Leadership Exam 2
zero based
justify every expense without reference to previous spending patterns, it requires ATs to evaluate each subfunction of the program and rank it according to how important it is to the accomplishment of the overall mission Start from 0 each year
barriers for nursing involvement in professional nursing organization
lack of information lack of time heavy workload personal matters lack of encouragement lack of ideas about activities lack of benefits prefer trade unions
incremental
looking at next years and multiples current years expenses by a certain figure (inflation rate, consumer price index)
performance
looks at outcomes, results oriented, looks at performance activities or areas of accomplishment
span of control
managers scope of responsibility
direct expenses
med, supplies, directly related to number of patients in hospital
quality assurance
minimum standards of patient care quality "doing it right" retrospective
empirical quality results
must participate in establishing quantitative benchmarks for measuring outcomes related to nursing
exemplary professional practice
must promote interprofessional collaboration and teamwork
Diagnosis
nursing productivity goal
strategic planning
organization plans for future aligns an organization with defined goals forecasts the future success of an organization by ensuring its mission, vision, and philosophy are up to date maximizes organizational performance
for profit organization
owned by stockholders or shareholders who reinvest in the organization and pay property and income taxes
nontraditional models
patient focused care partnership model nonclinical models integrated models
unit intensity
takes into account the totality of the patients for whom care is provided and the responsibilities of nursing staff
Reasons behind medical errors
- *Human factors*—include staffing levels, staff education and competency, and staffing shortages - Communication—includes intraprofessional and interprofessional communication as well as interactions with patients and their families - Leadership—includes leadership and management at all levels, organizational structure, policies and procedures, and practice guidelines
Steps of strategic planning
- Clearly define the purpose of the organization. - Establish realistic goals and objectives consistent with the mission and vision of the organization. - Identify the organization's external stakeholders and determine their assessment of the organization's purposes and operation. - Clearly communicate the goals and objectives to the organization's stakeholders. - Develop a sense of ownership of the plan. - Develop strategies to achieve the goals. - Ensure effective use of organization resources. - Provide a benchmark to measure progress. - Provide a mechanism for informed change as needed. - Build a consensus about where the organization is going.
benchmarking
a continuous process in which an organization can measure and compare processes with leaders in a particular area
competitiveness
a disposition to strive for satisfaction when making comparisons with some standard of excellence in the presence of evaluative others
unity of command
a management principle that workers should report to just one boss
Preceptor
a staff nurse recognized for his or her clinical competence, leadership abilities, organizational skills, and desire to orient new nurse graduates - Ensures that the new nurse graduate expands his or her basic nursing Serves as a role model and provides orientation to the orientee
safe and appropriate staffing
• Requires matching the expertise of RNs with the needs of patients while considering setting and situation• Results in fewer hospital-acquired infections, reduces nurse fatigue, reduces hospital costs, improves patient satisfaction, and increases nurse productivity • Nurse leaders and managers must‒ Make sure there is the appropriate number and mix of nursing staff at all times.‒ Understand and follow federal, state, and local regulations related to staffing and scheduling.‒ Uphold nurse practice acts, and verify and track licensure of nursing staff.
magnent recognition program
designated by American Academy of Nursing task force through a study on nursing practice in hospitals Requires the following three goals are met: Promote quality in a setting that supports professional practice Identify excellence in the delivery of nursing services to patients/residents Disseminate best practices in nursing services
Failure modes and effects analysis (FMEA)
determines what aspect of process need to change
quality improvement
doing the right thing opportunity for improvement
error of comission
doing the wrong thing
secondary care
emergency, acute care, diagnose treatment, limiting disability, hospital, urgent care
necessary care activities
essential in delivering patient care but don't directly benefit patient (call Dr, documenting, transcribing orders)
compromising
everyone giving something up and everyone getting something they want in return; usually effective
operating budget
expenses or revenues associated with day to day activities
bureaucratic management theory
focused on the structure of formal organizations, the authority of management, and rules and regulations to improve the success of an organization
personal approach to medical errors
focuses on errors that are a result of human behaviors (forgetfullness, negligence, incompetence) Focuses on unsafe acts of health care professionals and errors as the result of human behaviors Correct human behavior through naming, blaming, shaming, and retraining
principles of management
fundamental rules of management that could be applied in all organizational situations and taught in schools Identifying management, planning, control
not for profit organization
funding is from public or government, grants, private donations, tax exemptions
revenue
generated based on billable services and expenses associated with equipment supplies and staffing
accreditation
health care organizations meet national quality standards
primary care
health education and screening health care provider office, wellness center
innovators
individuals who accept society's approved goals but not society's approved means to achieve them
adverse event or patient safety
injury to patient by medical management
collaborating
involving a shared approach to resolve conflict; time-consuming but most effective
Six Sigma Model
is a statistics based model which focuses on redesigning processes to eliminate defects
Organizational culture
mission statement: describes organizations overall purpose vision statement: image of the future of an organization philosophy: organizations beliefs, values, and concepts
structural empowerment
must develop, direct, and empower staff to participate in achieving organizational goals and desired outcomes
new knowledge, innovations, and improvements
must focus on redesigning and redefining practice to be successful in the future
transformational leadership
must use futures thinking and demonstrate advocacy and support on behalf of staff and patients
workload
number of nursing staff required to deliver care for a specific time period; dependent on patient care needs
nonvalue - added care activities
performed by RN, do not benefit patient, not necessary to delivering patient care (looking for equipment, waiting for phone call, waiting for transport)
value added care activities
performed by RN, patient centered, directly benefit patient (assessment, vitals, wound care, meds, communication)
planning for the future
plausible future probable future possible future preferable future Nurse leaders and managers can contribute significantly to this preferred future by: honoring and respecting staff Keeping aware of possible trends Being a leading force
unsafe act
presence of potential hazard
health care organizations primary goal
provide the highest quality of healthcare for those in need while remaining a viable business in an uncertain and volitale market
capital budget
purchase of major new or replacement equipment buildings or renovation (value of equipment, exceeds a certain amount)
competing
pursuing one's own needs, desires, or goals at the expense of others; can result in aggression
productivity
ratio of output to input RN hours per patient day Nurse/Patient = productive nursing hours/patient days x 24
slips, lapses, and mistakes
refer to actions that do not result in the intended outcome
nonproductive time
refers to benefit time, such as vacation hours, holiday time, sick hours, education time, and jury duty
productive time
refers to the actual hours worked on the unit caring for patients
skill mix
refers to the varying levels of education, licensure, certifications, and experience of the staff
units of service (UOS)
reflects the basic measure of nursing workload based on different types of patient encounters
patient acuity
represents how patients are categorized according to an assessment of their nursing care needs
tertiary care
restoration/rehab to maintain and improve health rehabilitation and assisted living
regulations
rules governing the operation of all government programs that have the force of law directly and indirectly influence nursing practice
accomodation
sacrificing one's own needs or goals and trying to satisfy another's desires, needs, or goals; not usually effective
scientific management
the application of scientific principles to increase efficiency in the workplace Introducing financial reward to increase productivity
organizational conflict
the discord that arises when the goals, interests, or values of different individuals or groups are incompatible and those individuals or groups block or thwart one another's attempts to achieve their objectives
personnel budget
the largest of the budget expenditures because healthcare is labor intensive, staffing #s average daily census, based on workload not acuity
late majority
the last group of buyers to enter a new product market; when they do, the product has achieved its full market potential
workplace safety
the physical protection of people from injury or illness while on the job •Both physical and psychological harm are prevalent in healthcare •Physical harm: improper patient handling and mobility, musculoskeletal injury •Psychological harm: workplace violence, emotional abuse, bullying, and disrespectful treatment • •What are some barriers to safe patient handling? •What are some ways to avoid physical harm?
General Systems Theory
theory that organizations are a system composed of many subsystems and embedded in larger systems, and that organizations should develop communication strategies that serve both Based on an open and a closed system A closed system An open system, such as a health care organization Utilizes feedback
early majority
those whose adoption of a new product signals a general acceptance of the innovation
non productive time
time that has to be paid, not related to patient care (sick time, vacation time, personal education, holiday)
traditional care delivery methods
total patient care functional nursing team nursing primary nursing nursing care management
principles of negotiation, conflict resolution, and power sharing
underlying difference in human behavior to the role of to working in a group, power sharing
plausible future
what could be, focuses on what may occur based on current and projected trends
possible future
what may be, considering all possible scenarios that could occur
Assessment
what needs covered in a budget
preferable future
what should be and begins with a vision and a roadmap to get there
probable future
what will likely occur and actually reflects the present state with minimal changes
avoidance
withdrawing or hiding from the conflict; not always effective, may just postpone the conflict
Donabedian Model
‒ Structure—the conditions under which care is provided‒ Process—the activities that encompass health care‒ Outcomes—the desirable or undesirable changes in individuals as a result of health care
full time equivalent
• A unit that measures the work of one full-time employee for 1 year (or 52 weeks) based on a 40-hour workweek.• It may be comprised of one person working full time or several people sharing the full-time hours.
Classical organizational theories
• Bureaucratic management theory • Principles of management theory • Scientific management theory • Principles of negotiation, conflict resolution, and power sharing
synergy model for patient care
• Is based on the core concepts that‒ The needs of patients and families influence and drive the competencies of nurses.‒ Synergy occurs when the needs and characteristics of the patient, clinical unit, or system are matched with the nurse's competencies.• Includes eight patient characteristics and eight nursing characteristics derived from patient needs • Fosters effective communication and collaboration in achieving optimal, realistic patient and family goals• Is used in a variety of clinical settings
RN Scope of practice
• Licensed personnel who have completed a specific course of study at a state-approved school of nursing and passed the NCLEX-RN examination • Fairly consistent nationally and globally and includes all aspects of the nursing process• Responsibilities of RNs include‒ Assessment, diagnosis, planning, intervention, and evaluation‒ Patient teaching, discharge planning, and evaluating and monitoring changes in patient status‒ Assignment, supervision, and delegation
LPN/LVN Scope of practice
• Licensed personnel who have completed a specific course of study of a state-approved practical or vocational nursing program and passed the NCLEX-PN examination • The LPN/LVN‒ Is responsible for physical care, taking vital signs, and administering medication‒ Always works under the direction or supervision of an RN, advanced practice RN, physician, or other health-care provider designated by the state
patient and family centered care model
• Places an emphasis on collaborating and planning care with patients (and their families) of all ages, at all levels of care, and in all health-care settings• Is based on the following four foundational concepts: dignity and respect, information sharing, participation, and collaboration• In this model, nurses‒ Initiate and promote a safe healing environment.‒ Effectively communicate with patients and their families.‒ Provide all necessary information for patients to make an informed health-care decision.
staffing mix
• Refers to the appropriate numbers of RNs, LPNs/LVNs, and UAPs needed on a unit• Is based on the type of care required for specific patients and who is qualified to provide such care
nursing hours per patient day (NHPPD)
• Represents the nursing care hours provided to patients by nursing personnel over a 24-hour period• Usually based on unit census at midnight and reflects only nursing staff productive time
professional nursing practice model
• Requires higher RN-to-patient ratios, with RNs having greater autonomy and control over practice• Is identified as a core feature of Magnet hospitals • Results in higher rates of patient satisfaction, lower rates of nurse burnout, and safer work environments• Includes interprofessional and intraprofessional communication, and the RN controls the delivery of nursing care
Evaluation
Address deviation from budget process
Shared Governance
Empowerment of Nurses Participative Nursing Councils
Stage I
Novice—have no experience of situations in which they are expected to perform
consequences of workplace violence
•On the organization •Creates a culture of fear and diminishes staff morale •Impacts patient safety and job satisfaction •Results in disrupted work relationships, miscommunication, and an unhealthy work environment •Results in negative patient and nurse outcomes •On individuals •May result in physical effects such as frequent headaches and decreased energy •Results in psychological effects such as stress, anxiety, and depression, frustration
roles of leaders and nurse managers
•Open communication •Active listening •Engage all members •Positive interactions •Mutual respect •Needs versus wants •Compassion and empathy •Use 'I' statement
How to avoid medical errors
- Develop a culture that is founded on the concept of safety for both patients and staff. - Standardize as many processes as possible, while simultaneously allowing staff the independent authority to solve problems in a creative manner as well as avoiding automatic action. - Implement initiatives created by health-care organizations to improve safety and quality. - Analyze complex processes using appropriate tools. - Collect data on errors and incidents within their unit in order to identify opportunities for improvement and track progress.
AACN Hallmarks
- Manifest a philosophy - Recognize contributions of nurses knowledge and expertise - Promote executive-level nursing leadership - Maintain clinical advancement programs - Create collaborative - Utilize technological advances
Interviewing
- Seek out information - Prepare thoughtful questions - Plan to arrive to the interview a few minutes early - Ask for clear directions - Dress professionally
Agency for Healthcare Research and Quality (AHRQ)
- Set out to build a foundation to better understand patient safety - Established the Patient Safety Network (PSNet), a website featuring essential resources relevant to the patient safety community - Provides tips for preventing medical errors and promoting patient safety, and suggestions about measuring health-care quality - Nurse leaders and managers can use PSNet for the following: Suggestions about measuring health-care quality To access consumer assessment of health plans, evaluation software, report tools, and case studies
specialty certification
- validates specific knowledge - demonstrates responsibility for one's own practice - improves patient safety outcomes
Contemporary Organizational Theories
-Build on the classical theories, and elements of classical theories are present. -Reflect patterns, purposes, and processes and require a continuum-based, person- and outcome-driven system design. -Approach cyclically rather than linearly and require organizations to react with speed and flexibility. -Include the general systems theory, complexity theory, and learning organization theory. General Systems Theory Learning Information Theory Complexity Theory
Contributing to the nursing profession
-Join professional nursing organizations -Contribute to research and evidence -Lead and serve on institutional or health policy committees -Participate in the promotion and implementation of health policies -Promote communication of information and advancement
Organizational Theories
-Shape organizations and explain organizational behavior. -Provide a framework to bring people together to accomplish work. -Theories are not one-size-fits-all; various theoretical concepts may be needed.
Model Components of the Magnet Recognition Program
-Transformational leadership -Structural empowerment -Exemplary professional practice -New knowledge, innovations, and improvements -Empirical quality results
Transition to practice (TPP) programs
-ensure successful transition -integrate education, practice, regulations -can reduce turnover rates
core concepts of staffing
-full-time equivalent -productive time -nonproductive time -average daily census -staffing mix -workload and units of service -unit intensity -patient acuity -skill mix
five adopter categories
1. Innovators 2. Early Adopters 3. Early Majority 4. Late Majority 5. Laggards
IHI Model of Improvement
2 parts: 3 questions What are we trying to accomplish? How will we know a change is an improvement? What changes can we make that will result in improvement? PDSA Cycle: plan goal: increase ability to predict effect of 1 or more change would have if implemented
normative-reeducative strategy
A change agent strategy based on the assumption that people act in accordance with social norms and values.
decentralized structure
A design structure that relies on all employees to collect and communicate information, in order to make decisions and recommend changes. Autonomy, bottom up communication.
Steps to budgeting a forecast
A systematic plan that provides the best estimate of expenses and revenues Assessment Diagnosis Planning Implementation Evaluation
learning organization theory
A theory of formal organizations that developed on the premise that rational planning is not sufficient for an organization to survive in a rapidly changing environment such as the one in which we live, that formal organizations must become complex systems that are capable of constant learning Moves away from traditional authoritarian organizations and instead creates learning organizations Requires adoption of the following five disciplines: systems thinking: see the big picture personal mastery: committed to lifelong learning mental models: self reflection building shared vision team learning
empirical-rational strategy
Assumes that staff members are essentially self-interested and providing information and education will assist staff in changing behavior and adopting the change or innovation
The Joint Commission
Accredits and certifies health-care organizations in the United States based on established standards and reviews agency activities in response to sentinel events Established the Speak Up programs, with the goal of urging patients to take an active role in preventing medical errors by becoming informed participants in their care Established the National Patient Safety Goals (NPSGs) program to assist health-care organizations in addressing patient safety concerns
system approach to medical errors
Acknowledge that errors happen because humans are not perfect Focus less on the individual making the error and more on system processes that led to the error Concentrate on changing the work environment by establishing barriers and safeguards against the errors
Stage II
Advanced beginner—can demonstrate marginally acceptable performance of tasks
Mentor
An experienced individual (who may or may not be a nurse) - Should be open and responsive - Should inspire and challenge
centralized structure
An organizational structure in which there are several levels of authority, a long chain of command, and a narrower span of control. Few individuals with minimal innovation and creativity.
conflict management strategies
Avoidance Accommodation Compromise Collaboration Competitiveness
SWOT as a strategic planning strategy
Steps include the following: Collect data that may include staff and patient characteristics Analyze data and sort into strengths, weaknesses, opportunities, and threats S: advantages W: improvement O: trends T: ACA, competitors
types of conflict
•Types •Intrapersonal •Interpersonal •Intergroup •Organizational
differentiated nurse practice model
Care is differentiated based on the level of education, competence, and clinical expertise of RNs.• Goals include‒ Optimal nursing care matching patient needs with the nurse's competencies‒ Effective and efficient use of scarce nursing resources‒ Equitable compensation and increased career satisfaction among nurses• Recognizes that all nurses, regardless of education, are needed to provide high-quality, comprehensive care to all patients in all settings
Institute for Healthcare Improvement (IHI)
Collaborates with the health-care improvement community to remove improvement roadblocks and launch innovations that dramatically improve patient care Developed the 100,000 Lives Campaign to significantly reduce morbidity and mortality in the U.S. health-care system Developed the 5 Million Lives Campaign to significantly reduce illness or medical harm
Stage III
Competent—have 2 or 3 years of experience and can establish a plan of care
AHRQ Nurse Staff Model
Considers the complexity of hospital care today Accounts for patient, hospital, and organizational factors, nurse characteristics, nurse staffing, medical care, and their impact on patient outcomes and length of stay Based on two key consequences of safe nurse staffing: patient outcomes and nurse outcomes Provides nurse leaders and managers a realistic framework for staffing because it reflects the complex relationships among patient factors, nurse staffing, nurse characteristics, hospital and organizational factors, and patient outcomes
World Health Organization
Launched the Patient Safety Programme Established the High 5s Project, which• Addresses major concerns about patient safety globally• Uses standardization across multicountry settings and a multipronged approach to evaluating the standard operating protocols
complex theory
Derives from the general systems theory as well as physics Suggests that relationships are the key to everything Includes key concepts *attractors, patterns, nonlinerality, self-organization, and emergence*
A staffing plan
Describes the number and type of nursing staff needed shift to shift and day to day When developing a staffing plan, nurse leaders and managers must or should consider• Regulatory requirements, including federal and state legislation as well as State Boards of Nursing• Guidelines from accrediting agencies such as The Joint Commission• Standards of practice such as those outlined in ANA's Nursing Administration: Scope and Standards of Practice• Benner's novice-to-expert model for a framework for developing and implementing staffing plans
QI Models
Donabedian Model Six Sigma Model IHI Model of Improvement Failure Modes and Effects Analysis (FMEA) Root Cause Analysis (RCA)
Planning
Effective use of human material, nursing services, and management of the environment
near miss
Error of commission or omission that could have harmed a patient, but harm did not occur as a result of chance
Stage V
Expert—operate from a deep understanding of the total situation
ANA's principles for safe staffing
Focus on addressing the complexities of nurse staffing decisions and apply to all types of nurse staffing in all types of health-care settings Organized into the following five categories:• Characteristics and considerations of the health-care consumer• Characteristics and considerations of RNs and other interprofessional team members and staff• Context of the entire organization in which the nursing services are delivered• Overall practice environment that influences delivery of care• Evaluation of staffing plans
chain of command
Formal line of authority, responsibility and communication within an organization from top to bottom
Types of Healthcare organizations
Hospitals: length of stay, service, acute care, the largest type of health care organization, employ more nurses than any other type of healthcare organization Extended care facilities Retirement and assisted living facilities Ambulatory care centers Substance abuse treatment facilities
Hours per patient day
Hours of care provided per patient per day by various levels of nursing personnel. HPPD are determined by dividing total production hours by number of patients.
root Cause analysis
Identifies and understands cause or event system factors
American Nurses Association (ANA)
Launched the Patient Safety and Quality Initiative to educate nurses about quality measurement and inform the public about safe and quality health care Established the National Database of Nursing Quality Indicators (NDNQI) to measure and evaluate quality of care and assist in improving patient safety Designated nursing-sensitive quality indicators that reflect elements of patient care directly impacted by the quality and quantity of nursing care and include Structure indicators—relate to the care environment Process indicators—relate to how nursing care is provided Outcome indicators—relate to the results of nursing care
evaluating staffing effectiveness
Nurse leaders and managers must• Evaluate staffing effectiveness daily, weekly, and monthly.• Consider elements such as patient acuity trends, staffing overtime, staffing mix, patient satisfaction, and patient outcomes.• Use variance reports to evaluate staffing effectiveness by comparing planned staffing to budgeted staffing.• Investigate staffing concerns identified by nursing staff and act immediately on any issues that could negatively impact patient or nurse outcomes.
RN Safe staffing act of 2015
Introduced in Congress to empower RNs to drive staffing decisions in hospitals to improve quality of care Includes the following requirements, among others• Establishment of a committee (comprised of 55% nurses) in hospitals that participate in Medicare reimbursement to create nurse staffing plans that are specific to each unit • Limitation on "floating" nurses to ensure that RNs are not forced to work on units if they lack the education and experience in that specialty• Consideration of RN educational preparation, professional certifications, and level of clinical experience• Consideration of the number and capacity of available health-care personnel, geography of a unit, and available technology
The QI Process
Involves setting standards of care, taking measures according to standards of care, evaluating care, recommending improvements, ensuring improvements are implemented, and evaluating the improvements Nurse leaders and managers• Are integral in the QI process because they are responsible for ensuring the safety and quality of nursing care• Can improve patient safety by applying the QI principles using a patient-centered approach
just culture
Is part of a culture of safety Refers to a culture that is fair to those who make an error Improves patient safety because it encourages nurses to learn from each other's mistakes and to report all errors and near misses without fear of repercussions Requires responsibility for one's own actions and constructive feedback provided to peers
Implementation
Keep unit functioning in budget plan
Steps of the QI Process
Monitor and improve performance—Determine what to monitor, determine priorities in monitoring, select approaches for assessing performance, formulate criteria and standards, obtain the necessary information, choose how to monitor, construct monitoring systems, and bring about behavior change. Form an interprofessional team to implement the QI process, including nurses at all levels and promoting teamwork and collaboration. Foster staff involvement in safety initiatives and QI processes to begin changing the processes, attitudes, and behaviors of staff.
error of omission
Negative outcome from not acting
care delivery models
Organize and deliver nursing care and focus on structure, process, and outcomes. Balance the needs of the patients with the competencies and availability of the nursing staff. Provide for continuity of care across the continuum. Address the following five questions: Who is responsible for making decisions about patient care? How long do that person's decisions remain in effect? How is work distributed among staff: by task or by patient? How is patient care communication handled? How is the whole unit managed?
Quality Improvement
Originated in other industries and developed into total quality management (TQM) Used by health-care organizations through the implementation of QI programs Entails a systematic and continuous series of actions that leads to measurable improvement in health care Incorporates four key principles• QI works as systems and processes.• There is a focus on patients.• There is a focus on being part of the team.• There is a focus on the use of data.
Organization struture
Outlines who is accountable and responsible for the work in an organization and subsequently helps define working relationships Typically hierarchical reflecting chain of command, unity of command, span of control
Becoming a lifelong learner
Seek continuing education opportunities Stay informed - learn about new concepts, issues, and controversies Engage reflective learning activities Continuing education Can be in various formats Accreditation by the American Nurses Credentialing Center of continuing education programs and courses May be earned through university and college coursework Specialty certification Advance degrees
nursing care management
Patient care organized according to major diagnostic- related groups to achieve measurable quality outcomes while meeting predetermined time frames and costs Focus on decreasing fragmented care, improving patient self-care and quality of life, and optimizing use of resources and decreasing costs Occurs with care of high-risk populations primarily in the hospital setting but also in community settings A good approach to improve patient safety while transitioning patients between levels of care
Patient classification system (PCS)
Patient needs and requirements for nursing care are predicted. Patients are grouped according to acuity of illness and complexity of nursing activities necessary to care for the patients. Cons include lack of standardization, lack of credibility among nurse leaders and managers, and no consideration of patient flow. Incorporation of information technology can potentially decrease costs, improve staffing efficiency, and improve quality of care and patient safety. A PCS may be purchased or designed in-house.
early adopters
People who adopt new products early, choose new products carefully, and are viewed as "the people to check with" by later adopters
patient safety issues
Present an ongoing threat to achieving quality health care and a high risk of serious harm to patients. Remain a national and global public concern Nurses - Are in the key position to impact patient safety and quality care - Have an ethical obligation to promote safety and quality care - Must ensure patient safety in all aspects of care delivery
standardization
Process of developing uniform procedures and criteria to improve clinical outcomes reduce inefficiencies and decrease costs
contemporary models
Professional nursing practice model• Differentiated nursing practice model• Clinical nurse leader (CNL) model• Synergy model for patient care• Transforming care at the bedside• Patient- and family-centered care model• Safe and appropriate staffing
Stage IV
Proficient—have 3 or more years of experience and can perceive the situation as a whole
Culture of Safety
Provides blame-free environment in which staff members feel comfortable reporting errors and near misses - Supports nurses in that it is nonpunitive and emphasizes accountability, excellence, honesty, integrity, and mutual respect - Includes the following three stages: Safety management is based on rules and regulations Good safety performance becomes an organizational goal Safety performance is seen as dynamic and continuously improving 1. open communication 2. blame free environment 3. safety design 4. Employee and physician involvement in accountability
monitoring productivity
Related to the efficiency of a nursing staff in delivering nursing care and the effectiveness of the care delivered relative to its quality and appropriateness Can be measured using the following formula• Required staff hours/Provided staff hours × 100 = Productivity Nurse leaders and managers must• Balance safe and quality care with meeting organizational productivity requirements.• Monitor staff productivity and evaluate staffing effectiveness on a regular basis.
NDNQI Staffing benchmarks
Require hospitals to report unit-level data quarterly, and then provides feedback reports to hospitals quarterly. Facilitate the standardization of information on nursing quality and patient outcomes across the nation. Measure characteristics of the nursing workforce related to quality of patient care, including staffing levels and turnover as well as other nursing-sensitive quality indicators. Provide benchmark data for specific unit types that nurse leaders and managers can use to establish safe staffing plans.
competence
Requires performing at an expected levels Affects the safety and quality of care Is a shared responsibility of the profession Requires a culture of nursing competence
a healthy work environgment
Requires: calling to. care priority to self-care opportunity to role model responsibility to educate authority to advocate
QI tools
Run chart Bar chart Histogram Fishbone diagram Flow chart Pareto chart
National Quality Forum
Sets standards for health-care measurements Identifies and accelerates quality improvement priorities Advances electronic measurement to capture necessary data needed to measure performance Provides information and tools to help health-care decision makers Aims to reduce preventable hospital admissions and readmissions, the incidence of adverse health-care-associated conditions, and harm from inappropriate or unnecessary care Establishes its own set of nursing-sensitive quality indicators
Benner's Novice to Expert Model
Takes into account the tasks, competencies, and outcomes RNs can be expected to acquire Is based on the following five stages of experience• Stage I: Novice—have no experience of situations in which they are expected to perform• Stage II: Advanced beginner—can demonstrate marginally acceptable performance of tasks • Stage III: Competent—have 2 or 3 years of experience and can establish a plan of care • Stage IV: Proficient—have 3 or more years of experience and can perceive the situation as a whole• Stage V: Expert—operate from a deep understanding of the total situation
self-care
Taking care of one's own health and safety end the unhealthy cycle of putting others before one's self Lacking self-care linked to increased risk of errors, memory deficits, impaired mood, miscommunication, and overall poor performance
integrated models
The goal is to relieve RNs of non-nursing tasks to improve the quality of patient care.• UAPs provide both direct care and indirect care.• RNs may work with only a UAP or with an LPN/LVN and a UAP.• Communication is lateral, and the RN coordinates all nursing care.
functional nursing
This is implemented as a means to accomplish patient care with the assistance of ancillary personnel. Staff work side by side and are assigned to complete specific tasks for a group of patients. This nursing is often used in long-term care and ambulatory care facilities. It is viewed as efficient and cost effective but can result in fragmented care. Communication is hierarchical, and the charge nurse is primarily responsible for assigning shifts, supervising tasks, interfacing with physicians, and writing shift reports.
total patient care
This is the oldest model of care delivery, also known as case method. The responsibilities include complete nursing care of patient plus other duties, known as holistic care. It is often used in settings such as critical care and hospice care, and sometimes in a hospital setting. Communication is hierarchical, and the charge nurse is responsible for making assignments, interfacing with physicians, and shift reports. Some variations are used today.
staffing approaches
To determine adequate staffing levels, nurse leaders and managers must recognize• Unique patient care settings• Patient flow (admissions, discharges, and transfers)• Patient acuity• Skills, education, and experience of the available nursing staff Approaches to safe staffing include patient classification systems, ANA's Principles for Safe Staffing, Agency for Healthcare and Research Quality nurse staffing model, and National Database of Nursing Quality Indicators staffing benchmarks
role of nurse leaders and managers
To participate in redesigning nursing care delivery by focusing on patient-centered care To ensure frontline nurses participate in the decision- making process To maintain current knowledge of patient care delivery systems and innovations To be knowledgeable about various delivery systems and patient care models To serve as change agent when patient care work/workflow is redesigned To determine when new delivery models are appropriate, and envision and develop them
team nursing
Total care is delivered by licensed and unlicensed personnel under the direction of a team leader. The team leader must ‒ Assign duties to team members, based on licensure, education, ability, and competence. ‒ Supervise care provided and provide more complex care. ‒ Interface with physicians and provide shift reports to the oncoming team leader. Communication can be hierarchical, and the charge nurse is responsible for related tasks directly. This model is still in use today on medical-surgical units.
Automatic actions
When cognitive adaptive mechanisms kick in, resulting in "auto-pilot" Can negatively impact patient safety because nurses pay less attention to details
primary nursing
When the primary nurse is not available, an associate nurse cares for the same group of patients following the plan of care developed by the primary nurse. Decision making occurs at the bedside with the patient and family. This model is often used in ambulatory care units and home health- care settings. Communication is lateral, with the primary nurse being responsible for direct care, interfacing with physicians and other members of the health-care team, and providing shift reports.
Types of medical errors
adverse event or patient safety error of omission error of commission unsafe act slips, lapses, and mistakes near miss sentinel event
sentinel event
an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof
indirect expenses
aren't related to direct patient care, overhead costs
power-coercive strategy
assumes that people are followers who will listen to authority and do as they are told. this strategy says that not following the change will be harmful to employees and they could be punished or even fired if they do not comply
average daily census (ADC)
average total number of patients when census is taken (at midnight) over a given period of time, such as weekly, monthly, or yearly
organization
collection of people working together under a defined structure to focus on predetermined outcomes using financial, human, and material resources
intergroup conflict
conflict that occurs between two or more groups
interpersonal conflict
conflict that occurs between two or more individuals
intrapersonal conflict
conflict that occurs within an individual
laggards
consumers who like to avoid change and rely on traditional products until they are no longer available
fixed cost
costs that do not vary according to volume (building, equipment, depreciation, loan, mortgages)
variable cost
costs that vary with volume (increased patients, increased costs - meds, supplies, laundry)
continuum of care
delivery of healthcare over a period of time
partnership models
• The goal is to decrease the cost of nursing care while increasing productivity.• Examples include‒ Partnership in Practice (PIP)—RN hires and works with UAPs as partners on the same schedule‒ Partnership to Improve Patient Care (PIPC)—same as PIP except RNs not involved in hiring‒ Nurse extender models—same as PIP except RNs not involved in hiring• Communication is lateral, and RNs coordinate and provide care, and remain accountable for all patients.
clinical nurse leader model
• The goal is to improve the quality of patient care across the continuum and engage highly skilled clinicians in outcome-based practice and quality improvement.• The CNL‒ Designs, implements, and evaluates patient care by coordinating, delegating, and supervising the care provided by an interprofessional team‒ Is a provider and coordinator of care and fosters interprofessional and intraprofessional communication
transforming care at the bedside
• This is a care model that empowers frontline nurses and nurse leaders and managers to improve the safety and quality of patient care on medical-surgical units.• The goal is to empower nurses and other health-care team members to redesign work processes to improve the quality of patient care and decrease turnover.• Five themes are as follows: transformational leadership, safe and reliable care, vitality and teamwork, patient-centered care, and value-added care processes.
patient focused care
• This is a multiskilled team approach to nursing care, in which the registered nurse (RN) functions as the patient care manager.• Goals are to‒ Make nursing care more patient centered rather than caregiver centered.‒ Reduce the number of caregivers a patient sees during a hospital stay.‒ Increase direct patient care time for RNs.• Communication is lateral, and the team interfaces with the health-care providers.
nonclinical models
• Unlicensed assistive personnel (UAP) may or may not be partnered with the RN and do not provide direct patient care.• The UAP's role is supportive and includes nonclinical tasks.• Communication is lateral, and RNs are responsible for coordinating care.
UAP Scope of practice
• Unlicensed personnel specifically trained to function in an assistive role to RNs and may or may not be regulated by a state board of nursing• The UAP‒ Is responsible for activities of daily living, hygiene, and physical care‒ Performs tasks as delegated by an RN
nurse fatigue
•"Impaired function resulting from physical labor, or mental exertion" (ANA) •Causes: •Extended shifts of more than 12.5 hours—results in higher chance to make errors as well as slow reaction times, lapses of attention to detail, and compromised problem solving •Lack of rest breaks during working hours—not mandated by federal regulations and only by fewer than 25 states •Ways to improve: •Seek balance, arrive well-rested, use strategies to reduce fatigue •Support from nurse leaders
Lippit's Phase of Change Model (1958)
•7 steps: 1.Diagnose the problem 2.Assess the motivation and capacity for change 3.Assess the change agent's motivation and resources 4.Select progressive change objectives 5.Choose an appropriate role for the change agent 6.Maintain the change after it has started 7.Terminate the helping relationship
becoming a change agent
•A change agent must •Lead and manage the change process. •Gather data necessary to identify a problem that needs to be changed. •Set goals and objectives for the change and develop a plan. •Identify those who will be affected by the change and include them in the process. •Implement the change, and communicate throughout the process. •Evaluate the change and make modifications to the plan as necessary.
guidelines for healthy work environment
•ANA- American Nurses Association •Nurses' Bill of Rights, 2001 •AACN- American Association of Colleges of Nursing •Hallmarks of a professional nursing practice •AACN- American Association of Critical-Care Nurses •Standards for Establishing and Sustaining Healthy Work Environments, 2005 •AONE- American Organization of Nurse Executives •AONE Guiding Principles: Mitigating Violence in the Workplace, 2014
Lewin's Force Field Model Theory of Change (1951)
•Change results from two field or environmental forces •Driving forces (helping forces) -facilitate the change and move it forward •Restraining forces (hindering forces) -impede change and maintain the status quo 3 steps 1.unfreezing the status quo 2.moving toward the new way 3.refreezing or stabilizing the change for sustainability •Change results from two field or environmental forces •Driving forces (helping forces) -facilitate the change and move it forward •Restraining forces (hindering forces) -impede change and maintain the status quo
AONE Guiding Principles for TPP
•Commitment •Role of the nurse manager •Role of preceptors. •Preceptors are prepared •Structured TPP •Social affiliation supports •Organizations put in place policies and practices •Post-transition-to-practice policies •Collaborative relationships
change
•Constantly evolving •Inevitable and unpredictable, can create uncertainty •Affects staff, patients, and the organization overall •Can result in conflict •Planned change versus unplanned change
emerging theories
•Cyclical rather than linear •Require organizations to react with speed and flexibility •systems approach to change •Innovation that results in a comprehensive view and a realization that systems are complex •Include new theories based on complexity science •New theories based on systems theory and complexity science: •chaos theory •learning organization theory
Preparing A Strategic career plan
•Develop goals. •Identify specific action steps •Take inventory of available resources •Identify the indicators of success. •Review and revise
a healthy nurse
•Develops early in one's career evidence-based self-care strategies, including •Physical self-care •Mental self-care •Emotional self-care •Spiritual self-care •Relationship self-care •Choice self-care
healthy work environment
•Effective organizational performance •Improved outcomes •Safe •Work satisfaction •Meaningful work •Enjoyable •Increased retention and recruitment
strategies to prevent workplace violence
•Examine the workplace for the presence of elements of an unhealthy environment . •Increase awareness of workplace violence by providing information. •Model and promote positive and professional behaviors to foster a healthy environment. •Support the development of organizational "zero tolerance" of workplace violence programs and policies. •Ensure communication is open, nonbiased, and respectful at all times. •Deal directly with all reported incidents of workplace violence.
Developing a resume and cover letter
•Include pertinent work experience •Present a concise picture •Use headings •Develop a cover letter •End with appreciation for consideration.
nurse leader's role in change
•Instrumental in change at both the unit and organizational levels •Serve as change agents •Understand change theories and models •Embrace change and innovation to ensure that safe and quality nursing care •Develop empowered teams to implement change •Recognize that conflict is always present in the workplace •Develop empowered teams to implement change •Instrumental in change at both the unit and organizational levels •Serve as change agents •Understand change theories and models •Embrace change and innovation to ensure that safe and quality nursing care •Recognize that conflict is always present in the workplace Nurse leader's role in change: To effectively implement change, nurse leaders must develop high-functioning teams that know what is expected. They must serve as change agents and challenge the status quo. Nurse leaders need to have an understanding of change theories and models (we will discuss more on this in the upcoming slides). Nurse leaders need to embrace change while ensuring safe, quality patient care. Lastly, they need to recognize that conflict will always be present when change is inevitable.
Kotter's Eight Stage process of creating major change (1996)
•Involves a multistep process that overcomes all sources of resistance •Must be directed by high-quality leadership •Includes eight stages: 1.Establishing a sense of urgency 2.creating the guiding coalition 3.developing a vision and strategy 4.communicating the change vision 5.empowering broad-based action 6.generating short-term wins 7.consolidating gains and producing more change 8.anchoring new approaches in the culture
future of nursing
•Lifelong learning through formal & informal education •Ability to implement practice changes rapidly & well •Focus on outcomes & process improvements to influence the direction of health care •Recognition that the patient & the patient's family must be at the center of care •Partnership with other health-care professionals to improve patient care through teamwork & collaboration
strategies for dealing with resistance
•Normative-reeducative strategy •Empirical-rational strategy •Power-coercive strategy Resistance to change is common. The normative-reeducative strategy focuses on the relationship needs of staff, utilizes peer pressure, and relies on the staffs desires to have satisfactory work relationships. This strategy is used when some resistance is expected, however, there is a belief that the staff will succumb to peer pressure. Next, is the empirical-rational strategy. This strategy assumes that the staff are generally self-interested and believes that providing information and education will assist staff in changing behavior and adopting the change or innovation. For example: I worked in an area where one day management stated "You need to give 2 grams of Unasyn for all central line placements, starting today". Of course I asked....Why? As you could imagine, the answer was not well thought out from the management side and it left many nurses feeling anxious and weary! For patient safety, I looked it up on my own and found that it was more beneficial to provide 2 grams over one. A little something called EBP! Needless to say a little information and education go a long way! This tactic is used when little resistance is expected. My guess is, from the example I provided is that the leaders were unaware of this strategy for implementing change. The power-coercive strategy is based on power and authority and assumes that staff will respond to authority and threats of job loss. This style is used when resistance is expected, but the change will occur no matter how the majority feel. Staff must except the change or find a new job!
competencies for facilitating change
•Personal knowledge and accountability for one's own strengths and limitations specific to change and innovation •Understanding the essence of change and innovation concepts as well as the tools of innovation •The ability to collaborate and fully engage team members •Competence in embracing vulnerability and risk taking
nurse leaders and managers supporting change
•Position themselves to be in the forefront of change and innovation •Coaches, encouragers, and positive role models for change •Committed to and exhibit an attitude that supports the change/innovation •Emphasize relationships among staff •Build mutual trust and confidence •Manage conflict effectively •Anticipate and reward change •Provide predictability and stability •"can-do" attitude •Promote teamwork and process improvement
planned change
•Purposeful •Calculated •Collaborative •Utilizes change theories •Well received
Roger's Innovation Decision Process (1995)
•Recognizes behavior in response to change •Five stages of action and choices 1.Knowledge 2.Persuasion 3.Decision 4.Implementation 5.Confirmation
Advanced degrees
•Result in lower mortality rates •Help to provide safe quality care •Must be sought by nurse managers and leaders •Should be spearheaded by initiatives to •establish or increase tuition reimbursement • programs for nurses with a desire to return to school
model to promote a healthy and safe work environment
•Skilled communication model •Becoming aware of self-deception •Becoming reflective •Becoming authentic •Becoming mindful •Becoming candid
unhealthy work environment
•Stressful •Lack civility and respect •Ineffective interpersonal relationships •Workplace violence
unplanned change
•Sudden and necessary •Causes anxiety and stress
resources to create a safe work environment
•The Joint Commission—standards for addressing workplace violence or behaviors that undermine culture of safety •ANA—Code of Ethics for Nurses With Interpretive Statements; Nursing: Scope and Standards of Practice; Incivility, Bullying, and Workplace Violence •OSHA—Guidelines for Preventing Workplace Violence for Healthcare and Social Services Workers
making change and innovation
•Who—the key stakeholders (e.g., patients and families, employees, communities) related to the work to be changed •Why—a reasonable rationale for the change •What—the actual change or innovation being implemented •When—the point at which to start the change process and how long it will take to achieve the change •How—the techniques or processes needed for successful and sustainable change Managing change requires nurse leaders to know and understand the who, why, what, when, and how of change. Why-lack of understanding can lead to resistance to change.
workplace violence
•Workplace violence is any act of threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the work site. It ranges from threats to verbal abuse to physical assaults. •Nonphysical workplace violence •Bullying •Incivility •Lateral (peer to peer) •Vertical (higher to lower) •Third party violence •Nurse to patient violence •Patient to nurse violence •Organizational violence •External violence •Sexual harassment •Mass Trauma
