Chapter 20

Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 20Chapter 20Application of Theory in Application of Theory in

Nursing Administration and Nursing Administration and Management Management

Chapter 20Chapter 20Application of Theory in Application of Theory in

Nursing Administration and Nursing Administration and Management Management


Organizational Design Organizational Design • Work specialization

– Each step of the process performed by a different individual

– Efficient in use of worker skills

– May lead to boredom and low productivity

• Chain of command

– Line of communication and authority

– Employees should be responsible to only one supervisor.


Organizational Design—(cont.) Organizational Design—(cont.)

• Span of control

– Refers to the number of employees directed by a manager

– In nursing, managers should have 6 to 50 direct reports.

• Authority and responsibility

– Line authority—chain of command, superior–subordinate relationship; direct line

– Staff authority—support and advise work of line managers but don’t report to higher management


Organizational Design—(cont.) Organizational Design—(cont.) • Centralization vs. decentralization

– How decision making is dispersed or diffused throughout the organization

• Centralized decision making—Decisions are made by a person or small group at the top of the organizational structure.

• Decentralized decision making—Decisions are made a lowest levels feasible.

• Departmentalization

– Subdivides the work of the organization

– Allows for specialization of work


QuestionQuestion

Tell whether the following statement is true or false:

In centralized decision making organizations, decisions are made by a person or small group at the top of the organizational structure.


AnswerAnswer

True

Rationale: In organizations with centralized designs, most decisions are made by the chief administrators or a small group or board.


Shared GovernanceShared Governance

• “A structural model through which nurses can express and manage their own practice with a higher level of professional autonomy” (Porter-O’Grady, 2003).

• In nursing, professional nurses use self-directed work teams at the unit level to make professional practice decisions and to accomplish the work of the unit.

• Decentralized organizational structure requires participation of team members.


Shared Governance—(cont.) Shared Governance—(cont.)

• Models

– Councilor model—uses a coordinating council to integrate decisions made by staff and managers in subcommittees that report to coordinating council

– Administrative model—two tracks: managerial track and clinical track; both tracks include managers and staff.

– Congressional model—uses democratic process to empower nurses to vote on issues


Shared Governance—(cont.) Shared Governance—(cont.)

• Implementation of shared governance can take time and be expensive.

• Long-term savings can be seen.

• Can improve the work environment of nurses leading to increased satisfaction and improved retention


Transformational Leadership Transformational Leadership

• Creates vision

• Provides framework for generating commitment to the vision and establishing identity with the organization

• Develops and sustains organizational trust

• Attends to the self-esteem of those in the organization


Transformational Leadership—(cont.) Transformational Leadership—(cont.)

• Focus on relationships and develop personal skills

• Coordinate, integrate, and facilitate (rather than leading and controlling)

• Try to build coalitions and networks to move toward a shared vision or goal

• Focus on inspiring sense of commitment to the organization

• Are perceived to have strong ethical and moral character and are willing to take risks


Transformational Leader StrategiesTransformational Leader Strategies

• Know the people you work with.

• Help people learn and develop.

• Provide frequent feedback about performance.

• Award responsibility and status to coworkers.

• Reward coworkers for job well done.

• Make information available to all involved.


Patient Care Delivery Models Patient Care Delivery Models

• Total patient care (functional nursing)

– Most patients are assigned to nurses; one nurse attends to all of the patient’s needs during the shift.

– Patient care may be more efficient, and little confusion about responsibilities.

– May use a hybrid model with RN and unlicensed assistive personnel


Patient Care Delivery Models—(cont.) Patient Care Delivery Models—(cont.) • Team nursing

– Tries to reduce fragment care—RN is a team leader. Team may include:

• Other professional or technical nurses and aide

• Team is responsible for care of a group of patients.

– Team leader coordinates the group and assigns specific care requirements.

– Duties that cannot be performed by team member may be performed by team leader.

– Focuses on patients and their needs

– Requires considerable planning and coordination


Patient Care Delivery Models—(cont.)Patient Care Delivery Models—(cont.)

• Primary nursing

– Assigns each patient a “primary/professional nurse” who is responsible for planning and providing care to a group of patients

– When the primary nurse is not on duty, another RN would be responsible based on that care plan.

– Strong job satisfaction and improved continuity of care

– Requires a number of RNs and high degree of coordination


Patient Care Delivery Models—(cont.)Patient Care Delivery Models—(cont.)

• Patient-centered care

– Principles of PCC derived from quality improvement models.

– Goal is to decrease the number of health care workers needed and increase the time nurses spend with patients.

– Cost of care should decrease; quality of care should increase.


Patient Care Delivery Models—(cont.)Patient Care Delivery Models—(cont.)• Patient-centered care—principles

– Patient redeployment

– Support services decentralization

– Worker cross-training

– Creation of interdisciplinary teams

– Patient involvement

– Task simplification


ANCC Magnet Recognition ProgramANCC Magnet Recognition Program

• Originated as a result of a policy study by the AAN in 1983 to identify characteristics common among hospitals that could successfully recruit and retain good RNs

• Characteristics were termed “Forces of Magnetism.”


ANCC Magnet Recognition Program—(cont.)ANCC Magnet Recognition Program—(cont.)

• The Magnet Recognition Program was developed by the ANCC to recognize health care organizations that provide exemplary nursing care.

• Serves as a method to disseminate successful best practices and strategies in nursing among institutions

• Magnet hospitals provide solutions to address nurse recruitment and retention and improve nursing leadership.


ANCC Magnet Recognition Program—(cont.)ANCC Magnet Recognition Program—(cont.)

• Magnet recognition program is based on quality indicators and standards of nursing practice.

• Magnet model components

– Transformational leadership

– Structural empowerment

– Exemplary professional nursing practice

– New knowledge, innovations, and improvements

– Empirical quality results


Case Management Case Management

• Case management is “a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual’s health needs through communication and available resources to promote quality cost-effective outcomes” (CMSA, 202).


Case Management—(cont.)Case Management—(cont.)• Case management is a role developed in the 1980s in

response to the PPS and DRGs.

• It is an expansion of the total patient care system and was originally community based.

• Case managers serve as the liaison between patients and families, health plans, care providers, and purchasers to determine the extent of coverage and coordinate treatments.


Case Management—(cont.) Case Management—(cont.)

• Impenitent case management—models

– New England Medical Center Model—focuses on managing patient care to control resources

– St. Mary’s (or Carondelet) Model—Case manager is used to control costs associate with patient stays and reducing length of stay with optimal patient outcomes.


Case Management—(cont.) Case Management—(cont.)

• Typically, cases managers are assigned to groups of high-risk patients within a specific population (e.g., pediatric oncology, adult transplant).

• Case manager coordinates care from preadmission and often beyond discharge.

• Case managers may be employed by hospitals, HMOs, insurance companies, and disease management companies.


Disease ManagementDisease Management

• Disease management is “a patient care approach that emphasizes comprehensive, coordinated care along a disease continuum and across health care delivery systems.”

• It is proactive approach to providing health care services.


Disease Management—(cont.)Disease Management—(cont.)

• Evidence-based method to identify individuals with chronic illnesses who are at high risk of experiencing serious health problems and to provide early intervention to avoid or minimize these problems

• Typical diagnoses/candidates for DM

– AIDS

– CHF

– Some cancers

– Diabetes


QuestionQuestion

Which of these cases would be most appropriate for disease management?

A.A 7-year-old male with asthma

B.A 35-year-old male with AIDS

C.A 62-year-old female with an acute MI

D.An 86-year-old female with a hip fracture


AnswerAnswer

B. A 35-year-old male with AIDS

Rationale: Although all of the individuals might benefit from DM services, disease management is most for those individuals who are at very high risk for experiencing serious health exacerbations but promoting comprehensive, coordinated care across health care systems.


Quality ManagementQuality Management

• Key principles focus on:

– Customer: Quality is defined in terms of what is acceptable to the customer.

– Process improvement: efforts/steps taken to examine and improve work processes

– Variance analysis: monitoring and analysis of variations to routine systems and processes

– Scientific methods are used to statistically review variance and determine type of variation.


Quality Management—(cont.) Quality Management—(cont.)

• Key principles focus on—(cont.)

– Leadership: understanding of concepts and techniques of quality improvement and promoting involvement of all personnel

– Employee involvement: All members of the organization should be educated related to QM.

– Benchmarking: organized, planned methods and processes to identify, adapt, and disseminate best practices


Evidence-Based Practice (EBP) Evidence-Based Practice (EBP)

• EBP—problem-solving approach that enables clinicians to provide highest quality care through:

– Critical appraisal and critique of the most recent and relevant research

– Consideration of clinician’s clinical expertise

– Consideration of patient preferences and values

• To implement EBP in an institution, there must be support and commitment for administrators


QuestionQuestion

Which of the following is NOT a key principle of Quality Management?

A.Analysis of variations to routine processes

B.Attention to process improvement

C.Provider-defined quality

D.Use of organized methods and processes to disseminate best practices


AnswerAnswer

C. Provider-defined quality

Rationale: In quality management models, quality is defined by the customer.

Health & Medicine

Chapter 20