leadership Exam 2
hierarchical influence on decision making
influence by facility hierarchy centralized hierarchy, RN at top of org chart, make most choices decentralized hierarchy, staff nurse who have direct pt care included in decision ,making process large org benefits from use of decentralized decision making bc manager at top of hierarchy don't have 1st hand knowledge unit level changes or probs decentralized decision making promote job satisfaction among staff nurses
generational differences team members
influence value system of members of interprofessional team, can affect how member function w/i team gen differences can be hard for members of team, but working w/ ppl from different gen also can bring strength
Key concepts ch 12
many modern healthcare org continue to be org around line or line and staff design, have many attributes of bureaucracy, there is movement to less bureaucratic designs, such as ad hoc, matric, care centered systems bureaucracy proposed by Max weber, characterised by clean chain of command, rules, reg, specialization of work, division of labor, impersonality of relationships org chart depicts formal relations, channels of communication, authority through line and staff positions, scalar chains, span of control unity of command means that each person should have only 1 boss so that there is less confusion, greater productivity centrality refers to degree of communication of particular management position in centralized decision making, decisions are made by few managers at top of hierarchy decentralized decision making, decision making is diffused through org, probs are solved at lowest managerial level org structure affects how ppl perceive their roles and status given to them by other ppl in org org structure is effect when design is clearly comm, there are few managers as possible to accomplish goals, communicate, choices made at lowest possible level, informal groups, future leaders developed entities in org enviro that play role in org health and performance, which are affected by org = stakeholders authority, resp, account differ in terms of official sanctions, self directedness, moral integration organ culture is total of org beliefs, hx, taboos, formal, informal relations, comm patterns subunits of large org also have culture, subcultures may support or be in conflict w/ other cultures in org informal groups present in every org, they are powerful, although they have no formal authority, informal groups determine norms, assist members in socialization process shared goc refers to org design that empowers staff nurses by making them integral part of pt care decision making and providing accountability and resp in nursing practice magnet designation is conferred by the ANCC to health care org that exemplify 5 model components, transformational leadership, structural empowerment, exemplary prog practice, new knowledge, innovation, improvement, empirical quality results mag designated org demonstrate improved pt outcomes, higher staff nurse satisfaction that org that do no have mag status the pathway of excellence designation, also conferred by the ANCC, recognizes health care org, long term care org and long term institutions w/ foundations quality initiatives in creating a +work enviro, as defined by nurses and supportive research too many committees in an org is a sign of poorly designed organizational structure committees should have an appropriate number of members, prepared agendas clearly outlined takss, effective leadership if they are to be productive group thinking occurs when there is too much conformity to group norms
14 foundational forces of magnetism for magnet hospital status
quality of nursing leadership org structure management style personnel policies and programs professional models of care quality of care quality improvement consultation and resources autonomy community and hospital nurses as teachers image of nursing interdisciplinary relationships professional development
personal time management
refers to self knowledge = a leadership skill need short, long, time management goals goals, timelines, steps work redesign, clarify ob description, change type of care delivery system = probs time b/w personal and professional habits being self aware - important accomplish in ones life, stay focused on things that matter, taking care of yourself, timely, consistent manner lack punctuality = you dont value other ppl time
components of organizational structure
relationships and chain of command span of control managerial levels centralility weber organizational chart can help identity roles/expectations
responsibility accounting and forecasting
responsibility accounting - each org revenues, expenses, assets, liabilities is someone's responsibility most direct control or influence on any is held accountable = manager forecasting - edu budget estimate by hx data, pt census trends
variables that affect collaboration
decision making styles hierarchical influence on decision making behavioral change strategies stages of team formation generational difference team memebers
PPACA
decr # uninsured, incr access to coverage w/ preexisting conditions, mandated health care by employers Patient Protection and Affordable Care Act
nurse qualities for effective collaboration
-Good communication skills -Assertiveness -conflict negotiation skills -Leadership skills -Professional presence -Decision making & critical thinking
3 categories of prioritization
dont do do later do now
magnet designation and pathway to excellence
1980s american academy of nursing - research to see characteristics of hospitals that were successful to recruit and retain nurses high performance w/ well qualified nurse executives in decentralized enviro w/ org structures that incr open, participatory management ANA established american nurses credentialing center in 1990 ANA board of directors made magnet hospital recognition program for excellence in nursing services not prize/reward = its credentialing 7% of hospitals have it create/promote comprehensive prog practice culture, then apply to ANCC, submit comprehensive doc w/ standards of ANA scope and standards from nurs admin, multi day onsite eval, 5 model components w/o org 14 forces --> 5 model awarder for 4 yr period, then must reply given to individual orgs (not just hospitals) and systems ANCC - pathway to excellence in 2003 recognizes health care org and long term care institutions for + practice enviro where nurses excel must meet 12 practice standards
3 basic steps to time management
Allow the time to plan and establish priorities Complete the highest-priority tasks (nonflexible) first whenever possible and finish one task before another Reprioritize based on the remaining tasks and on new info that may be received cycle - so 3 steps must e accomplished sequentially
organizational theory and bureaucracy
Max Weber bureaucracy - institutional method for applying general rules to specific cases, making actions of management fair/predictable growth of large scale and correctly predicted that this growth required more formalized set of procedures for administrators 3 ideal types: legal-rational authority - belief legit of pattern of formality rules, rights of those elected authority under such rules rather than personal rules, characteristics of bureaucracies: clear division of labor ( all work divided into units that ppl/groups) hierarchy of authority (supervisors separated from subs, authority recognized, privileges, promotions) impersonal rules and impersonality of interpersonal relationships (bureaucrats not free to act however they want) system of dealing w/ rights/duties of each position selection of employment/promotion is based on technical competence
fiscal terminology
PG 238 - 240 LOOK TO SEE IF OTHER TERMS FROM STUDY GUIDE ON HERE
making lists
all do now items, written list is helpful list is a plan, not a product, creation of list is not the final goal list is a planning tool canbe monthly or weekly lists should not be longer than what can be realistic accomplished in 1 day dont always need list bc distract from priority tasks time for each tasks, blacks for built in unexpecteds not all urgent is important, not all important are urgent (mainly true when urgency is coming from external source) view lists from previous days to see what was not accomplished or completed if on list for many days, reexamined it, assess why sometimes need to be removed from lsit (low priority) break down big jobs into small ones if item stays on lists
Brans' 12 habits to master for personal time management
authentic - honest, wants, why you do this trusting - w. ppl, count on them, they trust you lifestyle w/ max energy - exercise, eat, sleep biorhythms, organize day - energy level, schedule accordingly few priorities - stick to them, 2 things turn down inconsistencies w/ priorities - say no to other ppl time for focused effort - work on 1 thin do things better/faster - how to improve solid processes - that last/run w/o your attention spot trouble, solve - think about future, face probs break down goals, think about 1 goal at a time finish important, stop wasting time
chain of command
board CEO, CNO directors/manager charge nurse can be vertical and horizontal driven by $, shared governance
provision 2.3
collaboration clear, articulated, represented, preserved trust, recognition, respect, transparency, shared decision making, open comm
factors to consider when org committees
committee should be composed of ppl who want to contribute in terms of commitment, energy, time member should have variety of work experience, edu committees should have enough members to accomplish tasks, but not so many discussion cant happen, 6-8 ppl tasks and responsibilities, reporting mechanisms, clearly outlines assignments should be given ahead of time, clear expectation that assigned work will be discussed at next meeting all committees should have written agendas, effective committee chairpersons
communitcation and continuity of care
communication tools: poor comm can lead to adverse outcomes (sentinel events) # of comm hand off tools are available to improve comm, promote pt safety (SBAR, PACE, PASS the BATON, 5P's) change-of-shift report: performed w/ RN who assuming resp of pt care describe current health status of pt informs next shift pertinent pt care info allow oncoming RN ask ?, clarify POC private area (conference room, bedside, HIPPA) report to provide: assess data integral to changes in pt status recommendation for change in POC clarify presciptions
provision 2.2
conflict of interest for nurses exam conflict b/w own personal and prof values, values/interest of others for are responsible for pt, values of pt promote safety, promote pt best interest, keep prof integrity of rn, support interprof collab identify and avoid conflicts of interests nurses who do billing services and nurse executives w/ budget repond must be aware of potential conflicts conflict b/w economic and self interest, prof integrity bonuses, sanctions, incentives targets to conflict disclose conflict w/ any relevant parties, nurse should withdraw w/o prejudice form further participation
case management
coordination of care provided by interprofessional team from time pt stats receiving care until no longer gets care
relationships and chain of command
defines formal relations w/i org formal relations, lines of communication, authority = solid lines (MOST) lines are horizontal or vertical solid horizontal lines = comm b/w ppl w/ similar spheres of responsibility, power but different functions solid vertical lines b/w positions denote official chain of command, formal paths of comm and authority greatest decision making authority are located at the top, level of significant status and power dotted/broken - staff positions, advisory, give info/assistance to manager but limited org authority, incr sphere of influence so manager can do more, org can function w/o these ppl advisory (staff) - no inherent legit authority, clinical specialists, in service directors in staff position lack authority, accomplishing role expectations hard bc formal authority is limited only line positions have authority unity of command - vertical solid lines, one person/one boss so employees have 1 manager to they report/responsible, simplifie manager-empolyee relations
span of control
determined by org chart # of ppl directly reporting to any 1 manager represent that manger's span of control and determine # of interactions expected of them inverse relations b/w span of control, # of levels in org theorists are divided regarding span of control for any one manager quantitative formulas for determining optimal span of control have been attempted w/ ranged from 3-50 ideal span of control in org depends on nature of job, managers abilities, employees maturity, task complexity, level in org at which work occurs number of ppl reporting to 1 supervisor must be = number that maz productivity and work satisfaction ideal span of control 15-20 subordinates per manager, use to be 6 flattening the org - decr # admin levels in org, incr spans of control
taking time to plan and establish priorities
fail to plan - plan to fail planning fallacies - time allow to carry out plan is shown over and over again to be bad, most ppl continue to be + that, which is no different plan will be realistic (ex. student w/ week full of homework is generally aware that will only do 1 or 2 assignments, yet hope this will be different than last time, behavior continues unchanged) happens bc in past ppl forget interrupted unexpectedly, subcomponents, narrow in their focus on tasks, subconsciously disregarded memories of how long tasks taken in past = serious planning errors, poor time management planning occurs 1st in management process bc ability to be organized develops from good planning think about how plan goes into action ppl think unproductive if take time out in beginning of day to plan out day = not true students fail to do plan - not sure what it should look like, unsure assignments due, how to break large assignments up = SMART for formal/in also apps for students to help
matrix structure
focus on both product and function function - all tasks needed to produce product, product is end result of function ex. good pt outcomes are product, staff edu, adequate staffing may be functions necessary to produce outcomes formal vertical + horizontal chain of command less formal rules, fewer levels of hierarchy ex. decision making slow bc necessity of info sharing, produce confusion, frustration for workers bc dual authority hierarchical design advantage - centralizing expertise frequently outweighed by complexity of comm required in design
referrals
formal request for service by another care provider pt can access care need by doc or consultant acute setting or outside facility pt d/c from care facilities to their home can still need nursing care knowledge of community, online resources is needed to appropriate link for pt w/ needed services d/c referrals are based on pt need in r/t actual/protection probs, can be w/ assistance of social services, especially if there is need for: RN role regarding referrals: begin d/c on admin eval pt/fam competencies r/t home care before d/c involve pt/fam in POC collab w/ other health prob to ensure all needs met, needed referrals made complete referral forms = reimbursement
Team intelligence
group of individuals who work together to develop a deep understanding of a specific business issue with the intent of developing strategy‐relevant insights, action possibilities, and recommendations.
Magnet Recognition Program
interprofes team charged w/ maintaining continuous QI nursing staff choose demonstrate quality nursing care by seeking mag rec American nurses credentialing center awards mag rec to health care facilities that give high quality pt care, attracts, retains well qualified RN mag recognizes facilities power to draw RN to facility + retain them 14 forces of ag give framework for mag review process 1st step for facility that applies for mag rec is to complete self appraisal based on set established standards important that all RN participate in application process after doc that standard have been met, on sit appraisal conducted facility meets the standards is awarded mag status for 4 yr period to maintain mag status, facility must maintain establish standards, submit annual report
collaboration w/ interprofessional team
interprofessional team - group health care professionals from various discipline nurse provider nurse to nurse (different lvls of RN) interpro team, pt, fam
behavior change strategies
interproff team can be resistance to change 3 strategies a manager can use to promote change rational, normative, power usually manager uses combo of these rational-empirical - manager provides factual info to support change, used when resistance to change is min normative-reeducative - manager focus on interpersonal relations to promote change power-coercive - manager uses reward to promote change, when ppl highly reistant to change
personnel
largest expenses is workforce or personnel bc labor intensive managers use hx about census prevent over/under staffing manager recognize staffing mix mix (%) of RN and CNA/NAP working pt acuity so that most economic staffing based on predetermined standard addresses in hr per pt day (JPPD), min per case (OR), visits (VNA) staffing formulas = nursing care hr (NCH) 6NCH/PPD calculate NCH in 24hr (including ward clerk) x # of staff on duty each shift by the hrs each worked in their shift each shit total + together to get total # of nursing hr workers in all 3 shifts or 24hrs = 136 2nd step, / nursing hours worker in 24hrs by pt census 136/25 = 5.44 which is more or less than your budget personnel include actual worker time ( aka productive time or salary expenses) and time org pay employee for not working (nonproductive time, benefit time) nonproductive time = cost of benefits, orientation, turnover, sick, holiday time, edu time, lunch break
dealing w/ interuptions
lower level manager experience most bc 1st/middle more involved in day planning, more contact w/ subs low level - no quite space to work, interruptions, stress need leadership skills
time management
making optimal use of available time optimizing - prioritizing duties, managing, controlling crises, decr stress, balancing work, personal time need leadership skills, management
committee structure in an org
managers responsible for designing, implementing appropriate committee structures poor structures = nonproductive communications created by line and line-and-staff structures, committees are used to facilitate upward comm committees incr staff participation in org gov may be advisory or coordinating or informal function generate ideas, creative thinking, improve services, improve quality and quantity of work committees can pool skills and expertise and help decr resistance to change can only work if committee appropriately organized and led wastes energy, time, money
balancing cost and quality
not always linear relationship cost containment - effective, efficient delivery of services while generate needed revenues for continue org productivity, depends on ability to use fiscal resources wisely cost effective - no same as inexpensive, producing good results for amount of money spent, product is worth the price, expensive items can be cost effective, inexpensive items may not be factors - length of service, need for service, availability of alternatives high spending does not mean high care duplication services, over use of service, tech exceeds needs
provision 2
nurse's primary commitment is to pt, whether an individual, family, group, community, population
limitations of organization charts
org charts show only formal relations = limited chart does not show informal structure informal leaders = provide feelings of belongings, either good or bad, usually long term employees, ppl in select gatekeeping positions = CNOs secretary, social activities, from relations that develop outside work enviro org charts limited to position degree of authority - official power to act, given by org to direct work of others, managers can hire, fire, discipline, can cause confusion, status influenced by skill, edu, specialization, level of resp, autonomy, salary position, have status w/ little authority constantly changing - ppl take new jobs, getting hired, getting fired = impossible keep chart current org charts - too rigid define job, look at chart see their responsibilities and then that's all they do, defines authority but not responsibility or accountability responsibility = duty or assignment accountability = like resp, internalized, agree to be morally responsible for consequences of their actions
types of budgets
personnel operating capital
managerial levels
several levels of managers usually exist top level manager - looks at org as a whole, coordinating internal/external influences, make choices w/ few guidelines/structures (CEO, nurse administrator, DON, chief nurse, CNO), some are not responsible for non nursing departments (might oversee resp, physical, OT) nurse manager is the top for nursing determine philosophy, policy, goals, priorities, need leadership skills, not involved in daily operations as lower level manager middle level managers - coordinate efforts of lower levels of hierarchy, conduit b/w lower and top level managers, day to day operations, some long term planning, (nursing supervisors, nurse mangers, head nurses, unit managers), rn many are decr, "directors", first level managers - specific unit's workflow, immediate probs in days, org needs, personal needs of employees, need management skills, bc work w/ pt and health care team, leadership roles = influence productivity (primary care nurses, team leaders, case manager, charge nurse, RN)
shared governance: org design for the 21st century
shared gov - most innovative, empowering org structures, mid 1980s, alternative to trad bureaucratic. considered flat type, but gov shared among board members, nurses, physicians, management = decision making/comm is altered so group structures called joint practice committees assume power and accountability for choices, prof com incr RN authority, control over practice incr comm, joint choices b/w nursing, others in health care team participatory management - others are allowed to partake in choices making over which someone has control = allow participation identifies real and final authority for participation o single model for shared gov gpc councils include nursing practice council, research council, prog development, edu council, nursing performance improve or quality council, leadership council some managers reluctant to switch to this, bc change their roles nurse manager becomes teach, collab, create enviro new role = had to accept
stages of team formation
teams work though group formation process b/f reaching peak performance forming - members of team get to know each other, leader defines tasks for team, offers direction storming - conflict arises, team members begin to express polarized views, team establishes rules, members begin to take on various roles norming - team establishes rules, member show respect for one another, begin to accomplish some tasks performing - team focus on accomplishment tasks
time wasters 5 steps
tech - internet, games, email, social media socializing paperwork overload poor filling system interruptions
integrating leadership roles and management functions in time management
time management is related to stress leadership skills - communication skills, resource, role model to subs, self awareness, understand own value system management - use time resourses wise, productivity, prioritive, short./long goals, analysis of time management on unit,
sample time management and productivity apps for students
timeful - iOS - an app that acts as calendar, to do lost, schedule evernote -
Assessing Organizational Culture
what is the org physical enviro: attractive, adequate, nursing stations crowded, noisy, good lobby size, quite areas, seating, conference rooms, lib, chapel what is org social enviro: friendships outside work, annual picnic, ppl like each other, departments get along, 1st name basis w/ everyone how supportive is the org: edu reinbust, low cost meals, employee lounges, funds for workshops, aises for extra effort, org pay for holiday party what is org power structure: how has the most power, which department is most powerful, who gets free meals, special parking, pagers, lab coats, overhead pagers, biggest office, how safe is org: lighted parking lot, active safety committee, security what is the communication enviro: upward written or verbal, informal comm, active grapevine, where is informal exchange (parking lot, nurses station, coffee shop) what are org taboos, who are the heroes: special rules/policies that can never be broken subjects or ideas forbidden relations that cannot be threatened
centrality
where a position falls on org chart, determined by org distance if small org distance can get more info than those who are more peripherally located middle manager often has broader view of org than other levels of management middle manager has large degree of centrality bc manager get info upward, downward, horizontally comm involves send and receive, messages may not be received clearly bc sender hierarchical position status and power influence receiver ability to hear info principal syndrome - what did i do wrong can go out of change of command, rare condition, should forewarn ppl you are bypassing them
fiscal planning
- Not intuitive - learned skill that improves with practice important but often neglected reflect philosophy, goals, objectives of org critical to nursing managers bc of incr emphasis on finance, "big business" of healthcare vision, creativity, knowledge of political, social, edo forces
short term
1-3hrs, less complex annual, quarter, week, daily, hrly no strategic or long range
SMART approach to studying
1. Set specific, clear goals to accomplished 2. Record progress as measurable progress maintains your interest 3. Identify steps needed to accomplish your goals 4. Be realistic about your time constraints, set goals that can be accomplished w/i constraints 5. Set time frame, plan for this
operating
2ns area of expenditure that involves managers reflect expenses that change in response to volume of services (elect, repairs, maintenance, supplies) personnel costs #1, supplies #2 managers know relation b/w supply use, pt mix, job rate, tech requirements, procedures save unused supplies (packs/trays), decr obsolete/slow moving inventory, decr pilgerage, monitor uncontrolled use of supplies rental vs. facility owned equipment, stocking products on consignment, just in time stockless inventory just in time ordering - inventory deliver to org by supplies onlu when needed, immediately before
capital
3rd type used by managers purchase of building or major equipment w/ long life (5-7yrs), not used daily, more $ than operating supplies long term planning, major acquisition, short term budget component long term major acquisitions outlines replances and org expansion that will exceed 1 yr e 0 positron imager, renovation short term - call lights, beds, med carts must exceed certain $ amount = 1000-5000 common
time wasters
4 need special attention tech - supposed to be time saver, consumes more and more of our time, use as procrastination, only check email 3 times a day need to "unplug", if not = burn out, no boundaries in work/personal life socializing - true for manager w/ open door policy, dont make yourself overly accessible - dont work at RN station, sit w/ back to others, close door, appointments interruptions - dont let ppl ramble, get to the point avoid promoting socialization - candy, chairs be brief - short comments, standup when your down talking scheduled long winded ppl - paper clutter - memos, staffin requests, quality assurance, incident reports, pt evals = usually redundant, unneeded = try to get ride of when it comes it filing system - invaluable to handle paper overload, use computer/email to decr paper interruptions - time to respond to emails/phones, dont be disturbed until urgent/emergency
ad hoc design
Modification of the bureaucratic structure Sometimes used temporarily to facilitate project completion within a formal line organization Overcomes the inflexibility of line structure Serves as a way for professionals to handle increasingly large amounts of info Uses a project team or task approach and is usually disbanded after a project is completed May result in decr employee loyalty to the parent organization
d/c planning
RN conduct d/c planning w/ both pt and pt fam starting point for continuity of care need identified, measure taken to prepare additional services (health health, pt, respite care) affressed b/d d/c so service is in place when pt arrives home w/o prescription for d/c = AMA immediately tell doc of pt risk of harm, RN explain risk of leaving sign form relinquishing resp for complications doc all comm, advice if try to prevent pt from leaving = legal assault, battery, false imprisonment charges
coordinating pt care
RN must have understanding of collaboration w/ interprof team, principles of care management, continuity of care (consultations, referrals, transfers, d/c planning), motivalonal principles to encourage, empower self, staff, colleagues, other members of the interprofessional team
nursing role in continuity of care
RN role as coordinator of care includes: continuity of care by members act as rep for pt, liaison when collab w/ doc and others, when act as liaison, rn serves in role of pt advocate by protecting right of pt, ensuring pt needs are met coordinator of care, RN is responsible for: admin, transfer, d/c, postd/c prescriptions initiation, revision, eval report pt status to other RN/doc coordinating d/c plan referrals, use community resources
Crucial Conversations State My Path How to speak persuasively, not abrasively
STATE: S - share your facts, start with the least controversial, most persuasive elements from your Path To Action (see + hear, tell a story, feel, act) - facts are least controversial, most persuasive, least insulting = begin w/ facts T - tell your story, explain what you're beginning to conclude = confidence, dont pile it on, look for safety probs, use contrast, don't apologize/water down your thoughts A - ask for others' paths, encourage others to share both their facts and their stories T - Talk tentatively, state your story as a story, don't disguise it as a fact, "perhaps you were unaware or in my opinion", don't be wimpy, goldilocks test E - Encourage testing, make it safe for others to express differing or even opposing views, play devils advocate, 1st 3 describe what to do last 2 tell how to do it Share risky meaning - speak their minds completely, in way that makes it safe for others to hear, and respond to it as well, frank and respectful Maintain safety - confidence to speak openly, humility to speak your mind and allow other to aswell, skill not to use fool's choice
types of organization structures
line structures ad hoc design matrix structure service line org flat designs
Generational characteristics
Veteran: 1925-1942 support status quo, accept authority, appreciates hierarchy, loyal to employer baby boomers: 1943-1960 accept authority, workaholic, struggle w/ tech, loyal to employer generation X 1961 - 1980 adapt easy to change, personal life/fam are important, proficient w/ tech, makes frequent job changes generation y 1981-2000 optimistic, self confident, values achievement, tech is life, at ease w/ cultural diversity
consultations
a prof who provides expert advice in particular area requested to help determine what tx/services the pt requires provide expertise for pt who require a specific type of knowledge or service (cardiologists a pt who had MI, psychiatrics for pt at risk for suicide must be assessed) RN role regarding consultations: consult, tell doc pt needs so consult happens give consult w/ all pertinent info about prob (info from pt/fam, EMR) incorporate pt recommendation to POC
advantages and limitations of the organization chart
advantages: maps lines of decision making authority help ppl understand their assignment, those of their coworkers reveals to manager, new personnel how they fit into the org contributes to sound org structure shows formal lines of comm limitations: shows only formal relations does not indicate degree of authority are difficult to keep current may show things as they are supposed to be or used to be rather than as they are may define roles too narrowly possibility exists of confusing authority w/ status
incremental budgeting
aka flat percentage simplests multiply current yr expenses by certain figure, (inflation rate or consumer price index) = projected budget simple and quick little budge expertise on manager = inefficient bc no motivation to contain costs, no prioritize services hospitals used in fiscal planning
basic budgets
budget - financial plan estimates expenses, income for a period of time accuracy dictates the worth of budget, more accurate budget blueprint, better institution plan plan most efficient use of resources budget = best prediction, plan, not a rule = flexible ongoing eval, revision fixed or variable/controllable/non fixed = do not vary w/ volume variable = vary w/ volume ex. building mortgage payment, managers salyer ex. payroll of hr wage workers, cost of supplies controllable - controlled or varied by manager uncontrollable - not ex - number ppl working on shift, staff mic ex. - equitment broken, # supplies needed by pt, overtime bc emergency
line structure
bureaucratic org = commonly called line structure or line org staff authority = staff org found in large health care, resemble Weber bc ppl familiar w/ structure = less stress authority, responsibility = clearly defined = efficiency, simple relationships formal design disadvantages - monotony, alienate workers, adjust rapid to altered circumstances difficult, adherence to chain of command comm (good leaders encourage upward comm to compensate for this), going out side can be inappropriate
principles of case management
case management focus on managed care of pt through collaboration of health care team in acute, post acute settings goal of case management - avoid fra care and control cost case manager collabs w/ interprof team during assess of pt, follows up by monitor achievement of outcomes w/i established time parameters case manager can be a RN, social worker, other professional case managers role/know expectations are extensize case manager are required to have adv practice degrees or adv training in their area case manager RN dont usually provide direct pt care case managers oversee caseload of pt who have similar disorders or txs case manager in community coordinate resources, services for pt whose care is based in residential setting critical or clinical pathway or car map can be used to support implementation of clinical guidelines or protocols tools are used based on cost/length of stay mandated by prospective payment systems (medicare/insurance companies)
continuity of care: consultations, referrals, transfers, d/c planning
consistency of care provided as pt move through health care system enchanges quality of pt care, facilitate achievement of +pt outcomes continuity of care is desired as pt move from one: level of care to another (ICU to MS unit) facility to another (acute to skilled) unit/department (PACU to post surg) RN responsible for facilitating continuity of care, coordinate care through doc, reporting, collaborating formal, written plan of care enhanced coordination of care b/w RN, interprofessional team members, providers
nursing role in case management
coordinate care, for pt w/ complex health needs continuity of care efficiency of care utilize resources quality of care limit unneeded costs, lengthy stays advocate
the nurse's role
coordinate interproff team hositalic, health care needs, health care system continuity of care, across disciplines link to post discharge resources = referral consultation r/t specific health issues opportunity partner in development of POC info during rounds/interprof teams status of pt health
flat designs
effort to remove hierarchical layers by flattening chain of command and decentralizing the org single manager or supervisor would oversee large # subord, wide span of control when $ well off, easy to add layers to org in order to get work done no $ = look at their hierachy to see where they can cut positions flattened org - continues to be line authority, bc org structure is flat, more authority, decision making can happen, managers have probs letting go of control, usually retain many parts of bureaucratic
stakeholders
entities in org enviro that play role in org health and performance or that affected by the org internal or external individuals or large groups shared goals or diverse goals internal - RN in hospital or dietitian in nursing home external - acute care hospital might be local school of nursing, home health agencies, managed care providers who contract w/ consumers in the area chamber of commerce in a city can be a stakeholder for health care org have interest in what the org does but may/not have power to influence org to protect interests interests varied, may coincide on some issues and not others orgs dont choose their own stakeholders may be supportive or threatening influence stakeholder analysis - should be preformed when there is need to clarify consequences of choices and changes prioritize stakeholders and determine their influence
formal and informal organizational structure
faylo 1949 org is formed when number of workers is large enough to require a supervisor how organizations are structures - formations, methods of communications, channels of authority, decision making process informal and formal positions formal - highly planned, visible, through departmentalization, work division = framework for defining managerial authority, resp, account, well defined formal structure, roles/functions defined, systematically arranged, different ppl have different roles, rank, hierarchy informal - unplanned, naturally forming social network of workers, hartzeil, fills gaps w/ connections, relationships that illustrate how employees network w/ one another to get work done, based on camaraderie, more immediate response from ppl, save time/effort, rely on informal if formal stops being productive = as org grows/changes, but does not reveal hierarchy or work groups, own communication network = grapevine = heart of all informal org, in break room, down halls, social media = can become gossip
transfers
from 1 unit, department, facility to another must continue continuity of care hand off tools incr continuity of care, pt safety RN role written, verbal report of pt status, needs: dx, doc demographics overview of health status, POC, progress alters that can precipt immediate concern VS, meds, PRN, when given assessment, needs w/i next few hrs allergies, diet, activity specific equipment (O2, suction, wheelchair) adv directives - DNR fam involvement in care, proxy
Time Efficient Work Environment
gather all supplies, equipment that will be needed before starting an activity - break into parts group activities that are in same location - go down hall, do everything, then go to RN station use time estimates - IV takes 30 min, do something else in that 30 min doc your nursing intervention ASAP after activity is done, ont wait till end of the day = inaccurate/incomplete always strive to end workday on time - not always possible, delegate staff RN - find when best breaks managers - stocked units, equipment = decr time finding stuff manager: beginning of day find priorities actions for long term goals lvl of achievement you expect for each tasks delegation review short/long term goals of unit plan ahead for meetings take breaks use electronic calendar
documentation
graphic records that illustrate trending of assessment data (VS) flow sheets that reflect routine care completed, other care related data RN notes that describe changes in pt status or usual circumstances pt care summaries, serve as quick references for pt info RN care plans that set standard for care provided: standard RN plan provide starting point for RN responsible for care plan development standardized plan must be ppl to each pt all doc should reflect plan of care
decision making w/i org hierarchy
hierarchy, pyramid = scalar chain where decisions are made w/i org centralized decision making - few managers at top, make choices, emphasis on top down control, execution of decision making, rapid paced decentralized decision making - probs to be solved by lowest managerial level, prob solved at level they occur, delays may happen, large org benefit from this Rai - centralized decision can/does work well in org where staff want more direction, guidance, coordination of activities from upper management
budgeting methods
incremental budgeting flexible budgeting Zero-based budgeting performance classified by how often it happens, base on which budgeting takes place
examples of stakeholders in community hosptial
internal: hospital employee physicians pt pt fam union shop stewards board of directors external: local business area colleges/universities insurance companies and HMOs community leaders unions professional org
decision making styles
interproff team w/i facility is challenged w/ making sound decision about how pt care is delivered different styles depending on situation group leader decided style team uses styles vary in regard to amount of data collected, # of option generated decisive - team uses min amount of data, generates one option flexible - team uses limited amount of data, generates several options hierarchical - team uses large amount of data, generates 1 option integrative - team uses large amount of data, generates several options
priority setting and procrastination
key to good time management some ppl lack self awareness about what important dont do, do later, do now dont do - reflect probs that will take care of themselves, already outdated, better accomplished y someone, ppl throw away unneeded info, passes it on person in timely faction, removes unneeded clutter from his or her work area do later - trivial probs, do not have immediate deadlines, may be procrastinated, what happens when something else outweigh value of doing it now, before setting items aside, leader manager must be sure that large projects have been broken down into smaller projects that specific timeline and plan for implementation are in place, short term, inter, final deadlines, dont ignore items w/o immediate time limits forever procrastination - appropriate in some cases, more often barrier to effective time management, ard prob to solve do now - most commonly reflect units dat to day operational needs, daily staffing needs, dealing w/ equipment shortages, schedules, hiring interviews, giving performance appraisals, also can represent items that had been put off earlier
reprioritizing
last step priorities or list will change during day, wk, or longer bc info is received need to after each major task is accomplished, other priorities set earlier may no longer be accurate may have crisis, may need to set aside tings for the day and reorganize, comm, delegate
integrating leadership roles and management function associated with organizational structure
leader-managers = both structures of org in which they work/external stakeholders, come to meetings w/ ideas make sure subord understand org structure, structure of unit level = be resource/role model, see if work accomplished in committees, manager - support staff, granting authority, know culture and sub culture, eval types of org structure/gov and implement those leadership - upward comm is encourage, periodic eval of structure, incr lower level decision making, share culture/subculture
leadership roles and management function in time management
leader: self aware of personal blocks/barriers in time management own value system influence use of time/expectation of followers role model, supporter, resource, set priorities for goals work cooperatively to max time prevent/filter interruption that prevent effective time management role models flexibility, work w/ others who time management style is different calm, reassure demeanor during periods high census prioritize conflic/overlapping requested for time quality of work needed in tasks manager: prioritize day-to-day plan to meet short/long term unit goals time for planning into work schedule how time managed on unit lvl by use job analysis, time and motion studies no enviro barrier paperwork, efficient, maintains neat work break down large tasks into smaller tech for comm, doc discrim b/w bad staffing, inefficient use of time when resources are inadequate to complete assigned tasks
leadership roles and management functions associated with organizational structure
leadership: eval org structure frequently to see management positions should be eliminated to shorten chain of command encourage, guides workers to follow chain of command, counsels workers who do not do so support personnel in advisory (staff) positions models resp and account for subordinates assist staff to see how their roles are congruent w/ and complement org mission, vision, goals constructive informal group structure positive org culture b/w work groups and subculture, crete shared values/goals incr decision making, shared gov to empower subordinates committees to facilitate group goals, not to delay decisions management: knowledge about org internal structure, personal, department authority, resp w/i structure constructive formal group structure accurate unit org chart, assists w/ interpretation maintains unity of command claridies unit of command when there is confusion follows subordinate complaints through chain of command span of control create constructive org culture, positive org climate informal org to meet org goals committee structure to incr quality, quantity of work workers, achieve level of operational excellence befetting org that would be eligible for mag status or some other recognition of excellence identifies, analyzes, promotes stakeholder interest in org
leadership roles and management function in fiscal planning
leadership: visionary, forecasting short/long needs = proactive political, social, ed factors shape reimburse flex in goal in rapid change anticipate, recognize, create budgets constraints influence others in short/long planning fiscal constraints = inability meet org goals pt safety not at risk by cost containment role model in health care reform prepare followers for changes/ reform, PPACA managers: short/long fiscal plans reflect unit needs doc unit needs to higher admin in/ex enviro of org in forecasting forces/barriers knowledge of budget, tech to budget opportunity for subs to participate unit lvl fiscal plan congruent w/ org goals/obj personnel needs w/ predetermined standards monitor budget control doc pt need for services is clear for org reimburse VBP/ACO, bundle, med hom, market may impact org
Service Line Organizational Structure
like matrix some large institutions to address shortcomings that are endemic to traditions large bureaucratic org service lines = aka care centered org = smaller in scale than large bureaucratic system ex - overall goals would be determined by larger org, services line would decide on processes to be used to achieve goals
organizational effectiveness
no one BEST way to structure org variables - size of org, capability of its HR, commitment level minimal requirements: structure clearly defined so employee know where they belong, where to go for help goal should be build fewest possible management levels, have short chain of command, = decr frust, stress, inertia unit staff need to be able to see where task fit into common tasks of org org should enhance comm org should incr decision making, incr performance organized staff in manner that incr informal groups to develop sense of community and belonging nursing services should be org to incr development of future leaders hard to move away from bureaucracies
using time inventory
ppl dont know how much time they spend on 1 task time inventory can help compare what you planned to do, what you actually did identify patterns of behavior do for days/wks repeat annually, long term changes
responsibilites and opportunities of committee work
present leader-manager w/ opportunities/responsibilities meets are major time requirement managers are members of committees and as leaders/chairperson managers should come well prepared, use skill to influence, gain power at meetings create enviro at unit committee meetings that lead to shared decision making staff from different cultures may have different needs in groups = multicultural committees should be the normal incr interaction free of status, power is important, seating arrangement, circle will incr motivation to speak up gender difference = try to include both
provision 2.1
primacy of the pt's interest rn primary commitment to recipients of nursing and healthcare services - pt = fam, individual, groups, community, pop plan of care must reflect uniqueness, worth, dignity of pt provide opportunities to participate in planning, implementing care, support available resources, tx options, capacity for self care addressing pt interests, w/i fam and other relationships pt wishes are in conflict w/ those of rn, resolve conflict when conflic continues = nurse remains to the identity of pt
provision 2.4
professional boundaries rn -pt rn - colleague promotion, protection, restoration no accepting gifts factors = intent, value, nature, timing, cultural follow facility policy no dating or sex
discharge instructions
step-by-step instructions for procedures at home do return demonstration of procedures to validate precautions to take when performing procedures or admin med med regimen instructions, AD, actions to min them s/s of complications to report names, # providers, community services to contact plans for follow up care and therapies.
chap 9 key concepts
time is finite = learn to use it wisely time management - 3 ways - allow time for planning, priorities, complete highest priority 1st, finish 1 before starting another, prioritize based on remaining tasks/new info time @ beginning of day to plan estimate more time for activities make lists, not too long, accomplished in 1 day, time for each item procrastination - break down large tasks into small ones, set short term, inter, long goals low level manager - more interruptions = situational stress, lower job satisfaction learn to cope w/ interruptions paperwork is redundant, unneeded, manager needs to prioritize it, eliminate clutter filling system = paper overload personal time management = knowing of self punctual = vale other ppl time, creates imperative for them to value your time time management - balance b/w work/life tie inventory - gain insight into how, when ppl most productive = time wasters
Explore others' paths
to encourage free flow of meaning, help others leave silence or violence behind = explore their Paths to Action start w/ attitude of curiosity, patience = restore safety explore others paths start w/ heart, get ready to listen encourage other's to retrace their paths inquiry skills (when, how what) use 4 powerful listening skills to retrace the other persons' Path to Action to its origins Ask - start by expressing interest in other person's views (don't worry about hurting my feelings, I want to know what you think, what's going on) Mirror - incr safety by respectfully acknowledging emo ppl appear to be feeling, "you seem angry at me" Paraphrase - as others begin to share part of their story, restate what you hear to show not just that you understand, but also that it's safe for them to share what they are thinking "let me see if I got this right..." Prime - if others continue to hold back, prime, take your best guess at what they may be thinking and feeling As you share your views, remember: Agree - when you share views Build - if others leave something out, agree where you shave views and build Compare - when you differ significantly, don't suggest others are wrong, compare 2 sides
org culture
total of org values, language, traditions, customs, sacred cows ex. hospital logo that had been designed by original boards of trustees is an item that may not be considered for updating change complex and importance of org culture assessing unit culture is management function building culture is leadership function subcultures - large orgs, w/ different/competing values, shape perceptions, attitudes, beliefs, change requires leaders and managers orgs culture must be told to person to person, not in philosophy NOT the same as org climate = how employees perceive org - as fair, friendly, formal, can be accurate or inaccurate
5 model components required for magnet status
transformational leadership structural empowerment exemplary professional practices new knowledge, innovation, improvements empirical quality results
the nurse's role w/ regard to d/c is to provide written summary including
type of d/c (prescribed, AMA) date, time who accompanies pt, how pt transported destination (home, long term care) summary of pt condition at d/c (gait, diet, assist device, blood glucose) description of unresolved probs, plans for follow up disposition of valuables, med from home, prescriptions copy of pt d/c instructions
steps in budget process
use nursing process 1. assess what needs to be covered, terminology, needs, labor, equipment, operating expenses 2. dx goal or what needs to be accomplished, cost effective mac resources 3. plan 12 months = fiscal yr, may/no coincide w/ calendar yr, quarters, monthly, semiannual, perpetual (continuous basis Q1 Month) 4. implement monitor, analysis happen to avoid excess fund at end of fiscal yr, some dept. inflate budget as cushion, correct unrealistic budget 5. eval review periodically, modify throughout yr, each unit manager accountable for budget, should be no large deviations
volume to value
value - function of quality, safety, cost decr incentives for redundant, inappropriate care PPACAs payment reform include VBP (value based purchasing), accountable care org (ACOs), bundled payment, medical home, health insurance marketplace Nursing = non income producing service RN-Managers = not given reason for budget they get
