NURS FPX 4005 Assessment 3 Interdisciplinary Plan Proposal
Student Name
Capella University
NURS-FPX4005 Nursing Leadership: Focusing on People, Processes, and Organizations
Prof. Name
Date
Interdisciplinary Plan Proposal
AdventHealth is currently addressing a critical issue: elevated patient readmission rates, which are often tied to inadequate discharge procedures and fragmented communication among care teams (Gledhill et al., 2023). This proposal recommends a structured interdisciplinary discharge plan to be implemented across the hospital’s care coordination and discharge departments. The central aim is to streamline collaboration among departments, implement standardized discharge protocols, and strengthen patient education. These strategies are designed to improve the transition of care and minimize avoidable readmissions. By fostering cross-disciplinary teamwork, this initiative aligns with AdventHealth’s commitment to providing safe, high-quality, and coordinated patient care.
Objective
The core objective is to roll out an evidence-based interdisciplinary program engaging key healthcare professionals—nurses, physicians, pharmacists, social workers, and case managers. These professionals will coordinate efforts during the discharge process to address gaps stemming from poor communication and uncoordinated care. The program incorporates several strategies: the teach-back method for patient education, weekly interdisciplinary team meetings, and use of an EHR-based discharge readiness tool. These components are expected to enhance information accuracy, improve patient adherence to post-discharge instructions, and promote accountability among care teams.
If effectively implemented, the initiative anticipates reduced hospital readmissions, increased staff collaboration, and improved patient outcomes. This effort supports AdventHealth’s mission to prioritize safety, patient-centeredness, and operational excellence.
Questions and Predictions
A key aspect of implementing this proposal involves addressing critical operational concerns and potential barriers. The following table outlines essential questions, anticipated challenges, and projected outcomes.
| Key Area | Approach/Prediction |
|---|---|
| Team Accountability | Utilize a shared performance dashboard to monitor team contributions—documentation, education delivery, and follow-ups. Regular audits will support compliance. |
| Potential Challenges | Resistance to change and siloed operations may impede implementation. Kotter’s 8-Step Change Model will be used to foster urgency and team buy-in. |
| Six-Month Outcome Projections | Expect a 20% drop in readmission rates, enhanced patient satisfaction concerning discharge clarity, and improved interdisciplinary performance metrics. |
Change Theories and Leadership Strategies
To effectively implement this plan, Kotter’s 8-Step Change Model serves as the foundational framework. This model enables a structured transformation process beginning with the identification of readmission-related problems and mobilization of a leadership coalition comprising nurses, physicians, pharmacists, and case managers (Barach et al., 2024). The goal is to establish a unified discharge planning system that includes regular sessions, shared protocols, and consistent follow-up communication to ensure patient understanding and continuity of care (Reifferscheid et al., 2023).
In parallel, Transformational Leadership will be employed to drive cultural change. This leadership style emphasizes vision alignment, role accountability, and team empowerment (Feo et al., 2022). Leaders will support interdisciplinary staff in voicing concerns, proposing solutions, and working collaboratively toward a common goal. Transformational leadership has been shown to improve team morale, enhance communication, and create trust among departments, all of which are vital for reducing readmissions and improving care outcomes (Labrague, 2023). These approaches together offer a dual strategy: structured change management and a supportive leadership culture.
Team Collaboration Strategy
AdventHealth’s Interdisciplinary Discharge Planning (IDP) model targets patients with chronic conditions such as diabetes and cardiovascular diseases. This strategy ensures a holistic approach to discharge by integrating the skills and responsibilities of various professionals into a cohesive system. Below is an overview of team member roles:
| Team Member | Primary Responsibilities |
|---|---|
| Nurse Case Manager | Coordinates high-risk discharges and ensures smooth care transitions. |
| Pharmacist | Conducts medication reconciliation and provides patient-specific medication counseling. |
| Social Worker | Addresses social determinants, organizes support services, and conducts 48-hour follow-ups. |
| Attending Physician | Leads interdisciplinary meetings to align discharge decisions with medical goals. |
These weekly team meetings ensure alignment across all departments. Monthly evaluations of readmission rates, patient satisfaction, and adherence to care plans will be used to assess the program’s effectiveness (Raffi et al., 2024). Integration of EHR tools further strengthens this approach by enabling transparent communication and timely documentation (Reifferscheid et al., 2023). A culture of mutual respect, empathy, and psychological safety will be promoted, fostering a collaborative environment where each team member’s input is valued. These efforts are anticipated to reduce readmission rates and improve continuity of care across patient transitions.
Required Organizational Resources
Efficient resource allocation is essential for implementing this interdisciplinary initiative. The plan outlines staffing, training, and technical investments necessary for success. The following table presents the budget breakdown:
| Resource Type | Details | Estimated Cost (USD) |
|---|---|---|
| Nurse Care Coordinators (2 FTEs) | Full-time roles for discharge coordination | \$160,000 |
| Part-time Social Worker | Addresses social needs and follow-ups | \$40,000 |
| Clinical Pharmacist | Conducts medication reconciliation | \$25,000 |
| Physician Involvement | Weekly discharge rounds | \$30,000 |
| Case Managers | Coordinates care and discharge planning | \$60,000 |
| Staff Training | Communication and discharge education | \$7,500 |
| EHR System Enhancements | Improves care coordination capabilities | \$12,000 |
| Total Estimated Cost | \$334,500 |
Given that hospital readmissions cost AdventHealth approximately \$17.4 billion annually, this program is cost-effective. Preventing just ten readmissions would offset the full implementation cost (Agube, 2023). Moreover, aligning with CMS readmission reduction mandates helps avoid financial penalties and enhances the organization’s reputation for quality care.
References
Agube, K. (2023). How provider education on identifying and referring eligible patients to a care management program affects readmission rates: An evidence-based project. https://digitalcommons.pvamu.edu/dnp-projects/1/
Barach, P., Wiggin, H., Risner, P., Johnson, J., Patrishkoff, D., Kurra, S., … & Popovich, E. (2024). A perioperative safety and quality change management model and case study: Muda Health. In Handbook of Perioperative and Procedural Patient Safety (pp. 245–329). Elsevier. https://doi.org/10.1016/B978-0-323-66179-9.00009-9
Feo, R., Urry, K., Conroy, T., & Kitson, A. L. (2022). Why reducing avoidable hospital readmissions is a “wicked” problem for leaders: A qualitative exploration of nursing and allied health perceptions. Journal of Advanced Nursing, 79(3), 1031–1043. https://doi.org/10.1111/jan.15220
Gledhill, K., Bucknall, T. K., Lannin, N. A., & Hanna, L. (2023). The role of collaborative decision‐making in discharge planning: Perspectives from patients, family members, and health professionals. Journal of Clinical Nursing, 32(19–20), 7519–7529. https://doi.org/10.1111/jocn.16820
NURS FPX 4005 Assessment 3 Interdisciplinary Plan Proposal
Labrague, L. J. (2023). Relationship between transformational leadership, adverse patient events, and nurse-assessed quality of care in emergency units: The mediating role of work satisfaction. Australasian Emergency Care, 27(1), 49–56. https://doi.org/10.1016/j.auec.2023.08.001
Raffi, B., Anjum, D. F., & Malik, A. (2024). Cross-disciplinary collaboration in healthcare: Enhancing outcomes through team-based care. Multidisciplinary Journal of Healthcare (MJH), 1(1), 11–19. https://www.researchcorridor.org/index.php/mjh/article/view/43
Reifferscheid, L., Kiely, M. S., Lin, M. S. N., Libon, J., Kennedy, M., & MacDonald, S. E. (2023). Effectiveness of hospital-based strategies for improving childhood immunization coverage: A systematic review. Vaccine, 41(36), 5233–5244. https://doi.org/10.1016/j.vaccine.2023.07.036
