Exam 3 (comp) Flashcards
delivery systems- 4 elements
clinical dm
work allocation
comm
management
del. systems- clinical dm
is there shared gov?
prof. practice exist?- Yes if there is control abt decisions
del. systms- work allocation
based on acuity lvl
what floor pt goes to
and indivi. nurse assignments
del systems- management
monitoring and eval, quality control
del systems- comm
chain of command
factors when choosing care del. system
skill/expertise of staff (scope of practice)
availability of RNs
economic resources
acuity of pts
complexity of tasks
case method
funnel (charge- nursing staff- pts)
total pt care
began when rich ppl had private nurses
one nurse assumes TOTAL responsibility for <3 ppl
ex. home health, iCU, community
case method- advantages v disadvantages
advantages-
unfragmented, inc pt satisfaction (client focused)
nurses have inc autonomy
disadv-
COSTLY
dec efficiency (takes inc coord)
poor pt care if wrkld high
learning curve for inexperienced RNs
functional nursing
‘divide and conquer’- scientific mngmnt (charge, RN, LPN, CNA- unit of pts)
task oriented- “care through others”
emphasis on efficiency
unskilled wrks become proficient w/ repitition
nurse is not responsible for total care
functional nursing- advantages v disadv
advantages-
efficient/effective (most wrk in least amnt time)
train wrks (less cost, less RNs)
disadvantages-
fragmented care
diff. to assess pt progress
dec accountability and responsibility
dec job satisfaction
team nursing
waterfall (charge, team leader, nursing staff, pt)
(similar to functional)
goal- dec fragmentation of care
provide pt centered care
democratic leadership works best
teams NO more than 5 members
team nursing- leader role
assign each member a pt or specific respons.
team nursing- adva and disadv
advantages-
inc pt satifs.
dm at lwr levels
*each member participates in dm process
INC COMMUNICATION
disadvantages-
inc time
poor leadership/implementation
primary nursing
desire for INC AUTONOMY= decentralization
1st formal professional model (can only access pt through nurse)
primary nurse for 24hr TOTAL pt care from admin to dc
(prefer BSN)
delegates to others when not working
*not used in acute care
primary nursing- advantages and disadv
advantages-
inc RN autonomy
continuity of care
psychosoci needs met
inc trust/communication
disadvantages
costly (all RNs)
burnout (total accountability)
trouble if RN shortage
client-focused care
Unit-based
organize care around pt needs
RN, LPNS, CNA, unit clerks and unit manager
pts dispersed in hospital based on care requirements v same dx
supplies brought to the pt
client focused care- principles
based on principles of primary nursing and case mngmnt
staff must be cross trained
caregivers @ bedside reduced but responsiblities are INC
client-focused care- advant and disadva
advantages-
inc pt satisf
service/waiting times dec
cost effective
disadv-
fewer # RNs
inc responsiblity for caregivers
role confusion
differentiated nursing practice
maximized nursing resources
3 components
education
experience
competence
2 models
differentiated nursing practice education model
role differentiation based on education
ADN- direct pt care
BSN- admin to dc, coord care and client ed
MSN- case mngmnt, collab w/ disciplines
differentiated nursing practice competency model
based on ANA standards and
Brenner’s 5 lvls of practice
*lvls do not transfer btw floors
novice- no experience
advanced beginner- some exper, performs effectively
proficient- perfor guided by standards
expert- intuitive understanding
differentiated nursing practice- adv v disadv
advantages-
dec cost, inc efficiency
best use of resources
disadv-
nurse is a nurse mentality
inc use of UAP
case management- 2 core components
coord of care
management of risk
case mngmnt- goal
assessing, planning, facilitation and advocacy
goal- promote quality, cost-effective outcomes
interdisc, involves the pt, uses critical pathways
case management- 4 principles
coord and integration of a continiuum of holistic care
promotion/preservation of health thru periods of transition and risk
conservation and allocation of scare resources
provision of FU care that tracks service long term (reduce fragm care)
case management- target pop
pts and families at great risk for neg outcomes
high cost
high risk
high recidivism (returning)
critical pathways
standards of care or clinical practice guidelines
map time and activity sequence
based on DRG classification
critical path- components
assessments
consults
test
treatments
meds
activities
nutrition
dc planning
critical path- varients
anything that alters system, pt or provider
positive (achieved b4 expected)
or
negative
centralized staffing- gen, pros and cons
decisions made by person in staffing center
pros-
fairer, cost effective, frees up manager
cons-
dec flexibility
don’t know employee needs
decentralized staffing- gen, pros and cons
unit manager schedules
*can be delegated to clinical coord or charge nurse
pros-
staff has inc autonomy
more flexibility
cons-
unfair rewards
time away frm manager
staffing alternatives
self-scheduling
float pools
per diem
agent/travel
flextime
intergroup/organization- conflict
btw 2+ grps of ppl, departments or organizations
intra- personal conflict
internal struggle
inter- personal conflict
btw ppl w differing values/wants/beliefs
sources of organizational conflict
pwr divisions
communication misunderstandings
personal goals diff than organizations
resource allocation
poorly define role expectations
varying background/beliefs btw members
conflict resolution- top lvl
= strengthened relationship
results in mutual benefits
conflict resolution- middle lvl
temporary agreement
little enhancement to the realtionship
conflict resolution- lower lvl
= mutual damage
one person submits to demands of the other
conflict process- 5 stages
latent conflict-
(no present conflict but conditions are conducive)
perceived conflict
(ppl recog logically before internalizing)
felt conflict
manifest conflict
action taken (debate or withdraw)
conflict aftermath
either + or -
positive effects of conflict
prov. intellectual stim and creativity
facilitates change
improves dm
improves grp performance
negative effects of conflict
dec comm
dec performance
dec cohesiveness
inc absenteeism and turnover
conflict resolution strategies- 5
compromising
competing
cooperating/accomodating
avoiding
collaborating
selection of conflict resolution
depends on nurse managers values regarding work production and human relationships
avoiding- balance
low results
low ppl
avoiding
use when ppl need to cool down
if more info needs to be gathered
cost of dealing w/ conflict exceeds benefit
one party is more powerful than the other
DO NOT use if you made a mistake
accommodating/cooperating- balance
HIGH ppl
low results
accommodating/cooperating
when you made a mistake
issue is more important to one party than the other
more concerned about preserving harmony
competing- balance
High results
low ppl
competing
quick, decisive action is needed (emergency situation or need to discipline )
if an unpop. action is needed
focused on pt safety and care
can be authoritarian
compromising- balance
medium results
medium ppl
compromising
if collab and competing fail
status quo
balance pwr and priorities
*b/ parties lose
collaborating- balance
HIGH results
HIGH ppl
collaborating
*optimal approach
satisfys all members
need to merge vastly diff viewpoints
discuss issues interfering w/ morale and productivity
if seeking creative and integrative solutions
dudley weeks- conflict partnership process
WE v “you and I”
deal w/ conflict in context of OVERALL relationships
resol should improve relationships
should result in mutual benefits
relationship building and conflict resol are CONNECTED
dudley weeks- 8 steps
- create effective atmosphere (non-threat. environ)
- clarify perceptions (what is the conflict abt, what have you done to add to it?)
- focus on indiv and shared needs (personal needs v grp needs)
- build shared positive pwr (power WITH, have clear self image)
- look at future, learn from past
- generate options (be prepared for hidden agendas)
- develop “do-ables” (neutral, obtainable, measurable steps)
- make mutual benefit agreement
mediate wrkplace conflict
responsibility of charge nurse- facil. resolution
address on own, then meet w/ antagonists together
determine own responsibility (is it unit problem)
have particip discuss and commit to a resolution
what to avoid in conflict resolution
believing that only ppl affected are the ones involved
do not meet sides separately
healthy response to conflict
recog/respond to things that matter to the o/ person
clam, nondefensive
readiness to forgive
ability to compromise
unhealthy response to conflict
explosive, angry, hurtful beh
inabil to compromise
fear and avoidance of conflict
budget
financial plan
aim at controlling allocation of resources
direct costs
attrib to specific source
ex. nursing time
cost of resources
indirect costs
overhead
what organization is spending money on no matter what
*cannot be directly attribut to one specific unit or pt
personnel budget
salaries
nurse managers do this
operating budget
expenses that change in response to vol. of service
daily operating costs
capital budget
expenses r/t capital assets or long term investments
traditional budget method
based on budget from previous yr + 3%
zero-based budget
justify all expenses for each yr
should have 0 at the end of e/ yr
takes lots of time and resources
performance budgeting
emphasize outcomes and results instead of activities
budgeting- unit managers responsibility
meeting fiscal goals of company
advocate for high quality and approp staffing
comm, unit needs
comm. budget to staff
bargain for scare resources
*CANNOT DELEGATE BUDGET NEGOTIATING
budget process
assess
dx
plan
implement
eval
budget variances
diff btw amnt that was budgeted and actual revenue cost
favorable variance
more revenue than expected
inc pt census
inc pt stay
inc pt acuity
unfavorable variance
more sick days
inc travel RNs
budget- promotion of cost control
time is money (dc pts faster)
efficiency/ standardization
motiv clients to recover
using supplies sparingly
nursing personnel budget
90%
most expensive item
how to calc cost of nursing
pt census
diag related grps
acuity/complexity of care
full time equivalent (FTE)
how to determine overall staffing plan
FTE
DRGs
dx related groups
reimbursement for care days
DO NOT account for acuity lvls and pt needs
census
avg dailiy census based on historical data
regulated by JCAHO
1 pt day= 1 pt/day
hours per pt day
HPPD
hrs of care per pt
per day
no diff is made based on acuity lvl of pt
HPPD= nursing hrs (24)/ pt census
productivity
ratio output to inputs
productivity outputs
nursing care, hrs of care, # home visits
productivity inputs
resources used to provide services, personal hrs, supplies
how to inc productivity
dec input and inc output
dec productivity= inc input and dec output
patient classification system
objective method to classify pts by determining amount and complexity of care needed
fed and state mandate use of PCS to determine staffing levels
category I - IV
I- 2hrs
iII- 6hrs
III- 7 hrs
IV- 9 hrs
how to calc nursing personnel budget- unit of service
unit of service (vol of work needed)/ pt days (avg daily census)
ex. 26 total pts
161 total/24hrs
161 (hr)/ 26 (#)= 6.19= 6.2 standard unit for budget
how to calc # of staff members needed (FTE)
HPPD (constant) x avg daily census x 365/ 2080 (1FTE) = # FTEs
ex. HPPD= 6.2
avg daily= 26
(6.2 x 26x 365)/ 2080 =
28.3 FTEs for year/unit
how to calc FTE for 1 staff member
hrs worked per wk/40
ex. 1 RN 3p-3a monday and wed
12 hrs- 2d/wk= 24
24/40= 0.6 FTE
calc NCD/PPD
number nursing hrs/ pt census
differentiated nursing practice
based on indivi, not # of staff
how to determine if calc budget is productive
ex. standard of care= 6.2 HPPD
161 hrs of care per 24hrs
26 pts
when 150 hrs are provided
161/150= 1.07
> 1 = productivity inc
<1= productivity dec
HR def
motivation of employees to perform productively
goal- organizational cul makes wrk interesting and leads to satisfied wrkers and clients
form of management controlling
perform appraisal def
systematic
standardized eval of quality of work
work contribution
potential for advancement
“D”
perform appraisal- measures what and should result in
nursing performance (based on standards)
should result in inc retention, productivity and pt care
components of competence
cognitive-
critical thinking, dm, problem solving
affective
interpersonal skills, comm.
psychomotor
physical tasks
performance appraisal strategies
trait scales
peer review
self eval
management by objectives
performance appraisal strategies- trait scales
absolute- eval performance against internal standards (ex. 1-5 rating)
BARS- form of absolute- description of what quantitative # means
ex. 1 novice, 5 excellent
behav. anchored rating scales- form for each job classification
comparative- compares employees to one another
personalized to grp- ranking depends on avg competence of class
not commonly used in HC
performance appraisal strategies- management by objectives
goals written in form of objectives
for given time period
mutually set w/ employee and manager
evaluator rating errors- halo effect v horn
1-2 positive aspects influence all other performance
generalized overall high rating
vice versa
overall poor rating
evaluator rating errors- sunflower effect
everyone high rates bc they belong to a “great team”
evaluator rating errors- central tendency effect
everyone average
does not know much about the person
evaluator rating errors- temperament effect
performance varies depending on rater
some ppl are more strict
evaluator rating errors- matthew effect
same appraisal results yr after yr
if you perform well you get good marks
if you struggle, you continue to struggle
absence freq
total # of distinct absence periods, regardless of duration
ex. 9 days in a row
= 9 total days absent, 1 freq period
ex. 9 mondays
= 9 total days absent, 9 freq periods
absenteeism types- vol v invol
vol- under employees control
invol- outside employees control
effects of absenteeism
inc cost
dec morale of peers (inc workload, dec productivity)
dec quality of care
inc stress/conflict
inc absenteeism
“D”
turnover- disadvantages
inc cost
dec morale
impaired team functioning (conflict, staffing issues)
loss of management potential
turnover- personal causes
relocation
family considerations
transportation
school
turnover- strategies to improve
clinical ladder programs
magnet designation
mentoring/coaching
residency programs
discipline
molding mind/character to bring out desired beh
(disiplina) latin= teaching, learning, growth
punishment- scientific management theory
old
used discipline to control beh
works for short term but is demoting and dec productivity
punishment- constructive discipline
new
helps employee grow
demonstrate the actual v expected performance
puts burden on employee to change
requires mutual trust
punishment- highest lvl
self discipline
effects of incivility
“disruptive beh”
low morale, high turnover, poor pt care
usually rude and can incl non-verbal beh
marginal employee
disrupts unit functioning
works to meet MINIMUM standards
“D”
strategies to address marginal employee
id who they are
dev explicit action plan
performance deficiency coaching
fire to transfer to diff unit if needed
strategies to deal w/ impaired employee
gather data, beh, work perform, attendance etc
confront
develop plan, goals (can refer to trtmnt)
have to be ubered home from work.
meeting w/in 24 hrs to discuss return
“D”
mcgregors hot stove- 4 componets
forewarning
know they will be discip if they break rule
immed conseq
consistency
everytime break rule
impartiality
progressive discipline def
eval performance
provide feedback
steps for sanctions start least severe to most
progressive discipline steps
verbal (remind of policies- counsel/coach)
written (employee must agree that beh needs to change)
suspension from work (day off w/ no pay- need to return to work w/ written decision)
termination
can apply directly after incident or if employee fails to comply in the future
discipline v punishment
discipline- training/molding to get desired beh
punishment- undesirable event s/t unacceptable beh
