NU 730 Unit 1 systems analysis example

Where the Connections Fail: A Systems Analysis of a 120-Bed Rural Community Hospital

Student Name

Department of Nursing, Herzing University

NU 730: Systems-Based Practice

Instructor Name

January 21, 2026

Where the Connections Fail: A Systems Analysis of a 120-Bed Rural Community Hospital

The Organization

The organization is a composite 120-bed community hospital in a rural county, the only hospital within 50 miles. It has a 14-bed emergency department, a 10-bed intensive care unit, two medical-surgical units, a small obstetric unit, an inpatient pharmacy staffed until 10 p.m., a laboratory that runs 24 hours with one technologist overnight, a discharge planning team of two case managers and one social worker on weekdays, and an affiliated outpatient primary care clinic in town that receives most of its discharged patients. Payer mix: about 52% Medicare, 24% Medicaid, 18% commercial insurance, and 6% uninsured. The hospital transfers critically ill patients who need specialty care to a tertiary center 90 miles away.

Health care organizations behave as complex adaptive systems, in which the parts interact in ways that cannot be predicted by examining each part alone, and outcomes often emerge from relationships rather than from any single component (Plsek & Greenhalgh, 2001). This analysis therefore follows what moves between the components, not what happens inside each one.

Four Flows Followed Separately

Four flows move through the hospital at different speeds: patients, information, medications, and money. Each is followed separately, because a flow can move smoothly while another breaks at the same point.

Patients enter mainly through the emergency department, about 70% of admissions, move to an inpatient unit, and leave to home, home with services, a skilled nursing facility, or transfer. Information moves through the electronic health record, phone calls, faxes to outside facilities, and verbal handoffs. Medications move from the pharmacy to automated dispensing cabinets on each unit, and at discharge as prescriptions sent to community pharmacies. Money moves as claims to payers, with Medicare payment determined largely by diagnosis at discharge and Medicaid and commercial payment varying by contract.

Failure Point 1: Emergency Department to Inpatient Unit

Patient flow breaks here most visibly. Once the decision to admit is made, patients board in the emergency department for a median of 4.5 hours before an inpatient bed opens, and for more than eight hours on weekday afternoons. The cause is not the emergency department. It is upstream: inpatient beds free up late because discharges cluster after 3 p.m. The connection that fails is between discharge on the inpatient units and admission from the emergency department, and neither department controls the other's timing.

Failure Point 2: Pharmacy After Hours

Medication flow breaks between 10 p.m. and 7 a.m., when the inpatient pharmacy is closed and new orders are reviewed remotely by a contracted pharmacist service. Remote review works for standard orders but slows first doses of nonstocked medications, which must be retrieved by the nursing supervisor from the locked pharmacy. Night nurses report delays of one to three hours for first-dose antibiotics ordered after admission. The failure is at the connection between the prescriber, the remote reviewer, and the physical supply.

Failure Point 3: Discharge to the Outpatient Clinic

Information flow breaks at discharge. The hospital's discharge summaries are completed a median of two days after discharge, and the affiliated clinic receives them by fax. In a review of 30 patients seen at the clinic within a week of discharge, the summary was not available at the visit for 11. Medications changed during the admission were the most frequent missing item, a pattern reported widely in studies of hospital-to-primary-care communication (Kripalani et al., 2007). The clinic and the hospital use different electronic record systems, so nothing moves automatically between them.

Failure Point 4: Weekend Discharge Planning

Patient and information flows both break on weekends, when no case managers work. Patients who become medically ready for discharge to a skilled nursing facility on Friday afternoon usually wait until Monday, because placement requires case manager contact with facilities and insurers. Each such patient occupies a bed for two to three extra days, which feeds directly back into Failure Point 1.

Money as a Flow

The financial flow explains why some failures persist. Under Medicare's prospective payment, the hospital receives a fixed payment per admission regardless of length of stay, so the weekend delay costs the hospital money but does not change its payment. Yet adding weekend case management is a budget line in one department, while the savings appear as shorter stays counted in another. The organization's budgeting follows departments, while the costs and savings follow patients, and that mismatch is itself a systems failure.

Where One Change Moves Several Flows

Because the failures are linked, the analysis points to connections where a single change would move several flows at once. The strongest of these points is discharge timing on the inpatient units: moving even a third of discharges before noon would free beds while the emergency department is filling, shorten boarding, and reduce the number of admissions arriving on the units after the pharmacy closes. The second is weekend discharge planning: one case manager working Saturdays would release beds held by patients awaiting placement. The third is an electronic connection between the hospital and the affiliated clinic, even a shared read-only portal, which would address the information failure without requiring either organization to change its record system.

None of these changes lies inside a single department's authority, which is why they have not happened. Each needs an owner who can act across the connection, such as a patient flow committee with members from nursing, pharmacy, case management, and the clinic.

What the Analysis Shows

The parts of this hospital mostly work. The emergency department, the inpatient units, the pharmacy, and the clinic each perform reasonably within their own walls. The failures occur where one part depends on another's timing or information, and three of the four failure points are linked: late and weekend discharges produce emergency department boarding, and boarding delays first-dose medications when admissions arrive at night. The national report on quality described exactly this kind of problem, arguing that the gap between the care patients receive and the care they should receive lies more in the design of systems than in the effort of individuals (Institute of Medicine, 2001). The implication for a nurse in advanced practice is that improvement efforts aimed at a single unit are likely to fail if they do not address the connection on which that unit depends.

References

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. National Academy Press. https://doi.org/10.17226/10027

Kripalani, S., LeFevre, F., Phillips, C. O., Williams, M. V., Basaviah, P., & Baker, D. W. (2007). Deficits in communication and information transfer between hospital-based and primary care physicians: Implications for patient safety and continuity of care. JAMA, 297(8), 831-841. https://doi.org/10.1001/jama.297.8.831

Plsek, P. E., & Greenhalgh, T. (2001). The challenge of complexity in health care. BMJ, 323(7313), 625-628. https://doi.org/10.1136/bmj.323.7313.625