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Group 1 Questions for Test II 1.

What is Medicare A) The nations health insurance program for Americans age 65 and older, and for younger adults with permit disabilities (Medicare consist of four parts, each covering different benefits 2. What is Medicaid A) Its the nations publicly financed health and long-term care coverage program for low income people. 3. Medicare and Madicaid were established in 1965 4. Medicare Eligibility Requirements: a. Most people age 65 and older are automatically entitled to part A if they or their spouse are eligible for social security payments and have made payroll tax contributions for 10 or more year (40 quarters) b. Individuals entitled to part A and others ages 65 and older may elect to enroll in part A c. Individuals are eligible for part C or Medicare advantage, if they are entitled to part A and enrolled in part B d. Individuals are eligible for prescription drug coverage under a part d plan if they are entitle to benefits under part a and/or enrolled in part B 5. How to apply for Medicare? One should sign up to Medicare a couple of months before your 65th birthday; if not one has 3 months to enroll after the 65th birthday before an increase in premium is applied. One can apply through the Social Security Office. How to apply for Medicaid? One should apply through Medicaid 6. Medicaid Eligibility Requirements a. A person must meet financial criteria and also belong to one of the groups that are categorically eligible for the program b. Mandatory groups are: pregnant women and children under age 6 with family income below 133 % fpl (federal poverty level), children between 6 and 18 below 100 % fpl and parents below states July 1996 welfare eligibility levels and most elderly and persons with disabilities who receive SSI What does Medicare Cover? Medicare provides coverage of basic medical service including care in hospitals and other settings, physicians offices, diagnostic tests, preventative services, and outpatient prescription drug benefit. What does Medicaid Cover? Mandatory services: Physicians services, hospital services, laboratory and Xray, early and periodic screening, diagnostic and treatment service for individuals under 21, federally qualified health center and rural health clinic services, family planning services and supplies, pediatric and family nurse practitioner services, midwife services, nursing facilities services for individuals 21 and older, home health care for persons eligible for nursing facility services and transportation services. Medicare Advantage is also known as Medicare part C. Its a program that allows beneficiaries to enroll in private health plans to receive Medicare covering benefits. CHIP (Childrens Health Insurance Program) through Medicaid. Most States cover all children below 200% below federal poverty level. Medicare part A: Helps pay for inpatient care provided to beneficiaries in hospitals and short-term stays in skilled nursing facilities and also covers hospice care post-acute home health and pints of blood received at a hospital or nursing facilities.


8. 9. 10.

Medicare part B: Helps pay for outpatient services, physician visits and other medical services including preventative services such as Mamograms and colorectal screenings. Also covers ambulance services, clinical lab services, durable medical equipment (wheelchairs, oxygen), kidney supplies and services, outpatient mental health care and diagnostic tests as Xrays and MRIs. Medicare part C (Medicare Advantage)

Medicare part D: Helps pay for outpatient prescription drug coverage through private health plans. Each patient pays a monthly premium along with cost-sharing amounts for each prescription 11. Medicare is financed by tax-payers 12. Medicaid is financed through a partnership between the federal government and the states, so that federal government matches state spending on Medicaid. 13. Medicare cost the federal government $528 billion or 3.5% of the GDP 14. Medicaid costs the state of Florida each year $14,691 million. 15. Issues related to Medicare and Medicaid a. Costs b. Fraud c. Donut holes 16. Medicare expansion related to healthcare act: Under the new law beginning in 2014 a new individual mandate will require most individuals to obtain coverage. The major expansion of Medicaid in health reforms reliance of the program as the foundation for coverage of low income people give Medicaid both a much larger and a distinctively national coverage role going forward. 17. Medicaid 3 day emergency means that up to 3 days of Medicaid is available to pay for the cost of emergency services for aliens who do not meet citizenship alien status or social security number requirements. 18. States can offer more limited benchmark Medicaid benefits to some groups. Medicaid benefits can benefit considerably across the states. They define amount, duration and scope differently. Group 2 1) What are the 4 major payment methods used for reimbursement to providers of health care? Medicare, Medicaid, Employer Sponsored Insurance, Private Non-Group, Self-Pay - (Retrieved from Dr. Shermans Powerpoint) Health Insurance : For Profit or Nonprofit: BC/BS (some states) Types: HMO: Managed Care/Gatekeepers/Choice can be limited PPO, POS, MCO Co-pay Out of Network Deductable Issues: costs, pre-existing conditions, new mandate

o o o

Medicare/Medicaid Military Health Care: TRICARE, Veterans Affairs Other Federal Healthcare Programs

(Retrieved from Health Care Delivery Overview PowerPoint) 2) How is usual and customary charges determined? The Usual and Customary fee is defined as the charge for health care that is consistent with the average rate or charge for identical or similar services in a certain geographical area. To determine the Usual and Customary fee for a specific medical procedure or service in a given geographic area, insurers often analyze statistics from a national study of fees charged by medical providers, such as the data base profile set up by the Health Insurance Association of America (HIAA). Some insurers compile their own data using their own claim information. The insurers use these statistics to chart a range of fees for each geographical area in which services are provided. Then, when you submit your claim for a specific treatment or procedure, the insurer pays all or part of the claim, depending on whether the amount of the claim is within the Usual and Customary allowance. (Retrieved from 3) What is DRG- Diagnosis-related group (DRG) is a system used to classify hospital cases according to principal diagnosis, type of treatment, age, surgery and discharge status, such as death. (Source: Beaty, L. (2005). A primer for understanding diagnosis-related groups and inpatient hospital reimbursement with nursing implications. Critical Care Nursing Quarterly, 28(4), 360-369.) There are approximately 500 groups, also referred to as DRGs. They have been used in the United States since 1983. There is more than one DRG system being used in the United States, but only the MS-DRG (CMS-DRG) system is used by Medicare. PPS- Prospective Payment System- which uses DRGs used to determine how much money Medicare providers should be paid RBRVS -Resource based relative value scale- used to determine how much money Medicare providers should be paid. (Retrieved from Health Care Delivery Overview PowerPoint) 4) What is capitation? Fee paid to a provider organization for each person signed up for the plan whether that person uses any healthcare services. Global capitation = inclusion of all services, inpatient/outpatient + physician costs in the capitated amount. Capitation may also be limited and only include outpatient and physician costs. (Retrieved from Health Care Delivery Overview PowerPoint) Capitation is a payment arrangement for health care service providers such as physicians or nurse practitioners. It pays a physician or group of physicians a set amount for each enrolled person assigned to them, per period of time, whether or not that person seeks care. These providers generally are contracted with a type of health maintenance organization (HMO) known as an independent practice association (IPA), which enlists the providers to care for HMO-enrolled patients. The amount of remuneration is based on the average expected health care utilization of that patient, with greater payment for patients with significant medical history. Rates are also affected by age, race, sex, type of employment, and geographical location, as these factors typically influence the cost of providing care. 5) What is managed care? Strategies for Cost Control Limiting Hospital Costs Preferred Provider Contracts

Case Management Vertically integrated healthcare systems Contracted physicians, laboratories, hospital, sub-acute facility, rehab facility and home care agency Allows the contracting organization to offer managed care corporations a package that provides care at all levels for each enrolled member of the managed care plan for a capitated fee. (Retrieved from Health Care Delivery Overview PowerPoint) A strategy for cost control such as an HMO/PPO. Patient stays within a network of physicians. The physician is paid a capitated dollar amount per member per month manage individuals placing financial risk on providers. 6) Discuss profit vs. non-for-profit agencies and how they can spend their profit. Non-for-profit are state, property and sales tax exempt (Retrieved from 7) Discuss the implications of fee for service vs. capitation environment? Fee for service will potentially recommend additional procedures, visits because each service is charged for. Capitation may encourage healthcare providers focus more on preventative care versus more procedures/visits. Shifts greater share of risk of providing healthcare from 3rd party payer to provider organization and which may lead to unconscious or deliberate attempts to deny medical care in an effort to keep costs down. 8) How is nursing care billed for? Generally it is not itemized as a specific service/procedure. Good Sam does seem to charge for nursing care/services. 9) What is value based purchasing? It is a way that Medicare rewards high quality patient care. Based on how well each facility performs on each core measure and how much they improve on a measure, compared to a baseline period. It is designed to promote better clinical outcomes for patients and their experience during their stay. How does this impact nursing? Most of the core measures directly pertain to nursing care. (Retrieved from MLN/MLNProducts/downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdf) Look at Exercise 12-7 Group Ch 12: Budgets 1. Define operating, capital and cash budgets. Operating budget: A financial plan for day to day activities of an organization. Ex: Capital expenditure budget: A plan for purchasing major capital items such as equipment or a physical plant with a useful life greater than one year and exceeding a minimum cost set by the organization. Pg 242 Cash budget: Operating plan for monthly cash receipts and disbursements. Ex: paying bills. Pg 242 Cost center: An organizational unit for which costs can be identified and managed. P. 240 Unit of Service: A measure of the work being produced by the organization such as patient days, patient or home visits, or procedures. P. 284 FTEs: Full time equivalent. An employee who works full time 40 hours per work or 2080 hours per year. Pg. 285 Productive hours: Paid time that is worked. P 240

Nonproductive hours: Benefit time such as vacation or sick time. Pg 240. Capital expenses: The purchases for capital expenditure budget. Pg 242 Variance: Anything that alters a patients progress through a normal care path. Pg 243 Productivity: the ratio of outputs to inputs or in nursing terms, of services to resources used to provide services. Pg 245 3. What are fixed costs vs. variable costs in a hospital/unit. Pg 237 Costs that do not change as the volume of patients changes (expenses related to rent loan payments, administrative salaries, and salaries of the minimum amount of staff to keep a unit open must be paid. Variable costs: costs that vary in direct proportion to patient volume or acuity (nursing personnel, supplies, and medications). 4. Review exercise 12-15 Yoder, p. 244. Examine table 12-3 and identify major budget variances for the current month. Are they favorable or unfavorable? What additional information would help you explain the variances? What are some possible causes for each variance? Are the causes you identified controllable by the nurse manager? Why or why not? Is a favorable variance on expenses always desirable? Why or why not? Review of Exercise 12-15 p. 244, using table 12-3 Identify major budget variances for current month -Everything but Clerical/technical and Office operating expenses is unfavorable

Additional information that would help explain the variances: -Nurse managers need reliable data about pt census, acuity, and LOS, payroll reports, and unit productivity reports. -factors that cause variance- patient census, pt acuity, vacation and benefit time, illness, orientation, staff meetings, workshops, employee mix, salaries and staffing levels. -Nurse manager's can control some, but not all factors that cause variance

What the nurse manager can control -Nurses and nurse managers directly influence an organization's ability to make a profit -At minimum a nurse manager controls personnel and the supply and expense part of the operations budget. -Include things like: pt census (what unit pt is sent to), vacation and benefit time, orientation, staff meetings, workshops, employee mix, staffing levels. -Can cut budget in one area to increase budget in another

-Is a favorable variance on expenses always desirable? No, having a favorable variance (under budget) may indicate cutting corners and result in undesirable patient outcomes

Group 4: Review for Exam 2: National Patient Safety Goals, TJC Core Measures, Florida Hospital Records 1) Venous Thromboembolism (VTE) a. Examples: a.i. VTE Prophylaxis

a.iii. VTE Patients with anticoagulation overlap therapy monitoring by protocol

a.ii. ICU VTE Prophylaxis

a.iv. VTE patients receiving unfractionated Heparin with dosages/platelet count a.v. VTE discharge instructions

2) Emergency Department a. examples Incidence of potentially-preventable VTE

a.ii. median Time from ED arrival to ED departure for admitted ED ptsoverall 3) Surgical Care Improvement Project: a. Examples a.i.

a.i. Admit decision time to ED departure time for admitted pts

rate, reporting measures, observation patients, psychiatric/mental health pts

a.ii. Urinary catheter removed on Postoperative Day 1 (POD 1) or Postoperative Day 4) Substance Use: a.i. 2 (POD 2) with day of surgery being day zero

Antibiotics given prophylactically one hour before surgery

a. Examples

a.ii. Alcohol and Other Drug Use Disorder Treatment Provided or Offered at 5) Tobacco Treatment: a. Examples: discharge.

Alcohol use screening

6) Pneumonia Measures a. Examples:

a.ii. Tobacco use treatment provided or offered

a.i. Tobacco use screening

a.i. Blood Cultures Performed Within 24 Hours Prior to or 24 Hours After Hospital Arrival for Patients Who Were Transferred or Admitted to the ICU Within 24 Hours of Hospital Arrival

a.ii. Blood Cultures Performed in the Emergency Department Prior to Initial a.iii. Initial Antibiotic Selection for CAP in Immunocompetent ICU Patient Antibiotic Received in Hospital

7) Immunization

a. Examples:

8) Acute Myocardial Infarction

a.ii. Influenza immunization

a.i. Pneumococcal Immunization to high risk populations (age 6-64)

a. Examples:

a.iii. Adult smoking cessation counseling 9) Childrens Asthma Care a. Examples: a.iv. Statin prescribed at discharge

a.ii. ACEI or ARB for LVSD

a.i. Aspirin at arrival

10) Heart Failure

a.ii. Home management plan of care given to patient/parent at discharge

a.i. Use of relievers for inpatient asthma

a. Examples:

11) Hospital-based Inpatient Psychiatric Services a. Examples:

a.iii. Smoking cessation counseling

a.ii. ACEI or ARB for LVSD

a.i. Evaluation of LVS function

a.iii. Admission screening for violence risk, substance use, psychological trauma 12) Perinatal Care history and patient strengths completed

a.ii. Hours of seclusion use

a.i. Hours of physical restraint use

a. Examples:

13) Stroke

a.iii. Exclusive breast milk feeding

a.ii. Cesarean Section

a.i. Elective delivery

a. Examples:

14) Hospital Outpatient Department a. Examples:

a.iii. Thrombolytic therapy

a.ii. Anticoagulation therapy for a-fib/flutter

a.i. VTE prophylaxis

a.iii. Aspirin at arrival

a.ii. Fibrinolytic therapy received within 30 minutes

a.i. Median time to fibrinolysis

a.iv. Median time to ECG

Question 2: 15) When were the national patient goal established? The Joint Commission established its National Patient Safety Goals (NPSGs) program in 2002, which became effective January 1st 2003. These goals were established to help organizations address specific areas of concern in regards to patient safety. Areas include: Ambulatory health care, behavioral health care, critical access hospitals, home care, general hospital areas, lab services, long term care, Medicare/Medicaid long term care, and office-based surgery. 16) How do the goals compare from 2012-2013? In 2012 TJC added another NPSG which was set to

target catheter-associated urinary tract infections in the critical access and hospital areas. The purpose was to implement evidence based practice to prevent such infections. The NPSG for 2013 include indentifying patients correctly, improving staff communication, using medications safely, preventing infection, identifying patient safety risks, and prevention of mistakes during surgery. All of these areas have specific targeted goals within them. **Compare the goals (2013) for ambulatory care and behavioral health: Ambulatory Care 17) Identify patients correctly a. Use 2 ways to identify patients (i.e. using patients name and DOB to ensure that patient gets the correct medicine and treatment)

18) Use medicines safely

a. Before a procedure, label medications that are not labeled (i.e. meds in syringes, b. Take extra care with patients who take blood thinners taken by the patient discharged medicine cups, and basins)

c. Know which medications the patient is taking and compare these with new medications d. Make sure patient knows which medications they should continue taking when e. Educate the patient to always have an up-to-date list of current medications a. Use the CDC or WHO guidelines for hand cleaning and use these goals to improve hand b. Use proven guidelines to prevent infection after surgery a. Ensure that the correct surgery is done on the correct patient and at the correct place on b. Mark the correct place on the patients body where the surgery is to be done c. Pause before the surgery to make sure that a mistake is not being made Behavioral Health A. Identify clients correctly a. Use 2 ways to identify clients (i.e. name and DOB to ensure that each client gets the correct medicine and treatment) the patients body cleaning

19) Prevent infection

20) Prevent mistakes in surgery

B. Use medicines safely

a. Know which medications the patient is taking and compare these with new medications b. Make sure patient knows which medications they should continue taking when c. Educate the patient to always have an up-to-date list of current medications a. Use the CDC or WHO guidelines for hand cleaning and use these goals to improve hand discharged taken by the patient

C. Prevent infection

D. Identify client safety risks

b. Use proven guidelines to prevent infection a. Find out which clients are most likely to try to commit suicide


The NPSG (2013) for behavioral health and ambulatory care are extremely similar. This is a big step in some differences in regards to patient safety due to the patients risks. Home Care Goals

the right direction to have these areas of health care on the same page. Of course, behavioral health has

Identify patients correctly- Use at least two ways to identify patients. For example, use the patients name and date of birth. This is done to make sure that each patient gets the correct medicine and treatment. Use medicines safely-Record and pass along correct information about a patients medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a

doctor. Prevent infection-Use the hand cleaning guidelines from the Centers for Disease Control and Prevention or the World Health Organization. Set goals for improving hand cleaning and use the goals to improve hand cleaning. Prevent patients from falling-Find out which patients are most likely to fall. For example, is the patient taking any medicines that might make them weak, dizzy or sleepy? Take action to prevent falls for these patients. Identify patient safety risks-Find out if there are any risks for patients who are getting oxygen. For example, fires in the patients home. Hospital goals Identify patients correctly-Use at least two ways to identify patients. For example, use the patients name and date of birth. This is done to make sure that each patient gets the correct medicine and treatment. Make sure that the correct patient gets the correct blood when they get a blood transfusion. Improve staff communication- Get important test results to the right staff person on time. Use medicines safely-Before a procedure, label medicines that are not labeled: for example, medicines in syringes, cups and basins. Do this in the area where medicines and supplies are set up. Take extra care with patients who take medicines to thin their blood. Record and pass along correct information about a patients medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor.

Prevent infection-Use the hand cleaning guidelines from the Centers for Disease Control and Prevention or the

World Health Organization. Set goals for improving hand cleaning. Use the goals to improve hand cleaning.

Use proven guidelines to prevent infections that are difficult to treat. Use proven guidelines to prevent infection of the blood from central lines. Use proven guidelines to prevent infection after surgery. Use proven guidelines to prevent infections of the urinary tract that are caused by catheters. Identify patient safety risks-Find out which patients are most likely to try to commit suicide. Prevent mistakes in surgery-Make sure that the correct surgery is done on the correct patient and at the correct place on the patients body. Mark the correct place on the patients body where the surgery is to be done. Pause before the surgery to make sure that a mistake is not being made. Comparison Identify patients correctly-same in hospitals and home care. Use medicines safely- same in hospitals and home care. Prevent infection- same in hospitals and home care. Prevent patients from falling-non existing in hospitals just in home care. Identify patient safety risks-on homecare is focus on oxygen usage and risk for fire while in the hospital the focus is on risk for suicide. Prevent mistakes in surgery-non applicable in home care settings.

**Discuss Florida's hospital records- in the annual report by TJC.

The Joint Commission created a list that states the 'Top Performers' for specific measures. The list is divided by individual states and is further broken down by specific hospitals. The measures include heart attack, heart failure, pneumonia, surgical care, children's asthma, hospital-based inpatient psychiatry, stroke, and venous thromboembolism (VTE). Various hospitals are listed for Florida, and a visual comparison is presented in the TJC annual report. No hospital listed for Florida was a 'Top Performer' in the areas of children's asthma, stoke, and VTE. Only one hospital in Florida was a 'Top Performer' in the area of hospital-based inpatient psychiatry. Most hospitals listed for Florida met the criteria to be a 'Top Performer' in the areas of heart attack, heart failure pneumonia, and surgical care. ort_quality_safety_2012/ **Article Reveiw: Masica, A., Richter, K., Convery, P., & Haydar, Z. (2009). Linking Joint Commission inpatient core measures and National Patient Safety Goals with evidence, Baylor University Medical Center Proceedings, 22 (2), 103-111. The article by Masica, Richter, Convery and Haydar titled Linking Joint Commission inpatient core measures and National Patient Safety Goals with evidence aims to emphasize the evidence link between hospital-based core measures and safety goals as they relate to patient outcomes (103). The 2008 Joint Commission hospital core measures and Joint Commission National Patient Safety Goals were used to develop the evidence. Because the data is so extensive, it is difficult to understand and often not utilized by clinicians; therefore, the authors aimed to create a one page reference card that summarizes the information. The focus was limited to 10 areas felt to be of major importance to hospital-based clinical staff (104). The core measures used included myocardial infarction management, heart failure management, pneumonia management (community-aquired and ventilator associated), surgical site infection prevention, prevention of central line-associated bloodstream infection, prevention of falls, DVT prophylaxis, medication reconciliation and prevention of adverse drug events, rapid response team use, and transitional

care planning. Each core measure is followed by a few bullet-points on the appropriate interventions and impact of each intervention on patient outcomes. The supportive evidence given for core measures and selected safety goals is meant to facilitate delivery of evidencebased practices to the bedside (108).
GROUP 5 ARTICLE REVIEW: Health Information Technology in the workplace: Findings from a 2010 national survey of registered nurses The study examines RNs experiences with health information technology (HIT) and perceptions of this technologys effect on quality of care. Survey of 1500 nurses (analysis was on 532 nurses) o RNs in hospitals had more access to HIT than those in outpatient settings o Majority of nurses felt the use of HIT made quality of care better o Study showed that RNs working in hospitals with a higher level of HIT functionality do not spend more time documenting o RNs had an overall positive impression about the effect of HIT on their daily work. o However, older nurses are significantly less positive then younger nurses about the use of HIT (both in its effect on quality and daily work)

ARTICLE REVIEW: The Effect of Hospital Electronic Health Record Adoption on Nurse-Assessed Quality of Care and Patient Safety The study examined the effects of using an electronic health record (EHR) and quality of care. Nurses working in hospitals with full EHR implementation reported significantly less unfavorable outcomes. Medication errors and fair/poor quality of care were reported less frequently. 21 of the 316 hospitals used fully implemented EHRs Nurses working in hospitals with at least a minimally functioning EHR were more likely to report nursing excellence and quality improvement efforts. The evidence is mixed regarding the impact of EHRs on quality of care. ARTICLE REVIEW: THE SOFTER SIDE OF NURSING Nurses fear that technology is going to take over nursing care, but technology actually helps nurses better care for their patients. Software translates data into information and with hardware that improves the way nurses collect the data. 1.Counteracting human errors Ex. Handwriting errors 2.improving human behavior performance management-helps monitoring length of pt stay, pt and physician satisfaction, pt falls, and computerized physician entry compliance mapping outcomes to practice- computers are able to recognize medical jargon. But the language of nursing is not recognized.- downfall education-work and teach at the same time 3. by putting nurses where they can be most effective- allows nurses to document faster and leaves more time to care for patients. Example-. Telemetry monitoring-constantly monitored patient so you dont have to take vital signs all day long>>>leaves more time to care for patient. Example-Increase opportunities to communicate with patient and other staff members

Technology enables compassion, does not replace it. Nurses will not be replaced by technology, only helped by it. Technology goes beyond efficiency in healthcare to actually help nurses provide better care. IT reinforces rather than destroys the unique and intangible quality of caring in nursing. Many nurses feel as though they will be replaced by a computer. Only a human can care, but a machine can help a nurse care. It can help improve care in three ways: counteracting human error, improving human behavior, and putting nurses where they can be most effective. It does this with software that translates data into information and with hardware that improves the way nurses collect that data. Technology helps to eliminate mistakes derived from handwriting. It also uses alerts and reminders to create systems of clinical checks and balances. In light of the nursing shortage, it reduces the administrative burden that creates overworked, error-proned nurses. The best way to eliminate human-induced errors is by improving human behavior. IT can help in several ways including: performance management, mapping outcomes to practice, and education. Performance management involves the monitoring of patient satisfaction, patient falls, and length of stay. Mapping outcomes to practice involves the use of a specific nursing language. IT enables data to be transcribed into practice. Education involves the use of distance learning to stay up-to-date with current practice. IT allows nurses to document faster and thus, provides more time for caring. DESCRIBE 3 TYPES OF TECHNOLOGY 1) Biomedical Technology a. Involves the use of equipment in the clinical setting for diagnosis, physiologic monitoring, testing or administering therapies to patients (p. 199) b. Examples i. Physiologic Monitoring: measure heart rate, blood pressure, and other vital signs (p. 199) ii. Diagnostic Testing: ABG, Pulmonary Function Tests, ECG, Glucose monitoring (p. 200) iii. IV Fluid and Medication Administration: automatic dispensing cabinets reduce medical errors (but only when safeguards are available and used). The institute for Safe Medication Practices has developed guidelines for safest use of ADCs. IV Smart pumps, Advanced pressure monitoring, (p. 200) iv. Therapeutic Treatments: administered via implantable infusion pumps, used to regulate intake and output, regulate breathing, assist with newborn care, mechanical ventilators 2) Information Technology a. Entails recording, processing and using data and information for the purpose of delivering and documenting patient care (p. 199) b. Examples i. Patient Care Databases, Faster/More accurate than humans (p. 200-201) 3) Knowledge Technology a. The use of expert systems to assist clinicians to make decisions about patient care. In nursing, these systems are used to mimic the reasoning of nurse experts in making patient care decisions (p. 199) b. Examples i. Clinical Decision Support Systems (CDSS): interactive computer programs designed to assist health professionals with decision-making tasks by mimicking inductive or deductive reasoning of a human expert. Basic components of CDSS: include knowledge base and inferencing mechanism, which is usually a set of rules derived from the experts and EBP (Box 11.5, p. 212). Benefit: help novice nurse make a decision at an expert level

DEFINE INFORMATICS AND CLINICAL DECESION SUPPORT SYSTEMS (CDSS) 1) Informatics a. Science that combines a domain science, computer science, information science and cognitive science (p. 208) b. Healthcare informatics in interdisciplinary, and focuses on the care of patients rather than on a specific discipline c. Model: Figure 11.1 p. 209 2) CDSS a. See above DISCUSS THE NURSING MINIMUM DATA SET (NDMS) What is the i-NMDS? The i-NMDS includes the core, essential, minimum data elements to be collected in the course of providing nursing care. The i-NMDS provides a framework for collecting information to describe and examine nursing practice, nursing resources and selected healthcare problems. The i-NMDS was built on the efforts already underway in individual countries. Why is the i-NMDS Important? The contribution of nursing care and nurses is essential to health care globally. It is imperative that local, national and international health care infrastructures support the collection and reuse of nursing data. The i-NMDS as a key data set will support: Describing client health status, nursing interventions, care outcomes, and resource consumption related to nursing services Improving the performance of health care systems and the nurses working within these systems worldwide Enhancing the capacity of nursing and midwifery services Addressing the nursing shortage, inadequate working conditions, uneven distribution and inappropriate utilization of nursing personnel Focusing on the challenges as well as opportunities of global technological innovations Testing evidence-based practice improvements; and Contributing to improved public health

Defining i-NMDS Elements: The i-NMDS project is under the auspices of the International Council of Nurses (ICN) and the International Medical Informatics Association Nursing Informatics Special Interest Group (IMIA NI-SIG). Project work is also coordinated with international standards organizations and other stakeholders to assure harmonization of these efforts. Building on the Nursing Minimum Data Set work of Werley and Lang (1988), the i-NMDS project has identified a framework with three categories of data elements: (a) setting; (b) patient demographics; (c) nursing care. Data elements are identified within each of the three categories. 1. Setting: agency location, ownership of facility, country system of payment, clinical service type, care personnel (number, gender, training and education, full time equivalent for types of personnel), and ratio of patients to personnel. care episode start and stop dates, country of residence, clinical service type, discharge status, year of birth, gender, and reason for admission.


Patient demographics:


Nursing care:

Nursing diagnoses, nursing interventions, patient outcomes, and intensity of care.

Along with building on the work already underway in individual countries, the i-NMDS Project is intended to build on and use the International Classification for Nursing Practice (ICNP), an ICN Programme. ICNP concepts can be used to represent the i-NMDS nursing care elements: nursing diagnosis, intervention and outcome. Overall, the i-NMDS can be used to coordinate international data collection and analyses of relevant nursing information to support the description, study, and improvement of nursing practice. How can you participate? A number of countries have expressed interest in participating in the i-NMDS project. There is an effort to organize country-based project teams consisting of a representative of the ICN member national nurses association, a representative of IMIA-NI (if applicable), and other experts. Project teams are listed on the iNMDS web site: . The i-NMDS work is coordinated through the Center for Nursing Minimum Data Set Knowledge Discovery, located at the University of Minnesota School of Nursing, USA. The Centre, accredited by ICN as an ICNP Research and Development Center, provides administrative and resource support for the advancement of the i-NMDS. Group 6 1. What factors should you consider when developing a staffing pattern? L&M,pg 273-274 Staffing involves planning for hiring, and deploying qualified human resources to meet the needs of a grp of pts. It is the primary responsibility of the nurse mgr. to ensure that safe and cost-effective care is provided by the appropriate level of caregiver. There is increased focus on nurse mgr. accountability for establishing and monitoring effective and efficient staffing systems. The acuity or severity of patients conditions, influenced by their age , primary diagnosis, comorbidity, and treatment stage, is a key component in determining the staff requires for safe care. Patient classification systems have been developed to tools and language to describe acuity levels.

2. Patient classification systems Discuss types and usage for staffing. L&M,pg 275 There are two basic types of patient classifications: 1. Prototype Evaluation System Considered both subjective and descriptive Classifies into broad categories to predict pt. needs Example: Relative Intensity Measures (RIM) classifies by Diagnosis Related Group (DRG) 2. Factor Evaluation System More objective evaluation system Each task, thought process, and pt/ care activity is given a time or rating Summing / weighting of these findings determine the hours of direct care required Combination of these systems is typically used Prototype - patients with a single healthcare focus (maternal deliveries, outpt. Surgical) Factor- pts. needing more complex care, or less predictable disease course (pneumonia, stroke).

3. What is the national database of nursing quality indicators? NDNQI is a national nursing quality measurement program that provides hospitals with unit level performance comparison reports for state, national, and regional percentile distributions. These nursing

sensitive indicators reflect the structure, process, and outcomes of nursing care. They demonstrate that RNs make the critical cost effective difference in providing safe, high quality patient care. The indicators include nursing staff skill mix, nursing hours per patient day, assault/injury rate, catheter associated UTIs, central line associated bloodstream infections, fall rates, hospital acquired pressure ulcer prevalence, peripheral IV infiltrations, pain assessment, restraint prevalence, RN education, RN surveys, ventilator associated pneumonia, and voluntary nurse turnover. 4. From the article An Increase in the Number of Nurses with Baccalaureate Degrees is Linked to Lower Rates of Postsurgery Mortality. By 2020 want to have 80% of nurses to have BSN. As of 2008 only 45% did. In 2003 the first study demonstrated that hospitals with a higher proportion of BSN nurses had lower patient post surgical mortality and failure to rescue rates. Studies have linked a BSN prepared nurses with increased ongoing patient surveillance. Nurses were surveyed in 1999 and 2006. Data measured for nurses included degree earned, number of patients cared for on last shift, number of years working as an RN. These were totaled for each hospital. Longitudinal study conducted at hospitals in PA. Data was obtained for patients aged 20-85 who were hospitalized for a DRG of general, vascular, or orthopedic surgery. Outcomes of interest were patient mortality within 30 days of admission and failure to rescue, meaning that the patient died of a development that could have been resolved but was not. These characteristics were looked at for patients in 1999 and 2006 and were totaled by hospital. In both years the avg. patient age was 60. Found that with a ten point increase in a hospitals percentage of nurses with a BSN there was a reduction of 2.12 deaths per 1,000 patients. If you look at the subset of patients with complications that number becomes a reduction of 7.47 deaths per 1,000 patients. The average number of patients per nurse was 5.7 with almost all hospitals falling within 1 patient of that. There was no significant difference between 1999 and 2006. This study did not find a change in mortality related to staffing which the researchers attribute to the very small variation of staffing overall. The implication is that if PA hospitals had increased the percentage of BSNs by 10% between 1999 and 2006 500 lives would have been saved in just the set of patients in for general, vascular, or orthopedic surgery. 5. Discuss external factors that influence staffing pattern (pg 278-279) a. Licensing regulations of the state: Regulations can relate to the minimum number of nurses required at a time b. National organizations

1. Joint Commission (TJC)- establishing standards and survey accreditation processes to support performance improvement 2. American Osteopathic Association (AOA) 3. Center for Accreditation of Rehabilitation Facilities (CARF) 4. Accreditation Association for Ambulatory Healthcare (AAAHC) 5. Det Norske Veritas (DNV) 6. National Committee for Quality Assurance in Behavioral Health 7. Community Health Accreditation Program 6. Differentiate between mandatory overtime and overtime (pg 280) a. Mandatory overtime- requiring staff to stay on duty after the shift ends to fill staffing vacancies. The ANA opposes it because it is a risk to patients and nurses b. Overtime- requesting staff to stay on duty to fill staffing vacancies No employment consequences after saying no Lots of research shows fatigue is associated with errors

7 - discuss ANA/FNA position statement on floating to other units "Patient safety: rights of RNs when considering a patient assignment" states that accepting such a floating assignment can place the nurse in jeopardy of caring for patients for which the nurse is not adequately prepared. When floating staff is necessary nurses should be assigned to comparable clinical areas. RNs have the right to refuse any patient assignment that could put themselves or the patient at risk for serious harm. 8. Forecasting Unit staffing Requirements pg 283 Consider the following : Projected units of service (productivity targets) Historical staffing requirements Effectiveness of the current staffing plan Trends in acuity on the unit Anticipated skill mix or other personnel changes Experience and education of the staff New physicians, programs, services or technology anticipated to affect staffing Patient outcomes Need for educational updates driven by changes in patient care guidelines Developing a scheduling plan (pg 285) Creating a flexible schedule with a variety of scheduling options that leads to work schedule stability for each employee is one mechanism that is likely to retain staff and is within the control of nurse managers. Variables to consider (pg 287) Hours of operation Shift rotations Weekend rotations Vacations and holidays , leaves of absence Continuing education time Number of part time employees 9 . When projecting FTE (Full time equivalents) consider: (pg 284) direct care hours used to care for the care of patients indirect care hours used to pay for other required unit activities, such as staff meetings or continuing education attendance productive time the paid hours that are actually worked on the unit (can be direct or indirect) Nonproductive time hours of benefit that are paid to an employee for vacation, holiday, personal, or sick time. *Nurse managers need to carefully allocate the budgeted FTEs into fulltime and part time positions to meet the staffing requirements for the unit when a portion of the staff is taking paid time off

10. Discuss the various types of schedules (pp285-286) a. Decentralized scheduling- the nurse manager prepares the schedule in isolation from all other units. b. Advantages: accountability rests in the managers, who are the ones responsible for the productivity of the unit in the first place. Disadvantages: cant see the big picture among various units Staff self-scheduling- staff makes their own schedule according to their needs Advantages: promote staff autonomy, team communication, problem-solving, negotiating skills, and increase staff accountability.


Disadvantages: need to be properly managed with staff and patient needs Centralized scheduling- a staff coordinator oversees all schedules in patient care units. Advantages: staffing coordinator usually is aware of the abilities, qualifications, and availability of the supplemental personnelalso the budget Disadvantages: limited knowledge of coordinator to patient acuity needs

11. Critical thinking exercise: Nurse Whitney has been promoted to nurse manager of a NICU. She has a lot going on and leaves work exhausted.

1. The problems in the scenario are she is overworked and has too much going on to complete everything adequately, leaving her exhausted. 2. This is a problem because she cannot complete her work and is so spread out what she does complete is probably not her best work. Since she leaves every day both physically and emotionally exhausted, she will probably burn out soon and maybe even leave nursing. She is so overwhelmed patient safety can become an issue because she cannot pay as much attention to the staff nurses, such as the one a physician voiced concern about. 3. First, she needs to take time to analyze her situation and figure out how to approach it in a better way. Afterwards, she can meet with her superiors and discuss her situation and stressors. 4. Nurse Whitney should asses and analyze why the night charge nurse and nursing supervisor are arguing and how to come to an agreement. She also needs learn more about the patient care concern issue and find a solution for it. The nurse causing concern from the surgeon should also be addressed on a one-to-one basis to learn more about the situation and how to solve it. For the night shift, relief staffing needs to be called in and the schedule should be analyzed to find any potential staffing problems. 5. Nurse Whitney is being stressed by the long hours at work, bombardment of phone calls and e-mails, the disagreements among her staff, patient care concerns, staffing shortages, giving tours for potential donors, and rushing to complete reports for the chief nursing officer. 6. When the nurse manager is stressed, it rubs off on the other staff members around her, causing more disagreements and the nurses to be more on edge. 7. Strategies to control stress include open communication between her and her staff as well as her and her supervisors. Also, she needs to have a plan on when to set aside specific time for getting organized so she can decrease that stress. She needs to find a few minutes of her day to take a break and reduce her stress so she does not leave as emotionally and physically exhausted. It is important to take care of self, especially for nurse managers overwhelmed with the needs of everyone else.

Group 7 (Chapter 19)

Definitions of terminology: 1. Collective Action- p.373 defined as activities that are undertaken by a group of people who have common interests. 2. Collective bargaining- p. 381 is the performance of the mutual obligation of the employer and representatives of the employees to meet reasonable times and confer in good faith with respect to wages, hours, and other terms and conditions of employment or the negotiation of any agreement or any question arising from those terms and conditions.

3. Arbitration- (dictionary) the use of an arbitrator (an independent person or body officially appointed to settle a dispute) to settle a dispute. 4. Bargaining unit- p.382 Box 19-4 ( specific group of employees who are covered by the same collective agreement or set of agreements and represented by the same bargaining agent or agents 5. Good faith bargaining- generally refers to the duty of the parties to meet and negotiate at reasonable times with willingness to reach agreement on matters within the scope of representation; however, neither party is required to make a concession or agree to any proposal. Discuss the National Labor Relations Act & The Taft-Hartley Act National Labor Relations Act Pg 381: National Labor Relations Act is also known as the 1935 Wagner Act administrated by the National Labor Relations Board (NLRB) established election procedures for employees to be able to choose their collective bargaining representatives freely. 1947 Taft-Hartley Act pg 381: placed curbs on some union activities excluded employees of not for profit hospitals from coverage but an amendment removed this restriction, giving these employees the same rights as industrial workers to join together and form labor unions. The removal of the exemption created a frenzy of activity as traditional industrial unions targeted healthcare facilities. Discuss shared governance Shared Governance is described as a democratic, egalitarian concept; it is a dynamic process resulting from shared decision making and accountability. The basic principles of shared governance include partnerships, equity, accountability, and ownership. It is more accurate to say that shared governance demands participation in decision making rather than provides for participation. (ch 19..pg377) Discuss the various types of bargaining units representing nursing Collective bargaining refers to the unionization of nurses and healthcare workers in an effort to secure reasonable and satisfactory conditions of employment, including the right to participate in decisions regarding their practice (p. 381). Bargaining units include various entities formed by participating members who work together to advocate for common goals whether or not they have formed an actual union. Bargaining units in nursing are formed when passionate nurses come together to work towards achieving a common goal. Suggestive criteria for selecting a bargaining unit includes as follows; - A strong commitment to nursing practice, legislation, regulation, and education - A well prepared practice, policy, and labor staff; a minimum of a bachelors degree in nursing - Representative of those the bargaining unit represents in both gender and ethnic makeup - National scope and local implementation - Control by individual members over bargaining unit activities [taken from pg. 382 box 19-4] Discuss whistle blower and at will employee (pg. 383-384) Federal employees are protected by the 1989 Whistle Blower Protection Act meanwhile workers in the private sector are not guaranteed any protection from raising awareness regarding wrong doing or harmful practices implemented within an organization. At will employees are individuals working without contractual obligations to their employer and are highly vulnerable to experiencing termination of their employment in the instance that they voice concerns about the practices occurring in the facility they are employed by. State and federal legislation require that termination not be based on discriminatory practices but offer no further protection for continuance of employment not otherwise negotiated by previous contractual agreements.

Discuss the federal whistle blower law and state laws (p. 383) Federal whistle blower law: the 1989 Whistleblower Protection Act protects federal workers. It does not cover the private sector. State laws: Some states have specific laws about whistleblower protection Group 8: Resource: Chapter 20 1. Define: - Quality management a corporate culture emphasizing customer satisfaction, innovation, and employee involvement and quality improvement activities. Often used interchangeably with total quality management, continuous quality management, quality improvement, and performance improvement. - Quality improvement an ongoing process of innovation, prevention of error, and staff development used by an organization that has adopted a quality management philosophy. - Performance improvement the application of quality improvement principles on an ongoing basis. - Total quality management a comprehensive program designed to achieve perfection and quality of care. - Continuous quality improvement a comprehensive program designed to continually improve the quality of care. - Quality assurance a process that focuses on the clinical aspects of a providers care, often in response to an identified problem. - Sentinel events a serious, unexpected occurrence involving death or injury such as suicide, infant abduction, or wrong site surgery. - Benchmarking best practices, processes, or systems identified by a quality improvement team to be compared with the practice, process, or system under review. 2. Discuss the customer service model in healthcare - Consumer relationships in healthcare delivery refers to the multitude of encounters between the consumer (client, patient, or customer) and healthcare system representatives. - Customer Care Modelo Implemened through patient survey, o Hospital Consumer Assessment of Healthcare Providers and Systems- HCAHPS. - Survey measures: o The HCAHPS Survey is composed of 27 items: 18 substantive items that encompass critical aspects of the hospital experience (communication with doctors, communication with nurses, responsiveness of hospital staff, cleanliness of the hospital environment, quietness of the hospital environment, pain management, communication about medicines, discharge information, overall rating of hospital, and recommendation of hospital); four items to skip patients to appropriate questions; three items to adjust for the mix of patients across hospitals; and two items to support congressionally-mandated reports. - Reductions in reimbursement for HCAHPS score compared to other facilities- up to 2 %. 3. What is the QI process? - Quality improvement is an ongoing process of innovation, prevention of error, and staff development used by an organization that has adopted a quality management philosophy. - The QI process is a structured series of steps designed to plan, implement, and evaluate changes in healthcare activities and most parallel the nursing process. - Steps in the QI Process: Identify needs most important to the consumer of healthcare services Assemble a multidisciplinary team to review the identified consumer needs and services Collect data to measure the current status of these services Establish measurable outcomes and quality indicators Select and implement a plan to meet outcomes Collect data to evaluate the implementation of the plan and the achievement of outcomes 4. Review standard nursing outcomes resources:

ANA Standards of Care/Practice o The nurse collects comprehensive data pertinent to the patients health or situation o The nurse analyzes the assessment data to determine the diagnoses or issues o The nurse identifies expected outcomes for a plan individualize to the patient or the situation o The nurse develops a plan that prescribes strategies and alternatives to attain expected out comes o The nurse implements the identified plan of care o The registered nurse coordinates care delivery. o Health teaching and health promotion o The nurse evaluates progress towards attainment of outcomes o Code of Ethics The ANA collaborates with other healthcare associations depending on the specialty to publish the best quality and standards of care for nursing practice. Ex. Pediatric nursing: scope and standards of practice is a collaboration with the ANA, the Society for Pediatric Nurses, and the National Association of Pediatric Nurse Practitioners. This is used as a reference and guideline in reviewing nurse practice. TJC TJC developed patient education standards that impacts individuals and organizations. If hospitals dont comply with the standards, they can face financial disadvantages. TJC has developed the National Patient Safety Goals as a way to optimize patient care. o The company updates its accreditation standards and expands patient safety goals on a yearly basis, and posts them on its Web site for all interested persons to review, making this information and process transparent to all stakeholders ranging from institutions, to practitioners, to patients and their advocates. The purpose of The Joint Commissions National Patient Safety Goals is to promote specific improvements in patient safety. The Goals highlight problematic areas in health care and describe evidence and expert-based solutions to these problems. Recognizing that sound system design is intrinsic to the delivery of safe, high quality health care, the Goals focus on system-wide solutions, wherever possible.[27] The NPSGs have become a critical method by which The Joint Commission promotes and enforces major changes in patient safety in thousands of participating health care organizations in the United States and around the world. The 2009 NPSGs include new regulations targeting the spread of infection due to multidrug-resistant organisms, catheter-related bloodstream infections (CRBSI), and surgical site infections (SSI). The new regulations for CRBSI and SSI prevention apply not only to hospitals, but also to ambulatory care and ambulatory surgery centers. Engaging patients in patient safety efforts is also a major new component of the NPSGs

ANCC Nurses are required to have 150 continuing education hours. The reasoning behind this is to ensure that nurses have additional experience in their field. Therefore, with the additional experience, there will be better patient outcomes. Agency for Healthcare Research and Quality o The Agency for Healthcare Research and Quality's (AHRQ) mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. o They provide evidence based practice guidelines. Health care practitioners can follow these guidelines for implementation into their clinical practice. o Sources for these guidelines are: The National Guideline Clearinghouse (NGC), an AHRQ initiative, is a publicly available database of evidence-based clinical practice guidelines and related documents. Created in 1984, the U.S. Preventive Services Task Force (USPSTF or Task Force) is an independent group of national experts in prevention and evidencebased medicine that works to improve the health of all Americans by making

evidence-based recommendations about clinical preventive services such as screenings, counseling services, or preventive medications. o Guide to Clinical Preventive Services, 2011-2012 This new pocket guide is an authoritative source for making decisions about preventive services. - NANDA Nursing diagnoses can be labeled using NANDA-I. These diagnosis labels represent clinical judgments about actual or potential health problems. Each diagnosis contains a definition, major and minor defining characteristics, and related factors. Accurate nursing diagnoses guide the selection of nursing interventions to achieve the desired treatment effects, determine nursingsensitive outcomes, and ensure patient safety (p. 400). Group 9 List laws passed in 2012 o Random Florida laws passed in 2012 related to various organizations about things such as board members, financing, tasks force, rabies vaccinations, and insurance. Over 30 list laws were passed in one session. o Relating to Nursing Home Facilities- Revises provisions relating to other needed services provided by nursing home facilities, respite care, adult day & therapeutic spa services. Defines day for purposes of day care. o Relating to background screening- revises exemptions from background screening requirements for certain mental health personnel & law enforcement officers, elimination of staggering of rescreening schedule o Relating to Department of health- Revised purpose of DOH, duties of state surgeon general, eliminated officer of womens health strategy & Florida Drug, Device & Cosmetic Trust Fund. 2 or more counties may combine county health dept operation, DOH must be responsible for state public health system, requires DOH provide leadership for partnership with government, etc. No effective date listed. Box SB612 o Florida bill requiring disclosure of yourself as DO or NP when you have a PhD/doctorate degree. o Health Care Practitioners; Requiring that certain health care practitioners make specified disclosures when introducing themselves as "doctor" when rendering health care, etc. Effective Date: October 1, 2013 o Still not passed, not a criminal offense Box 10-1 & 10-3 o 10-1: Power Strategies for nursing leaders- Basically display comportment, take initiative and have a moral compass. o 10-3: Developing Political Skills- Become an advocate, be proactive, get involved, become aware, join organizations that take part in politics. Take the political astuteness inventory where are you? o Astuteness based on how politically active- registered to vote, knowing your representatives, how to contact them, their stance, and the implications of decisions o Most of us were completely unaware Group 10 Questions- Exam 2 1. Types of healthcare organizations Page 118 Purpose Primary Entry into system, health maintenance, long term care, chronic care, treatment of temporary nonincapacitating malfunction Organization or unit providing services Ambulatory care centers, physicians offices, preferred provider organizations, nursing centers, independent provider organizations, health maintenance organizations, and school health clinics

Secondary Tertiary

Prevention of disease complications Rehabilitation and long term care.

Home healthcare, ambulatory care centers, nursing centers Home healthcare, long term care facilities, rehab centers, skilled nursing facilities, assisted living programs/retirement centers

2. A) The accrediting body: Page 121 - Joint Commission: provides accreditation for ambulatory care, behavioral health care, acute care and critical access hospitals, laboratory services long term care, and hospital based surgery. Their purpose according to the Joint Commision website is To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. - The National Committee for Quality Assurance (NCQA): a non-profit organization that accredits, certifies, and recognizes a wide variety of healthcare organizations. B) The purpose of accrediting bodies: Page 124 a. They set standards for the operations of healthcare organizations, ensure compliance with federal and state regulations developed by governmental administrative agencies, and investigate and make judgments regarding complaints brought by consumers of the services and public. 3. A) Models of nursing care delivery: Functional nursing: Page 251-253 A method of providing patient care by which each licensed and unlicensed staff member performs specific tasks for a large group of patients. o Nurse managers role: main responsibility is achieving patient outcomes, budgetary constraints, and quality of patient care delivery. Their role is viewed as autocratic o Staff RN: becomes skilled at the tasks that are usually assigned by the charge nurse. Team nursing: Page 254-255 a modification of functional nursing that was devised to improve patient satisfaction. care through others is the hallmark of team nursing. o Nurse manager: must determine which RN is skilled and interested in becoming charge nurse or team leader. Provide an adequate staffing mix and orient team members, a liaison between team leaders and other professionals, they delegate. o Staff RNs: use the strengths of each caregiver and develop expertise in care delivery. Primary nursing: Page 255-258 An adaptation of the case method. One RN functions autonomously as the patients primary nurse. Responsible for patient care from admission to discharge. o Nurse manager: They must be able to identify which nurses want to be primary nurses. They function as a role model, advocate, coach, and consultant. o Staff RN: caregiver, advocate, decision maker, teacher, collaborator, manager. Since they cant be present 24 hours a day they have to depend on associate nurses. Nursing case management: Page 259-261 the process of coordinating healthcare by planning, facilitating, and evaluating, interventions across levels of care to achieve measurable cost and quality outcomes. o Role of manager Page 261: They facilitate interdepartmental communications. They also oversee case management to ensure that the clinical pathway is diagnosis-related group (DRG) appropriate and that case management is adequately managing their case loads. o Role of staff RN Page 261: This is the nurse working with the patients. They also must ensure that they are providing care that the case manager specifies. They must know the extent of the case managers role. Must have effective communication. 4) Article by Martins

The objective of this research is to understand the experiences of homeless people with the health care system. The design was a descriptive phenomenological study. Interview were conducted and analyzed. The most common acute ailments in the homeless population are upper respiratory infections, trauma, parasites, and skin ailments. Lacerations and wounds are the most common traumas, followed by sprains and fractures. Malnutrition and vitamin deficiencies are also observed. Environmental risk factors such as cold temperatures make homeless people more susceptible to frostbite and hypothermia 4 major themes emerged: (1) living without essential resources compromises health; (2) putting off health care until a crisis arises; (3) encountering barriers to receiving health care to include (a) social triage, (b) feeling labeled and stigmatized, (c) a nonsystem for health care for the homeless, (d) being treated with disrespect, and (e) feeling invisible to health care providers; and (4) developing underground resourcefulness. Conclusions and Implications: Although homeless persons articulated many problems in the health care system encounters, they also described their own resourcefulness and the strategies they employ to manage being marginalized by society and the health care system. An increased understanding of health care experiences from the homeless persons perspective can guide public health nursing emancipatory actions. 5) Discuss the clinical nurse leader role (yoder-wise) Table 13.1: Fundamental aspects of the clinical nurse leader Leadership in the care of the sick in and across all environments Design and provision of health promotion and risk reduction services for diverse population Provision of evidence-based practice Population-appropriate heath care to individuals, clinical groups/units, and communities Clinical decision making Design and implementation of plans of care Risk anticipation Participation in identification and collection of care outcomes Accountability for the evaluation and improvement of point of care outcomes Mass customization of care Client and community advocacy Education and information management Delegation and oversight of care delivery and outcomes Team management and collaboration with other health professional team members Development and leverage of human, environment, and material resource Management and use of client0care and information technology Lateral integration for specified group of patients

6)Transformed care at the bedside. Page 265 Box 13.2 (Yoder-Wise) -Patient-centered work redesign can create value added care processes and result in better clinical outcomes and reduced costs. -Effective care teams to improve patient outcomes. -Management practices and organizational culture significantly impact work environment -Matching staff's competence to work responsibilities to increase employee job satisfaction. -Improve efficiency through work redesign to increase the satisfaction and morale of staff. Box 13-3 -Reliability: The care for moderately sick patients in the hospital is safe, reliable, effective, and equitable. -Vitality: Effective care teams thrive for excellence in a joyful, supportive, and nurturing environment that lends to professional and career development. -Patient-centeredness: Patient centered care on medical/surgical units that honors the whole patient and family, respects values and choices, and ensures continuity of care. -Increased values: All care processes are free of waste and continuous flow is promoted.

Health care delivery systems Model of care: give meds all day is fx, ex relate to nursing style Healthcare del- put off care until crisis arises Table 13.1 p 265 Be aware of what a CNL means/roles Laws passed Quality mgmt. terms- matching Group 8: matching terms Ch 22: consumer relations Customer service (want high patient survey) TJC- edu standards.. make sure facilities are following the standards Patient safety advisory group Accreditation means better pt outcomes NANDA- helps develop care plans and interventions Collective bargaining ANA position statement about floating (legal and ethical issues)-Nurses should only be assign to units they are familiar in Know 3 types of scheduling (group 6) 3 types of tech (group 6) p 199 MDS Box 11.8 and 11.2 Know medicare (all 4 parts) and Medicaid- what are they for for both Reimbursement Value based purchasing- Sherman ppt Team 3: budgets, terminology need to know: fix cost in hospitals Team 2: national pt safety goals 2013