471 Midterm

NDNQI indicators

- Nursing Hours Per Patient Day by RN, LPN, UAP - Nursing turnover - Nosocomial infections - Patient falls (with & without injury) - Pressure ulcer rate (HAP, CAP, unit acquired) - Pediatric pain assessment & reassessment - RN certification - RN surveys (job satisfaction & work environment) - Restraints Staff mix Others: - Pay for performance (P4P) - Hospital and physician report cards - Hospital consumer assessment of HC providers and systems survey (HCAHPS - H-caps) - 27 item survey on pt perception of hospital experience

Strategic Planning Considerations

- Values: beliefs or attitudes of org - Vision: describe goals - Mission: broad, general statement of reason for existence - Philosophy: written statement reflect value, vision, mission - Goals: specific statement as to what is to be achieved

Magnet Hospitals

- Well-qualified nurse executives in a decentralized environment, with organizational structures that emphasize open, participatory management - Autonomous, self-managing, self-governing climates - flexible staffing - adequate staffing ratios - clinical career opportunities - professional practice culture - ANA compliance

QM evaluation tools

- benchmarking - best practice - critical event analysis and root cause analysis: help ID what happened, how, why, and ensure preventable negative outcomes dont recur - Pt outcome

Refreezing

anchor and sustain change. Provide support and training.

chaos theory

order in apparently random data. small changes can drastically alter a systems long term behavior

Problem Solving

process of cognition that occurs when a goal must be reached by critical thinking/reasoning. Must find reason. Ask why questions.

Filley's Conflict Management

three basic strategies for handling conflict, according to outcome: win-win, lose-lose, and win-lose. competition (win-lose), accommodation (lose-win), avoidance (lose-lose), compromise (no lose or win), and cooperation (win-win)

Power-coercive strategy

uses authority to implement change; legal changes, new laws, policies, must accept it or leave; ex: CMS enacted policy changes for reimbursement-DVT, post-op infections, pressure injuries, state mandated changes, JC makes a change

Principles of Bureaucratic Theory

1. Authority hierarchy 2. formal rules and regulations 3. division of labor 4. career orientation 5. impersonality 6. Formal selection process

Transformational Leader Traits

Trust. Long term vision (see bigger picture), influential. Team oriented. Recognize effect of interactions with others. Deal with conflict well. Sees necessary change as positive.

Centrality

Where a position falls on an organization chart Degree of communication of a particular management position The middle manager often has a broader view of the organization. Decisions are made by a few managers at the top of the hierarchy.

A nurse leader wants to ensure that the team is always practicing proper hygiene after caring for a patient. A complaint was filed against a nurse for not washing the hands before examining a wound on a child's knee. What is the nurse leader's control criteria? Why the team is not practicing proper hygiene Whether the team is practicing proper hygiene Who on the team is not practicing proper hygiene If there are enough hygiene reminders in each patient's room

Whether the team is practicing proper hygiene

conflict resolution

conflict managed/resolved using different strategies

what are the 3 roles in lewins change theory

1. unfreeze 2. movement/change 3. refreeze

What is the final step of the quality improvement process that the nurse leader must complete in order to improve patient care?

evaluation

Unit of Command

indicated by solid vertical line - one person/one boss

Qualities of a good leader/manager

inspires. empowers others and builds team. takes risks. involved and goal oriented. Clear vision and expectations. collaborates. communicates well. visionary. determined. approachable and professional.

Laissez-faire leadership

lack of control/decisions, permissive, open communication, group focused.

Participatory management

lays the foundation for shared governance implies that others are allowed to participate in decision making

Perceived Conflict

one person or group making assumptions a conflict exists

Nurse leaders need to understand that in order to be effective, the quality control process must be _______. Ongoing Reflective Formative Cyclical

ongoing

Environmental factors that influence health care can be restraining forces, driving forces, or both. From the factors listed select all that can be termed only as restraining forces: poverty, government regulations, rising HC costs, population demographic's, stress, workplace shortages

poverty, rising HC costs, stress, workplace shortages

emotional intelligence

the ability to perceive, understand, manage, and ones emotions and the effects they have on others - self awareness, self regulation, motivation, empathy, social skills

Hawthorne effect

the tendency for people to behave differently when they know they are being watched - increases productivity.

Which step in the problem-solving process assists the nurse leader to prioritize the problem or issue? Identifying the problem Identifying causative factors Identifying bias Identifying stakeholders

Identifying the problem

Strategic Planning

- process on long range and ongoing planning for the future (3-7 years ahead) - guides organization direction - follows objectives and specifies actions - identifies personnel responsibility for each activity - projected cost - criteria for meeting goals - expected date of completion - current status

Flat design

- remove hierarchal layers by flattening scalar chain and decentralizing organization - have line authority, but more authority and decision making occur where work is carried out - tends to maintain characteristics of bureaucracy

Barriers to discharge planning

-patients ability to participate in the plan -lack of support network -lack of payor or payor approved services -complexity of the discharge needs: wound care, IVAB etc -limited availability of resources home care, skilled facility etc.

A nurse manager discusses with the health care team the importance of performing core measures for the designated areas of implementation. What should the manager be sure to inform the team may be the consequence of noncompliance? The hospital will lose accreditation by The Joint Commission Discontinuation of participation in Medicaid and Medicare. A 5% reduction in the Medicaid annual payment. A 2% reduction in the Medicare annual payment.

A 2% reduction in the Medicare annual payment.

Complex Adaptive Systems (CAS) Theory

A model that views organizations as constantly developing and adapting to their environment, much like a living organism. achieved through connection among change agents NOT top down. Cant predict stages, must adapt to uncertainty. goals plans and structure just emerge. patterns repeat throughout organization. butterfly effect. most powerful change at microlevel.

A nurse manager is attempting to ensure adequate resources are available in order to meet changing patient needs. What would be the best type of audit for the manager to perform? A structure audit An outcome audit A process audit A quality audit

A structure audit Rationale:A structure audit assumes that a relationship exists between quality care and appropriate structure. It includes resource inputs such as the environment in which health care is delivered. does not address actual care provided

The nurse is admitting a new patient and is collecting data through obtaining a health history and physical assessment. What phase of the problem-solving process is the nurse focusing on with the patient? Implementing Planning Assessing Evaluating

Assessing

Which of the following qualities do nurse leaders possess that makes them obtain excellence in their role? A. Ability to provide clear visions, goals, and expectations B. Ability to be a reactive communicator C. Ability to provide occasional constructive feedback D. Ability to act in a positive and reactive manner

Ability to provide clear visions, goals, and expectations Rationale: The nurse leader should have the ability to provide clear visions, goals, and expectations for team members. The nurse leader should be a proactive communicator, provide timely feedback, and act in a positive but proactive manner. These qualities lead to excellence in nursing leadership.

There are hallmarks that are associated with effective quality control programs. Select those hallmarks from the following list: Administration support, organizational support, process is ongoing Annual process, community support, organizational support Organizational support, community support, fiscal support Fiscal support, administrative support, annual process

Administration support, organizational support, process is ongoing

A nurse manager is implementing a quality control tool that is systematic and will allow the official examination of a record for patients with postoperative infections. What type of tool is the nurse manager using to collect and evaluate this data? An examination An evaluation A review An audit

An audit Rationale: An audit is a systematic and official examination of a record, process, structure, environment, or account to evaluate performance. Examination, evaluation, and review may or may not use a systematic approach when collecting and analyzing data.

The oncology unit has recently experienced a higher-than-normal patient census, which is requiring that nurses to pick up an additional patient. The hospital CFO has indicated that there are no additional funds available to hire additional full-time nurses. As such, the unit manager anticipates some behavioral responses by the stakeholders of change (the nursing staff) within the unfreezing phase. What are some possible behavioral responses? (Select all that apply.) Anger Withdrawal Acceptance Passivity Discontentment

Anger Withdrawal Discontentment

Conflict Resolution Strategies

Avoiding: issue not addressed. lose-lose Collaborating: work together. win-win Competing: challenging the other. win-lose. Compromising: both give up something equally. Cooperating/accommodating: one gives to satisfy the other. win-lose Smoothing: one party pacifies the other, focus on positive. Temporary win-win. Negotiating: like collab or cooperation. help develop relationship and watch hidden agendas. win-win

A health care team has been challenged to determine what other facilities are doing to decrease the number of hospital-acquired infections so that an action plan can be created to decrease the rate in their facility. What will the health care team do to achieve this challenge? Benchmarking Best practices Root cause analysis Patient outcome evaluation

Benchmarking

Which of the following are sources conflicts that nurse leaders might face? (Select all that apply.) Between members of the health care team Patient's support system Multigenerational nurses Novice and seasoned nurses Cultural differences

Between members of the health care team, Patient's support system, Multigenerational nurses, Novice and seasoned nurses, Cultural differences

Nurse leaders understand that there are various stages of conflict. What is the final stage? Conflict aftermath Latent conflict Manifest conflict Conflict resolution

Conflict aftermath Rationale: Stages are latent conflict --> perceived conflict --> felt conflict --> manifest conflict --> conflict resolution --> conflict aftermath. Conflict Aftermath, can be positive (those involved in the conflict felt that they were heard and treated fairly) or negative (the conflict issues remain and may reemerge and cause ongoing conflict).

Managing Conflict

Confrontation: ask those involved to deal with it 3rd party consultation: use outside source behavior change: for serious events Responsibility charting: clarify duties Structure change Soothing one party: temp, for high emotions Alternative dispute resolution: before any legal ramifications Seeking consensus: negotiation

A nurse manager would like to determine how well the team is doing in terms of meeting the hospital's goal of increased patient satisfaction. What action should the manager take after determining best practices? Reevaluate. Capture when the team is and is not using best practices and the outcomes. Take corrective action. Make a judgment about the quality of the team's work.

Capture when the team is and is not using best practices and the outcomes.

One of the Nurse Leaders QM responsibilities is providing easy to understand data on health care quality to all consumers. Which one of the following is the root influence for this responsibility? Joint Commissions creation of National Patient Safety Guidelines Institute of Medicines 1999 report To Err Is Human National Quality Forum Centers for Medicare and Medicaid

Centers for Medicare and Medicaid

Centralized vs. Decentralized Decision Making in Scalar Chain

Centralized: top managers make all important organizational decisions. decisions = rapid. Decentralized: decisions are diffused throughout the enterprise, and middle- and lower-level managers actively participate in, and make, key decisions. decisions = delayed. Seen in larger organizations.

Utilization management

Controls health care costs and the quality of health care by reviewing cases for appropriateness and medical necessity. Provide clinical info to insurance company.

Decision Making

Choosing among two or more alternatives.

According to Marquis and Huston (2021), there are other critical elements that nurse managers/leaders use to complete the decision-making process. From the following choices, select those that are considered crucial to problem solving and decision making. Clearly define objectives Carefully gather pertinent data Develop realistic timeline Generate one alternative solution Think logically Delay making a decision as long as possible

Clearly define objectives Carefully gather pertinent data Develop realistic timeline Think logically

An older adult patient fell out of bed 2 days after a hip replacement and had to return to surgery. What process should be done in order to prevent future negative outcomes such as this? Patient outcome evaluations Benchmarking An audit Critical event analysis

Critical event analysis Rationale:Root cause analysis or critical event analysis helps to identify the process of error and to make sure that it does not reoccur. Benchmarking is the process of measuring products, practices, and services against best performing organizations as a tool for identifying desired standards of organizational performance. An audit would not be appropriate for this grave error since it will only collect the data and not ensure future negative outcomes. Patient outcome evaluations isolate the outcomes that are related to something the nurse does.

A nurse is tasked with performing an audit on patients in the long-term care facility who are developing pressure ulcers. After identifying the information relevant to the criteria, what is the nurse's next action? Determine ways to collect data Analyze the data Make a judgment about quality Reevaluate

Determine ways to collect data

3 of 3 The nurse leader should identify ___________ forces prior to attempting to implement change

Driving and Restraining Rationale:Lewin described driving (facilitator) and restraining (barriers) forces. It is imperative that the nurse identify these facilitating factors prior to attempting implementation because barriers could prevent the implementation stage.

What are the focus areas of the To Err is Human recommendations? (Select all that apply.) Enhance knowledge Identify errors and provide solutions for prevention Set performance standards for safety Implement safety systems Enhance leadership

Enhance knowledge Identify errors and provide solutions for prevention Set performance standards for safety Implement safety systems Enhance leadership

The six aims for improving quality health care as directed by the Institute of Medicine include safe, effective, patient-centered, timely, efficient, and _____. Equitable Holistic Naturalistic Alternative

Equitable

Institute of Medicine (IOM)

Est 1970 Non-governmental, independent, and nonprofit organization that provides unbiased, expert advice to governmental and private decision-makers, as well as the public.

FADE

Focus: DEFINE and VERIFY the PROCESS improved Analyze: coLlect and analyze data to establish baselines, ID ROOT CAUSES, and point toward POSSIBLE SOLUTIONS Develop: based on data. develop ACTION PLANS for improvement including IMPLEMENTATION, COMMUNICATION, & MEASURING/MONITORING Execute: IMPLEMENT action plans, pilot basis Evaluate: install ONGOING SYSTEM measuring monitoring (process control) to ensure success

A nurse is determining whether the outcomes were met for a patient preparing for discharge with an open abdominal wound and reassessing if not met. What phase of the nursing process is the nurse performing? Assessing Planning Implementing Evaluating

Evaluating Rationale:Determining whether the optimal outcome was accomplished and reassessing if it wasn't is part of the evaluating phase.

T/F: Quality control is the process of being reactive in order to minimize continued risks or hazards.

FALSE Rationale:The quality control process is intended to be proactive to create an environment that minimizes the risk from errors.

T/F: For the nurse leader to be effective in their role, the leader does not need to identify the stages of conflict but only acknowledge its existence to begin the resolution.

FALSE. Rationale:To manage conflict, the nurse leader/manager should assess the stage the identified conflict is at in the conflict process.

T/F: Change should be immediately implemented if the need for change has been identified.

False Rationale: Lewin noted that change should be implemented for an established reason; however, it should be gradual to prevent resistance and provide the nurse leader with the opportunity to develop a plan for the change using the change process.

A nursing unit in a busy hospital is planning to undergo a major restructuring, and several staff members have expressed anxiety about the impending change. What type of conflict exists in this situation? Latent conflict Perceived conflict Felt conflict Manifest conflict

Felt Conflict Rationale:Felt conflict is the third stage in the conflict process. It occurs when the conflict is emotionalized. Felt emotions include hostility, fear, mistrust, and anger. Latent conflict is the first stage in the process, and implies the existence of antecedent conditions that are ripe for conflict, although no conflict has actually occurred and none may ever occur. Perceived conflict is the second stage. This is when a person recognizes the conflict logically and impersonally as occurring but has not yet emotionalized it. Manifest conflict is when action is taken in response to the conflict. The action may be to withdraw, compete, debate, or seek resolution.

The RN on a medical-surgical unit that has experienced several changes in its administrative structure due to conflicts with the mission of the hospital. The RN realizes that conflict should be managed to allow for what outcomes? (Select all that apply.) Growth within the organization Reduced employee satisfaction Enhanced productivity Diminished productivity Innovation

Growth within the organization Enhanced productivity Innovation

IOM Crossing the Quality Chasm: A New Health System for the 21st Century

Healthcare system needs improvement. 6 goals: 1. Safe 2. Effective 3. Patient Centered 4. Timely 5. Efficient 6. Equitable

A health care team is implementing the Toyota Production System (TPS) because the facility is having financial difficulty and may have to consider minimizing its workforce. Prior to implementing TPS, what should the team consider? (Select all that apply.) How it will allow for problem solving How it will change the organization's culture, values, and roles The commitment of time and resources from the facility's leadership The level of staff preparation and involvement that will be required The ease with which the transition will take place

How it will change the organization's culture, values, and roles The commitment of time and resources from the facility's leadership The level of staff preparation and involvement that will be required

Which of the options below correctly correlate the decision-making model to the nursing process? (Select all that apply.) Assess: Identify criteria for decision, identify alternatives Plan: Identify the decision, collect data Implement: Choose alternative, implement alternative Evaluate: Evaluate decision-making steps

Implement: Choose alternative, implement alternative Evaluate: Evaluate decision-making steps Rationale: The definition for assess and plan need to be switched in the options to make them correct

A nurse determines that action is justified for a patient with limited mobility after an injury. After a plan for a solution has been identified, what is the next step in the problem-solving process? Assessing Implementing Evaluating Diagnosing

Implementing

One of the Nurse Leaders QM responsibilities is reporting on "ear misses" of medical errors. Which one of the following is the root influence for this responsibility? Joint Commissions creation of National Patient Safety Guidelines Institute of Medicines 1999 report To Err Is Human National Quality Forum Centers for Medicare and Medicaid

Institute of Medicines 1999 report To Err Is Human

The members of a nursing staff claim that the lab department is not reporting patients' critical values fast enough, but the lab department claims that it is. The nursing manager and the lab department director are sent to conflict resolution to come to a solution that will be in the best interest of patient continuity. Based upon this scenario, which type of conflict exists? Interpersonal conflict Intrapersonal conflict Transpersonal conflict Intergroup conflict

Intergroup conflict

A new graduate nurse has been assigned to a RN preceptor with a history of being tough, uncivil, and intimidating to new nurses. During the first day on the job, the graduate nurse has a harsh exchange with the RN. What type of conflict is this? Interpersonal conflict Resolution conflict Intergroup conflict Intrapersonal conflict

Interpersonal conflict

A new graduate RN has a desire to work in a trauma hospital facility located in Los Angeles but has an aging mother who lives in small town in Pennsylvania and is reluctant to leave her alone. What type of conflict is this? Intergroup Interfunctional Interpersonal Intrapersonal

Intrapersonal

Types of conflict

Intrapersonal - within oneself Interpersonal - between people Intergroup

Which statement about total quality management is correct? It is a process with a definitive endpoint. It involves only a select few employees in an organization. It considers the individual as the focal element on which production and service depend. It emphasizes that profit should be considered before quality.

It considers the individual as the focal element on which production and service depend.

A nursing instructor is discussing ways to improve critical thinking during a clinical rotation with a student. The student asks the nurse what critical thinking is. What is the best response by the nursing instructor? It is a simple approach to decision making. It is narrower in scope than decision making. It requires reasoning and creative analysis. It is a synonym for the problem-solving process.

It requires reasoning and creative analysis.

One of the Nurse Leaders QM responsibilities is proactively creating an environment that minimized risk from error. Which one of the following is the root influence for this responsibility? Joint Commissions creation of National Patient Safety Guidelines Institute of Medicines 1999 report To Err Is Human National Quality Forum Centers for Medicare and Medicaid

Joint Commissions creation of National Patient Safety Guidelines

Hierarchy of Evidence

Level 1. Systematic review or meta analysis of relevant randomized controlled trials (RCTs) and evidence based clinical practice guidelines Level 2. One well designed RCT Level 3. Well designed controlled trial w/o randomization Level 4. Well designed case-control and cohort studies Level 5. Systematic reviews of descriptive and/or qualitative studies Level 6. Single descriptive and/or qualitative studies Level 7. Expert opinion/expert committee reports.

Classical Theory

Max Weber - founder of organizational theory - bureaucracy = ideal, intentionally rational, most efficient form of organization. - efficient through design. - 4 Elements: 1. division and specialization of labor: divide work = less tasks per employee = inc efficiency and product. work = standardized and better controlled. 2. chain of command 3. organizational structure 4. span of control

Which of the following best describes the nurse leader in the role of negotiator? A. Mediates internal or external conflict with various stakeholders B. Resolves internal conflict with all team members C. Focuses on external conflicts that negatively impact the health care delivery system D. Focus is primarily resolving conflict between patient support system and staff

Mediates internal or external conflict with various stakeholders Rationale: The nurse leader must be prepared to successfully negotiate conflicts arising from both internal and external sources and from various stakeholders. The nurse leader should not be narrowed in focus because all conflicts directly or indirectly affect all members of the health care delivery system including the patients and their support systems.

One of the Nurse Leaders QM responsibilities is using standard QM tools. Which one of the following is the root influence for this responsibility? Joint Commissions creation of National Patient Safety Guidelines Institute of Medicines 1999 report To Err Is Human National Quality Forum Centers for Medicare and Medicaid

National Quality Forum

Novice vs Expert Nurse

Novice = linear thinker, black and white, react quick, lack data for rationale, need clear instructions/guidelines, task oriented, learning to delegate and prioritize Experts = organize data well, assess early then prioritize and act, know when and how to do things, timely, confident, pay attention to patient response, vast knowledge

Strategies for time management in nursing

Organization - do not procrastinate. Group activities Estimate time gaps. Document in real time.

The nurse manager of an acute care unit determines the increase in the incidence of medication errors over the last six months and identifies this as a focus area for improvement. What is the next action by the nurse manager? Organize a total quality management (TQM) meeting Identify variations Implement action plan Assess results

Organize a total quality management (TQM) meeting

Root Causes of Errors

Patient ID. care planning process. Continuum of care. Staffing levels. Orientation and training of staff. Competency assessment/credentialing. Supervision. Communication. Availability of Information. Adequacy of Technology support. Equipment Maintenance. Physical Environment.

Quality control tools used by the nurse leader include which of the following? Process audits and structure audits Outcome audits and structure audits Program audits and process audits Outcome audits and program audits

Process audits and structure audits Rationale: The process audit allows the nurse manager to assess and measure how nursing care is provided, and the structure audit establishes a relationship based on quality care and correct structure. Both are used by the nurse leader to assess the quality of patient care. Outcomes are used to measure goal obtainment, and program evaluation is performed not program auditing.

A nurse leader works at a facility that has total quality management (TQM) as the backbone of its organizational goals and objectives for quality control. Which activity reflects how the leader can practice TQM on their unit? Encourage employees to think of a unit slogan. Develop a quota system for number of patients cared for. Explain to the staff that 'if it's not broke, don't fix it.' Promote teamwork rather than individual accomplishments.

Promote teamwork rather than individual accomplishments.

PDSA model

QI cycle Plan: set goals, predict, plan data collection Do: test plan, document problems Study: data analysis, review lesson, decide action Act: implement, eval, decide next cycle

An older adult patient recently had a hip replacement with an indwelling catheter inserted. The patient developed symptoms of a urinary tract infection (UTI) postoperatively, and the nurse placing the catheter was reeducated by the nurse leader regarding avoidance of UTIs when inserting catheters. Which quality approach did the nurse leader use? Quality assurance techniques Total quality management techniques Continuous quality improvement techniques Continuous quality management techniques

Quality assurance techniques Rationale:The nurse leader is responsible for proactively creating a work environment that minimizes risk for errors. The leader reacted and reviewed proper procedure, which is in keeping with quality assurance. Total quality management and continuous quality improvement are tools that the nurse leader can use to prevent any nurse in the system from making this error in the future. Continuous quality management is not a term used in quality management.

A staff nurse is having difficulty with problem solving in patient care and the nurse manager is counseling the nurse. What suggestions by the nurse manager may assist the staff nurse in improving problem solving skills? (Select all that apply.) Slow down thinking Systematize data collection Override bias Combine personal and professional feelings Ask closed-ended questions

Slow down thinking Systematize data collection Override bias

case management

Speciality practice. Collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual's health needs through communication and available resources to promote quality, cost-effective outcomes It coordinates care through an episode of illness. focus = individual clients

Which of the following strategies should nurse leaders use to promote evidence-based practice? Staying current with professional issues Use one reliable professional resource Do not take risks Limit evidence-based research to nursing

Staying current with professional issues

Measures of quality

Structure: assume relationship between quality care and appropriate structure ex. staffing ratios, staff mix, ED wait times, fire extinguishers in pt areas Process: used to measure process of care or how care was carried out. assume relationship between nurse process and quality of care. Policies/procedures/protocol/critical pathways. Outcome: end result of care d/t intervention. non nursing sensitive outcomes (mortality, morbidity, LOS) and nursing sensitive outcomes (falls, nosocomial infections, pressure injuries, restraint use, pt satisfaction scores)

T/F: Conflict can have a negative or positive influence on those involved.

TRUE

T/F: If you become aware of the elements of the decision-making process, you will develop effective decision-making skills.

TRUE

Formal Organizational Structure

The emphasis is on organizational positions and formal power. Provides a framework for defining managerial authority, responsibility, and accountability - roles and functions as defined. ppl have diff roles. - rank and hierarchy = evident

The unit manager of a medical-surgical unit is transitioning the unit to electronic charting. According to Lewin's model, which of the following roles describes you as the change agent? The unfreezer The mover The refreezer The role player

The unfreezer

A nurse is using the nursing process to plan the care of a newly admitted patient that has had a stroke. What is the benefit of using the nursing process to devise a care plan? This method of problem solving can be transferrable to non-patient problems. The process will always lead to optimal patient care. The nurse will be able to diagnose the patient's medical problem immediately. The patient will have the best outcome from the stroke.

This method of problem solving can be transferrable to non-patient problems.

Levels of Management

Top Level: board of directors, chief executive officer, admin Middle Managers: nurse supervisors, department heads First Level Managers: team leads, charge nurse, primary care nurse, case managers

Quality Improvement (QI)

a formal approach to the analysis of a healthcare team's performance and systematic efforts to improve it - involves prospective and retrospective views (target ongoing and continually improving quality) - Goal = IMPROVEMENT. - attempt to avoid blame. create system to prevent errors. - OPPORTUNITY (look at things different, think outside box, develop new options/solutions)

democratic leadership

a leadership style in which managers work with employees to make decisions. less control. motivated by rewards. open communication. constructive feedback. Transformational leadership.

Benchmarking

a process by which a company compares its performance with that of high-performing organizations - measure products, practices, services. Data drives improvement.

best practices

a program protocol relating to improvements to quality of life, quality of care, staff development, or cost effective practices. institutions submit outcomes related to QI initiatives. data from multiple benchmarked entities.

shared governance

based on philosophy that nursing practice is best determined by nurses (at every role) nurses gain control over practice, efficiency, and accountability improved. mitigate powerlessness.

What are the rules of implementation relevant to lewins change theory? - change should only be implemented for good reason - change should never be gradual - all change should be unplanned, sporadic, and sudden - all individuals who may be affected by the change should be involved in planning for the change

change should only be implemented for good reason. all individuals who may be affected by the change should be involved in planning for the change

Conflict Aftermath

consequences of conflict. can be positive or negative.

Authoritarian (autocratic) leadership

control, coercion, closed minded, makes decisions without input. sometimes necessary in urgent/emergent situations

Scalar Chain

decision-making hierarchy, or pyramid

Decision Making Process

defining and analyzing problem --> develop alternative solution --> evaluate solutions --> select best one --> implement decision --> follow up/eval

What is an outcome audit?

determine what results occurred as a result of specific nursing interventions outcomes are the most valid indicators of quality care, but many factors contribute to patient outcomes, so it can be difficult to separate out those that are directly related to the nursing intervention

National Database of Nursing Quality Indicators (NDNQI)

Founded by ANA in 2001. Gold standard for nursing quality data. Tracks up to 19 nursing sensitive quality measures based on structure, outcome, and process

Types of Organizational Structures

Functional structure Line structures Ad hoc design Matrix structure Service line organization Flat Designs

Ad Hoc Design

- Modification of the bureaucratic structure that allows for more flexibility • Uses a project team or task approach that lasts for the duration of a project. - usually temporary to facilitate project completion - allows professionals to handle large amounts of info - may result in decreased loyalty to parent organization - has both self contained and functional units - usually result of growing org

Service line organization

- Used in some large institutions to address the shortcomings that are endemic to traditional large bureaucratic organizations - all functions needed to produce product/service are grouped together in self contained units - decentralized structure - Smaller in scale than large bureaucratic systems - preferred in large, complex orgs - rapid response in unstable environment - used when orgs require frequent adaptation and innovation

Disadvantages of organization chart

1. Does not show the informal structure of the organization 2. Does not indicate the degree of authority held by each line position 3. May show things as they are supposed to be or used to be rather than as they are 4. Possibility exists of confusing authority with status

Kouzes and Posner's Five Practices for Exemplary Leadership

1. Modeling: values, self awareness 2. Inspiring a shared vision: inspirational vision, followers want to work with leader on goals 3. challenging the process: see change is needed, makes it happen 4. empowering others 5. encouraging the heart: celebrates achievements

Audit Process

1. establish control criteria 2. identify the info relevant to the criteria 3. determine ways to collect the info 4. collect and analyze the info 5. compare collected info with the established criteria 6. make a judgement about quality 7. provide info and if necessary take corrective action regarding findings 8. reeval

Frederick Taylor - Scientific Management

1900-1930s. How to motivate employees. - efficiency, control o time and energy - match employee to the job - employees motivated by money - common goals - role of manager and employee = separate Result = INC PRODUCTIVITY AND PROFIT, EFFICIENCY

Fayol & Gulick - Management Process

1920-1930 - Planning: what are goals, objectives, rules and changes - Organizing: how will change occur/plans - Staffing: who is responsible - Directing: how will it et done (motivate, conflict management, delegation, collaboration) - Collaborating: performance, eval, legal/ethical control, fiscal

Human Relations Era

1930-1970; managers are one with the employee; employee participation in decision making; flexibility (see the worker, engage the worker) Hawthorne Effect

Interactional Leadership theory and Transformational Leadership

1970-present. what is the situation and how will the leader respond. leader = motivator. has vision, able to empower and inspire staff use problem solving process manager models behavior and encourages shared values.

A nurse manager must make an important decision regarding a staff member's continued employment on the unit. In order to avoid the pitfalls involved in decision-making, what should the nurse manager do? Involve several staff members on the unit to assist with the decision. Choose a decision-making style that will best fit the situation. Base the decision on the first impression of the staff member. Make the decision based on past history

Choose a decision-making style that will best fit the situation. Rationale:The nurse manager should choose a decision-making style that best fits the specific situation. The situation related to a staff member's employment is sensitive and therefore requires discretion on the part of the nurse manager. It would not be prudent to discuss this with other members of the staffing team. One of the most common pitfalls of decision making is to base a decision on a first impression because this leads to confirmation bias. The manager should not allow the past to influence current decisions.

A nurse has a difficult decision to make regarding patient care. What should the nurse do to influence a positive outcome? (Select all that apply.) Gather data and input from a variety of sources. Identify a number of different options. Understand the repercussions of each option. Slow down the thinking process Make a quick decision and act on it immediately

Gather data and input from a variety of sources. Identify a number of different options. Understand the repercussions of each option. Slow down the thinking process

A nurse is educating a patient who is scheduled to undergo an open cholecystectomy how to turn, cough, and deep breathe in order to prevent complications after the procedure. What phase of the nursing process is the nurse providing? Assessment Planning Implementation Evaluation

Implementation Rationale:Implementation of the plan is the active portion of the plan of care and the nursing process. Education of the patient is essential in order to prevent potential complications.

Joint Commission National Patient Safety Goals (NPSG) 2018

Improve accuracy of Pt ID Improve effectiveness of communication between caregivers improve safety of using meds reduce harm associated with clinical alarm systems reduce the risk of HC associated infections Reduce risk of pt harm from falls Prevent HC associated pressure ulcers Identify safety risks for patient population Prevent mistakes in surgery

The charge nurse of a step-down unit is implementing a new procedure for charting, which will impact all of the nursing staff. According to Lewin's Model of Change, the 'Movement stage' can be more successful if certain things are considered by the change agent. (Select all that apply.) Include all stakeholders Ignore resistance to change Set target dates Implement the change Have flexible target dates

Include all stakeholders Set target dates Implement the change Rationale:During the Movement stage, a lack of planning by the change agent can fuel uncertainty and heightened anxiety. To facilitate more success during the Movement stage, Lewin recommends that the change agent include everyone who will be affected by the change during its planning, set target dates, and implement the change while being available to offer support and encouragement throughout the process. Ignoring resistance to change and having flexible target dates will only increase the levels of uncertainty and anxiety during the Movement stage.

A nurse leader is trying to bring about change on the unit. Which intervention is associated with the nurse leader role? Inspiring staff to maintain high standards regarding patient care Being aware of the changes in quality control regulations Reviewing research results upon which to base changes Identifying outcomes that support quality nursing care

Inspiring staff to maintain high standards regarding patient care

Who developed a theory which included the stages unfreezing, movement, and refreezing.

Kurt Lewin

A nurse exhibits leadership traits associated with the role of nurse leader. What activities demonstrated by the nurse would demonstrate these leadership traits? (Select all that apply.) Mentoring two new managers Appointing a successor Providing feedback about job performance Establishing goals for the coming year Advocating for an employee regarding personnel policies Providing a motivational speech at the new employee orientation

Mentoring two new managers Providing feedback about job performance Establishing goals for the coming year Advocating for an employee regarding personnel policies Providing a motivational speech at the new employee orientation

T/F: Nurse leaders should understand the criteria or standards that are needed to establish effective quality control process.

TRUE

T/F: Total quality management is referred to as continuous quality improvement and is used to meet the Healthy People Living 2020 goals.

TRUE

T/F: Using first impressions to guide the decision-making process is a common flaw and considered a pitfall in using decision-making tools

TRUE

T/F: Health care shifted focus from patient care to issues of cost and quality.

TRUE Rationale:The shift is due to consumer and provider complaints. Errors in health care delivery have resulted in the pressure from stakeholders to increase quality to reduce errors and costs

A new graduate asks the nurse manager what organization develops the standards of the nursing profession so that the quality of practice can be measured. What is the best response by the manager? The Joint Commission (JC) The American Medical Association (AMA) The American Nurses Association (ANA) The Institute of Medicine (IOM)

The American Nurses Association (ANA) Rationale: The ANA develops the standards of the nursing profession that provide a foundation for how to measure the quality of practice. The JC is an accrediting body that holds facilities accountable for the standards of practice. The AMA and IOM are medical models and do not develop standards for the nursing practice.

TQM (Total Quality Management)

also CQI (continuous quality improvement) a commitment to excellence that is accomplished by teamwork and continual improvement created by Dr. W Edwards Demming (father of quality evolution) first adapted by Japanese in WWII for industrial development, then in US for improving quality of health care

Challenges to case management

availability of safe care environments transportation issues prevention of exposure to other ppl and communities timely access to care staff shortages surge capacity patient throughput social media misinformation Fear, isolation

Unfreezing

idea is born from change agent. determine what needs to change - prepare. create need for change. Need strong leadership and support. manage & understand doubts and concerns

Felt conflict

emotions and feelings around the conflict. When conflict is validated, person or group may experience hostility, feat, mistrust, or anger

IOM 5 Core Competencies

patient centered care Work in interdisciplinary teams Employ EBP Apply Quality improvement Utilize informatics

Discharge Planning Nursing Process

systematic process of preparing the patient to leave the health care facility and for maintaining continuity of care Assessment: current medical records. tests and procedures. verbal reports. patient and/or support system Planning: discharge and transition of care (what setting or level of care are they going to, home vs facility etc) Discharge planning: must be available for all pts. reassess regularly. Implementation and eval: identify at risk for poor transition pts. complete comprehensive transition assessment (health insurance benefits/utilization, goals and care needed, caregiver understanding, ADLS, advanced directives)

span of control

the number of subordinates who report directly to a manager - determines # of interactions expected by manger. - too many ppl reporting = delay in decision making - too few ppl reporting = inefficient, top heavy organization Complex organizations = "Tall". numerous departments, highly specialized and differentiated, authority is centralized Less complex = "Flat". authority is decentralized, several managers supervise large work groups.

Karl Marx social conflict theory

theory that society is in a state of perpetual conflict because of competition for limited resources. social order is maintained by domination and power, rather than by consensus and conformity.

IOM recommendations

- culture of safety - blame free work environment - staff safety (needle sticks, infections, violence) - IHI series (institute for healthcare improvement): every american has best and most safe healthcare as possible - TCAB (transforming care at the bedside): safe and reliable, vitality and teamwork, pt centered, value added care process - Joint Commission annual safety goals

functional structure

- employees are grouped by the functions they perform for the organization (speciality or similar tasks by the same group) - Centralized decision making

matrix structure

- focus on both product and function - formal horizontal and vertical chain of command - fewer formal roles and levels of hierarchy - slows decision making d/t info sharing - can cause confusion and frustration for workers - dual authority - integrate product and functional structure into 1 overlapping structure different managers responsible for function and product

Advantages of organization chart

1. Maps lines of decision-making authority 2. Helps people understand their assignments and those of their coworkers 3. Reveals to managers and new personnel how they fit into the organization 4. Contributes to sound organizational structure 5. Shows formal lines of communication

A nurse leader is performing a process audit. Which would be a consideration on a process audit? (Select all that apply.) Assessing the availability of fire extinguishers in patient care areas Checking the completeness of a patient's medical record Comparing a patient's medication order to the medications the patient has been taking Ensuring that machines are recalibrated according to department policy Ensuring that a patient has access to television in their room

Checking the completeness of a patient's medical record Comparing a patient's medication order to the medications the patient has been taking Ensuring that machines are recalibrated according to department policy Rationale:Process audits measure how nursing care is provided against standard guidelines, and consider specific tasks such as recalibrating machines to departmental policy, completing a patient's medical record thoroughly, and reconciling medication orders. Process audits would not include the availability of fire extinguishers in patient care areas nor would they include the patient's access to television because those standards aren't within the nurse's scope of providing high-quality patient care.

A patient is planning to have a surgical procedure but is concerned about poor patient care quality at the local hospital, and performed a quality check and comparison of several hospitals. What conglomeration of non-healthcare Fortune 500 companies defined quality measurements to allow consumers to compare hospitals? Leapfrog Patient Safety Center National Quality Forum Prevention of Medical Errors, Inc.

Leapfrog Rationale: Leapfrog is a growing conglomeration of non-health-care Fortune 500 companies that defined quality measurements to allow consumers to compare hospitals. This group built on the IHI's report cards by informing the public about their four evidence-based standards. Leapfrog hopes to provide easy-to-understand data on health care quality to all consumers. Their ultimate goal is to reduce costs through improved quality and efficiency. The other entities do not allow for comparison of other hospitals.

After a patient had a negative outcome related to a medical error, the nurse follows the policy for sentinel events. What organization does the nurse recognize monitors the adherence to this type of policy for accreditation? American Nurses Association (ANA) Leapfrog The Joint Commission (JC) Institute of Medicine (IOM)

The Joint Commission (JC) Rationale: The JC maintains one of the nation's most comprehensive databases of sentinel events by health-care professionals and their underlying causes. Leapfrog is a growing conglomeration of non-health-care Fortune 500 companies that defined quality measurements to allow consumers to compare hospitals. The IOM published an article related to the increase in patient deaths due to medical error but do not monitor the sentinel events for accreditation purposes. The ANA does not monitor sentinel events.

stakeholders

people involved and interested in the change process, in nursing = those affected by change

organizational climate

perceived characteristic of the org - physical attributes, org structure, lines of communication, policies

change agent

person who initiates change within a group. in nursing = person who understands and implements required change process

Hospital Care at Home program

prevent or decrease # of days in hospital improve hospital throughput daily virtual visit with provider nurse navigator calls daily provide O2, EKG, xray, labs, pulse Ox

organizational structure

process of aligning an organizations structure with its mission

How do leaders enhance clinical reasoning?

provide education, discussion, reflection, eval EBP, work group. support new nurses. know resources. apply nursing process. communicate with teams.

Results of QI to:

recommend practice change implement revised practice revise policies and procedures provide education go through cycle again (CQI)

Quality Assurance (QA)

retrospective process - target current existing quality. policing and often punitive. determine who is at fault. OLD TERM (1970s)

How do we make change easier?

see vision. capture purpose. empower people. positive feedback. build trust. communication.

Conflict

source = external or internal. due to a perceived differences - actions, goals, ideas, backgrounds change = expected.

restraining forces

forces that hinder change ex. lack of resources/data/knowledge. fear of liability. conflicts

EBP (evidence based practice)

- the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients - problem solving approach - uses theory, seeks to generate new knowledge or test interventions, results ADD to body of knowledge

Theory of Cooperation and Competition

- to compete vs to cooperate - depends on negotiators' perceived goal interdependence can be negatively interdependent--one party's success correlating with the other's failure = competitive relationships with a win-lose orientation. can be positive, work together to finish a task assigned.

line structures (bureaucratic)

- used in large health facilities - authority, responsibility, and relationships defined - may produce monotony, alienate workers - may restrict upward communication

social determinants of health

financial limitations poor health literacy housing/food instability lack of social support unreliable transportation unhealthy behaviors

Six Sigma

A business process for improving quality, reducing costs, and increasing customer satisfaction Define: what is the problem. The customer and their definition of value. Measure: what processes and inputs have greatest impact on variation in outcome. Develop a data collection plan and gather data Analyze: analyze data with statistical methods to determine the part of the process causing the most (unwanted) variation in the outcome Improve: decide on solution/solution set. develop implementation and monitoring plans for the solution Control: sustain gains achieved. Transition solutions to person responsible.

A nurse leader at a long-term care facility wants to determine if vital signs are being checked according to policy. What can the leader do to measure this process of care? A critical event analysis A process audit Patient outcome evaluation Benchmarking

A process audit

A nurse educator determines that the present classroom environment is ineffective in promoting critical thinking. What methods could the educator employ in the classroom to improve critical thinking? (Select all that apply.) Lecture Study guides Case studies Simulation Problem-based learning exercises

Case studies Simulation Problem-based learning exercises

A nurse manager is implementing the National Patient Safety Goals (NPSG) for the acute care unit. What will the manager have the staff implement to meet these goals? (Select all that apply.) Check identification bracelet and ask the patient name and date of birth prior to medication administration. Ask the patient about their financial status to determine ability to pay for hospitalization. When handing off report to other staff, use SBAR format. Have patient identify surgical site prior to going to the perioperative suite. Ensure that urinary catheters are properly secured to promote unobstructed urine drainage.

Check identification bracelet and ask the patient name and date of birth prior to medication administration. When handing off report to other staff, use SBAR format. Have patient identify surgical site prior to going to the perioperative suite. Ensure that urinary catheters are properly secured to promote unobstructed urine drainage.

Which of the following is considered a nursing leadership role with regard to quality control? Embraces, supports, and champions the quality improvement process Uses findings to determine educational staff needs Selects and uses quality control tools Establishes measurable patient outcomes

Embraces, supports, and champions the quality improvement process

Why do we resist change?

complacency. fear. comfort/habits. loss of control. poor timing. its a surprise. threat to current process

Latent conflict

conditions are ripe for conflict but there is no conflict yet. Try stopping it before it starts, or anticipate what can cause conflict.

Manifest Conflict

conflict acknowledged and some kind of action (withdrawal, debate, confrontation, or seeking resolution) happens. Not uncommon for no action to be taken for fear of retaliation or other things.

Environmental factors that influence health care can be restraining forces, driving forces, or both. From the factors listed select all that can be termed only as driving forces: education, generosity, economy, medical advances, technology explosion, new health care policies

education, generosity, , medical advances, technology explosion

High Reliability Organizations (HROs)

entities or businesses with systems in place that are exceptionally consistent in accomplishing their goals and avoiding potentially catastrophic errors - hospitals strive for this - challenge of quality and reliability

Consider stakeholders in strategic planning

entities that play a role in orgs health and performance - internal: nurses and hospital staff - external: managed care providers, nursing homes, schools of nursing, chamber of commerce. every org should be viewed as part of greater community of stakeholders

Informal Organizational Structure

focus on naturally forming social network and their relationships. - Based on camaraderie. rely on informal structure if formal structure becomes ineffective - informal group communication channel (grapevine)

Driving forces

forces that push towards change ex. resources, promotion/recognition. social or personal gain. family support. money.

Chain of Command

hierarchy of authority and responsibility within the organization Line authority = linear hierarchy Staff authority = advisory relationship (Admin --> director of nursing --> assistant director of nursing --> staff dev coordinator --> nurse supervisor --> charge nurse --> staff nurse --> nurse assistant)

Change (movement)

implement change. communicate often dispel rumors, empower action, involve people

organizational culture

set of values, ideas, attitudes, and norms of behavior that is learned and shared among the members of an organization - traditions, rituals etc. (uniform, where reports given, whats tolerated). different from climate because people in org can still have different perceptions of same organization

normative-reeducative strategy

strategy based on the assumption that people act in accordance with social norms and values. being part of a group. developing relationships (build confidence and peer support). change agent = team player.

rational-empirical strategy

strategy for change. Evidence based practice (what does literature say and supportive evidence) ex. hourly rounding, bed side reports

Strengths and Weakness of Service line organization

strengths: - easy coordination across function - reduced role conflict - client satisfaction usually high weakness: - possible duplication of resources - lack of in depth technical training and supervision -services operate independently and often compete - dept of nursing may not be shown on organization chart

Dual Concern Theory

the most effective negotiation strategy and the best outcomes will occur when the negotiators care not only about their own outcomes but also the outcomes of the other party.

what of these qualities of change agents are relevant to lewins change theory visionary, risk taker, flexible, creative, sensitive, current

visionary, flexible, creative

Nurse leaders make use of quality control tools to identify various types of errors as outlined by the IOM report. What are some of the most common types of errors reported in today's health care system? Select all that apply. Medication errors Diagnostic errors Communication errors Equipment errors Spelling errors

Medication errors Diagnostic errors Communication errors Equipment errors

A single parent raising two children and relying on public transportation, is determined to become a registered nurse. What are the restraining forces in this situation? (Select all that apply.) Relying on public transportation An advancement in medicine Being a single mother Stress of being away from children Student success center established within the nursing department

Relying on public transportation Being a single mother Stress of being away from children

According to the institute of medicine, which of these sources caused the most deaths in 1999? MVA Breast cancer medical errors AIDS

medical errors

A nurse leader is having a discussion with a team member about changes that will be made on the unit. Which statement by the team member demonstrates the greatest problem for the leader? 'Your plans for the changes will be difficult to implement.' 'I don't think you heard what the rest of us had to say.' 'Do you have an idea what direction we need to go?' 'Can you tell me why my suggestion will not work?'

'I don't think you heard what the rest of us had to say.' Rationale:Getting feedback about difficult implementation or requests for additional information are things that a leader can work with. Being perceived as someone who isn't listening to the messages of their staff, however, is a critical problem that results in decreased trust and employee engagement. Effective listening is essential to leadership. Additional direction or feedback are things that a leader can provide.

A staff nurse informs the nurse manager that the nurse would like to gain broader experience in other departments of the acute care facility. What response by the nurse manager demonstrates effective leadership? 'Getting broader experience isn't as valuable as specializing.' 'I would like you to be a preceptor for the new nurse that was just hired.' 'Would you be willing to help on another unit? They need a shift leader for a couple weeks.' 'Would you be willing to work with one of the senior nurses for a while, until you learn how we operate here?'

'Would you be willing to help on another unit? They need a shift leader for a couple weeks.' Rationale:Working in another unit would not only meet the nurse's goal of broadening their professional experience, but it might also meet a personal desire to stay fresh by experiencing a different unit's culture. A nurse who has a goal of gaining broader experience likely wants to avoid stagnation. Taking on a new challenge of being a shift leader of an unfamiliar unit would keep the nurse motivated and to gain varied experience. Precepting for a new nurse does not offer the staff nurse the variety that is being requested, nor does working with a senior nurse in the same department.

A nurse manager is making a decision based on a problem with a staff member. What would be the optimal end product of the decision? An alternative problem A chosen course of action An action that guarantees success A restatement of the solution

A chosen course of action Rationale:Decision making implies there are at least two options that have been presented as possibilities for action. At a minimum, the choices are act and don't act. The ultimate end product of the decision-making process is a chosen course of action.

You are the nurse manager of a medical-surgical unit that is in need of a change in staffing rotation patterns, which will lead to major changes in how the unit is staffed. According to Lewin's Change Theory, what forces are in play to enact these changes? Freezing forces Restraining forces Driving forces Refreezing forces

Driving forces

A nurse on the acute care unit demonstrates the positive traits of a good leader when working with new employees. What trait does the nurse manager cite when performing the nurse's evaluation? The assigned position Role modeling Planning a unit's goals Decides daily patient assignments

role modeling Rationale:A leader is a good role model. Modeling is also an effective teaching method for developing team members who aspire to leadership. An assigned position, planning a unit's goals, and deciding daily patient assignments are all traits or actions of a manager, but a leader may not always be a manager.