Nursing Leadership & Management

Patricia Kelly-Heidenthal 0-7668-2508-6

Delmar Learning
Copyright 2003 Delmar Learning, a Thomson Learning company

Chapter 14
First-Line Patient Care Management
Delmar Learning
Copyright 2003 Delmar Learning, a Thomson Learning company

Objectives

Upon completion of this chapter, the reader should be able to:

Define first-line patient care management. Discuss elements of strategic planningphilosophy, mission, vision. Define nursing shared governance. Identify Benners concepts of novice, advanced beginner, competent, proficient, and expert nursing practice. Identify accountability-based care delivery systems. Identify measures of a units performance.
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Introduction

First-line patient care management is the coordination of resources and clinical processes at the point of service delivery. First-line patient care management uses the nursing process to plan, implement, and evaluate the outcomes of care for populations of patients as opposed to individual groups of patients.

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Strategic Planning

Strategic planning is a process designed to achieve goals in dynamic, competitive environments through the allocation of resources.

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Unit Strategic Planning

Unit or departmental strategic planning begins with examination of the external environment, both independent of and through the lens of the larger organizational system of which the unit/department is a member. The group developing the unit strategic plan must examine the impact that the external environment will have on the particular unit.

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Unit Strategic Planning

The group must also examine the internal environment that supports the work unit to determine the state of the human resources, clinical systems, support services, information infrastructure, and finances available to deliver care. Unit strategic plans should be consistent with and support the mission, vision, strategic plan, and annual operating plan of the organization of which they are a part.
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Philosophy Based on Values That Drive Unit Practice

A philosophy is a statement of beliefs based on core valuesinner forces that give us purpose. A units mission and vision is most authentic if it is developed based on the philosophy or core beliefs of the work team. A units core beliefs or values should be incorporated into the units mission and vision statements.

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Mission Statement

Mission is a call to live out something that matters or is meaningful. An organizations mission reflects the purpose and direction of the health care agency or a department within it. A mission statement has three elements:
A mission statement is no longer than a couple of sentences. It states the units purpose using action words. It should be simple and from the heart.
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Vision Statement

A unit vision statement describes how the mission of the unit within an organization will be actualized. A vision statement includes four elements:
A vision statement is written down. It is written in present tense, using action words, as if it were already accomplished. It covers a variety of activities and spans broad time frames. It addresses the needs of providers, patients, and environment in a balanced manner that anchors it to reality.
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Goals and Objectives

The work unit develops broad strategies that span the next three to five years, and then develops annual goals and objectives to meet each of these strategies. Goals are written as specific aims or targets that the unit wishes to attain within the time span of one year. Objectives are the measurable steps to be taken to reach each goal.

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Structure of Professional Practice

In an organization where professional nursing practice is valued, development and implementation of strategic initiatives is most effectively carried out through a structure of shared governance and shared decision making between management and clinicians.

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Shared Governance

Shared governance is an organizational framework based on the idea of decentralized leadership that fosters autonomous decision making and professional nursing practice. It implies the allocation of control, power, or authority (governance) among mutually (shared) interested vested parties.

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Shared Governance

In most health care settings, vested parties in nursing fall into two distinct categories:
Nurses practicing direct patient care, such as staff nurses Nurses managing or administering the provision of that care, such as managers

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Shared Governance

Clinical Practice Council: the purpose is to establish the practice standards for the work group. Quality Council: the purpose is to credential staff and to oversee the unit quality management initiatives. Education Council: the purpose is to assess the learning needs of the unit staff and develop and implement programs to meet these needs. Research Council: At the unit level, this council advances research application with the intent of incorporating research-based findings into the clinical standards of unit practice.
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Shared Governance

Management Council: this council ensures that the standards of practice and governance agreed upon by unit staff are upheld and that there are adequate resources to deliver patient care. Coordinating Council: the purpose is to facilitate and integrate the activities of the other councils. This council usually facilitates the annual review of the unit mission and vision, and develops the annual operational plan.
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Competency/Professional Staff Development

Competency is defined as possession of the required skill, knowledge, qualification, or capacity. Competency of professional staff can be ensured through credentialing processes developed around a clinical or career ladder staff promotion framework. Clinical ladders acknowledge that staff members have varying skill sets based on their education and experience.
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Benner's Novice to Expert

There are five progressive stages of Benners model of nursing practice:

Novice: task-oriented and focused Advanced beginner: demonstrates marginally acceptable independent performance Competent: has been in the same role for two to three years; demonstrates conscious, deliberative planning Proficient: perceives situations as wholes as opposed to a series of tasks Expert: intuitively know what is going on with patients
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The Process of Professional Practice: Situational Leadership

Situational leadership maintains that there is no one best leadership style, but rather that effective leadership lies in matching the appropriate leadership style to the individuals or groups level of taskrelevant readiness. Readiness refers to how able and motivated an individual is to perform a particular task.

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The Process of Professional Practice: Situational Leadership

A leader should help followers grow in their readiness to perform new tasks by adjusting leadership behavior through four styles along the leadership curve:
Telling Selling Participating Delegating

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Accountability-based Care Delivery

Accountability-based care delivery systems focus on roles, their relationship to the work to be done, and the outcomes they are intended to achieve. Competence is evidenced not by what a person brings to the work, but instead by the results of the application of the persons skills to the work.

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Primary Nursing

In a primary nursing model, one nurse is accountable for the care a patient receives during a given episode of care. She functions through associate nurses during the hours of the day when she is not present in the workplace. The hallmark of primary nursing is that one nurse maintains 24-hour accountability for a specific patients care.
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Patient-focused Care

Patient-focused care is a model of differentiated nursing practice that emphasizes quality, cost, and value. The first-line patient care manager takes on an expanded role, assuming accountability to manage nurses and staff from other departments. The focus has expanded to include overseeing the coordination of all care activities required by patients and their support systems.
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Case Management

The primary goal of case management is to deliver high-quality patient care in the most cost-effective way by managing human and material resources. Secondary goals are to:
Manage the delivery of care within a given time frame Decrease length of stay for inpatient care Ensure appropriate use of services and resources Improve continuity of care Standardize the care delivered for a given diagnosis Improve patient outcomes from a given episode of care
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Measurable Quality Outcomes

Regular evaluation of a units performance to ensure that the outcomes of care delivery are meeting the objectives of professional practice as outlined in the units annual operational plan is an important component of first-line patient care management. The development of process improvement measures in todays health care organizations is driven by the standards of quality required by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the National Council for Quality Assurance (NCQA).
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Unit-based Performance Improvement

To develop a comprehensive unit-based quality improvement program, the first-line patient care manager should track outcomes from four domains:
Access Service Cost Clinical quality

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Population-based Quality Improvement

In todays health care environment, organizations are able to track their aggregate performance in caring for select populations of patients against evidence-based standards of care. Quality compass:
Functional status Clinical outcomes Cost and utilization Patient satisfaction
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