NURS FPX 4005 Assessment 2

Name

Capella university

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

Prof. Name

Date

Interview Summary

The interview centered on Cedar Valley Health Center. It is a medium-sized hospital serving urban and rural populations. Dr. Angela Reyes has been the Chief Operating Officer (COO) for seven years. She oversees day-to-day operations, ensures regulatory adherence, and leads initiatives to enhance quality care and institutional performance. A key issue identified at the facility is the elevated readmission rates for patients diagnosed with diabetes and heart disease.

These recurring hospital visits have adversely affected patient satisfaction metrics and the allocation of healthcare resources. Dr. Reyes attributed these challenges to fragmented discharge planning and weak care transition processes (Ibrahim et al., 2022). Cedar Valley Health Center introduced a discharge education and post-discharge appointment scheduling initiative under its leadership program to address the concern. Although early outcomes appeared encouraging, the program failed to reduce readmission rates due to patients’ difficulties maintaining follow-up care. Leadership is currently reevaluating the initiative to guide its future direction.

NURS FPX 4005 Assessment 2

Dr. Reyes emphasized that while the internal work setting is supportive, gaps in collaboration between the hospital and community-based services hinder continuity of care. She supported stronger partnerships with external healthcare providers and social service agencies to safeguard support for discharged patients. With extensive experience managing multidisciplinary teams, Dr. Reyes has focused on enhancing patient safety and quality outcomes. A collaborative project involving nursing staff, pharmacists, and case managers improved medicine reconciliation. It showcases the power of teamwork in resolving systemic challenges. 

A semi-structured interview style was utilized, which allowed for open-ended discussion while ensuring key topics were addressed. For example, the respondent was asked, “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?” These queries offered insights into workplace realities. She noted high readmission rates were linked to poor communication. These issues compromised continuity of care and contributed to inefficient treatment outcomes. Active listening techniques, clarification prompts and detailed documentation contributed to capturing rich and dependable data (Tal & Epstein, 2021).

Issue Identification

The elevated patient readmission rates at Cedar Valley Health Center among persons with heart problems and diabetes have emerged as an issue that requires an evidence-based, interdisciplinary approach. Addressing this challenge demands collaboration among nurses, pharmacists, case managers and social staff to establish complete discharge plans and safeguard continuity of care post-hospitalization.

By leveraging the expertise of multiple disciplines, the center can confront the underlying contributors to readmissions, such as inadequate medication management, patient education and insufficient community follow-up resources (Hayes et al., 2024). Fostering interprofessional collaboration enhances the transition of care from inpatient settings to community settings. Coordinated efforts across expert roles are vital for managing chronic illnesses, care gaps, and sustaining long-term patient engagement (Hayes et al., 2024).

Change Theories That Could Lead to an Interdisciplinary Solution

Kotter’s 8-Step Change Model provide a structured and effective framework for designing interdisciplinary interventions to address the high readmission rates at Cedar Valley Health Center. The model outlines a clear progression of steps for executing transformational change. It begins with recognizing an urgent need and culminates in integrating new practices into the organizational culture.

Applying this model requires underscoring the pressing nature of the readmission issue. It is supported by data representing its clinical and financial effects (Harrison et al., 2021). Formulating a strategic vision for reducing readmissions involves assembling a leadership team composed of nursing professionals, pharmacists, case coordinators, and social workers. This alliance drives the development and rollout of enhanced discharge protocols, patient education efforts, and cross-departmental coordination to safeguard seamless care delivery. Clear and consistent messaging is vital to build awareness and support among staff.

Empowering employees to take active roles in the change process fosters ownership and engagement. Achieving quick triumphs helps build momentum and reinforces desired behaviors. It embeds them into routine clinical practice. During a third hospital-wide initiative, the Kotter model was instrumental in guiding change from problem recognition to fully integrating improved procedures. It improves stakeholder alignment and increases staff morale and process efficiency (Harrison et al., 2021). This outline supports Cedar Valley Health Center in strengthening interdisciplinary collaboration and reducing readmission rates. The source is credible as it was published in the peer-reviewed Journal of Healthcare Leadership. It validates the model’s relevance and proven efficiency in managing healthcare system improvements.

Leadership Strategies That Could Lead to an Interdisciplinary Solution

Transformational leadership presents a dynamic framework for fostering interdisciplinary solutions to lower Cedar Valley Health Center’s readmission rates. This leadership style cultivates a shared vision among healthcare providers. It empowers team members to collaborate and strive toward collective objectives (Pattison & Corser, 2022). Transformational leadership encourages a culture of inspiration and innovation, where nurses, case managers, pharmacists, and social workers are motivated to contribute to the growth of streamlined care pathways.

By guiding teams with purpose and promoting interdepartmental synergy, transformational leaders can align discharge procedures, patient education initiatives and follow-up care systems to improve continuity and reduce the chance of rehospitalization. Pattison and Corser (2022) emphasized that this leadership method enhances the healthcare setting and strengthens nursing empowerment, job fulfillment and structural loyalty. The credibility of this source is reinforced by its publication in Leading Global Nursing Research, a peer-reviewed journal recognized for advancing evidence-based practices. The article highlights how the leadership model has been executed to enhance outcomes and reduce disciplinary workplace cultures. 

Collaboration Approaches for Interdisciplinary Teams

One impactful strategy to strengthen interdisciplinary collaboration is the implementation of interprofessional rounds. It brings together healthcare experts from various disciplines, such as physicians, nurses, case coordinators, pharmacists and social workers, to assess patient conditions, share expertise and synchronize care plans. This structured, team-based dialogue fosters mutual understanding and facilitates problem-solving across care domains. Karam et al. (2021) highlight that equipping care teams with communication and interaction skills enhances psychological safety and transparency. It lowers perceived patient safety risks. Integrating this method into routine care coordination can streamline teamwork and elevate patient outcomes. Employing Collaborative Care Models (CCMs) is another effective approach to enhancing interdisciplinary engagement.

CCMs emphasize joint duty, inclusive clinical decision-making among diverse healthcare experts. All contributing to improved health outcomes. Rawlinson et al. (2021) emphasize how these models foster accountability and cohesion within care teams. Harrison et al. (2021) illustrate that CCMs bridge physical and behavioral healthcare services. Models boost care quality and lowers costs in outpatient settings. Both sources are highly credible and published in the International Journal of Integrated Care. They support the connection between psychological safety and communication. Harrison et al. (2021) appear in the Journal of Healthcare Leadership, reinforcing practical application and benefits of collaborative care structures. Integrating interprofessional rounds and CCMs at Cedar Valley Health Center is recommended to address the drivers of hospital readmissions proactively.

Conclusion

The elevated readmission rates at Cedar Valley Health Center highlight the pressing need for an interdisciplinary solution that addresses care fragmentation and strengthens transitional support. The interview with Dr. Reyes revealed critical gaps in discharge planning and follow-up coordination. Using Kotter’s 8-Step Change Model delivers a strategic roadmap for initiating and sustaining change, while transformational leadership encourages a joint insight and motivates healthcare professionals to collaborate effectively.

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

NURS FPX 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, Volume 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

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

NURS FPX 4005 Assessment 2