Module 13 Professional Models of Practice, delegation, and evaluating quality of care
Nursing Care Delivery Models
"As nurses have moved to accept more professional status and the responsibility of delegating and working through others, they have moved into advanced practice models in which there is less supervision, more opportunity for independent thought & creativity and more accountability." (Kerfoot, 1995) Functional nursing Team nursing Total care or case nursing Primary nursing Case management Patient-centered or Patient-focused care
Delegating Nursing Care
"Delegation involves the transfer of responsibility for the performance of an activity to another individual while retaining accountability for the outcome" (Taylor, et al, 2015) "Delegation is the act of transferring to a competent individual the authority to perform a selected nursing task in a selected situation" (National Council of State Boards of Nursing [NCSBN], 2004)
Dedication
The ability to spend the time necessary to accomplish a task
Creativity
The ability to think differently
Core Competencies for Inter- Professional Collaborative Practice
"When multiple health workers from different professional backgrounds work together with patients, families, caregivers, & communities to deliver the highest quality of care." (WHO, 2010) Goal: to deliberately work together with the common goal of building a safer & better patient-centered & community population oriented US Health Care System.(IEC, 2011) Core Competencies 4 Domains that break down into 10 indicators ¡Domain 1: Value/Ethics ¡Domain 2: Roles & Responsibilities ¡Domain 3: Inter-professional communication ¡Teams & Teamwork
The Seven Crucial Conversations in Healthcare
1.Broken Rules 2.Mistakes 3.Lack of Support 4.Incompetence 5.Poor Teamwork 6.Disrespect 7.Micromanagement
Team Nursing Model
A care delivery model that assigns staff to teams that are then responsible for a group of patients A unit is usually divided into 2 or more teams each led by an RN A team leader supervises and coordinates all of the care provided by those on the team Care is further divided into the simplest components and then assigned to the care providers with the appropriate level of skills In team nursing the RN functions as a team leader and coordinates a small group (no more than four or five) of ancillary personnel to provide care to a small group of patients. "As coordinator of the team, the registered nurse is responsible for knowing the condition and needs of all the patients assigned to the team, and for planning the care of each patient" (Marquis and Huston, 2000). The team leader is responsible for encouraging a cooperative environment and maintaining clear communication between all team members. The team leader's duties include planning care, assigning duties, directing and assisting team members, giving direct patient care, teaching, and coordinating patient activities. Team nursing is an effective, efficient method of patient care delivery and has been used in most inpatient and outpatient health care settings. The team leader must have strong clinical skills, good communication skills, delegation ability, decision-making ability, and the ability to create a cooperative working environment.
Patient Centered Care Disadvantages
Can be extremely costly to decentralize major services in an organization Some perceive the model as a way of reducing RNs and cutting costs in hospitals
5 Whys
A question asking method used to explore the cause/effect relationships underlying a particular problem The goal is to determine the ROOT CAUSE of a problem
Leadership
Ability to direct or motivate people to achieve a goal Have explicit or implied power Influences the beliefs, opinions, or behaviors of a person, group or groups of people Combines intrinsic personality traits, characteristics of the situation ¡Leadership Qualities ÷Unique personality characteristics ÷Dynamic, personable (people skills) ÷Exceptional clinical expertise ÷Communication skills ÷Problem solving skills ÷Self-evaluation skills
Management
All nurses that work with others essentially manages A good manager should also be a good leader Management role ¡Plan ¡Organize ¡Direct ¡Control resources ÷Human, material & financial resources ¡Involves problem-solving & decision-making ¡Maintain control of day-to-day operations ¡Manage change ÷Lewin's Change Theory ÷Unfreezing, Moving & Refreezing
Leadership and Management
Are intertwined concepts Are different Difficult to discuss one without the other "Nursing is over managed and under lead."
Members of the Healthcare Team
Patient & patient's family/significant others Physician Physician Assistant Nurse Advanced Practice Nurse Therapies (PT, OT, ST) Respiratory Therapy Dietician Pharmacist Discharge planner ¡Social worker ¡RN Unlicensed Assistive Personnel
QSEN Competencies
Based on IOM's Core Competencies Defines quality & safety competencies for nursing ¡Established 5 Core Competencies ¡Provide patient - centered care ¡Work in interdisciplinary teams ¡Employ evidenced - based practice ¡Apply quality improvement ¡Utilize informatics
Functional Nursing Advantage
Care can be delivered to a large number of patients Uses other types of health care workers when there is a shortage of RNs
Transformational Leadership
Challenges themselves & others to grow personally & professionally & to learn
Primary Nursing Model
Clearly delineates the responsibility an accountability of the rn Places the rn as the primary provider of care to pt Pt are assigned a primary care nurse They are responsible for developing the pt plan of care Other nurses caring for the pt follow this plan of care Pt are assigned to their primary nurse regardless of geographic
Concurrent evaluation
Conducted by using direct observation of nursing care, patient interviews and chart reviews to determine if criteria are met.
Total Patient Care Advantages
Consistency of one individual caring for patients an entire shift Enables development of pt and family trust Provides higher # of RN hours of care than other models The nurse has more opportunity to monitor the progress of the patient
Primary Nursing Disadvantage
Cost is higher due to the higher RN skill mix The person making the assignments needs to be knowledgeable about all the patients and staff to ensure appropriate matching of nurse to pt Lack of geographical barriers with the unit may require the nursing staff to travel long distances at the level to care for their primary pt Nursing time is often use in functions that could be completed by other staff Nurse to patient ratios must be realistic
Quality Improvement (QI) - the Next Step
Defined as "the commitment and approach used to continuously improve every process in every part of an organization, with the intent of meeting and exceeding customer expectations and outcomes." (Schroeder, 1994) Unlike QA, QI is: ¡internally driven ¡Focuses on patient care rather than organizational structure ¡Focuses on processes rather than individuals ¡Has no end points
ANA (2005) Critical Thinking and Delegation
Delegation A skill set that must be taught & practiced for the nurse to become proficient A process that involves professional development & application of critical thinking skills Reflect & review the steps you miss Learn from your mistakes Recognize issues that reduce your focus on work issues Participate in or lead discussions on clinical issues Participate in mentor/preceptor programs Develop educational plan Trust your intuition Use a model of creative thinking
Patient-Centered Care Model
Designed to focus on pt needs rather than staff needs All pt services are decentralized to the pt care Care teams are established for a group of pt The team includes all disciplines
Planned Change
Eight Step Process: Recognize a need for change Identify a problem to be solved through change Determine & analyze alternative solutions Select a course of action Plans for making a change Implement the course of action Evaluate the effects of change Stabilize the change
Benefits of delegation
Enhances skills & abilities of the delegate Builds self-esteem Promotes morale Enhances teamwork & attainment of the organization's goals
Nursing Case Management Model
Evolution of Case Management Case management is a model of care delivery in which an RN case manager coordinates the patient's care throughout the course of an illness. The concept of case management was first introduced in the 1970s by insurance companies as a method to monitor and control expensive health insurance claims, usually created by a catastrophic accident or illness (More and Mandell, 1997). Today, virtually every major health insurance company has a case management program to direct and manage the use of health care services for their clients. Case management by payer organizations (e.g., health insurance companies, health maintenance organizations [HMOs]) is known as external case management. The ANA has defined nursing case management as "a dynamic and systematic collaborative approach to providing and coordinating health care services to a defined population. It is a participative process to identify and facilitate options and services for meeting individuals' health needs, while decreasing fragmentation and duplication of care and enhancing quality, cost-effective clinical outcomes. The framework for nursing care management includes five components: assessment, planning, implementation, evaluation, and interaction" (ANCC, 2001, p. 1). Assessment. • Review the client's history and current status • Perform comprehensive health assessment • Identify available resources and support system (e.g., individual, family, financial, health insurance, community) • Identify barriers to accessing necessary treatment (e.g., lack of health insurance coverage; no family support) Assessment. Identify health promotion and disease prevention opportunities • Identify adherence patterns, educational needs, and ability to learn • Determine potential for overuse or under use of resources • Find, appraise, and use research findings as the basis for treatment decisions (evidence-based practice) Planning. Prioritize needs and set realistic, measurable goals and outcomes Identify realistic treatment options Coordinate various providers involved in the plan of care (e.g., physician, physical therapist, dietitian) Determine appropriate levels of care and realistic treatment settings (e.g., home, long-term care, rehabilitation facility) Identify and address gaps in care Ensure continuity of care Negotiate and manage financial aspects of care Implementation Ensure implementation of the care plan in a safe, timely and cost-effective manner Coordinate services and referrals to providers or agencies Ensure compliance with federal, state, and local regulations and standards Use appropriate community resources Document progress toward achieving goals and outcomes Accept accountability for implementation of the care plan Evaluation • Measure clinical goals, functional improvement, satisfaction with services and cost-benefit of treatment plan • Is/was the plan of care realistic, collaborative, and mutually beneficial to all involved? • Are/were the established time frames realistic? • Are/were the best possible and most cost-effective treatments used? • Are/were individual educational opportunities maximized? Interaction • Interact on a daily basis with diverse groups of people: client, family members, and significant others; health care team members; payer representatives; representatives from other health care agencies and community organizations • Motivate diverse groups to cooperate, collaborate, and work in the best interest of the client • Use good communication, negotiation, facilitation, and documentation skills. Nursing case management in a health care facility is a supplemental form of nursing care delivery and does not take the place of the nursing care delivery model in place to provide direct patient care. Case management is not needed for every patient in a health care facility and generally is reserved for the chronically ill, seriously ill or injured, and long-term, high-cost cases.
Collaborative Practice Model
Excellent pt. care relies on expertise of several care providers Promotes shared participation, responsibility & accountability
Evaluating Quality of Care
Formal and Informal mechanisms in place to ensure quality nursing care ANA Standards of Practice 7 & 8: #7 - Quality of Practice: the RN systematically enhances the quality and effectiveness of nursing practice #8 - Professional Practice Evaluation: the RN evaluates one's own nursing practice in relation to professional practice standards and guidelines, relevant statutes, rules, and regulations
Magnanimity
Giving credit where credit is due
Integrity
Having clear ethical principles and aligning one's actions with the stated values
Root Cause Analysis
Identifies needs for systems changes Is a process that is as impartial as possible As well as a tool for identifying prevention strategies There are various tools to use
Quality-Assurance Programs
In 1975, the American Nurses Association (ANA) developed a model quality-assurance program to be used within institutions. ANA model focuses on 3 essential components of quality care: Structure Evaluation: (audit) focuses on the environment in which care is provided Process Evaluation: focus in the nature & sequence of activities carried out by nurses implementing the nursing process Outcome Evaluation: focuses on measurable changes in the health status of the patient or the end results of nursing care. The critical element in evaluating care is demonstrable changes in a patient's health status.
Healthy Work Environments
In 2005, the American Association of Critical-Care Nurses (AACN) developed 6 essential standards for establishing & sustaining healthy work environments ¡Skilled Communication ¡True Collaboration ¡Effective Decision Making ¡Appropriate Staffing ¡Meaningful Recognition ¡Authentic Leadership
Nursing Leadership Roles
Patient care provider Patient advocate Case manager Clinical nurse leader Financial resource manager Collaborative team member ¡The nurse exhibits teamwork and collaboration when recognizing the contributions of other team members in helping the patient achieve health goals and when assuming the role of a team member or leader, depending on the situation.
Functional Nursing Care Delivery Model
In the functional nursing method of patient care delivery, staff members are assigned to complete certain tasks for a group of patients rather than care for specific patients. For example, the RN performs all assessments and administers all intravenous medications; the LVN/LPN gives all oral medications; and the assistant performs hygiene tasks and takes vital signs. A charge nurse makes the assignments and coordinates the care. Divides nursing work into functional roles that are then assigned to one fo the team members In this model each care provider is responsible for the specific task Technical rather than professional nursing care oftern results Decision making usually at the level of the charge nurse
Factors Prompting Change in the Healthcare Industry
Increased number of chronically ill and older people Increased role of government and industry in healthcare Rising cost of healthcare Changing patterns of healthcare delivery
Evaluative Programs
Regulatory agencies require nurses to document that nursing standards are being implemented & maintained. Agencies include: ¡State boards of nursing ¡The Joint Commission ¡The Professional Standards Review Organization ¡The National Health Planning and Resources Development Act of 1975
Qualities of effective leaders
Integrity, dedication, magnanimity, humility, openness, and creativity.
Functional Nursing Disadvantages
Lack of Continuity of care Pt may feel care is disjointed
Autocratic/Directive Leadership
Leader assumes complete control over decision making
Laissez-Faire/Non-Directive Leadership
Leader relinquishes power to the group
Quantum Leadership
Leading in the age of information
Team Nursing Advantages
Maximizes the role of the RN Nurse is able to get work done through others
Modular Nursing Model
Modular nursing is a modification of team nursing and focuses on the patient's geographic location for staff assignments. The patient unit is divided into modules or districts, and the same team of caregivers is assigned consistently to the same geographic location. Each location, or module, has an RN assigned as the team leader, and the other team members may include LVNs/LPNs and UAP (Yoder Wise, 1999). The concept of modular nursing calls for a smaller group of staff providing care for a smaller group of patients. The goal is to increase the involvement of the RN in planning and coordinating care. Communication is more efficient among a smaller group of team members (Marquis and Huston, 2000). To maximize efficiency, each designated module should contain all the supplies needed by the staff to perform patient care. May hear of it as modular nursing A kind of team nursing that divides a geographic space into modules of patient with each module having a team of staff lead by an RN to care for them Useful with decentralized nursing stations
Patient Centered Care Advantages
Most convenient for patients Expedites services to patients
Total Patient Care (Case Method) Delivery
Nurse is responsible for planning, organizing, and performing all care Common use areas—intensive care unit (ICU) and postanesthetic care unit (PACU) The oldest method of organizing patient care is total patient care, sometimes referred to as case nursing. In total patient care nurses are responsible for planning, organizing, and performing all care, including personal hygiene, medications, treatments, emotional support, and education required for their assigned group of patients during the assigned shift.
Why have Performance Improvement (PI)?
Nurses discover problems with the delivery of nursing care in their area of practice Each nurse must decide HOW to respond when he/she perceives that patient care is being compromised 4 Steps in Performance Improvement: ¡Discover a problem ¡Plan a strategy using indicators ¡Implement a change ¡Assess the change; if outcome is not met, then plan a new strategy
Quality Improvement
Outcome: improving quality rather than assuring quality Major premises of QI: ¡Focus on Organizational mission ¡Continuous improvement ¡Customer orientation ¡Leadership commitment ¡Empowerment ¡Collaboration/crossing boundaries ¡Focus on process ¡Focus on data and statistical thinking
Team Nursing Disadvantages
Patients often receive fragmented depersonalized care Communication is complex Shared responsibility and accountability can cause confusion and lack of accountability
Resistance to Change
People resist change for many reasons Threat to self Lack of understanding Limited tolerance for change Disagreement about the benefits of change Fear of increased responsibility Others???
To Determine if Delegation is appropriate, the RN will
Perform an assessment of the patient Develop a specific plan of care Analyze ¡Within the RN's scope of practice ¡Are rules, laws & regulations that support this delegation ¡Is the RN competent to perform the skill ¡Is the UAP competent to perform the skill ¡Is RN supervision available Monitor implementation of the delegated task as appropriate to the overall plan of care Evaluate pt.'s response to the delegated task Evaluate the UAPs skills & performance of tasks & provide feedback if needed
Change
Process of transforming or modifying something Planned, unplanned, developmental or ever-present
Primary Nursing Advantage
Pt and families are able to develop a trusting relationship with the nurse Accountability and responsibility of the nurse developing the plan of care with the pt and family are defined Facilitates continuity of care Authority for decision making is given to the nurse at the bedside
Principles for Delegation
RN takes responsibility & accountability for provision of care RN directs care & determines appropriate use of resources RN delegates task but not the nursing process RN considers agency policies/procedures RN delegates based on complexity of patient care & competency of person accepting delegation RN acknowledges concept of mutual respect Organization/agency provides resources to enable delegation Organization/agency ensures the RN access to competency information about other staff Organization/agency policies on delegation developed with RN participation
Qualities of Effective Managers
Self-belief Self-awareness Self-management Personal integrity A drive for improvement ¡Be focused on the patients rather than themselves to deliver quality, patient-focused care. ¡Desire to improve the status quo to provide higher levels of quality in the care delivered. A skill is a developed aptitude. ¡Skills are the tools by which a manager carries out the work. American Organization of Nurse Executives (AONE): ¡Communication and relationship building ¡Knowledge of the health care environment Leadership ¡Professionalism ¡Business skills
Democratic/Participative Leadership
Sense of quality between leader & followers
Quality-Assurance (QA) Programs
Specifically designed programs that promote excellence in nursing Range from small programs conducted by nurses on a unit to those developed for an institution, state or country. Enable nursing to be accountable to society for the quality of nursing care Also a response to the public mandate for professional accountability Ensure survival of the profession, encourage nursing's commitment to its moral and ethical responsibilities, and aid nursing in complying with other external pressures Two different approaches for ensuring quality: ¡Quality by inspection: focuses on finding deficient workers & removing them ¡Quality as opportunity: focuses on finding opportunities for improvement & fosters an environment that thrives on teamwork, with those sharing skills & lessons they have learned. Mistakes seen as a result of a problem in the system.
Openness
The ability to listen to other points of view without prejudging or discouraging them
Humility
The ability to recognize that no one is superior to another
Peer Review
This is the evaluation of one staff member by another staff member at the same level within the organization Mechanism used to improve professional performance May be formal or informal
Team Work & Collaboration
To Function effectively & achieve quality pt. care within nursing & inter-professional teams: ¡Open communication ÷Discuss effective strategies ÷Manage/Resolve conflicts ¡Mutual respect ÷Identify roles of team members ¡Shared decision making ÷Identify strengths & barriers
Total Patient Care Disadvantages
Utilizes a high number of RN staffing More costly than other models
Goal of the RCA
What happened? Why did it happen? What to do to prevent it from happening again
Delegation
is a tool that allows the delegator to spend more time on tasks that cannot be delegated.
Retrospective evaluation
may use post-discharge questionnaires, patient interviews (telephone or in person)or chart review to collect data
Nursing Audit
method of evaluating nursing care that involves reviewing patient records to assess outcomes of nursing care or the process by which these were achieved.
The delegator
retains accountability for the outcome
The delegate
the person who assumes responsibility for the actual performance of the task or procedure
Problem Solving & Root Cause
v When confronted with a problem most people like to tackle the obvious symptom and fix it v This often results in more problems v Using a systematic approach to analyze the problem and find the root cause is more efficient and effective Tools can help to identify problems that aren't apparent on the surface (root cause)
The Five Rights of Delegation
¡Task ¡Circumstances ¡Person ¡Direction/communication ¡Supervision/evaluation
Situational leadership
•changes approach depending on the situation •The situation includes a number of factors, such as characteristics of the group the type of business and the economic climate
