must work collaboratively to ensure that patient and family member needs are met in a timely manner.

Diagram using the STAR Model

Achieving effective chronic illness care and management on a continuous basis requires an effective understanding of the challenges and issues that are experienced across the different stages of the treatment plan. This process requires a high degree of coordination of care and treatment to prevent inconsistencies and to avoid overlap. These conditions reflect the importance of new strategies to improve patient care outcomes and to reflect upon the challenges of managing a chronic illness with the intent to minimize symptoms, increase comfort, and improve quality of life.

The STAR model for chronic care offers a unique approach to using a clinical microsystem in order to effectively coordinate care and treatment between different team members (Nelson et.al, 2011). STAR is an acronym for the following: 1) separateness, which enables different perspectives regarding the relationship; 2) tuning, which enables participants to talk and listen to address concerns; 3) action, which supports creative approaches and improvements; and 4) reason to work together, which enables all parties to the relationship to benefit in different ways (Nelson et.al, 2011). A sample diagram from the Nelson et.al (2011) text is as follows:

This model supports the development of a strategy that will be used to address the complex relationships that are associated with the care and treatment of chronic disease, whereby there are significant patterns to achieve an organized treatment model for consideration in achieving the desired objectives for the patient. In this context, the STAR model represents a means of developing new strategies to achieve greater relationship development and growth in order to fulfill the expectations and needs of the treatment plan. This model also enhances quality of care and supports a greater understanding of the continuum of care that is require to support the growth of the treatment plan a positive and consistent manner over time.

Part Two: Barriers to Achieving Generative Relationships Barriers to key relationships

The process of establishing a comprehensive COPD treatment plan requires an effective understanding of the options and challenges of treatment that will impact quality of care. Patients receiving treatment for COPD require a high level of coordinated care and treatment so that all parties are on the same page and are provided with the tools and resources that are necessary to support and enhance the desired outcomes for patients. This process engages the development of new approaches to ensure that patient care outcomes are achieved, and the development of new strategies to ensure that patient care is optimized at all times.

For patients with COPD, it is important to identify the relationships that comprise a team-based environment for the condition and the treatment of COPD for patients. This process will ensure that patient outcomes are not compromised and that there are sufficient alternatives in place to prevent any disruptions to care and treatment (Uijen et.al, 2012). The continuity of care is essential to achieving greater quality of life for this patient population, as there are significant challenges associated with the ability to adhere to strict requirements regarding the continuum of care for patients (Uijen et.al, 2012). It is known that “In primary care, new care modes are being introduced to improve quality and to cope with the increased workload of COPD in primary care globally. Practice nurses take over elements of COPD care and self-management programmes are introduced to increase patients’ self-care. There are concerns that the introduction of these new care modes may be a threat to patients’ experienced continuity in primary care, both in terms of personal continuity (seeing the same care provider) and team continuity (continuity by the primary healthcare team). Other studies have shown that decreased personal continuity is related to less confidence in care providers and less satisfaction with care.Moreover, patients’ adherence to treatment and prevention might decrease” (Uijen et.al, 2012). This perspective demonstrates that it is important to identify the types of resources that are required to ensure that patient outcomes are achieved and that there are sufficient opportunities for patients to receive consistent care that includes familiar team members (Uijen et.al, 2012). This process is of critical importance in providing an effective approach to COPD treatment that will not only be comprehensive, but will also identify the specific needs associated with treatment that support the desired results and quality of life for patients (Uijen et.al, 2012).

Personality conflicts

Patient care teams for the treatment of COD require different types of clinical experts across different specialties. These teams must be congruent in their objectives and focus and provide a high level of care and treatment that will be effective in promoting positive patient outcomes as best as possible. The treatment of COPD, however, may result in personality differences across these teams, particularly when different treatment recommendations are made; therefore, this process must demonstrate the importance of addressing possible conflicts to the degree that they do not interfere with the practice environment and its impact on patient care and wellbeing for this patient population.

Differences of opinion regarding treatments

As mentioned previously, some cases involving COPD may bring about different perspectives regarding the required course of action for treatment. Nurses, physicians, and respiratory therapists may have differences of opinion that could impact the treatment plan, including a possible delay in administration if these differences are not resolved in a timely manner. This process discourages high quality care if providers are unable to agree regarding the chosen treatment methods; therefore, it is important to overcome these differences as early as possible in the treatment plan so that plans are not disrupted by lack of knowledge or understanding of the intended result.

Lack of knowledge

Limited knowledge regarding COPD may be an issue for some care providers who have limited experience with the disease, the chosen treatment method, and the intended outcomes. Since COPD poses many challenges to patients, the chosen treatment method must be effective in providing the desired level of care and treatment at all times. Since COPD represents many different complexities, it is important to identify the resources that are required to determine the best possible course of action that will ensure that patient care outcomes are appropriate and timely for the condition and the needs of this population. When knowledge is lacking, it is imperative that clinicians research the disease and obtain information from their fellow providers regarding the condition and how it impacts the care and treatment plan for patients.

Consequences for patient care

If therapeutic relationships are challenged in any way by personal conflicts, differences, of opinion, or other factors, there is a greater chance that these relationships will pose a significant strain on the level of care that patients receive. This is an ongoing process that poses a number of difficult questions regarding patient care quality and the need for cohesive care and treatment, in spite of personal differences. Achieving effective quality of care is instrumental in supporting the treatment plan and in supporting the development of new strategies that will minimize differences in order to overcome barriers to patient care that currently exist. These practice methods will ensure that patient care consequences are minimal or nonexistent so as not to disrupt quality of care and the overall direction of the treatment plan as required.

Ineffective treatment methods

The decisions that are made by therapeutic teams regarding individual care and treatment for patients must demonstrate the importance of new approaches to patient care quality that will ensure that patients are receiving the best possible care, given the circumstances of their condition. Although a combination of efforts are recommended for the treatment of COPD in patients, it is also known that “The goal of pharmacotherapy for COPD is to reduce symp­toms, prevent exacerbations, improve exercise tolerance, and improve overall health.7 Unfortunately, current medications have not been shown to affect long-term decline in lung function associated with COPD.7 Therefore, treatment must be focused on symptom control and must be individualized based on patients’ disease severity and risk of exacerbation” (Garvey et.al, 2014, p. 12). Therefore, it is expected that the use of specific pharmacological treatments as the preferred method without consideration of other therapies is not the best use of resources, and that other considerations must be made that will accommodate this patient population in an effective manner with the intended results (Garvey et.al, 2014). This process will also ensure that patient care needs are achieved through a comprehensive mechanism rather than a single source of treatment that may not have the intended impact, nor the comprehensive approach that is required to treat COPD effectively over time (Garvey et.al, 2014).

Untimely treatments

For some patients, the problem of untimely treatments exists and causes great concern for patients with COPD. This process requires a greater understanding of the issues that lead to the exacerbation of symptoms and how to treat these symptoms effectively to improve health and wellbeing. This process requires an effective understanding of the issues that are likely to improve patient care and treatment through the use of methods that are largely effective and appropriate for the needs of patients over time. It is impractical to administer treatments to patients that will be ineffective in treating patients over the long term; therefore, other measures must be considered that will have a positive impact on patient care outcomes and the special needs of this population with respect to the course of treatment. When symptoms are exacerbated, this is typically cause for serious concern, and timely treatment of these symptoms is essential in order to achieve the intended results of the treatment plan, rather than to administer treatments that will not achieve the intended result.

Part Three: Using Measurement to Improve Health Care Value

Measuring the value of health care is a challenging proposition that involves many different components. This process involves the use of different vehicles to address care and treatment, while also considering other factors that ultimately contribute to comprehensive patient care and treatment. These opportunities require an effective understanding of how to measure health care value in a manner that is consistent with the desired objectives and frameworks. Managing COPD in this environment requires a greater understanding of the different perspectives that will facilitate effective outcomes for patients through the exploration of new approaches using the clinical value compass as a measurement tool. This model is likely to be effective in supporting COPD patients on many levels.

Clinical Value Compass (CVC)

The implementation of a clinical value compass supports the development of new strategies to address the measurement of value in health care across different spectrums, including the use of measures such as risk, functional status, perceptions, and costs in order to improve value for patients (Nelson et.al, 2011). The model represents an opportunity to explore the different dimensions of patient care that will be effective in supporting new strategies to improve quality of care and to achieve the intended results with the treatment methods that are chosen. This model will be explored in greater detail in the following section.

Diagram of Side A and Side B

Side A of the Clinical Value Compass diagram for COPD patients is conveyed as follows (Nelson et.al, 2011):

Outcomes: COPD Patients

Aim: The intended aim is to minimize symptoms and achieve greater quality of life for this patient population.

Functional

• Achieving greater physical functioning
• Addressing mental health concerns and psychological wellbeing
• Social needs and concerns
• Physical activity levels

Clinical

• Mortality rates
• Symptoms
• Complications

Satisfaction

• The promotion of high quality health care delivery
• Improved health and wellbeing through treatment methods
• Patient satisfaction rates

Costs

• Direct costs of care: treatments
• Indirect: facilities, equipment, personnel

Balanced Scorecard

Side B of the Clinical Value Compass is conveyed as follows (Nelson et.al, 2011):

 Four points of success

The factors associated with the Clinical Value Compass require a greater understanding of the challenges of achieving high quality care and treatment for patients with COPD, while also considering other factors that play a role in shaping patient care outcomes and the support of the clinical microsystem environment and its comprehensive nature. For example, learning and innovation tools, clinical processes, customer perceptions, and financial results demonstrate the importance of developing new approaches in order to ensure that patient care outcomes are achieved in the desired manner and with the desired expectations in mind.

Strategic learning and innovation

There are significant advantages to improving strategic learning and innovation within an organization in an effort to achieve the desired outcomes. This is an important step towards the discovery of new techniques and strategies to improve patient care and wellbeing, while also considering other factors that require the organization to use its resources wisely to meet patient care needs in an efficient manner. Therefore, clinicians must be properly trained and must be provided with the tools that are required to ensure that patient care outcomes are met in a timely manner, while also evaluating this training in the context of its value to patients.

Key processes

A number of key processes must be considered as part of the treatment plan in order to achieve the intended results. This process will also support the development of new strategies for growth that will include new perspectives regarding achieving greater quality of care for patients in this manner. It is imperative to demonstrate that the clinical microsystem environment is cohesive and appropriate for the needs of this patient population, while also considering other resources that are necessary in supporting effective patient care outcomes. The clinical team must be on the same page with respect to the treatments that patients require, as well as the type of care that is essential to meet their needs effectively. This process will ensure that patient care outcomes are achieved in the desired manner and that patients will be supported by a comprehensive continuum of care at all times.

Customers’ view of goodness

Customers (patients) must also be able to experience high levels of satisfaction with the care that they receive, and this requires a greater understanding of the challenges and needs of patients as they change and evolve. Customers must be able to recognize the positive nature of the work that is performed in their favor and should be able to demonstrate their understanding of this goodness through patient satisfaction surveys, communication with care providers, and other methods that will demonstrate their understanding of the scope of care that they receive on a continuous basis.

Financial results

From a financial perspective, the organization must be able to demonstrate the value that it provides throughout the course of the patient care process. This requires an effective understanding of the challenges that are associated with care and treatment, as well as the opportunities that are presented through specific challenges in order to achieve the desired care outcomes. Financial results should be favorable and must be demonstrated in the form of greater cost efficiency and effectiveness through the use of the appropriate treatments for COPD patients as best as possible.

Part Four: Critiquing Data Collection Methodologies

Existing research frameworks and studies provide a basis for exploring new insights regarding the effectiveness of clinical microsystems as they support patients with COPD who require continuous care and treatment for this challenging and progressive disease.

Review of five studies

Study #1

A study by Vogelmeier et.al (2011) addresses the significance of Tiotropium versus Salmetrol and their effectiveness in alleviating symptom exacerbations of COPD. This study sought to determine which approach was more effective and consistent in treating the condition and the potential outcomes that might occur in alleviating symptoms for this population group (Vogelmeier et.al, 2011).

Validity of the psychometric instrument used for data collection

The data collection instrument included randomization as a means of evaluating the two treatment methods for a large group of study patients in order to determine the clinical properties of both drugs and their overall effectiveness in alleviating COPD exacerbations (Vogelmeier et.al, 2011).

Method used to deliver instrument

The randomized, double-blind, double-dummy, parallel-group method was designed to determine the effectiveness of the treatment and to determine which drug is more appropriate in treating COPD exacerbations in patients (Vogelmeier et.al, 2011).

Measures taken to ensure accuracy, reliability, and freedom from bias

The study protocol was supported by the study team and provided further evidence of the accuracy of the protocol and the chosen approach and study method, as well as the completeness of the study results (Vogelmeier et.al, 2011).

Study #2

A study by Drexel et.al (2011) sought to examine the role of a continuing medical education program in improving knowledge and evidence-based practice for patients suffering from COPD.

Validity of the psychometric instrument used for data collection

The instrument employed an evaluation of a continuing medical education training session as a means of determining the overall effectiveness of the protocol and the opportunities that were available to advance the education of its participants (Drexel et.al, 2011).

Method used to deliver instrument

The instrument was a half-day continuing medication education course to provide advanced education regarding COPD and evidence-based practice (Drexel et.al, 2011). Participant responses were evaluated using a survey instrument to determine the impact of evidence-based practice and its integration into the chosen plan of care (Drexel et.al, 2011).

Measures taken to ensure accuracy, reliability, and freedom from bias

This study demonstrated that there are current gaps in knowledge and the care that clinicians provide to COPD patients, thereby creating a gap between knowledge its overall impact on patient care and treatment (Drexel et.al, 2011). It is important to address these concerns in future studies in order to achieve greater outcomes and to determine how to best move forward with the chosen treatment plan (Drexel et.al, 2011).

Study #3

A study by Fan et.al (2012) addressed the significance of comprehensive care management programs (CCMP) and their ability to reduce the risks associated with COPD and to prevent hospitalizations for this patient population.

Validity of the psychometric instrument used for data collection

This study used an educational method across 20 different Veterans Affairs outpatient clinics in order to determine the efficacy of the management program and its impact on COPD care to prevent further hospitalizations (Fan et.al, 2012).

Method used to deliver instrument

This instrument was delivered by using a COPD educational framework that included the distribution of materials to patients within this population group, in addition to telephone calls as a method of case management for these patients (Fan et.al, 2012).

Measures taken to ensure accuracy, reliability, and freedom from bias

There were a number of issues with this study, including an imbalance between the two study groups and their mortality rates; therefore, the study was terminated early to protect patients from further adverse events and harm (Fan et.al, 2012).

Study #4

A study by Jones et.al (2011) addressed the importance of administering indacaterol as part of the treatment framework for patients with COPD. Indacaterol is a form of bronchodilator and was measured for its efficacy in treating this patient population over other alternatives (Jones et.al, 2011).

Validity of the psychometric instrument used for data collection

The instrument used for this study used four sub-studies in order to determine the impact of this treatment in comparison with other treatment options, and the study appears to demonstrate its value in providing effective treatment to the COPD study population (Jones et.al, 2011).

Method used to deliver instrument

The instrument included an evidence-based review of four prior studies, including an examination of spirometry, breathlessness, exacerbations, and the use of salbutamol for patients in order to determine the effectiveness of indacaterol as a viable treatment method (Jones et.al, 2011).

Measures taken to ensure accuracy, reliability, and freedom from bias

This study provides evidence that there may be potential bias with the measurement of tiotropium, as this study was not blinded; otherwise the study appeared to be free from bias and was reliable in nature (Jones et.al, 2011).

Study #5

A study by Woodruff et.al (2011) addressed the significance of oral zileuton in order to treat COPD exacerbations that have required patients to be hospitalized for treatment.

Validity of the psychometric instrument used for data collection

This study examined the treatment using a valid method for consideration in its use as a means of managing COPD exacerbations (Woodruff et.al, 2011).

Method used to deliver instrument

The study employed a double-blind, placebo-controlled, parallel format to determine its effectiveness in treating the chosen study population (Woodruff et.al, 2011).

Measures taken to ensure accuracy, reliability, and freedom from bias

The study was supported by all authors and sought to achieve the greatest possible accuracy at all times in order to prevent study bias (Woodruff et.al, 2011).

References

Almagro, P., & Castro, A. (2013). Helping COPD patients change health behavior in order to improve their quality of life. International journal of chronic obstructive pulmonary disease, 8, 335.

Drexel, C., Jacobson, A., Hanania, N. A., Whitfield, B., Katz, J., & Sullivan, T. (2011). Measuring the impact of a live, case-based, multiformat, interactive continuing medical education program on improving clinician knowledge and competency in evidence-based COPD care. Int J Chron Obstruct Pulmon Dis, 6, 297-307.

Fan, V. S., Gaziano, J. M., Lew, R., Bourbeau, J., Adams, S. G., Leatherman, S., … & Niewoehner, D. E. (2012). A comprehensive care management program to prevent chronic obstructive pulmonary disease hospitalizationsa randomized, controlled trial. Annals of internal medicine, 156(10), 673-683.

Fletcher, M. J., & Dahl, B. H. (2013). Expanding nurse practice in COPD: is it key to providing high quality, effective and safe patient care?. Primary Care Respiratory Journal, 22(2).

Garvey, C., Hanania, N. A., & Altman, P. (2014). Optimizing care of your patients with COPD. Nursing: Research & Reviews, 4.

Heitz, D. (2013). What do you want to know about COPD? Healthline, retrieved from http://www.healthline.com/health/copd

Jones, P. W., Barnes, N., Vogelmeier, C., Lawrence, D., & Kramer, B. (2011). Efficacy of indacaterol in the treatment of patients with COPD. Primary Care Respiratory Journal, 20(4).

Nelson, E., Batalden, P.B., Godfrey, M.M., & Lazar, J.S. (2011). Value by Design: developing clinical microsystems to achieve organizational excellence. Jossey-Bass.

Uijen, A. A., Bischoff, E. W., Schellevis, F. G., Bor, H. H., van den Bosch, W. J., & Schers, H. (2012). Continuity in different care modes and its relationship to quality of life: a randomised controlled trial in patients with COPD. British Journal of General Practice, 62(599), e422-e428.

Vogelmeier, C., Hederer, B., Glaab, T., Schmidt, H., Rutten-van Mölken, M. P., Beeh, K. M., … & Fabbri, L. M. (2011). Tiotropium versus salmeterol for the prevention of exacerbations of COPD. New England Journal of Medicine, 364(12), 1093-1103.

Vrijhoef, H. J. M., Diederiks, J. P. M., & Spreeuwenberg, C. (2000). Effects on quality of care for patients with NIDDM or COPD when the specialised nurse has a central role: a literature review. Patient Education and Counseling, 41(3), 243-250.

Woodruff, P. G., Albert, R. K., Bailey, W. C., Casaburi, R., Connett, J. E., Cooper Jr, J. A., … & COPD Clinical Research Network. (2011). Randomized trial of zileuton for treatment of COPD exacerbations requiring hospitalization. COPD: Journal of Chronic Obstructive Pulmonary Disease, 8(1), 21-29.