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Case Study Mercy Hospital
Mercy Hospital, started in 1895, is a 143-bed hospital in a small community of 37,000 people. Mercy Hospital is located on a small hill in the center of the town surrounded by upper and upper-middle class homes on the hill and low-income neighborhoods at the base of the hill and surrounding a main street of shops, restaurants, and services. The main buildings consist of dark red brick with two floors in the center and wings out to each side. Several additions had been added to the rear of the building in the 1960’s.
The dingy green halls are lined with long windows overlooking the lawns. Few changes have occurred to renovate the hospital in the last twenty years. Most of the patient rooms hold four patients each, except the section of private rooms set aside for those who can afford them. The operating suite occupies on wing of the top floor. There is a small pediatric unit and small maternity unit, both appear to be stuck in the 1950’s. There are no security devices on the doors to these units.
As one walks through the halls, it is not unusual to see patients lying alone on stretchers, patient care technicians and nurses gather in nursing stations while patient call lights go unanswered, and soiled linens dropped on the floor. Physicians give directions to nurses who refuse to follow their orders. Families can be seen caring for family members because there is no one else who seems to care. While a simple electronic medical record system was installed, it is not used by physicians or nurses who state it is too difficult to use and they do not have time to learn.
A stop at the Pharmacy indicates that many medications are misplaced on the shelves, there is a backlog of prescriptions to fill, and there is no system for managing unit dosing for patient safety. The electronic system for managing patient prescriptions has been installed but is not used reportedly because “there is just not enough time and it is too difficult.” Several pharmacy technicians work in the pharmacy to help in filling prescriptions and transporting them to the units. However, there is no evidence that these technicians have been trained in a formal program or have passed the national pharmacy technician exam.
Further along, the Central Service Department provides sterile supplies to the units. Unfortunately, it is obvious there is no system for cataloging or rotating the supplies. This leads to outdated sterile equipment and often inadequate supplies when requested by the units. Cleaning products used for equipment meets the requirements for type; however, it is being mixed improperly so as to be too weak for adequate disinfection. Because this is handled in the Central Service Department, it becomes an issue throughout the hospital.
The dietary department provides adequate meals for patients but is known to confuse patient diets. Families complain that their family members who only eat kosher food have been routinely given products that are not approved. Cultural insensitivities are common from lack of translators, to biased comments, to outright cultural slights. Patients and staff also complain of the poor quality of the food prepared, that it is often over cooked, under cooked, or simply bland. The kitchen have passed the Department of Health inspections for cleanliness but lack updated equipment to streamline service and delivery.
The laboratory lacks adequate qualified staff to manage the required laboratory tests. Inspection of the blood bank shows that normal blood banking procedures are lacking, refrigeration is inadequate, and labeling is inadequate. Equipment is outdated. Spilled blood and other bodily fluids are observed on lab tables. Samples are lying about the lab, some labeled and some without. Refrigeration temperatures for blood are adequate.
Sentinel events occur often including: Surgical and nonsurgical invasive procedures on the wrong patient, wrong site, or wrong body part, unintended retention of a foreign object in a patient after surgery, blood transfusion reaction involving administration of blood or blood products having major blood group incompatibilities (ABO, Rh, other blood groups.) In addition, patient fall rate and medication errors occur much too often. These were all noted by the latest visit of the Joint Commission. The Nursing Director states that this was all just an over zealous visit team. However, the visit was stimulated as a result of regular reports that are required on sentinel events.
The Human Resource department occupies a small room, little more than a closet on the first floor. The HR manager has been with the hospital for 25 years, during which time he has maintained a low profile and accomplished little to enhance the conditions or benefits of the staff. His main objective is to make it through a few more years until retirement. Staff morale, which is at an all time low, does not seem to be a concern to the department. Staff benefits have not changed in the last 15 years, with few, if any, raises, no increases in healthcare benefits, and limited contributions to retirement accounts.
The Nursing Director has also been with the hospital for over 25 years and demonstrates little leadership skills, and has made no attempt to improve nursing conditions or professional development for almost as long. She has an authoritarian management style and tends to manage from a position of fear. On questioning, she is not well informed about current regulations or policies. Having grown up in the community, attended nursing school at a local diploma nursing program, and beginning her first job at Mercy Hospital, the Nursing Director appears a fixture at Mercy and rules with an iron fist. This leaves no room for nursing staff involvement in governance or any incentive to engage in evidence based practice. Therefore, standardized practices such as wound care, tracheotomy care, etc, have not been updated for many years. The management of the nursing department has resulted in many of the staff feeling bullied. This has led to a high turn over rate especially among the new graduate employees. The nurses who have stayed have become complacent and “just put in their time.” When the nurses do not agree with doctors’ orders, they do not question them but rather simply refuse to carry the orders out. Staffing on most units is very minimal. Usually one RN manages the unit with one or two patient care technicians. Because the RN is the only one who can give medications, assess patients, provide most treatments, and interact with other departments, medications and treatments are often late and mistakes are made. The patient care technicians appear to resent the position of the RN and do little to work as a team.
The finance department sits next to admissions. It is as dysfunctional as other parts of the hospital, with losses in revenue due, not only to a reduction in patients, especially those with insurance, but due to poor systems of insurance billing and coding. In addition, hospital acquired infections and fall rates have affected the income from Medicare. An electronic health care system to manage billing does not exist. Payments to vendors consistently run 60 -90 days late, and some as much as 180 days. Salaries have not been raised in years and while staff is often required to work overtime, no additional pay beyond the usual salary is provided.
The Office of the Chief of Medicine is a bit further down the hall and appears to be the only cheery place in the hospital. The Chief of Medicine is a portly gentleman in his fifties who has been with the hospital for several years, having moved to the community from a nearby urban center. He had grown up in the community and moved away for some time after medical school to specialize in surgery. He was wooed back to the community to help Mercy Hospital turn itself around after multiple issues with their Joint Commission review. A sense of loyalty to his home town and a deep sense of caring for the community led him to take on this monumental task. Since coming to Mercy, the Chief of Medicine has been met with continual barriers from staff, the board of directors, and even patients. Services are limited and outdated, patient safety and quality is poor, staff is ineffective, and morale is at an all time low. He is faced with patient care technicians playing cards while patients go uncared for, supplies that are often in short supply because of theft, and systems that do not exist in any part of the hospital.
Current bed occupancy is at 60%. No new service lines have been added in recent years. Technology based services such as CTs, specialized sonography, and technology based diagnostics and surgery are not available at the hospital, requiring patients to travel over 30 miles for the service. The emergency department is often full, being used by the community for routine medical care. Without outpatient clinics, vulnerable populations flock to the emergency department for a variety of illnesses and routine care. The emergency department becomes as much of a place for social gathering as for care.
A new for-profit hospital, owned by a major medical corporation, has opened approximately thirty miles from Mercy. While inconvenient for most of the community, it offers a much fuller range of services including high tech diagnostics and surgery. Being new, the hospital has bright walls and shiny floors. Most rooms are singles and a few doubles. The hospital accepts most insurance policies and medicare but otherwise, payment for services is due at the time of service. While families in the community of Mercy are still loyal to their hospital, the improved services available are a definite draw. This is having a negative impact on the revenue stream for Mercy Hospital.
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