Capella 4005 Assessment 2

Name

Capella university

NURS-FPX4005 Nursing Leadership: Focusing on People, Processes, and Organizations

Prof. Name

Date

Interview Summary

The interview was conducted with Dr. Angela Reyes, Chief Operating Officer at Cedar Valley Health Center, a mid-sized hospital that caters to both urban and rural populations. Dr. Reyes has served in this leadership role for seven years, overseeing daily operations, regulatory compliance, and quality improvement initiatives. A significant challenge identified during the discussion was the high readmission rates of patients with diabetes and heart disease. These recurring admissions negatively affected patient satisfaction and strained hospital resources. According to Dr. Reyes, the core issues contributing to these readmissions were ineffective discharge planning and weak transitional care processes (Ibrahim et al., 2022).

To address these concerns, the hospital launched a discharge education and post-discharge scheduling program. While initial metrics suggested positive outcomes, the program ultimately did not succeed in lowering readmission rates, primarily due to patients’ inability to adhere to follow-up care plans. Dr. Reyes emphasized the lack of integration between hospital services and community-based healthcare systems as a major obstacle to ensuring continuity of care. She advocated for the strengthening of partnerships with external providers and social agencies.

The interview followed a semi-structured format, allowing for open-ended discussion while ensuring consistency across critical themes. Sample questions included, “How have elevated patient readmission rates impacted care quality at Cedar Valley Health Center?” and “What challenges have you faced in promoting collaboration within the interprofessional team?” Responses revealed that inadequate communication and interprofessional disconnection were primary contributors to compromised continuity of care. Data was collected using active listening, clarification techniques, and robust documentation practices, enhancing its validity (Tal & Epstein, 2021). Dr. Reyes also highlighted a successful interdisciplinary initiative that involved nurses, pharmacists, and case managers, which improved medication reconciliation—a key example of teamwork addressing systemic inefficiencies.

Summary Table: Key Interview Insights

Category	Details
Interviewee	Dr. Angela Reyes, COO
Institution	Cedar Valley Health Center
Key Challenge	High readmission rates (Diabetes & Heart Disease)
Identified Cause	Fragmented discharge planning and weak transition care
Initiative Introduced	Discharge education and follow-up scheduling
Outcome of Initiative	Initial success, but long-term ineffectiveness due to follow-up adherence
Future Focus	Strengthen hospital-community partnerships
Successful Project	Medication reconciliation via interdisciplinary collaboration

Issue Identification and Change Theories

Cedar Valley Health Center faces an urgent issue of elevated patient readmission rates, particularly among those with heart conditions and diabetes. This situation requires a coordinated interdisciplinary approach to improve outcomes and resource utilization. Multidisciplinary collaboration involving nursing staff, case managers, pharmacists, and social workers is essential for creating comprehensive discharge plans and sustaining post-discharge support. These collaborations are crucial in managing complex conditions by addressing medication adherence, patient education, and ensuring seamless transition from inpatient to community settings (Hayes et al., 2024).

A structured approach to addressing this challenge can be found in Kotter’s 8-Step Change Model, which offers a sequential method for implementing change. The model begins with establishing a sense of urgency—an appropriate response given the clinical and financial implications of the hospital’s current readmission rates. According to Harrison et al. (2021), assembling a cross-functional leadership team is the next critical step. This team can lead new discharge protocols and community partnership efforts. The use of clear communication and short-term achievements can maintain momentum, while long-term changes are embedded into the organization’s culture. Cedar Valley previously applied Kotter’s model in a hospital-wide initiative, which proved effective in enhancing morale and operational efficiency. This framework continues to offer a practical guide for healthcare leadership seeking sustainable improvements.

Table: Application of Kotter’s Change Model

Kotter’s Step	Application at Cedar Valley Health Center
1. Create urgency	Highlight high readmission data and its consequences
2. Build guiding coalition	Form team of nurses, pharmacists, social workers, and managers
3. Form strategic vision	Aim to lower readmissions via improved transitions and education
4. Communicate the vision	Use clear messaging across all staff levels
5. Empower action	Involve frontline staff in implementation and problem-solving
6. Generate short-term wins	Track initial drops in readmission or increased follow-up compliance
7. Sustain acceleration	Build on early success with additional interventions
8. Anchor changes in culture	Integrate successful practices into routine discharge planning

Leadership and Collaborative Strategies

Transformational leadership serves as a valuable strategy for motivating interdisciplinary teams to collaboratively reduce patient readmissions. This leadership style emphasizes shared vision, open communication, and continuous inspiration across departments (Pattison & Corser, 2022). By creating an environment where nurses, pharmacists, case coordinators, and social workers feel empowered, transformational leaders can align efforts toward shared goals. These include patient-centered discharge planning, health literacy promotion, and community health integration. Additionally, this leadership model supports increased staff satisfaction, job loyalty, and organizational performance—all of which are essential for sustained care improvements.

Interprofessional collaboration is equally critical. Implementing interprofessional rounds—daily meetings involving multiple care professionals—fosters coordinated care planning. This practice enhances team communication, improves transparency, and reduces safety risks (Karam et al., 2021). Another effective approach is the adoption of Collaborative Care Models (CCMs), which emphasize shared accountability, inclusive decision-making, and team-based patient management. These models are particularly effective in bridging medical and social service gaps, thus ensuring that discharged patients receive holistic support (Rawlinson et al., 2021; Harrison et al., 2021).

Table: Comparison of Collaboration Strategies

Strategy	Description	Outcome/Benefit
Interprofessional Rounds	Regular meetings involving physicians, nurses, and support staff	Enhances care coordination and transparency
Collaborative Care Models	Shared accountability and joint decision-making	Improves chronic illness management and patient outcomes
Transformational Leadership	Motivates teams via shared vision and empowerment	Builds morale, commitment, and interdepartmental synergy

Conclusion

Cedar Valley Health Center’s struggle with high readmission rates underscores the need for a holistic, interdisciplinary response. The interview with Dr. Reyes revealed gaps in post-discharge care, compounded by poor communication and insufficient community integration. Applying Kotter’s Change Model offers a structured path to initiate and sustain meaningful reforms, while transformational leadership encourages collaborative problem-solving. Enhanced strategies such as interprofessional rounds and collaborative care models promise improved care transitions and long-term patient engagement. Through interdisciplinary commitment and evidence-based interventions, the organization can progress toward reducing readmission rates and elevating care quality.

References

Harrison, R., Fischer, S., Walpola, R. L., Chauhan, A., Babalola, T., Mears, S., & Le-Dao, H. (2021). Where do models for change management, improvement and implementation meet? A systematic review of the applications of change management models in healthcare. Journal of Healthcare Leadership, 13(2), 85–108. https://doi.org/10.2147/JHL.S289176

Hayes, C., Manning, M., Fitzgerald, C., Condon, B., Griffin, A., O’Connor, M., Glynn, L., Robinson, K., & Galvin, R. (2024). Effectiveness of community‐based multidisciplinary integrated care for older adults with general practitioner involvement: A systematic review and meta‐analysis. Health & Social Care in the Community, 2024(1). https://doi.org/10.1155/2024/6437930

Capella 4005 Assessment 2

Ibrahim, H., Harhara, T., Athar, S., Nair, S. C., & Kamour, A. M. (2022). Multi-disciplinary discharge coordination team to overcome discharge barriers and address the risk of delayed discharges. Risk Management and Healthcare Policy, 15(15), 141–149. https://doi.org/10.2147/rmhp.s347693

Karam, M., Chouinard, M.-C., Poitras, M.-E., Couturier, Y., Vedel, I., Grgurevic, N., & Hudon, C. (2021). Nursing care coordination for patients with complex needs in primary healthcare: A scoping review. International Journal of Integrated Care, 21(1), 16. https://doi.org/10.5334/ijic.5518

Pattison, N., & Corser, R. (2022). Compassionate, collective or transformational nursing leadership to ensure fundamentals of care are achieved: A new challenge or non-sequitur? Journal of Advanced Nursing, 79(3), 942–950. https://doi.org/10.1111/jan.15202

Rawlinson, C., Carron, T., Cohidon, C., Arditi, C., Hong, Q. N., Pluye, P., Bridevaux, I., & Gilles, I. (2021). An overview of reviews on interprofessional collaboration in primary care: Barriers and facilitators. International Journal of Integrated Care, 21(2), 1–15. https://doi.org/10.5334/ijic.5589

Capella 4005 Assessment 2

Tal, K., & Epstein, N. (2021). The importance of combining open-ended and closed-ended questions when conducting patient satisfaction surveys in hospitals. Health Policy OPEN, 2(2), 1–6. https://doi.org/10.1016/j.hpopen.2021.100033