Capella 4005 Assessment 2

Capella 4005 Assessment 2

Student 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, the Chief Operating Officer (COO) at Cedar Valley Health Center, a moderately sized hospital catering to both rural and urban populations. Dr. Reyes has held the COO position for seven years and is responsible for operational management, compliance oversight, and leading institutional initiatives aimed at improving healthcare quality and outcomes. A pressing concern at the center is the elevated rate of hospital readmissions among patients suffering from diabetes and cardiovascular conditions. These frequent readmissions have negatively influenced patient satisfaction scores and strained hospital resources. Dr. Reyes attributed these trends to fragmented discharge processes and inadequate care transition mechanisms (Ibrahim et al., 2022). In response, the hospital launched a discharge education program alongside a post-discharge appointment scheduling system under its leadership initiative. Although the program initially seemed promising, it did not produce a notable decrease in readmission rates due to patients’ inability to maintain post-discharge care. The leadership team is now reconsidering this strategy to refine its approach.

Dr. Reyes also emphasized that although the hospital provides a supportive work environment, a disconnect between hospital-based services and community resources hinders care continuity. She advocates for robust collaborations with external healthcare partners and social service organizations to support discharged patients more effectively. Additionally, her multidisciplinary leadership has led to initiatives such as a team project involving nurses, case managers, and pharmacists, which successfully improved medication reconciliation processes—an example of the benefits of collaborative practice.

A semi-structured interview method was applied, allowing open-ended conversation while addressing critical focus areas. Key questions posed included: “In what ways have higher readmission rates impacted care delivery at Cedar Valley Health Center?” and “What challenges have emerged in promoting teamwork among diverse professionals?” These questions revealed that poor interprofessional communication was a significant driver of ineffective care transitions. Data collection methods such as reflective listening, clarification probes, and detailed notes enhanced the accuracy and depth of responses (Tal & Epstein, 2021).

Issue Identification

The consistently high readmission rates of patients with chronic conditions like heart disease and diabetes present a significant operational and clinical challenge for Cedar Valley Health Center. Addressing this issue necessitates an integrated, evidence-based, and interdisciplinary strategy involving nursing, case management, pharmacy, and social services. This collaborative approach ensures that discharge plans are comprehensive and that patients continue to receive necessary support following their hospital stay. Inadequate patient education, poor medication adherence, and limited access to community-based resources have all been linked to preventable readmissions. Enhancing cooperation among diverse health professionals will help address these gaps and promote effective transitions from hospital to home (Hayes et al., 2024).

Change Theories That Could Lead to an Interdisciplinary Solution

Kotter’s 8-Step Change Model offers a reliable and structured framework for guiding interdisciplinary reforms aimed at reducing readmission rates. The model starts by identifying the urgency of the problem and moves through phases including forming guiding coalitions, creating a shared vision, and embedding new practices into the organizational culture. At Cedar Valley Health Center, using this model involves emphasizing the serious implications of readmissions with both clinical data and financial metrics to support the case for change. A leadership coalition composed of nurses, social workers, pharmacists, and case managers can collaboratively design new discharge and education protocols.

Effective communication plays a pivotal role in building organizational support. Encouraging staff participation in implementing these changes fosters accountability and long-term commitment. Quick successes further drive momentum and help institutionalize the new workflow. Dr. Reyes noted that a previous facility-wide initiative benefitted from Kotter’s structure, helping align stakeholder interests and improve team morale. The framework has proven beneficial in transforming healthcare practices and is validated by peer-reviewed literature (Harrison et al., 2021).

Leadership Strategies That Could Lead to an Interdisciplinary Solution

Transformational leadership is well-suited for guiding interdisciplinary collaboration in reducing hospital readmissions. This approach promotes a unified vision and inspires healthcare professionals to work collectively toward shared goals (Pattison & Corser, 2022). Transformational leaders encourage innovation and cultivate an inclusive culture where professionals across disciplines—including nursing, social work, pharmacy, and care coordination—contribute to refining patient care transitions. By harmonizing efforts across departments, these leaders help streamline discharge planning, enhance patient education programs, and ensure consistent follow-up care.

Such leadership models not only improve team performance but also enhance individual staff satisfaction and institutional loyalty. In Cedar Valley Health Center’s context, applying transformational leadership principles has shown potential in empowering nursing staff and reinforcing collaborative behavior across units. The strategy supports structural changes necessary for sustainable improvement in readmission metrics and aligns with best practices described in scholarly literature (Pattison & Corser, 2022).

Collaboration Approaches for Interdisciplinary Teams

Implementing interprofessional rounds is a highly effective method to promote interdisciplinary teamwork. These rounds unite physicians, nurses, case managers, pharmacists, and social workers to collaboratively assess patient needs, share knowledge, and coordinate discharge planning. Such interaction improves understanding among team members and accelerates problem-solving in complex care situations. Karam et al. (2021) emphasize that enhancing communication competence among team members boosts psychological safety and reduces perceived clinical risks.

Additionally, adopting Collaborative Care Models (CCMs) further enhances interdisciplinary engagement. CCMs emphasize shared accountability, team-based decision-making, and integrated planning. These models foster cohesion within care teams and bridge gaps between physical and behavioral healthcare services. They have been proven to reduce care costs and improve quality in outpatient and community settings (Rawlinson et al., 2021; Harrison et al., 2021). Integrating both interprofessional rounds and CCMs at Cedar Valley Health Center can help address systemic shortcomings in discharge coordination and minimize hospital readmissions.

Table 1

Strategies to Enhance Interdisciplinary Collaboration at Cedar Valley Health Center

Strategy	Description	Supporting Source(s)
Interprofessional Rounds	Team-based discussions involving multiple disciplines to coordinate patient care plans.	Karam et al., 2021
Collaborative Care Models (CCM)	Integrated decision-making and shared responsibility for improved health outcomes.	Rawlinson et al., 2021; Harrison et al., 2021

Conclusion

The interview with Dr. Reyes revealed that Cedar Valley Health Center faces significant barriers in managing chronic disease readmissions due to poor care transitions and insufficient community linkages. Applying Kotter’s 8-Step Model offers a blueprint for orchestrating change across departments, while transformational leadership provides the motivation and structure necessary for sustained collaboration. Interdisciplinary strategies such as interprofessional rounds and collaborative care models represent practical, evidence-based tools to bridge communication gaps and enhance care continuity.

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