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Leadership > Exam 2 > Flashcards

Exam 2 Flashcards

1
Q

Hospital Consumer Assessment of Healthcare Providers + Systems: HCAHPS

Basics (4)

A
  • nationally standardized publicly reported survey about patient perspectives of hospital stay
  • measures patient satisfaction
  • hospital needs 300 surveys a year
  • 29 items (18 r/t to critical aspects of care)
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2
Q

HCAHPS

  • Eligibility Criteria (6)
  • Exclusions (4)
A
  • randomized
  • 18 yr. or older at admission (no pediatric)
  • at least 1 over night stay and admitted as inpatient (med surg or maternal child)
  • Survey given within 48 hrs to 6 weeks after discharge
  • NON psychiatric diagnosis
  • Alive at discharge

Exclusions
- not discharged home (prisoners, hospice, nursing home)
- observation/outpatients or psych
- foreign address
- no publicity patients (patients who request for their room # to not be shared ex. Famous or IPV cases)

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3
Q

HCAHPS: Uses (3)

A
  • 25% of value based purchasing (2% penalty if hospital chooses not to report)
  • Used to get a star rating on Hospital Compare website where you type hospital name and get quality info
  • LeapFrog scoring, r/t hospital SAFETY (letter grade to analyze hospital efficacy
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4
Q

HCAHPS: Domains (10)

A
  • Communication with Nurses (Reason for whiteboards in rooms)
  • Communication with Doctors
  • Responsiveness of Hospital Staff (Answering call lights)
  • Communication about Medication (Med ed. at discharge)
  • Discharge Information
  • Care Transition
  • Cleanliness of Hospital Environment
  • Quietness of Hospital Environment (Stoplights on units)
  • Overall Rating of Hospital
  • Recommendation of Hospital
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5
Q

HCAHPS: 3 goals

A
  • Produce Comparable objective data across hospitals
  • Create incentive for hospitals to improve quality of care b-c they are publicly reported, comparisons can be made
  • Increases public accountability b-c increases transparency
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6
Q

Nursing Sensitive Quality Indicators: (NDNQI)

Purpose (3)

How does it differ from HCAHPS?

A

Purpose
- compare data of healthcare orgs to support QI (only national nursing quality data comparison across facilities)
- part of ANA’s safety and quality initiative
- Developed to understand link between nursing staffing and patient outcomes

Difference from HCAHPS: represents Nursing Sensitive indicators i.e nurse driven quality (things nurse can control)

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7
Q

NDNQI Clinical Indicators: Structure (4)

A
  • Nurse turnover
  • ED throughput
  • Patient volume and flow
  • Staffing and skill mix
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8
Q

NDNQI Clinical Indicators: Process (5)

A
  • Care coordination
  • Patient falls
  • Pressure ulcers (prevent via turning)
  • Restraints
  • Device utilization
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9
Q

NDNQI Clinical Indicators: Outcomes (7)

A
  • CAUTI (prevent via timely foley removal)
  • CLABSI
  • Hospital readmissions b-c nurse does education
  • C-diff
  • MRSA
  • Pediatric peripheral IV infiltrations
  • VAPS
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10
Q

Standardization

Definition

Types
- Clinical protocol - 2
- Critical/Clinical Pathway - 2

A
  • Process improvement approach where you develop and adhere best practices via repeating key processes the same way every single time

Types
Clinical protocol (Ex. MRT, stroke team, standing order; blood glucose control; protocol for codes, sepsis protocol (draw lactic acid)
- Decision path that has been approved by the physician based on a specific episode
- Don’t need to call for permission for these incidences

Critical pathways
- written plan that describes optimal sequencing of events for common diagnoses
- Explains what needs to be done on each DAY to get pt through the SYSTEM over the length of their stay

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11
Q

Health Information for Economic + Clinical Health Act (HITECH)

Purpose (2)
Unintended consequences (4)

A
  • Promote the use /adoption of EHRS in the U.S via giving incentives to hospital (If hospital chose not to participate, received 1-3% decrease in incentives)
  • Supports the meaningful use of technology in healthcare

Unintended consequences
- Security threats r/t malware
- Increased burden and complexity of documentation
- usability issue
- safety concerns

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12
Q

Meaningful Use: Examples

Purpose of both

CPOE (2)
Bar Code Scanning (2)

A

Purpose of both: reduce errors (Prior to bar code scanning, 1 med error per patient per day)

Computerized Provider Orders Entry (CPOE)
- rule that providers have to put orders in the computer rather than just verbalizing it to you
- Goal = physician put in 80% of discharge prescriptions, 60% of med order, 30% of lab orders, and 30% of radiology orders in computers to meet meaningful use standards

Bar Code Scanning
- Still need to do 5 rights of med administration and look at labels
- MUST SCAN MEDS b-c shows up if meds not scanned and can lead to decreased reimbursement

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13
Q

Medicare Promoting Interoperability

What is it?
Program Objectives (4)

A
  • replaces meaningful use but hospital still submit data to receive incentives

Objectives
- Focus on electronic prescriptions
- Health information exchange
- Provider to patient information exchange
- Public health + clinical data exchange

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14
Q

Meaningful Use: Priorities (5)

A
  • improve quality, safety, efficiency, and reduce health disparities
  • engage pt + families in their own health
  • Improve care coordination
  • Improve public + population health via looking at trends
  • Ensure privacy + security protection for personal health record (i.e passwords on computer)
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15
Q

Meaningful use: Basics (3)

A
  • Defines minimum U.S govt standards for electronic health records
  • Outlines clinical data that can exchanged b/w providers, insurance, and patient
  • Provide exchange of healthcare info to improve quality of care
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16
Q

Risk management

What is it?
Responsibilities (3)

A
  • Process of developing and implementing strategies to minimize risk and mitigate the impact of adverse events on the hospitals

Responsibilities
- Preventing patient injury in hospital
- Minimizing financial loss after a problem (i.e. prevent hospital being sued or reducing amount sued for)
- Preserving the organization’s reputation

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17
Q

Risk Manager: Role (9)

A
  • Mandatory reporting
  • Identifying risk + any vulnerabilities r/t patient safety, equipment malfunction via risk assessment and reports
  • Do claims management (investigation and coordinate legal depositions)
  • Regulatory compliance (DNV, TJC, CMS)
  • Investigate errors via Root cause analysis (looks at processes)
  • Track and trend events or incidents
  • Responsible to ensure hospitals compliant w/ policy and security
  • Concerned w/ safety of patient and hospital
  • Collab w/ state and local officials
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18
Q

Mandatory Event Reporting (15)

A
  • Any abuse or neglect regardless of unit
  • Nosocomial infections (SSI, CAUTI, CLABSI)
  • Unexpected occurrences or accidents that lead to death (Any death within 24 hrs of admission)
  • EMTALA Violations (25-50K fine for violations)
  • Deaths related to restraints and seclusion
  • Wrong site surgery (Reason for marking site; time out; checklists)
  • Retained surgical objects
  • Infant deaths, births, and reportable fetal deaths
  • Infants discharge to the wrong person
  • Patient suicides or attempted suicides
  • Stage 3 or 4 hospital acquired pressure ulcers
  • Patient deaths from falls
  • Sexual assaults of patients
  • Drug overdoses r/t Opioid crisis
  • Sentinel events
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19
Q

Healthcare law: EMTALA (Emergency Medical Treatment and Labor Act)

Basics (4)

A
  • prevents patient dumping
  • Must do medical screening exam in ED before transferring patient or asking about insurance
  • Must have legitimate reason for transfer; cannot be r/t insurance and cannot be unstable patient including pregnant woman
  • Hospital have to document every pt that was transferred out of ED, where they were transferred, and need to say WHY VIA EMTALA log
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21
Q

Falls

Definition
Tips (3)
Factors (5)

A

Definition: unplanned descent to the floor WITH or WITHOUT injury (even if someone catches you)

Tips
- Always need to assess pt fall hx (falls at home = will fall at hospital)
- Multidisciplinary issue! Everyone in the hospital can help prevent a fall!!
- CMS does not pay for fall-related injuries issue (1/3 preventable)

Factors
- Age is a key factor of fall due to physical changes + cognitive changes (20-30% of older people who fall suffer moderate to severe injuries (Fractures))
- medication (meds for cholesterol = rhabdomyolysis risk)
- disease process
- ambulatory issues
- noncompliance

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21
Q

Unusual Occurrence Report/Incident Report:

Tips (6)

A
  • Needs to be confidential, not discoverable!!!
  • Should not be mentioned in the pt’s medical records b-c it could then be discovered
  • Be objective (do not make assumptions)
  • Do not photocopy or take pictures of the incident report
  • Never ordered by physician
  • always assess patient and let HCP know about incident prior to filing report
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22
Q

Sentinel Event: Types (11)

A
  • Discharge pt from ED and then they commit suicide within 72 hrs
  • Unintentional death of full-term infant
  • Discharge of infant to the wrong family
  • Any event that requires transfer to higher level of care
  • Abduction of patient
  • Hemolytic transfusion reaction
  • Elopement: pt leaves that has been admitted (if results in adverse outcome) —Different from AMA; Elopement is they go missing and you do not know they are gone
  • Wrong site surgery
  • Raped, assaulted, or killed
  • Fire, flame, smoke in equipment during direct patient care
  • Maternal deaths unrelated to admission reason
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23
Q

Unusual Occurrence Report/Incident Report:

When to file? (5)

A
  • Patient injury
  • Unanticipated patient death
  • Malfunction or failure of equipment
  • Adverse events related to patient care
  • Safety issues related to the physical environment
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24
Q

Sentinel Event: Basics (3)

A
  • patient safety event that reaches a patient and results in death, permanent harm, or severe temporary harm.
  • Unrelated to patient’s condition
  • Require additional surgery, or treatment or transfer to higher level of care
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25
Q

Never Event: definition

Ex. Stage 3 or 4 pressure ulcer, DVT, fall, HAI, air embolism, blood incompatibility, poor glycemic control

A

Serious and costly preventable complication or error that occurs during an in-patient stay that could be reasonably prevented through adherence to evidence-based guidelines.

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26
Q

How to avoid risk management issues (9)

A
  • Remain current in skills
  • Know job description
  • Be confident w/ the skills you perform
  • Follow all safety protocols when administering meds
  • Ensure you follow orders and get clarity if you need it
  • Be trained on any equipment you use
  • Document all patient activities and communication
  • Be familiar w/ policies + procedures of hospital
  • ALWAYS USE PROPER PT IDENTIFICATION
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27
Q

Health Insurance Portability and Accountability Act (HIPAA)

Basics (2)
What to know (5)

A

Basics
- privacy rule and confidentiality law for PHI
- Gives patient rights to control the release of information

What to know
- Only professionals that are directly involved in care can look at medical records
- Cannot disclose to unauthorized family member
- Policies on viewing your own medical records (may not be able to review until finalized)
- No part of record can be copied except b/w health care institutions
- Communication with patient needs to take place in a private place i.e., patient room; password protection on computer; no social media

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28
Q

Healthcare law: Patient Self-determination Act

Basics (2)
Concerns (2)

A
  • Requires written notification on admission of rights regarding end of life care
  • all patients must be asked about advance directives and educated about them if does not have it

Concerns
- If have living will or power of attorney, need to bring with them to hospital.
- CPR must be initiated UNLESS there is a written order for DNR even if living will says otherwise

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29
Q

Differences between the following:

Nurse Practice Act (7)

A
  • law/ statute in each state that regulates practice of nursing
  • Defines scope of practice (Procedures, actions, duties, processes that RN can do)
  • Delineates categories of nurses and the scope of practice for each: RN, LPN, APRN
  • sets the educational and examination requirementsnecessary for licensure
  • Defines the standard of competent performance
  • Defines what behaviors represent misconduct or unprofessional behavior for disciplinary action
  • If state is in compact agreement, they are regulated by the nurse practice act they are working in not the state their license is in
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30
Q

Nursing Consideration: Leaving AMA

Nurse role (4)

A
  • cannot detain a pt who is MENTALLY COMPETENT (cannot block patient from leaving)
  • notify supervisor and HCP
  • need to tell pt what the risks are + document that you did
  • Get patient to sign AMA document if possible otherwise two RNs sign it
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31
Q

Informed Consent

Components HCP must discuss (4)
Nurse role (3)

A

Components HCP must discuss
- Reason for procedure
- Risks and benefits of procedure or treatments
- Risks/Consequences for not doing treatment
- Other options available

Nurse role
- Witness signature
- ensure informed consent is obtained by HCP
- If you find out that pt does not understand, stop everything and tell HCP to come back and re-explain (part of patient advocacy)

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32
Q

Restraints

Components of order (4)
Tips (4)

A

Components
- Reason (type of behaviors warranting restraints?)
- Type
- Location of restraint: where the restraints are going
- How long they can be used

Tips
- Always use least restrictive and they are never the first option
- Reevaluated q24h and document, need a new order q24 hrs
- ensure current and adequate documentation (Need to include that you toileted pt and got them up etc. No redness, good pulses; fed)
- wrongful restraint = False imprisonment

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33
Q

Liability

Personal (3)
Vicarious (2)
Corporate (1)

A

Personal
- you are accountable for your practice and compliance
- Each person responsible for their own actions or omission of actions
- “I am responsible for what I do and for what I do not do”

Vicarious
- Because I work for someone, they are accountable for my actions
- employer can be held accountable for negligence of employee

Corporate
- institution (corporation) is responsible and accountable to ensure an environment where quality health care will be delivered to all consumers

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34
Q

Nurse Practice Act: Behaviors that represent misconduct (11)

A
  • Practicing without a valid license
  • Conduct representing boundary issues (Questionable behavior between nurse and patient OR sexual misconduct)
  • Practicing while impaired with alcohol or drugs
  • Violating HIPAA/patient confidentiality
  • Failure to supervise someone that you’ve delegated to
  • Inaccurate or false documentation
  • Failure to use appropriate Nursing judgment
  • Medicare Fraud (billing Medicare for services not rendered)
  • Not reporting violations r/t poor nursing conduct by another nurse
  • Gross negligence or failure to follow standards of practice or care
  • Non-professional conduct (ex. felony convictions, practicing outside the scope of license or misuse of drugs)
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35
Q

Differences between the following:

Board of Nursing (2)
Nursing License (2)

A

Board of Nursing
- the law enforcement (Board of nursing enforces the nursing practice act)
- required by Nurse Practice Acts

Nursing license
- privilege and not a right
- Purpose: protect the public and protect title of RN

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36
Q

Negligence: Most common charges that become Malpractice (6)

A
  • Failure to follow standard of care
  • Failure to use equipment in a responsible manner (must know what you’re using)
  • Failure to communicate (w/ provider or patient)
  • Failure to document in the medical record
  • Failure to assess and monitor pt correctly (shift assessments)
  • Failure to act as a patient advocate
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37
Q

Negligence: Definition (2)

A
  • Failure to use such care
    as a reasonably prudent and
    careful person would use under
    similar circumstances (below standard of care)
  • Equated with carelessness (deviation from standard of care)
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38
Q

Malpractice: Basics (3)

A
  • Improper or unethical conduct or unreasonable lack of skill
    by a holder of a professional
    or official position
  • Type of negligence by someone with a license
  • Must prove 6 elements: Duty, breach, foreseeability, causation, injuries, damages (note: license does not have to be proved)
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39
Q

Elements of Malpractice

  • Duty Owed the Patient - 2
  • Breach of the Duty of Care Owed the Patient- 1
  • Foreseeability - 1
  • Causation - 2
  • Injury - 2
  • Damages - 1
A

Duty Owed the Patient
- Must be employed wherever this incident happened
- If you accept the assignment, you are accepting duty

Breach of the Duty of Care Owed the Patient
- if your actions fall below standards of care

Foreseeability
- Certain events can reasonably be expected to cause specific results

Causation
- hardest to prove esp. if many comorbidities
- Direct relationship between nurse’s failure to meet standard of care and patient’s injury

Injury
- Must sustain some physical harm
- Cannot be psychological harm or transient harm

Damages
- Financial damages have come from the events that happened

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40
Q

Avoiding Liability: Nurse Manager’s role (5)

A
  • Ensure all personnel have a current license
  • Report unethical, illegal,and incompetent practices (i.e. assessment w/o stethoscope)
  • Address disciplinary issues with employees
  • Ensure that the standard of care, policies, and procedures are followed by employees (via random documentation reviews and annual performance appraisals)
  • Educate the staff on policy changes or standard of practice changes
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41
Q

Malpractices: Causes for Nurse Managers (5)

A
  • Assignment, Delegation and Supervision (delegating to incompetent people OR not effectively communicating)
  • Duty to Orient, Educate and Evaluate staff ( must investigate any allegation made by patient about someone who is incompetent)
  • Failure to Warn (not warning potential employers or board of nursing about staff misconduct)
  • Staffing Issues (inadequate staff:patient ratio (need to notify CNO); inadequate training of agency staff; floating RNs w/o training
  • Protective and Reporting laws (Elder and child abuse; STDs, Other certain infections; Incompetent practitioners)
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42
Q

Avoiding Liability: Staff Nurse’s role (6)

A
  • Always have open, honest respectful communication practices with patient and their family
  • Maintain competence and best practices in your area of practice
  • Only practice within your scope of practice and under your job description (esp. if in school for higher degree)
  • Know what your strengths and weaknesses are.
  • Be familiar with nurse practice act of state you work in
  • only tell facts in deposition
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43
Q

Healthcare Laws

Title VI - 1
Age Discrimination in Employment act - 2
Equal Pay Act of 1963 - 1
Family and Medical Leave Act - 2

A

Title VI (discrimination law)
- Law that says it’s illegal to refuse to hire, discharge, or discriminate against someone because of their sex, race, gender, or origin

Age Discrimination in Employment Act of 1967
- Prevents discrimination for those > 40 years old
- no mandatory retirement

Equal Pay Act of 1963
- Illegal to pay lower wages to one gender over another when job requires equal circumstances (skills, effort, exertion, accountability, training, and education)

Family and Medical Leave Act
- Ability to take 12-week unpaid medical leave if you’re sick or need to take care of a family member (includes births) w/o losing job
- Applicable for men and women
Provides job security if you must take unpaid leave (12 weeks)

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44
Q

Healthcare Law: Occupational Safety and Health Act (OSHA)

What is it?
Includes (4)

A
  • Ensures healthcare workers are working in safe environment

Includes
* isolation procedures and universal precautions
* proper handling and grounding of equipment
* violence in workplace
* Certain place to store things to keep safe (cannot set O2 tanks on floor)

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45
Q

Healthcare Law: American with Disabilities Act (4)

A
  • Prohibits employers from discriminating against hiring someone who has a disability unless that person is not qualified or otherwise unable to do the job
  • Disability: physical or mental impairment that limits 1 or more functions of the person; must be record of disability
  • You don’t HAVE to hire them but you cannot NOT hire them if they are qualified
  • Employer must make reasonable accommodations for the disability
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46
Q

Healthcare Law: Good Samaritan Law

Basics (2)
Requirements if you stop (3)

A
  • Protects HCP from malpractice when giving emergency assistance outside normal job
  • nurse not required to stop

Requirements if you stop
- Must meet standard of care
- Stay with victim until handed off to another provider (b-c you have established nurse-patient relationship)
- Must not provide care with expectations of getting paid for care

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47
Q

Ethical Principles: Definition and Leadership Perspective

Autonomy
Beneficence
Nonmaleficence

A

Autonomy
- addresses personal freedom and right to self determination. “I have the right to make the decisions I want to make”
- Leadership perspective: employee has responsibility to meet job expectations or accept the consequences of actions

Beneficence
- obligation to do GOOD by acting in ways that promote welfare in best interest of others
- Leadership perspective: nurse management encourage staff to grow and assume additional responsibility for growth

Nonmalefiecence
- Do no HARM, act in a way to not harm
- Leadership perspective: in performance appraisal giving both positive and negative feedback to not harm employee; just giving bad feedback can be harmful

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48
Q

Differentiate the following:

Ethical Dilemmas - 1
Moral Courage - 2
Moral Dilemma - 1

A

Ethical dilemma
- Decisions must be made on what’s right or wrong in a situation where individual must make a choice between equally unfavorable alternatives

Moral Courage
- Being able to stand up for what is right and acting based on ethical principles regardless of consequences
- Protects ethical values such as honesty, integrity, respect, fairness, empathy, compassion

Moral Dilemma
- Occurs when someone knows the ethically correct action to take, but they feel powerless to act
Internal values conflict with what is happening

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49
Q

Ethical Principles: Definition and Leadership Perspective

Veracity
Fidelity
Justice

A

Veracity
- Telling the truth or demanding that the truth be told completely
- Leadership perspective: Nurse manager should inform an employee about the challenges + benefits of the position

Fidelity
- Keeping promises or commitment
- Leadership perspective: Honoring commitment to days off

Justice
- Treating all people equally and fairly
- Leadership perspective: nurse manager uses it to decide whose turn it is to float to another unit OR who gets time off

50
Q

ANA Code of Ethics: Nurse will… (9)

A
  • practice with compassion and respect
  • primary commitment is to the patient
  • advocate for the health, safety and rights of the patient
  • has authority, accountability, and responsibility for nursing practice
  • owes same duty to self as to others
  • contributes to the healthcare environment
  • promotes advancement of the nursing profession
  • promotes community and world health (health diplomacy, protect human rights and reduce health disparities)
  • promotes profession of nursing
51
Q

Hospital Ethics Committee: Models (3)

A
  • Autonomy Model (Facilitates decision-making)
  • Patient-Benefit Model (Use judgement to consider what patient wants)
  • Social Justice Model (Looks at broader social models and accountable to overall institution)
52
Q

Hospital Ethics Committee: Role (4)

A
  • Provide structure and guidelines for potential problems
  • serves as a RESOURCE and open forum to discuss and make decisions
  • provide guidance and recommendations (not decisions)
  • Serves as patient advocate (Patient must be consulted before ethical committee involved)
53
Q

Change

What is it? (4)

A
  • alteration to make something different
  • complex process which occurs over time
  • can flow back and forth through stages
  • influenced by many variables
54
Q

Types of Change

Planned (2)
Unplanned (3)

A

Planned
- change that is well-thought out, organized, and deliberate
- advance planning w/ goal to improve something

Unplanned
- change that is unorganized and unanticipated
- adaptive response to something
- does not include staff input (leader says what to do)

55
Q

Three changes organizations constantly undergo

A
  • Organizational restructuring (flattening leadership)
  • Quality improvement
  • Employee retention
56
Q

Forces Driving Changes in Healthcare (8)

A
  • Rising healthcare costs
  • Declining reimbursement (insurance does not want to pay for things)
  • New quality imperatives
  • Workforce shortages (Ex. Agency nurses)
  • New and emerging technologies (robotic surgery)
  • Growing elderly population b-c people are living longer
  • Alternate methods of care (Telemedicine)
  • Increase in use of health care extenders i.e. APRNs
57
Q

Lewin’s Change Theory: Three stages

A

Unfreezing: thawing out of the system via assessing readiness and motivation for change (has disequilibrium and no status quo)

Moving: visual change takes places and is implemented

Refreezing: change is integrated, stabilized and becomes new status quo

58
Q

Lewin’s Change Theory: Unfreezing Stage

Manager’s role (5)

A
  • Gather data
  • Accurately diagnose what the problem is
  • Decide if change is really needed
  • Make employees aware that there needs to be a change
  • Help employees accept, buy in, and be on board with the change
59
Q

Lewin’s Change Theory: Moving Stage

Manager’s role (8)

A
  • Develop strategies and plan for change
  • Set goals + objectives w/ target date
  • Identify areas of support + resistance
  • INCLUDE everyone impacted by the change in process
  • Implement change
  • Offer support + encouragement about the change
  • Evaluate change
  • Revise plan as necessary
60
Q

Lewin’s Change Theory: Refreezing Stage

Manager’s role (3)

A
  • Inspect and reinforce positive behavior to hardwire change
  • respond to employee concerns
  • ensure everyone is doing what they should be
61
Q

Force Field Analysis

  • What is it?
  • Driving Forces
    (Ex. scheduling, informal leaders that encourage everyone to do walking rounds)
  • Restraining Forces
    (Ex: employees that don’t want to participate and protest changes; employee fear)
A
  • CURRENT STATE BEFORE the change occurs (present or desired state)

Driving forces: positive forces that push change forward or advance system toward change

Restraining forces: obstacles that impede change

62
Q

How do Lewin’s Theory of Change match up with nursing process and problem solving?

A

Unfreezing
- Nursing Process: assessing and diagnosis
- Problem Solving: Identification of problem, define problem

Moving
- Nursing Process: planning and implementing
- Problem Solving: Problem Analysis, seeking alternate solutions, implementation

Refreezing
- Nursing Process: Evaluating
- Problem Solving: Evaluation

63
Q

Lewin’s rules for Implementing Change (7)

A
  • need good reason for making change (do not change for sake of change)
  • Always needs to be planned and implemented gradually (Should never be abrupt or unexpected)
  • All people affected by change should be involved in planning process to help them buy into change via giving them ownership
  • Varied reactions and Resistance to change are normal
  • Communication is important (rumors need to be dispelled)
  • Managers must plan to inspect change to ensure it is sustained
  • Celebrate small wins
64
Q

Reactions to Change (7)

A
  • Active resistance (May be aggressive)
  • Passive resistance (i.e. Silent noncompliance)
  • Indifference (i.e. Redirect conversations, Ignore changes)
  • Fear of loss (of job)
  • Fear of unknown
  • Fear of failure
  • Disruption of interpersonal relationships (Ex: change that makes it so you can’t see your friend during shift change anymore = disruption of interpersonal relationships)
65
Q

Budget: Basics (4)

A
  • financial plan that includes estimated expenses + revenues
  • Designated for period of time (typically 12-month period)
  • Dynamic process that guides the allocation/distribution of resources and expenditures to ensure business can function daily and achieve goals
  • Aligns with identified strategic plan, mission, and vision
66
Q

Budgeting Process: 4 steps

A
  • Planning
  • Coordinating & Communicating
  • Monitoring Progress
  • Evaluating Performance
67
Q

Budgeting Process:

  • Planning (4)
  • Coordinating and Communicating (2)
A

Planning (Ex. Plan to give 3% raise so plan for increase in expenses)
- Most important function of budgeting process
- Determine the goals of organization
- Identify resources
- makes Budget assumptions (reasonable expectations on revenue (income) and expenses)

Coordinating and communicating (Ex. If you are going to open a new service, you will talk about that here)
- Bring various people together to discuss resources and involved factors
- Discuss allocation and distribution of resources based on strategic plan

68
Q

Budgeting Process:

  • Monitoring Progress (2)
  • Evaluating Performance (3)
A

Monitoring progress
- Compare actual performance against budget
- Do variance analysis (deviations from budgeted dollars are examined by comparing actual performance results to expected or budgeted performance) if there is variance

Evaluating performance
- Determine effectiveness of manager (i.e. managing of overtime, labor, and supplies)
- Staff role in preventing variance: ensure you clock in and out on time AND be mindful of supplies taken into patient’s room
- Staffing office role in preventing unfavorable variance: controlling budgeted staff

69
Q

Variance

What is it?
Favorable vs unfavorable

A

The difference between the planned budget and the actual results

Favorable: results better than expected = SPENDING LESS (Ex. Less sick patients, understaffing)

Unfavorable: results are worse than you thought = SPENDING MORE (Ex. Sicker patients, Overstaffing , staff turnover)

70
Q

Factors that cause Variance (5)

A
  • Vacation/sick days
  • Patient acuity (favorable if less sick, unfavorable if more sick)
  • Staff calling in sick (unfavorable labor variance but favorable budget variance because you save money)
  • Staffing level and overtime
  • Hours not moved correctly when nurse is floated to a different unit
71
Q

Differentiate the Following:

Productive time
Nonproductive time

A

Productive time (Ex. Secretary (responds to call lights), UAP, RN)
- any time directly in patient care. Includes hourly and overtime

Non-productive time (Ex. Orientation, education, doing chart audits, vacations, holidays, sick time)
- working on/off the unit not in direct patient care

72
Q

Budgets: Operational Budget (4)

A
  • financial plan for organization that lists the plans, revenues, and expenses in a designated period
  • looks at day-to-day expenses
  • Every hospital has operational budget
  • includes labor and supply expenses
73
Q

Budgets: Labor Budget (4)

A
  • includes salaries, Overtime, benefits, education, staff development and training
  • subset of operational budget
  • LARGEST EXPENSE OF OPERATIONAL BUDGET
  • Nursing typically makes up 65% of labor budget
74
Q

Budget: Capital Budget (5)

A
  • Money allocated for major equipment and construction projects
  • expenses between >$500-$2000
  • item has to have a life expectancy of >1yr
  • Considered long term investments
  • Payment for capital expenses spread over couple of years
75
Q

Budget: Cash budget (3)

A
  • Money that flows in and out of organization
  • Includes billing + collections, cash on hard
  • Helps CFO know if they are spending budget productively.
76
Q

Budgeting Methods

Incremental (2)
Zero-based budgeting (3)

A

Incremental budgeting
- Used most often b-c simple
- Look at historical data and make adjustments based on growth or declines

Zero-based budgeting
- Start from scratch (0) every year
- Requires justification and detail for every expense (labor intensive)
- Hospitals don’t do this type of budgeting

77
Q

Unit of Service

What is it?
What are the unit of services for:
- Nursing Units
- Cath lab
- OR/PT/OT
- Home health

A

Unit-of-service: basic measure of product or service being produced

  • Nursing Units: patient days (total # of days patients admitted over time period)
  • Cath lab: procedures
  • OR/PT/OT: time (15-minute increments)
  • Home health: patient visits
78
Q

Costs considered to determine cost of healthcare (4)

  • Definition of each
  • Example of each
A

Direct Costs
- costs directly associated w/ a unit of service
- Ex: nursing care, admission kits

In-direct costs
- things r/t to operating expenses but not directly r/t to things servicing patient
- Ex: housekeeping services, utilities, maintenance fees

Fixed costs
- do not change regardless of unit of service i.e., business of unit
- Ex. manager or administrative salary

Variable costs
- cost that varies based on changes in the unit of service
- varies w/ volume of patients
- Ex: IV supplies will vary w/ the amt of pts that you have

79
Q

Budgeting: Nurse Manager’s Role (6)

A
  • Responsible for unit-level budget (labor and supply)
  • managing patient flow such as ADT
  • Eliminate never events (something that happens in HCO that should never happen if best practice is followed)
  • Reduce 30-day readmission and length of stay
  • Improve pt satisfaction on the unit
  • Reduce staff turnover (costs $60,000 to train a new nurse)
80
Q

Patient Protection and Affordable Care Act (ACA): 3 goals

A
  • Improve quality of healthcare
  • Slow the unsustainable growth in healthcare costs
  • Move the focus to prevention vs acute illness
81
Q

ACA: Key Components (10)

A
  • individuals b/w 100-400% FPL receive subsidies
  • Companies w/ > 200 employees must provide insurance
  • Healthcare exchange allows people to afford insurance at lower rate
  • Healthcare must cover certain services: mental health, Ambulatory, L& D, preventative care, emergency
  • Must cover preexisting conditions
  • Allows you to stay on parental insurance until 26 yrs old
  • 80% of premium must go toward healthcare
  • Establish Hospital Acquired Infection Program (Medicare will no longer pay for HAIs)
  • Establish Hospital Readmission Reduction Program (Medicare reduced payment for preventable readmissions)
  • Establish Value Based Purchasing
82
Q

Healthcare Reimbursement/Financing: Fee for Service (3)

A
  • hospitals bill and receive payment for EVERY SINGLE service provided
  • No incentive to manage the costs because all services paid for by hospital
  • Frequency of services provided did not = quality care
83
Q

Healthcare Reimbursement/Financing: Inpatient Prospective Payment System (IPPS) - 4

A
  • hospital payment system in which 3rd party payer or CMS decides what will be paid
  • Utilizes the DRG (Diagnosis-related group) for basis of payment (every diagnosis falls under a DRG)
  • If pt discharged earlier, then hospital gets to keep the money if they get out later the hospital eats the money
  • Encourages efficiency but no real incentive for quality and safety
84
Q

Healthcare Reimbursement/Financing: Value Based Purchasing

Basics (3)

A
  • Hospital paid based on quality, safety, and efficiency measures (paid for performance)
  • ONLY program WHERE HOSPITAL CAN EARN A BONUS IF DO WELL OR BE PENALIZED IF THEY DO POORLY (Hospitals are rewarded if quality care; hospitals are punished for poor outcomes)
  • Budget neutral for healthcare consumers (b-c some hospitals do bad and others do good at end of year performance eval
85
Q

Healthcare Reimbursement/Financing: Value Based Purchasing

What does it promote? (5)

A
  • quality care (adopt EBP)
  • safe experience (reduce healthcare errors)
  • cost effectiveness (redesign programs for efficiency)
  • Positive experience of Medicare beneficiary
  • Transparency b-c quality metrics are out there for everyone to see
86
Q

Healthcare Reimbursement/Financing: Value Based Purchasing

What nurse can do on front line (7)

A
  • Infection prevention (wash hands to prevent c-diff and MRSA)
  • Isolation precautions
  • C-Diff. = prevention and timely testing (may be protocol to test in ED if pt has diarrhea)
  • Nurse-driven protocols for urinary catheters (may can be removed in 24 hr)
  • Evaluate patient needs for central lines
  • Clear, concise documentation
  • Discharge planning (Chronic condition education, Patient and family engagement, Medication reconciliation)
87
Q

Healthcare Reimbursement/Financing: Value Based Purchasing

4 domains (each 25% of score)

A
  • Safety
  • Patient and Community engagement (HCAHPS)
  • Efficiency and Cost Reduction (spending per hospital Patient with Medicare Beneficiary)
  • Clinical Outcomes
88
Q

Value-Based Purchasing: Domains

Safety (6)

A
  • Patient Safety and Adverse Events
  • C-Diff: Clostridium Difficile Infection
  • CAUTI: Catheter-Associated Urinary Tract Infection (Reason to remove foley early)
  • CLABSI: Central Line Associated Blood Steam Infections
  • MRSA: Methicillin-resistant Staphylococcus aureus bacteremia
  • SSI: Post Surgical Site Infections for Colon Surgery or Abdominal Hysterectomy
89
Q

Value-Based Purchasing: Domains

Clinical Outcomes (6)

A
  • AMI: Acute Myocardial Infarction 30-day mortality rate
  • HF: Heart Failure 30-day mortality rate
  • PN: Pneumonia 30-day mortality rate
  • COPD: Chronic Obstructive Pulmonary Disease 30-day mortality rate
  • CABG: 30-day mortality rate
  • Complications Hip & Knee: Total hip and knee arthroplasty complications
90
Q

Staffing

Basics (4)

A
  • process of identifying + allocating right # of nurses on a unit based on patient needs (acuity)
  • Daily operational function each shift
  • No perfect staffing method (JCO/ CMS don’t tell you how to staff, just say you have to provide adequate care)
  • staffing is complex and challenging and longest management function)
91
Q

Staffing: Outcomes of Adequate Staffing (9)

A
  • Reduced medical and medication errors
  • Reduced potential for errors
  • Decreased patient complications b-c patient gets more attention, assessed more frequently so complications noticed earlier
  • Decreased mortality (1.98% decrease)
  • Improved patient satisfaction b-c nurses checking on them more often and more attentive
  • Reduced nursing fatigue and burnout
  • Increased job retention and satisfaction
  • Decreased lengths of stay b-c you know more about the patient
  • Reduced readmissions
92
Q

Goal of Staffing (4)

A
  • Provide right number of nurses
  • with the right qualifications/skillset
  • to deliver safe, high-quality, and cost-effective care to a group of patients and their family
  • evidenced by positive health outcomes
93
Q

Conceptual Framework for Nursing Staffing and Patient Outcomes

Chart flow (4)

A
  • Patient factors and nurse characteristics impact nurse staffing
  • nurse staffing impacts nurse outcomes
  • nurse staffing, nurse outcomes, patient factors, hospital factors, organization factors, medical care impact patient outcomes
  • patient outcomes impact length of stay
94
Q

Conceptual Framework for Nursing Staffing and Patient Outcomes

Factors
- Patient (5)
- Nurse Characteristics (5)

A

Patient Factors
- age
- primary diagnosis
- acuity and severity
- comorbidity
- treatment stage

Nurse Characteristics
- education
- experience
- age
- contract nurses
- Internationally educated nurses are very different than the nurses trained in U.S (More orientation needed b-c function more like nursing assistants)

95
Q

Conceptual Framework for Nursing Staffing and Patient Outcomes

Factors
- Nurse Staffing (3)
- Hospital (4)
- Organization (3)

A

Nurse Staffing
- HPPD (delivered care hours and total paid hours)
- Skill mix
- Nurse Staffing Ratio

Hospital factors
- size (Small hospital may do something very different and people wear different hats)
- volume
- technology
- teaching (Teaching hospital you may have interns and residents)

Organization factors
- Clinical units
- Duration of shift (8 vs 10 vs 12)
- Shift rotation

96
Q

Conceptual Framework for Nursing Staffing and Patient Outcomes

Factors
- Nurse Outcomes (3)
- Patient Outcomes (4)

A

Nursing Outcomes
- Satisfaction
- Retention
- Burnout

Patient outcomes
- Mortality
- Adverse drug events
- Patient satisfaction
- Nurse quality outcomes

97
Q

Define the following:

  • Skill mix
  • Staffing pattern
  • Forecasted workload
  • Average Daily Census (3)
A

Skill mix
- combo of categories of workers employed to take care of the patients (Ex. RN, LPN, UAP)

Staffing Pattern
- lists the total number of direct-care staff by level of skill scheduled for each day and each shift (i.e. 1:5 nurse; 1-12 UAP ratio)

Forecasted workload
- determines staffing pattern based on combo of average daily census (ADC) and recommended standards (Hours per patient day (HPPDY))

Average Daily Census
- sum of daily census for 1 yr/365 days
- perfect staffing = adequate for ADC
- may be under or over staffed if ADC differs from actual patient load

98
Q

HPPD: Hours per patient day

What is it?
What is the problem?

A
  • hours of nursing care provided per patient by various levels of nursing personnel
  • used to determine forecasted workload with average daily census

Problems
- financial metric that does not take into account patient acuity

99
Q

Define the Following:

  • FTE (2)
  • ADT (3)
  • Average Length of stay (2)
  • RIF (2)
A

Full Time Equivalent
- one FTE = 40 hrs in one wk; 2080 in yr (36 hr per week = 0.9 FTE)
- does not equal people (only used for developing staffing pattern)

Admissions, discharges, transfer (ADT)
- turnover of patients
- not factored into staffing b-c hard to predict
- adds to complexity of nurse work each day

Average Length of Stay
- average # of days each patient is in hospital
- has reduced overtime b-c used in DRG and decreased reimbursement for longer stays

Reduction in Force (usually not nurses)
- Permanent separation of employment due to
lack of funds, work, or redesign OR elimination of the positions with no likelihood that employee will be recalled
- not the same thing as a “work call-off”

100
Q

Scheduling

Definition
Types (4)

A

process of determining the set number and type of staff for a future time period (4 weeks) by assigning individual personnel to work specific hours, days and shifts in a specific unit for a designated time period

Types
- centralized
- decentralized
- self-scheduling (nurse creates schedule based on certain requirements)
- fixed/cyclic scheduling (set hrs and days worked each week)- not common in nursing

101
Q

Define the following:

Patient Acuity (3)
Nursing intensity

A

Patient acuity
- severity of illness or complexity of care needs
- higher acuity = more assistance
- Forecasted workload (HPPD and ADC) do not account for acuity

Patient intensity
- amount of care required by patient

102
Q

Factors that affect patient acuity (9)

A
  • Age of patient (older = higher acuity)
  • Functional ability
  • Communication skills (If they do not speak English, acuity will increase b-c need translator)
  • severity and urgency of the condition
  • Procedures scheduled
  • Complexity of care needs of patient. (Ex: extensive ulcers will require extensive wound care)
  • Geography of the environment (ex: better for nursing station to be in the middle for access)
  • Availability of technology
  • Experience of staff providing care
103
Q

Models of Nurse Staffing

  • Budget based on HPPD (2)
  • Nurse-patient ratio (3)
  • Patient acuity (3)
A

Budget based on HPPD
- Most predictable model of nurse staffing
- financial metric used by hospitals

Nurse-patient ratio
- Pure method
- Not cost effective b-c one patient over budget = need a whole nurse for that one person
- Not used by hospitals

Patient acuity
- Most likely need people on call
- Must be calculated everyday
- ambiguous so not used

104
Q

Productivity Index

Basics
Factors (4)

A

Basics: how well workforce uses available staff; you want correct # of staff to take care of patients so productivity = 100% ( > 100% = understaffed; <100% = overstaffed)

Factors
- Variance (do variance analysis)
- Overtime
- agency nurses
- nurses in nonproductive time (training, orientation,education)

105
Q

Factors Impacting Staffing Requirements

  • Nursing Leadership Considerations (9)
A
  • Projected unit workload and units of service for next year (is anything on unit going to change)—Ex: if you have a new cardiac surgeon and now the unit will have more cardiac pts, predict a change
  • Historical staffing requirements
  • Effectiveness of current staffing plan (may need a change)
  • Trends of acuity on the unit
  • Anticipation of skill mix. ex: using LPN, UAP
  • Experience + education of staff(new physicians; educational hours)
  • New technology (new programs or service needs)
  • Patient outcomes (ex. if you have a lot of bad pt outcomes w/ current staffing, there may need to be a change)
  • Productivity index
106
Q

Factors Impacting Staffing Requirements

  • Staff Preparation (3)
A
  • Must have competencies to work in the unit you are supposed to be working in
  • Must have knowledge and skills for the unit
  • Are they experienced? (novice to expert) —Never schedule all new nurses to work at once
107
Q

Factors Impacting Staffing Requirements

  • Organizational Needs (4)
A
  • Financial (salaries are the largest expense for any HCO)
  • Productivity (Has DIRECT impact on bottom line/budget)
  • Licensing + Accreditation ( does not mandate any type of staffing, but they observe unit’s atmosphere to see if nurses are freaking out or calm and collected; interview patients, and check licenses)
  • Customer Satisfaction (ex. HCAHPS publicly reported)—NEVER okay for nurse to discuss short staffing with a patient b-c jeopardizes pt’s trust; Critical to be competitive in the market
108
Q

Scheduling: Decentralized

Basics
Pros (2)
Cons (2)

A

Decentralized: Nurse manager responsible and accountable for schedule on individual unit including covering scheduled + unscheduled absences

Pros
- Staff can request time off directly to manager
- Staff has more flexibility and autonomy b-c can change shifts w/ coworkers

Cons
- May lead to manager giving certain people special treatment (unfairness)
- May not be as cost effective because there is not a single person seeing all the units of the hospital

109
Q

Scheduling: Centralized

Basics
Pros (5)
Cons (2)

A

Centralized: When staffing decisions are made by staffing office rather than the manager

Pros
- wide view of whole organization rather than just one unit
- encourages optimal utilization of staffing resources
- Easier to consistently implement staff policy (float pool, agency, Per diem (1 day) nurses are pulled in and often paid more b-c must be flexible and work wherever they’re sent)
- More cost effective than decentralized staffing
- Frees up manager to have more time to do other management functions since not dealing with staffing all day

Cons
- Office doesn’t always know the particulars regarding patient acuity on individual units
- manager not in tune w/ productivity on unit b-c not worried about staffing

110
Q

Patient Assignments

  • Acuity (3)
  • Block (3)
A

Acuity
- Take into consideration the complexity of care and the resources needed for the patient
- skip rooms
- Ideal way to do it (but not always possible if no tool to rate acuity)

Block
- Easiest way to make assignments
- Rooms are dives up amongst number of nurses
- You take patients in a row

111
Q

Considerations in Making Patient Assignments

  • Continuity of care (2)
  • Patient Safety (3)
  • Patient Satisfaction
  • Staff Satisfaction
A

Continuity of care: consistency of care provided
- Promotes quality of care
- Facilitates positive outcomes (patient satisfaction and increased rapport w/ patients)

Patient Safety
- Assign nurses based on knowledge, skills, competencies
- Factor in acuity + severity of pt conditions
- Look at primary diagnosis, comorbidity + where patient is in their treatment.

Patient Satisfaction
- If pt does not want the nurse, may be reassigned

Staff Satisfaction
- If you have difficult pt, may need to rotate staff to prevent staff burnout

112
Q

Staffing Effectiveness: Indicators (2)

A

Clinical/Service Indicators (quality indicators)
- # of patient and family complaints
- # of adverse drug events
- # of injuries to patients
- post-op infections
- Upper GI bleeding incidences
- Cardiac arrest
- Length of stay

Human Resource Indicators (people things)
- Overtime
- Staffing vacancy rate -> Understaffing compared to budgeting staffing plan
- Staffing turnover rate
- Nursing care hours per patient days
- Staff injuries (Ex: needle stick)
- sick call
- Use of on call or per diem

113
Q

Case Management: Role (5)

A
  • Coordinating care by interprofessional team from admissions to discharge for group of patients
  • not in staffing, do not provide direct patient care of patient!!! (Can be nurse, social worker, or another discipline)
  • May be unit based, service line (follow patient through specific areas), or for group of patients
  • Help w/ utilization management by identifying barriers to discharge (very aware of DRG and length of stay)
  • Coordinate care after discharge (DME, home health, wound care, med at home, follow up MD visit)-community resources
114
Q

Patient Navigator: role (3)

A
  • Help patient navigate through maze of all visits, labs, and radiology needs instead of patient having to make individual appointments on their own
  • Emerged after healthcare reform onset (expensive inpatient moved to less expensive outpatient)
  • Must be careful and not try to make choices for patient
115
Q

Nursing Care Delivery Models

What is it?
What does it describe? (3)

A
  • Method used to provide care to the patient ( # and types of caregivers matched to patient needs)

Describes
- how healthcare workers will perform tasks
- Who is responsible for doing what
- who has authority to make decisions

116
Q

Total Patient Care

What is it? (2)
Where is it used?
Pros (3)
Cons (2)

A
  • Oldest model of organizing patient care
  • Nurses are doing everything: planning, organizing, performing all care including hygiene, med, treatment, education –“ I am doing everything as the RN”

Used in ICU

Pros:
- Care is not fragmented
- Nurses have a high degree of autonomy
- Lines of responsibility and accountability are clear b-c RN reports to charge nurse and that is it

Cons:
- May not be enough nurses available for this model
- Costly because RNs are doing things UAP can do for cheaper (B-c no nursing assistances)

117
Q

Functional Nursing

What is it? (3)
Pros (3)

A
  • Staff assigned to complete certain tasks for a group of patients rather than care for specific patients
  • Very task oriented (tasks determined by scope of practice)
  • Charge nurse = coordinates assignments and has to be knowledge about everyone’s skill set

Pros
- tasks completed quickly and efficiently
- Little confusion about who’s responsible for what because assignments are clear
- Do not need as many nurses to supervise

118
Q

Team Nursing

What is it?
Requirements of team leader (4)

A
  • RN functions as team leader and each team given group of patients to care for

Requirements of team leader
- coordinates care for group of patients
- responsible for knowing condition and needs of all pts on her team
- Requires cooperation within team w/ delegation and supervision
- Requires clear communication and leadership skills (Be careful who you pick as a team lead)

119
Q

Primary Nursing

What is it? (2)
Requirement of Primary Nurse (4)
Where is it used?

A
  • You have a patient and you provide total care for it 24h/day
  • Associate nurse fills in for primary and follows primary nurse plan of care when primary nurse is not on shift

Requirements
- needs to be able to communicate effectively because she delegates + manages care 24 hr. a day
- Must coordinate care even when not on shift (is called)
- Must have high degree of clinical judgment, decision making
- Works better with 5 8h shifts rather than 3 12h shifts

Used in home health or hospice

120
Q

Functional Nursing

Cons (5)

A

Cons
- fragmented care
- huge potential to overlook priority needs of itssince everyone is task oriented
- Very confusing model to patient b-c patient does not really know who their nurse is
- Care is not individualized or personalized so patient can perceive this module as lack of customer service
- caregivers can become frustrated b-c repetitive work all day

121
Q

Team Nursing

Pros (2)
Cons (2)

A

Pro
- provide high quality, safe, effective care
- Each team member can bring their own expertise and decision making

Cons
- Expensive
- Continuity of care can be lost b-c assignments can change every day

Leadership (4 decks)

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