Leadership/Management in Nursing

Week 5

Announcements

Midterm next week: covers Week 1 through Week 4

Resume assignment: remember to include score sheet from syllabus.

Kaiser: return ID badges and Kaiser evaluations directly to Stacey

SNO Announcements

Topics for Today

Health Care Organizations Delivery of Nursing Care Trends Affecting Nursing Practice Patient Classification Systems The Joint Commission Quality Assurance

Health Care Organizations

Important to consider when beginning your job search. Centralized Decentralized Matrix

Participative Management Shared Governance

Centralized organization characteristics Control comes from a central authority, such

as the CNO. Control of things such as financial management changes regarding nursing care innovations

More common in small organizations Paternalistic

Centralized Organization

Decentralized organization characteristics Staff nurses are given a wide range of

authority that involves decision making policy formulation

At the bedside, the nurse has increased responsibility to make patient care decisions to deliver the highest quality care

Trend toward this system Nurses more empowered

Decentralized Organization

Matrix

A mixture of centralized and decentralized Many hospitals are this – very few are purely

centralized or decentralized Think about how things are done in your

hospital to assess which type of organizational structure it fits into.

Participative Management

Staff nurse participates in and provides advice about issues but does not make actual management decisions.

Shared Governance

A step beyond participative management. Staff nurses begin to share in some

management decisions: Self-scheduling Quality improvement projects Recruitment / retention programs

As healthcare systems are becoming more decentralized, important activities are being transferred to the manager (and, ultimately, the bedside nurse).

Delivery of Nursing Care

Seldom find pure systems of nursing care delivery.

Models change due to fiscal realities. 1970’s to early 1980’s: shift toward more RNs 1990’s: shift toward fewer RNs and more

UAPs Today: patient ratios mandate more RNs…

Models of Nursing Delivery

Private Duty Functional Nursing Team Nursing Primary Nursing Patient Focused Care Case Manager Model

Private Duty

The original system of nursing care delivery RNs hired by the patient / family of the patient Student nurses staffed the hospital

Functional Nursing

Task-oriented Fragmented Impersonal Co$t-effective

Team Nursing

RN takes responsibility for management of patients

Delegates tasks to LVNs, CNAs Requires strong communication skills TL: Usually RN Conferences are vital to ensure the

necessary care is being delivered

Primary Nursing

RN is responsible for care of patients 24 hours a day in partnership with associate nurses

RN designs plan of care RN provides follow-up with referrals and

discharge planning Associate nurses carry out prescribed plan of

care when primary nurse not working

Patient Focused Care

Evolved within past 15 or so years. Centralized tasks on the unit under the

direction of the RN. RN assigns and supervises the performance

of tasks. UAPs are cross-trained to perform more than

one task (increased productivity).

Case Manager Model

Nurse manages a caseload of patients that s/he is responsible from pre-admission to post-discharge.

Focus: outcomes. Case Manager: usually a Master’s prepared

nurse Clinical Pathways: allow everyone to know

where a patient should “be” on any given day of hospital stay

Trends affecting nursing practice in the 21st century.

Nursing is assuming a more dominant role in health care.

Geriatric nursing is becoming more important. Nursing will play major role in health care

policy. Nurses will provide expertise in order to

promote holistic care. Technology provides assistance to the nurse,

providing high quality, cost-effective care.

Trends affecting nursing practice in the 21st century.

Outcome criteria will become important in determining the quality of care.

Case-managed care will replace the traditional sick-care approach.

More women and nurses will be involved in governmental decisions related to health care.

Education will become more user-friendly. Nursing will begin sharing information on a

more global level.

Patient Classification Systems

Provides a basis for staffing and making assignments.

Also known as “acuity” systems. Usually use a formula

Can be “altered” by creative nurses to modify staffing needs…

Types of Patient Classification Systems

Descriptive A set of narrative descriptions to categorize

patient acuity. Example: 1 = minimal, 5 = extensive Forces each patient into a specific category. Very subjective. Example: ICU patient on MV less “work” –

why? Checklist

Reduces subjectivity, but essentially the same.

Types of Patient Classification Systems

Time-Based Acuity based on the time required to complete

various nursing interventions. Does not take into account inefficiency of

ancillary services. Advantage: patient can be billed for nursing

care.

Assignments

Things to consider: Census

More patients = more staff needed Can fluctuate during the shift JC mandates that staffing not be based on census

alone. Staff mix

Higher acuity = need for more RNs Productive vs. nonproductive time

Report time Inservices Evaluations

The Joint Commission

The Joint Commission has been a leader demanding evidence of quality health care

TJC evaluates and accredits more than 15,000 health care organizations and programs in the United States.

The Joint Commission

Mission: “To continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations.”

The Joint Commission

Since 1951, the Joint Commission has maintained state-of-the-art standards that focus on improving the quality and safety of care provided by health care organizations.

The Joint Commission also awards Disease-Specific Care (DSC) Certification to health plans, disease management service companies, hospitals and other care delivery settings that provide disease management and chronic care services.

Continuous quality improvement.

We are continually looking for opportunities to improve.

Even if we think we are doing a good job, we are relentless in our pursuit to do better.

We not only look at nursing, but also how the systems of the unit in the hospital can be improved to provide better care at lower cost.

Quality Assurance

A system of procedures used to evaluate the service and the providers of that service so it can be improved.

Must be unit-based* Must be done by all staff*

*per The Joint Commission

Quality Assurance – 3 Types

Structure Setting and resources Facilities Equipment Staff finances

Process (most commonly done) Actual activities carried out

Outcomes Results of activities, patient teaching, nursing

interventions

Quality Assurance -- Procedures

Many different methods are used: Chart review Interviews Observation Surveys Audits

Quality Assurance -- Implementation

Participative approach is best If generated by employees, likely to be more

enthusiasm

Quality Assurance