Healthcare Administration Practice Case Studies
Healthcare5 Case StudiesUpdated Sep 2026
Five fictional cases follow, each drawn from the everyday pressures of running a health service. They cover escalation of changing symptoms, handover of patient information, sharing scarce capacity, reading inconsistent outcome data, and handling consent and confidentiality when a case becomes difficult. Each case is set in an invented organization and asks what the patient needs, what the clinical evidence shows, how the team is coordinating, and which care protocols apply. Pay particular attention to responsibility that was assumed rather than confirmed, because that gap runs through most of them.
Case Study 1
Rising observations on an evening medical ward
Tarrow Field Regional Hospital, an acute general hospital with a medical ward and an outreach team.
The situation
Tarrow Field Regional Hospital is a 310-bed acute hospital serving a mixed urban and rural catchment. On a weekday evening in the third week of a busy winter period, the medical ward was running with one resident covering three wards. A 71-year-old man admitted two days earlier had shown a slow rise in heart rate and temperature through the afternoon, and his breathing had become quicker. The observations were charted at each round, but nobody had trended them, so the change looked smaller on paper than it was. Dana, the charge nurse, noticed a new breathing concern and asked Marcus, the resident, to review him.
The challenge
Marcus had two admissions waiting and a handover from the day team still open. The local deterioration protocol called for a senior review when the early warning score reached a set threshold, and the score had crossed it about an hour earlier, although nobody had totaled it since. Dana was unsure whether to call the outreach team directly or wait for Marcus. The patient was drowsy but answering questions, and his family had gone home for the night.
Analysis
Start with what the patient needed, not with the protocol. He needed his trend read as a whole, since one set of observations in range can hide a steady drift. The chart held the evidence: rising heart rate, rising temperature, a new breathing concern, and a change in alertness. Together they described a man who was getting worse and might not be able to say so. A useful review asks whether the trend is in front of the team, whether the score has been totaled, and whether anyone has examined him since the change began. Here the answer to all three was no until Dana prompted the review.
The coordination problem here was about permission and ownership. Dana had the clinical concern but no authority to order a review beyond asking, and Marcus had the authority but was pulled across three wards. The protocol gave the answer on paper: a score at or above the threshold triggers a call to the outreach team without waiting for the resident. Teams grounded in Healthcare Administration Practice tend to treat that rule as a standing duty, not as a favor to be requested. A shared trend chart and a rule allowing direct calls to outreach when the score is met would have helped.
- 1Trend the observationsRead the chart as a sequence, not as separate readings.
- 2Total the early warning scoreCalculate it from the trend and compare with the local threshold.
- 3Decide who respondsFollow the protocol: nurse, resident or outreach, by score and time.
- 4Examine and recordReassess the patient at the bedside and document the agreed plan.
- 5Review at a set pointConfirm the plan held, and escalate again if the trend continues.
Actions taken
- Dana would call the outreach team now and document the time, the score and the reason for the call in the chart. She would not wait for the resident to finish his other reviews.
- Marcus would review the patient at the bedside within the protocol window, recalculate the score from the trend, and record a plan agreed with outreach.
- The ward would add a trended observation chart to the admission record and a daily check that every score above threshold has a documented response.
- The charge nurse would brief the next shift on the case at handover, naming who holds the patient and what would trigger a call to outreach.
Results
The outreach team attended within the hour and confirmed the patient needed a higher level of monitoring. He was moved to a bed nearer the nurses' station and reviewed again before the end of the shift. The patient's breathing was reassessed and the team agreed on the next review point. The ward audit found the trend chart complete for every patient admitted that week, and two other late escalations traced to the same gap. The ward agreed to make the trend chart part of the daily board round.
Questions for discussion
- What information did Dana have that Marcus did not, and how should a ward make that information reach the resident before a call is needed?
- Under the local protocol, which decisions belonged to the nurse, which to the resident, and which to outreach, and where would you draw those lines?
- How would you test whether a deterioration protocol is actually used on a busy evening rather than only described in policy?
Case Study 2
A handover gap after an overnight ward transfer
Pellham Crossing Health System, a three-site network with a shared handover standard.
The situation
Pellham Crossing Health System runs three hospital sites and a shared handover standard built around a structured verbal report and a written summary. Late on a weekend night, a 64-year-old woman was moved from the surgical ward to the general medicine ward after an unexpected change in her condition. The surgical registrar gave the verbal report at the end of a long shift, and the written summary was sent before a pending laboratory result was added to it. The receiving nurse, Ana, had a full ward and a second admission arriving at the same time, so the report was taken in pieces.
The challenge
The written summary did not mention the pending result or the family's request to be called before any change in the plan. Neither the registrar nor Ana had a second check built into the process at that point. By the time the on-call doctor reviewed the patient, the result had been back for about two hours and nobody had connected it to the plan. The incident review in the following week would need to establish who had owned the open items, and whether the policy had made that clear.
Analysis
The patient needed continuity more than anything else. Her condition had changed quickly, so the receiving team needed to know what had been observed, what had been tried, what was still waiting, and what she and her family had been told. The evidence needed to make a safe decision on the ward was spread across three documents: the observation chart, the operative note and the laboratory system. A pending result not visible at handover leaves the next decision waiting on information nobody is watching for. Good handover turns open items into a short list with a named owner and a time for the next check.
The coordination failure was not a single error. The registrar followed the standard in giving a verbal report and a written summary, but the standard did not require the open items to be read back. The receiving nurse was under pressure and did what many would do with a partial report, which was to act on what was in front of her. The overnight transfer checklist asked for a read-back of allergies and code status, yet it had no field for pending results. Read-back works when the receiver is given time and a prompt, and when the sender knows the receiver will check.
- Before transferSurgical team gives verbal report and writes summary.
- At handoverPending result is not listed on the summary or the checklist.
- Early in the shiftReceiving nurse is interrupted by a second admission.
- About two hours laterResult returns; nobody links it to the plan.
- Next morningIncident review traces the open item to the form design.
Actions taken
- The sending team would add a pending results section to the written summary, with each item named, owned and given a time for review.
- The overnight checklist would require a verbal read-back of open items, with the receiving nurse repeating each one before the sending clinician leaves the unit.
- Charge nurses would protect fifteen minutes at the start of a receiving shift for transfer reports, so that a second admission cannot compete with the first.
- The quality team would audit twenty overnight transfers each month for open items at handover, reporting the share with a named owner and a set review time.
Results
Over the next quarter the pending results section was completed in nearly every overnight transfer, and the audit showed open items with a named owner rising from under half to about nine in ten. In one follow-up, a result returned after transfer was reviewed within the set window. The receiving nurses reported that the read-back took about four minutes on average and that they felt less reliant on the sender's memory. Two sites adopted the checklist as a standing agenda item for their transfer meetings.
Questions for discussion
- Which items on the overnight transfer checklist carry the most risk if they are left out, and who should be able to see them?
- How would you balance a longer read-back against the pressure of a full ward without weakening the safeguard?
- What would a receiving nurse need to hear from the sender to know that an open item is still theirs to watch?
Case Study 3
Scarce scanning slots and a choice about who waits
Sunmarrow Community Care Partnership, a county service running clinics, home visits and community diagnostics.
The situation
Sunmarrow Community Care Partnership coordinates outpatient clinics, home visits and a community diagnostic service across a county with two imaging sites. In the middle of the winter quarter, referrals for one type of scan rose sharply and the waiting list grew from about four weeks to over nine. The service had two scanners, three sonographers on rota and a booking system that allowed one slot per referral regardless of urgency. One sonographer was on sick leave and a scanner was out for repair in the second week. Sunmarrow's capacity manager, Tomasz, had to decide how to ration the remaining slots.
The challenge
Some referrals were routine follow-up checks, while others came from primary care with a clinical question that could change the next treatment decision within days. The booking system could not tell them apart. Tomasz also had a commitment to keep the home visit team's schedule intact, since those patients had no other route to a review. Every option moved risk somewhere else, and he had to explain the choice to the service board by the end of the week.
Analysis
The clinical question was whether each referral needed the scan within days or could wait without harm. That depends on evidence the booking form rarely captures well. A referral marked as urgent by a general practitioner may reflect a worry rather than a finding, while a routine request may mask a change that the referrer did not know to flag. Good triage asks the referrer for the specific question the scan must answer, the symptoms that prompted it, and any result that would change management within the week. Scoring referrals against agreed criteria helps only when clinics apply them the same way.
Coordination across the two sites is where the capacity problem became visible. Each clinic booked its own list with no shared view of the other's gaps, so a slot freed at one site often went to a routine case. The partnership's access protocol set out priority bands and required a clinical sign-off for any change in band, but the sign-off was held by one senior clinician on a limited rota. A workable response combines a single daily pool of urgent slots, a named triage lead at each site, and a rule that patients on the home visit list keep their existing review dates.
Actions taken
- Tomasz would open a shared daily pool of urgent slots, released at a fixed time, so that either site can fill an urgent referral before routine bookings.
- Each site would name a triage lead who reviews incoming referrals against the access criteria and records the specific question each scan must answer.
- The home visit schedule would be ring-fenced, with existing review dates kept unless a clinician documents a change in need.
- The sign-off for band changes would move to a rota of two clinicians, with a written record of each decision and the reason for it.
Results
Within the quarter, the urgent pool was used on most days, and the average wait for urgent referrals fell from about five days to under two. Routine waits lengthened somewhat, from about four weeks to five, which the board accepted as a visible trade-off. The home visit schedule was not cancelled once. Clinicians reported that the sign-off rota became a bottleneck in the second month, so a third name was added. Tomasz kept a short log of the decisions, which became the basis for the board paper.
Questions for discussion
- What information would a referrer need to provide so that triage reflects clinical need rather than the urgency box ticked on the form?
- When a service cannot meet demand, which commitments should be protected first, and how should that choice be explained to the people who wait?
- How would you decide whether a new sign-off rota adds safety or simply moves delay to a different point in the process?
Case Study 4
Inconsistent follow-up rates across six primary care clinics
Kestle Ridge Ambulatory Network, six primary care clinics sharing one records system and one quality committee.
The situation
Kestle Ridge Ambulatory Network runs six primary care clinics that share a clinical records system and a single quality committee. Over the last two quarters, the committee reviewed a set of anonymized indicators for unplanned visits, and the results varied widely between sites. The indicator tracked whether a patient who had an unplanned visit was seen for review within fourteen days, and the proportion ranged from about four in ten at one clinic to nearly eight in ten at another. The committee's lead, Ravi, a practice manager with a background in nursing, wanted to know whether the gap reflected care or recording.
The challenge
The lowest clinic, Clinic D, was not obviously worse in staffing or patient mix. Its recorded follow-up rate was low, but the notes suggested that many reviews had happened by telephone and were not coded in the same way. Some patients at the highest clinic had reviews booked automatically by a template that recorded a booking rather than an attendance. The committee needed to separate real differences in care from differences in how care was recorded before setting any target.
Analysis
Patients who return unexpectedly need a review that closes the loop: someone checks what happened, whether the plan changed, and whether the patient understood the next step. A follow-up rate is a proxy for that, and proxies can mislead. The evidence here came from the indicator, the coded visit records and a sample of notes read by two clinicians. The sample showed that unplanned visits at the low clinic were often by patients with more than one long-term condition, and that their reviews were more often done by telephone and coded as advice calls. Only some of the gap was care.
Teams grounded in Healthcare Administration Practice treat an indicator as a question to be tested, not a verdict on a clinic. The committee's protocol for quality reviews asked each site to submit a summary and an action plan, but the template did not ask how visits were coded, so the comparison was never like for like. Clinic D's manager, Hana, reported a rota gap and two new staff, while the highest clinic had a clinical lead who had set the template and held strong views on it. Coordination across sites depended on the committee chair holding both sets of records together, which no single person did.
- Measure with checks Sample unplanned visits monthly and confirm coded outcomes against notes.
- Split the gap Compare sites only after a shared coding guide is applied.
- Test one change Give Clinic D temporary capacity for backlog review and record the effect.
- Monitor and report Report monthly by site, with coding changes shown as separate lines.
Actions taken
- The committee would agree a shared coding guide for telephone reviews and advice calls, signed off by all six clinic managers before any new data is compared.
- Each clinic would check a random sample of twenty unplanned visits a month, confirming the coded outcome against the clinical note.
- Clinic D would receive a temporary sessional nurse for three months so that the review backlog could be cleared without moving staff from other duties.
- Monthly reports would go out by site, with coding changes shown as separate lines so that care and recording movements stay distinguishable.
Results
After the coding guide was in place for two months, the committee compared like with like for the first time. The gap between the highest and lowest clinics narrowed from about forty points to about eighteen, though the lowest clinic remained behind. Just over half of the original gap had been recording, which the committee had not expected. Clinic D's backlog was cleared within the period, and its monthly figure rose steadily in the months that followed. The indicator now carries a short note on coding changes, and the committee reviews the sample findings at every meeting.
Questions for discussion
- Which findings in this review would have been missed if only the headline indicator had been reported?
- How would you set a target for a clinic whose recorded performance partly reflects how its visits are coded?
- What would make the monthly sample check sustainable for a busy team without weakening its value?
Case Study 5
Confidential request from a patient with fluctuating capacity
Vantry Hollow Teaching Hospital, a large acute hospital with an ethics service and a consent policy.
The situation
Vantry Hollow Teaching Hospital is a large acute hospital with a consultant-led ethics service and a standing policy on consent, capacity and information sharing. A man in his late sixties was admitted after a fall at home and was assessed as able to take part in decisions about his own care on most days, though his confusion worsened in the evenings. His daughter, Yolanda, held a health care proxy and asked the team to tell her everything about his condition and plans. He had told the nurse, Felix, that he did not want his daughter to know about a private matter he had raised earlier.
The challenge
The team had to decide what could be shared, when a capacity judgment was needed, and who should make it. The proxy could act only for decisions the patient could not make for himself, and his ability to decide varied through the day. The on-call consultant, Ngozi, wanted a clear plan before the next family meeting. Felix was unsure whether his earlier request still applied. A relative on the ward had already shared part of the picture, which made the position harder to hold.
Analysis
Start with the patient's own account, recorded as clearly as possible at the time he gave it. His request about his daughter was specific, and that specificity matters. Clinical evidence about capacity was mixed: the assessment was good in the mornings and weaker in the evenings, so a single judgment would not settle the question. A capacity assessment is decision specific, so the team should ask whether he can understand, retain, weigh and communicate this particular choice at this time. Nothing in the file shows that the disclosure would prevent harm, so the default is to respect his request while capacity is reassessed.
The information sharing protocol says a proxy acts only where the patient lacks capacity for the decision, and that a documented wish should be respected unless safety requires otherwise. The problem was that the team had no single owner for the question. Ngozi had the medical plan, Felix had the bedside relationship, and the social worker had the family meeting. Shared decision making works best when each person's part is named and a time is set for reviewing whether the capacity picture has changed. Escalation meant asking the ethics service for a second view and the legal office about proxy scope.
Actions taken
- The team would hold a short meeting within the day, with Ngozi, Felix and the social worker, and name one person to hold the plan for the family.
- Felix would record the patient's request about disclosure in his own words, with the time, the setting and what he had understood about its limits.
- A capacity assessment for this specific decision would be repeated at two set points in the day, and the result written beside the disclosure request.
- Yolanda would be offered a meeting to hear the plan for her father's care and how the team will involve him, without disclosing the private matter.
Results
The capacity assessment was repeated at two set points over the next two days, and on each occasion he was able to take part in decisions about his care. He confirmed the disclosure request in both assessments, and the team recorded it as a standing instruction. Yolanda attended the meeting and was able to ask questions about her father's plan. The ethics service confirmed the approach in its written note. The team later agreed that a named plan owner should be part of the admission record for any patient with a proxy in place.
Questions for discussion
- How should a team weigh a patient's earlier request for confidentiality against a proxy's legal right to information when capacity fluctuates?
- What would you need to see in a record to be confident that a capacity judgment was made for the specific decision at hand?
- At what point should a difficult case move from the ward team to the ethics service, and who should make that call?
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