A structured Method for Collaborative Decision-making in In-hospital Cardiac Telemetry Quality Improvement

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A Structured Method for Collaborative Decision-making in In-hospital Cardiac Telemetry Quality Improvement


Varun Sharma

B.S., Pennsylvania State University, 2010

Submitted to the Graduate Faculty of

Department of Health Policy and Management

Graduate School of Public Health in partial fulfillment

of the requirements for the degree of

Master of Health Administration

University of Pittsburgh




This essay is submitted


Varun Sharma

June 29, 2015

and approved by

Essay Advisor:

Nicholas Castle, PhD ______________________________________


Department of Health Policy and Management

Graduate School of Public Health

University of Pittsburgh

Essay Reader:

Rosemary L. Hoffmann, RN, PhD ______________________________________

Associate Professor

Clinical Nurse Leader Program

School of Nursing

University of Pittsburgh

Copyright © by Varun Sharma



Nicholas Castle, PhD
A Structured Method for Collaborative Decision-making in in-Hospital Cardiac Telemetry Quality Improvement

Varun Sharma, MHA

University of Pittsburgh, 2015

Telemetry is a hospital service which is delivered by many different hospital professionals acting in concert. These inter-connections challenge telemetry work designs to account for each actor’s role and his effect on the system. Other difficulties in designing safe, efficient telemetry arise from the nature of telemetry. The ergonomics of device interfaces and operational idiosyncrasies can contribute to the instability of systems when employees react to stresses by departing from the ideal protocol. If that occurs too frequently, organized quality improvement becomes necessary to resolve the aggregate uncertainty surrounding the structure-process relationship. Thus, an equilibrium may be restored between caregivers and hospital structures.

A structured method is proposed to facilitate front-line employee participation in collaborative decision-making throughout all stages of quality improvement. Employees are encouraged to conduct improvements within a decision space between the minimum regulatory requirement (resource minimum) and break-even budget constraint (resource maximum.) Decision-making occurs in two stages after employees are grouped by department. A nominal group technique is conducted within departments to generate ideas. These are sent to the hospital level. There, a modified Delphi technique includes a representative from each department.

After consensus has been established, the group delineates an implementation path consistent with its other needs. Because a larger number of employees has participated in their creation, the structures resulting from this improvement initiative are likely to decay more slowly. But once they do, there will be a need for further modifications. Then, formal and informal infrastructure for quality improvement collaboration will still exist.

Non-profit healthcare organizations create quality improvement infrastructure with partial subsidization by the community. Thus, the opportunity cost in the marketplace must be outweighed by decision-making infrastructure’s benefits to the total welfare. These benefits range across subjective and objective dimensions. More individuals’ preferences may be addressed, increasing aggregate utility. If the breadth of data collection contributes to a net allocative efficiency, objective outcomes may improve in the furtherance of public health.


preface 8

1.0 Introduction 1

1.1The Effects of Telemetry 2

1.2Quality Improvement 4

1.2.1Uncertainty in Quality Improvement 5

1.2.2Telemetry 6

1.2.3Quality Improvement in Telemetry 9

1.2.4Summary of Telemetry Quality Improvement Literature 15

1.2.5The Sociology of Telemetry Improvement 16

2.0 Program 18

1.3Objective 19

1.4Rationale 20

1.5Content 22

1.5.1Education 23 Quality Improvement Terms 24 25

1.5.2Structured decision-making 26 Selection and Weighting 27 Group Technique 29 Voting 30 Improvement 31

3.0 Conclusion 32

1.6real-world application 34

1.7Public Health Relevance 35



appendix c: examples of program applications 38

bibliography 31

Figure 1. 2004 Electrocardiography Guidelines 37

I owe a debt of gratitude to my advisor and reader for this document. Drs. Nick Castle and Rose Hoffmann, respectively, devoted a significant amount of time and expertise to this ambitious project. More broadly, the entire faculty of the Graduate School of Public Health contributed by offering an eclectic education and being patient enough to indulge my inquisitive mind.

But before I even set foot in this city, I had the good fortune of being indulged by two parents who lived as to ensure the success and happiness of the next generation. I have certainly received quite a bit of material support along the way, but it pales in comparison to the unspoken lessons I was lucky enough to collect from my role models. These are the most useful tools I have acquired thus far in the quest for future happiness.

It seems fortuitous, then, that Pitt’s sample figure to help format this document was Guayasamin’s Mother and Son. The same inquisitive mind that was nurtured by my parents and indulged by my professors led me to a cursory Wikipedia search of Oswaldo Guayasamin. Per Wikipedia, Guayasamin’s “Chapel of Man” is meant to document the worst tendencies of human nature but also demonstrate humanity’s potential to achieve ascendancy. That innate contradiction is a fundamental truth of the human experience which the reader will recognize as he proceeds through this document.

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