Leadership/Management in Nursing

1. Leadership/Management in Nursing Week 5

2. 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

3. Topics for Today • Health Care Organizations • Delivery of Nursing Care • Trends Affecting Nursing Practice • Patient Classification Systems • The Joint Commission • Quality Assurance

4. Health Care Organizations • Important to consider when beginning your job search. • Centralized • Decentralized • Matrix • Participative Management • Shared Governance

5. 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

6. Centralized Organization

7. 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

8. Decentralized Organization

10. 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.

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

12. 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).

13. 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…

14. Models of Nursing Delivery • Private Duty • Functional Nursing • Team Nursing • Primary Nursing • Patient Focused Care • Case Manager Model

15. Private Duty • The original system of nursing care delivery • RNs hired by the patient / family of the patient • Student nurses staffed the hospital

16. Functional Nursing • Task-oriented • Fragmented • Impersonal • Co$t-effective

18. 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

20. 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

22. 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).

23. 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

27. 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.

28. 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.

29. 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…

30. 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.

31. 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.

32. 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

33. 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.

34. 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.”

35. 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.

36. 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.

37. 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

38. 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

39. Quality Assurance -- Procedures • Many different methods are used: • Chart review • Interviews • Observation • Surveys • Audits

40. Quality Assurance -- Implementation • Participative approach is best • If generated by employees, likely to be more enthusiasm

41. Quality Assurance