PATIENT CARE DELIVERY

How can a care delivery system be effective?

LEADERSHIP ROLES AND MANAGEMENT FUNCTIONSIN ORGANIZING PATIENT CARE

LEADERSHIP ROLES
•Periodic evaluation of the organizational structure
•Adequate resources and support
•Examines human element in work redesign and provide support
•Inspires team effort
•Inspires subordinates to achieve higher levels
•Ensures chosen nursing care delivery models advance the practice of professional nursing

Leadership roles
Encourages and supports the use of nursing care delivery models
Congruence b/n the organizational mission, philosophy and PCDS
Assures that each member in I/MT participates in team planning
Assures that the patient and family are the focus of PCD

MODALITIES OF CARE
TRADITIONAL PATIENT CARE DELIVERY METHODS
Disadvantage of Total Patient Care
 Caregiver can theoretically modify the care regimen
 Patient could receive 3 different approaches
 Maybe costly (requires highly skilled)
 Inadequately prepared or inexperienced caregiver
 RNs provider of total patient care –early days
 Now, some hospitals assigns > LVNs, LPNs

Disadvantage of Functional Nursing

 Quality care and holistic care are not the highest priority
 Fragmented care > overlooking patient priority needs
 Can result to low job satisfaction
 May not be cost effective due to the need of many coordinators.
Disadvantages of Team Nursing
 Improper implementation rather than with philosophy itself
 TL > good communication, organizational, management and leadership

Know what?
 Most TEAM NURSING was never practiced in its purest form but was
instead a combination ofteam and functional structure.
MODULAR NURSING
 Mini-team (two or three members with at least one member being an RN)
 Modular Nursing team sometimes called, care pairs
 Patient care units are typically divided into modules or districts
 Assignments are based on geographical location of patients.
 Requires less communication, allowing better useof their time for direct patient care
activities

PRIMARY NURSING
•Relationship-based nursing
•Developed in 1960's
•Used some concepts of total patient care
•Brings back RN back to bedside to provide clinical care.
•Many experts suggested that the role ofprimary nurse should be limited to RNs"PRIMARY
NURSING CAN SUCCEED WITH A DIVERSE SKILL MIX JUST AS TEAM NURSING OR ANY OTHER
MODEL CAN SUCCEED WITH AN ALL-RN STAFF" -Manthey (2009)
•Originally designed for use in hospitals
•Hospice nursing and other outpatient health-care delivery enterprises
•Clear communication among patients, nurses, associate and team members
•Direct patient care allows holistic, high-quality patient care.
•Although high in jobsatisfaction>difficult to implement➢Degree of responsibility and
autonomy required of the primary nurse.
INTERPROFESSIONAL/MULTIDISCIPLINARY HEALTH CARE TEAMS
•New Model of health-care delivery system
•Interdisciplinary teamwork
•Complex process involving two or more health professionals with
complementary backgrounds and skills
•TM share common health goals in assessment, planning, evaluation
•Interdependent collaboration, open communication and shared decision
making
•Melding clinical expertise from each team member to best serve patients.

Disadvantages of Challenges
•Each discipline may believe that theirperspective is most important and undervalue the
contributions of other team members.
•Requires efficient means of communication

CASE MANAGEMENT
•Proposed to meet patient needs
•(CMSA, 2017) "Collaborative process of assessment, planning, facilitation, care coordination,
evaluation and advocacy for options and services to meet individual's and family's
comprehensive health needs through communication and available resources to promote
quality, cost-effective outcomes"
•Reserved for advance practice nurse or RN with advanced training

Disadvantages to Case Management Model

•Implementation challenges associated with case management revolved around
CONFUSION related to the specific job of the case manager because case management
entails different roles and functions in different settings.
Evidence-Based Practices in Nursing

Evidence-Based Approach
❑Research based or science based
❑Evidence based means that the approach has been reviewed by expertsin
the field using accepted standards of empirical research and that reliable
evidence exists that the approach or practice works to achieve the desired
outcomes.
❑PICO-Patient or population,Intervention, Comparison, Outcome
❑Best practices in nursing care and decision making are alsoevidence-
based practices (Prevost & Ford, 2020).

National Nursing Core Competency Standards (NNCCS)

Three(3) major roles of nurses:
Beginning Nurses' Role in Client Care
Beginning Nurses' Role in Leadership and Management;
Beginning Nurses' Role in Research
Can be applied to the practice of professional nurses and can serve as a guide for nursing
specialty practice.
2012 National Nursing Core Competency Standards (NNCCS)

2012 National Nursing Core Competency Standards (14 Responsibilities)

Beginning Nurse's Role in Client Care
•Practice in accordance with legal principles and code of ethics in making personal and
professional judgement
•Utilizes the nursing process in the interdisciplinary care of clients that empowers the clients
and promote safe quality care.
•Maintains complete, accurate and up-to-date recording and reporting system.
•Establishes a collaborative relationship with colleagues and other members of the team to
enhance nursing and other health care services.
•Promotes professional and personal growth and developmet.

Beginning Nurse's Role in Leadership & Management

 Demonstrates management and leadership skills to provide safe and quality care.
 Demonstrates accountability for safe nursing practice.
 Demonstrates management and leadership skills to deliver health programs and services
effectively to specific client groups in the community setting.
 Manages a community-village based health facility component of a health program or
a nursing service.
 Demonstrates ability to lead and supervise nursing support staff.
 Utilizes appropriate mechanisms of networking, linkage building and referrals.

Beginning Nurse's Role in Research

 Engage in Nursing or health related research with or under the supervision of an
experienced researcher
 Evaluates a research study/report using guidelines in the conduct of a written research
critique.
 Applies the research process in improving patient care in partnership with a quality
improvement/quality assurance/nursing audit team.

Philippine Professional Nursing Practice Standards (PPNPS)

Nursing Practice Standard Domains
PRBON and its Technical Working Group (TWG) continually worked on the competency
standards by refining the set of competencies and the indicators of performance using the
following four (4) domains:
•Value-Based Nursing Practice
•Knowledge-driven Nursing Practice
•Outcome-oriented professional relationship
•Leadership and Governance

Value-based Nursing Practice Standards

1. Care of clients
2. Ethical, moral and legal practices
3. Personal and professional values

Care of Clients
1. Provides quality and safe nursing care utilizing the nursing process
2. Demonstrates appropriate knowledge and skills based on the health/illness statusof
individual, families, population groups and/or communities.
3. Provides sound decision makingin the care of individuals, families, populations groups and
communities considering their beliefs and values.
4. Promotes client safety.
5. Set priorities in nursing care based on client's needs.
6. Implements sound nursing care to achieve identified client outcomes.
7. Ensures continuity of care.
8. Participatesin quality improvement activities

Ethical, Moral and Legal Practices

Ethical – trust, fairness, respect and benevolence
Moral – beliefs of what is right or wrong
Legal – conformity to the provisions of relevant laws and jurisprudence.

Personal and Professional Values

• Personal - Set of Individual's principles, standards, concepts, beliefs and ideas that are
internalized from the society or culture in which one lives.
• Professional– values are beliefs and principles that guide nursing practice and which
influence one's work behavior. These are acquired through experience,
education, training and practice considering Code of Ethics
Patient Care Safety Standards

DOH Administrative Order No. 2008-0023 Reinforcement and Institutionalization of the

Implementation of Quality Assurance for patient safety.

Strategies to promote safety

 Leadership and Management Commitment to patient safety
 Ensuring a safe environment in the health facility
 Health personnel safety established

Ethic-Legal and Moral Considerations in Nursing Leadership Management

Ethics
• A system of moral conduct and principles that guide a person's actions in regard to right
and wrong and in regard to oneself and society at large.

Moral Issues or Ethical Dilemma faced by Nurses

1. Moral Indifference – individual questions why morality in practice is
necessary
2. Moral Uncertainty or Moral Conflict – unsure which moral principles or
values apply and may even include uncertainty as to what the moral
problem is.
3. Moral distress – occurs when the individual knows the right thing to do,
but organizational constraints make it difficult to take the right course of
action.
4. Moral outrage - witnesses the immoral act of another but feels powerless
to stop it.
❖ Moral or Ethical dilemma is being forced to choose between two or more
undesirable alternatives.

Ethical Frameworks for Decision Making MEWORK SIC PREMISE

Utilitarian (teleological) - Provide the greatest good for the greatest number of people
Rights based (deontological) - Individuals have basic inherent rights that should
not be interfered with
Duty based (deontological) - A duty to do something or to refrain from doing
something
Institutionist (deontological - Each case is weighed on a case-by-case basis to
determine relative goals, duties, and rights

AUTONOMY- Autonomy (Selfdetermination)- Promotes self-determination

and freedom of choice
Beneficence (Doing good)- Actions are taken in an effort to promote good
Non-maleficence- Actions are taken in an effort to avoid harm
Paternalism- One individual assumes the right to make decisions for another
Utility- The good of the many outweighs the wants or needs of the individual
Justice (Treating People Fairly)- Seeks fairness; treats "equals" equal and treats "unequals"
according to their differences
Veracity (Truth Telling)- Obligation to tell the truth
Fidelity (Keeping promise)- Need to keep promises
Confidentiality (Respecting Privileged Information)- Keeps privileged information private

Code of Ethics and Professional Standards

• A professional code of ethics is a set of principles established by a profession, to
guide the individual practitioner.
• First Code of Ethics for Nurses was adopted by > ANA (1950)
• ICN International Council of Nurses, Code of Ethics for Nurses > guide for action based on
social values and needs, has served as the standard for nurses worldwide since it was
adopted in 1953 (revised in 2012) RERUBLIC ACT 9173- ALSO KNOWN AS PHILIPPINE NURSING
ACT OF 2002

RECORDS MANAGEMENT

RECORD
• Permanent written communication that documents information relevant to a client's
healthcare management.
• Clinical, scientific, and administrative and legal document relating to the nursing care
given to the individual family
or community.
• Ex. Client chart

RECORDS MANAGEMENT
• Systematic and effective control of records (paper, electronic) throughout their life cycle
from creation or receipt through to the time of their disposal.

NURSING OFFICE RECORDS

Personal Record (Form 201)

- personal data, performance rating evaluation, references, achievement, staff and
professional activities and confidential information.

Master Staffing Pattern

• Daily assignment of the nursing personnel which will help the Chief Nurse visualize the
coverage of all nursing units, serving as a guide and support for proposing additional
positions in the Nursing Service.

The Daily Census of Patients

• Detailed list of actual patients in the different inpatient and the total census for 24 hours.

Daily Time Records or Bundy cards

• These indicate the time each personnel reported to and from duty

Reports
• Verbal or written informational work in a particular matter made with an intention to relay
events, situations in a presentable manner for decision making.
• It can compiled dailt, weekly, quarterly, annually.

Sentinel Events
• Sentinel events occur when a patient is seriously injured (permanently or temporary) or
causes death,happening outside the predictable course of the
patient’s disease process.

Anecdotal Report
• A brief description of an observed behavior that appears significant for evaluation
purposes.
Ex. Observation done by the Nurse supervisor during clinical rounds

Incident Reports
• Problem occurred in nursing care delivery
• Non-judgemental, factual, consequences
• IR are simply records of all events that are not part of routine medical care
NURSING KARDEX
• A medical information system used by nursing staff
• Way to communicate important information on their patients.
• Quick summary of individual patient needs that is updated at every shift change

Communication Leadership
Interpersonal Communication
Communication between two or more individuals involving face-to-face interaction while all
parties are aware of the others on an ongoing basis.

Inter professional Communication

Communication between two or more members of the interdisciplinary care team/

Intercultural communication
Communication across cultural contexts. It applies equally to domestic cultural differences
such as ethnicity and gender and to international differences such as those associated with
nationality or world region. (Bennet, 2013)

Non-verbal communication
Unspoken, this communication is composed of effective or expressive behavior.

Persuasion, negotiation, and bargaining

Persuasion is the conscious intent by one individual to modify the thoughts or behaviors of
others. Negotiation is dialogical discussion between two or more parties to arrive at an
agreement about some issue. To bargain is to make series of offers and counteroffers about
what each party will do, give, receive, etc. until an agreement is reached to the satisfaction
of all.

Verbal Communication
Includes both written and spoken communication

THE NURSING SERVICE- Nursing Services as "the part of the total health organization which
aims to satisfy the major objective of the Nursing Servies,
and that is –prevention of disease and promotion of health."

Nursing Service constitutes

▪ BACKBONE of the health care system
▪ Nursing group – 40% to 50% of the total workforce
▪ Largest health care workforce in the clinical setting
▪ Collaborates, coordinates and integrates
▪ Constantly present at the bedside monitoring patients
▪ Pivotal in significantly influencing patient clinical outcomes and
satisfaction for the entire population it served.

Vision
▪ The Nursing Service envisions to be globally recognized in providing excellent health care
and allied services to all Filipinos and other clients

Mission
▪ Provide quality and culturally competent nursing personnel through research,
learning and development in adherence o international standards and accreditation.
▪ Guarantee equitable, sustainable, and quality healthcare
▪ Establish performance standard
▪ Participate in the development on improving local
communities, self-reliance and participatory decision making
Philosophy
▪ The Nursing Service believes and respects that patients have the right to receive holistic
and quality care regardless of race, age, creed, gender, culture,
religion, political affiliations and socioeconomic status.
▪ Committed to assess and meet the physiological, physical, psychological, emotional,
spiritual, social, rehabilitative, and financial needs of every patient served in the community.
▪ Life-long learning, research, innovative strategies, professional nursing practice and
education

CORE VALUES
▪ Integrity
▪ Commitment
▪ Compassion
Strategic goal
❑ Service-oriented
❑ Dynamic
❑ Empowered health care force

Conceptual Framework- Shows the functions and respective roles of the Nursing Service
administrators. A clear understanding of this process and how they are applied in different
organization levels are necessary to achieve the objectives and goals set by the agency.

As an administrator, the Chief Nurse basically performs the major management

functions namely:
Planning- First Management function that primarily deals with the future. It entails forecasting
of setting the broad outline of the work to be done
▪ What
▪ Why
▪ Where
▪ How
▪ Who

Types of Planning

Strategic
▪ Continuous systematic process that emphasize assessment organizational environment
(external and internal)

Operational
▪ Detailed work plan or written blueprint in which the objectives of nursing
unit/department are put into measurable actions.

Organizing - Process of identifying and grouping the work to be performed, defining and
delegating responsibility and authority and establishing relationships for the
purpose of enabling people to work most effectively together in accomplishing the
objectives (Lows Al Allen, 2011). It follows planning as a second phase of the management
process.

Nursing Succession Planning

Strategy for identifying and developing potential future nursing leaders who can replace
them in case of retirement, separation from service or any inevitable circumstances to ensure
continuity of leadership and services.
Five-step Process in Succession Planning
Identify: Identity Key areas and positions
Identify: Identify capabilities for Key Areas and Positions
Identify: identity Interested Employees and Assess then Against capabilities
Develop and Implement: Develop and Implement Succession and Knowledge
Transfer Plan
Evaluate: evaluate effectiveness

TOOLS in PLANNING

SWOT ANALYSIS
STRENGTH (extraordinary reputation, services, clinical experts, supportive leadership,
high performing team)
WEAKNESSES (need improvement; poor patient care, understaffing, vague
organizational direction - goal
OPPORTUNITIES (absence of dominant competitors, advancement in technology,
training specialty hospital)
THREATS (low retention rate, lack of highly skilled nurses, low salary, statutory laws
affecting the nursing practice

Organizing the Nursing Service

Process of identifying and grouping the work to be performed, defining and delegating
responsibility and authority and establishing relationships for the purpose of enabling people
to work most effectively together in accomplishing the objectives (Lows Al Allen, 2011). It
follows planning as a second phase of the management process

PURPOSE OF ORGANIZING
Formulate a team so that they may work together to achieve objectives
Assign activities with an authority that can supervise the team
Design a formal system so that roles are clear, everyone knows who is to do, what
and who is responsible for what results
Establish a positive work environment for the staff to effectively accomplish their goals
Collaborate and coordinate productively within and outside their department

STEPS IN ORGANIZING
Consider the plans and goals of the organization
Determine the work activities necessary to accomplish objectives
Classify and group activities that are interrelated
Assign work and delegate appropriate authority
Design a hierarchy of relationships both horizontal and vertical

FORMS OF ORGANIZATIONAL STRUCTURE

▪ HIERARCHICAL (tall, centralized, bureaucratic)
❑ Commonly called
▪ DECENTRALIZED (flat, horizontal, participatory)
▪ MATRIX
▪ HYBRID

CHARACTERISTICS OF AN ORGANIZATIONAL STRUCTURE

Division of work - each box represents and individ sawual or sub-unit responsible for a given
task of the organization's work load (ex. nursing services)
Chain of Command-reflected in the organization structure with a solid line. or known as line
of authority. Who reports to whom - (can be flat or tall)
Type of work to e performed - Indicate the lable or description in the boxes (Ex. Patient care
services)
The Groupings of Work Segment or Homogenous Assignments-Shown by clusters of work (EX.
Delivery Room Unit)

Types of Organizational structures

▶ Formal Structure
Shows relationship among employees and their job positions. Describes the tasks,
responsibilities and relationships.
Can be in a diagram called the organizational chart

►Informal Structure
- Based on social relationships rather than on positional authority.
Ex. Groups who belong to the same unit having lunch together

ORGANIZATIONAL CHART AND ITS IMPLICATIONS

An organizational chart is a line drawing composed of boxes that show how the parts
of an organization are linked.

Depicts formal organizational relationships, areas of responsibility. persons to whom

one is accountable for and channels of communication (Tomey, 2004).

Two lines in the organizational chart

► Unbroken Solid lines

-The unbroken solid lines are classified into two. The solid horizontal lines represent
communication between people with similar spheres of responsibility and power but different
functions.

-The solid vertical lines between positions denote the official chain of command and formal
path of communication and authority.

NOTE:

Those having the greater decision-making authority are at the top; those with the least are at
the bottom.

Characteristics of Organizational Effectiveness

There is Strong Transformational Leadership:
There is High Employee Morale
There are Shared Goals, which are already cascaded:
Learning and Development of Staff are maximmized.

Team Building

►Process of gathering the right people and getting them to work together for the benefit of
a project.

Staffing- IDENTIFYING WORK FORCE REQUIREMENT, RECRUITING, INTERVIEWING,LEADING

HIRING ETC.

Directing- KEY HEART OF MANAGEMENT PROCESS. MANNER OF DELIGATING ASSIGNMENTS,

ORDER ETC.
Controlling- MEASURING PERFORMANCE AGAINST GOALS, PLANS ETC. CONTROL INCLUDES

POLICIES- BROAD GUIDELINES FOR THE MANAGERIAL DECISIONS

RULES- SET OF UNDERSTOOD REGULATIONS OR PRINCIPLE.

INTRA-DISCIPLINARY AND MULTI-DISCIPLINARY TEAM WORK AND COLLABORATION

Interdisciplinary
▪An approach that involves team members from different disciplines working collaboratively,
with a common purpose,to set goals, make decisions and share resources and responsibilities.

Multidisciplinary
▪An approach involves team members working independently to create discipline-specific
care plans that are implemented simultaneously, but without explicit regard to their
interaction.
▪MD assumes leadership

Intradisciplinary
▪Intradisciplinary teamwork is work performed by multiple members who work in the same
field.
▪Intradisciplinary need effective communication, coordination, and shared responsibility to
be effective.Failure in these core principles could result in adversepatientoutcomes, medical
errors, and ineffective use of resources (Kuziemsky& Varpio, 2010)

Teamwork
Teamwork in health is defined as two or more people who interact interdependently with a
common purpose, working toward measurable goals that benefit from leadership that
maintains stability while encouraging honest discussion and problem solving

Benefits of Teamwork in Nursing

❑Improved satisfactionoutcome
❑Higher job satisfaction
❑Increased professional accountability
❑Lower rates of turn over
❑Improved engagement in the workplace

FIVE (5) ways to Foster Teamwork in Nursing

1. Start the wave

❑Be the first to help another nurse with a difficult patient. Assist with activities of daily living,
bathe the patient, or do whatever your colleague needs to stay on schedule.

2. Be a mentor
❑Take new nurses under your wing and help them feel at home in your department.
❑Offer to be a resource if their preceptor is unavailable.

3. Ask for help when you need it

▪If you found yourself falling behind in your schedule, ask a colleague for assistance.

4. Think Ahead
▪Have as much preparation ready for the next shift as possible.
For example: place another bag of intravenous solution in your patient's room if the current
bag is almost empty, or leave a spare set off sheets in your patient's room for middle-of-the-
night bed changes.

5. Be prompt for a Report

❑Unless you're in the middle of an emergency, give report when the next shift is ready for it.
Nothing is more frustrating than starting a shift behind schedule.

Development of TEAM COLLABORATION

▪Teamwork in healthcare is significant.
▪It employs the practices of collaboration and increased communication to expand the roles
of nurses and to make decisions as a unit or division that works towards a common goal that
of delivering healthcare to clients.
▪Working as a team has been established to reduce errors and increase patient safety.
▪Research studies have also established that teamwork reduces burnout and that successful
team effort produces more satisfaction at work.

Collaboration
▪Assertive and cooperative strategy in which individuals work together to find a mutually
satisfying solution.

TEAM COLLABORATION IN HOSPITAL SETTING & COMMUNITY

▪Patient care is the top priority in nursing.
▪For patients to receive the best health care possible, nurses must communicate with
relevant professionals about their patients’ treatment plan while also understanding the role
of each assigned team member.
▪In essence, nurses serve as a bridge between doctors, patients, and the hospital. Teamwork
and collaboration are critical to this role.