n471 final

patient protection and affordable care act

reduce uninsured, increase access to care, help for preexisting conditions, changes with governmental changes

value based purchasing

decreases costs, work with vendors

accountable care organizations

group of providers working together to take care of patient groups, goal of seamless, quality care, coordination of care

bundled payments

payment model that combines the cost of multiple services into a single payment — paid per diagnosis and all associated costs

medical home

team-like process for improved access to services, quality, and outcomes of patient care, reduce hospitalizations and high-cost medical services

cost containment

(hospital inpatient care)

• focus on effective, efficient and quality services

• equals out in revenue

• everyone is responsible

• unit manager considers each unit’s budget

hospital budgeting

• expenses and income for a certain time period

• must be as accurate as possible

• fixed expenses — mortgages, salaries

• variable expenses — payroll of hourly employees, costs of supplies

• controlled expenses — how many people work during a shift

• uncontrollable expenses — emergencies, needing more staff/time, specific supplies needed to care for patients

budgeting steps

1. assess — what are the needs

2. diagnosis — what needs are priority

3. plan — set time/goals

4. implementation — continue to assess for change

5. evaluation — review, add, remove

budget types

• personnel - largest expenditure

• operating - expenses that change (electricity, repairs, maintenance, supplies)

• capital - buildings, major equipment

medicare

federally funded program for seniors over age 65 or disabled recipient pays into insurance plan; several plans of MC cover a variety of services

medicaid

federal/state plan to assist indigent population, disabled, long term care

prospective payment system

regulations as to what providers/healthcare agencies can charge based on a diagnosis rather than patient specific

managed care organization

health program that looks at efficiency, access and cost, PCP as gatekeeper

budgeting RN opportunities

• staff nursing

• managers/leaders

• quality department

• technology department

• fiscal budget

• supply allocation/distribution buyer/manager

• vendor representative

• insurance nurse

interprofessional communication

communication with

• patients, families, colleagues, leadership

necessary for continuity and productivity

organizational communication

more complex than interpersonal

• more communication channels

• more individuals

• more information

• new technology

communication process

• internal and external climate

• effective communication requires sender to validate what receivers see/hear

• differences in gender, power, status can affect organization and unit org

internal climate

includes values, feelings, stress levels of both sender and receiver

external climate

status, power, authority of sender/receiver, timing and organizational climate

assess org communication

• formal vs. informal

• who communicates with who

• what is the pace of communication

• understand structure & who’s affected by decisions

• use clear, simple, precise communication

• seek feedback on whether communication received is accurate

• use multiple modes of communication

• don’t overwhelm people with unnecessary info

upward communication

manager makes needs/wants known to higher level

downward communication

manager communicates info to colleagues under them

horizontal communication

manager communicates with others on same hierarchical level

diagonal communication

manager interacts with other managers or physicians on different hierarchical levels

grapevine communication

info flows quickly and haphazardly among people at levels

written communication

use when documentation is needed

• can be formal or informal

• tone can be mistaken

face to face communication

formal or informal

• depends on intent, ender/receiver needs

• watch body language

telephone/text

rapid communication, formal or informal

assertive verbal

direct, honest, does not infringe on rights

passive verbal

person remains silent about issue even though they have strong feelings; “suffer in silence”

aggressive verbal

direct, threatening, condescending, infringes on rights

passive aggressive verbal

an aggressive message presented in a passive way (incongruent message)

SBAR

standardized professional communication to provide quality patient care and reduce errors

• situation, background, assessment, response

listening skills

• understanding own emotional intelligence — values, beliefs, past experiences, biases, limits, emotional awareness and control

• balance the needs around you

• understand conversation coming in, interpret meaning, restate misunderstandings

group - forming

way of establishing behaviors in groups

• who are leaders and dependents

• what behaviors are among the group

• identify rules, tasks, responsibilities

group - storming

resistance is normal when forming groups

• see what influences come within the group, how they resolve, or rebel

• how are demands of tasks resolved

group - norming

group starts to develop more efficiently, conflict resolves, cooperation develops

group - performing

group completes tasks, members perform in their roles, problems are resolved

leadership and emotional intelligence

• know self first before leading others

• know the team

• know the unit culture

• see the bigger picture

• communication

• live by virtues/values

motivation

process of inducing, inspiring, and energizing people to work willingly with zeal, initiative, confidence, satisfaction and an integrated manner to achieve desired goals

• moral boosting activity

intrinsic motivation

comes from within a person

• often influenced by upbringing, family structure, culture, values, beliefs are formed at a young age

• can be developed and change over time

extrinsic motivation

comes from outside the person

• financial, emotional, self, personal, relational factors

• can develop and change over time

team building

• encourages trust

• goal attainment

• cooperation

• see other views

• improves efficiency

• resolves conflict

role model desired behaviors

• listen

• take action about concerns

• uphold values when challenges arise

• stay positive

• encourage others

• demonstrate care at the bedside

• accountability

• remember our purpose

• don’t make excuses

synergy

the cooperative working together of 2+ people or orgs, when their combined effect is greater than sum of their individual efforts

creating synergism

• hire the right people

• stay positive when challenged

• go the extra mile

• share common interests, values

• compliment skills

• stronger as a group

• empower group members

• be committed

worker engagement

• active in their work

• increases performance/outcomes

• more than “just a job”

• employees love what they do

• committed

• balancing work life

• make decisions

• creative thinking/innovation

• know job expectations

positive reinforcement

• validation of work effort

• be specific

• recognition of extra effort

• hire for the fit, not just to fill a vacancy

• show trust in decision

• let employees “create” at work

• external rewards are not always positive

• give praise during huddles, unit or personnel specific

• encourage one another

leaders can motivate by

• set clear expectations

• be fair/consistent

• be strong in decision making

• create a team atmosphere

• rave individual uniqueness

• encourage diversity, equity, inclusion

• provide growth opportunities

• give credit for ideas

• communicate org needs

• don’t micromanage

• create trust/being part of team

• be a positive role model

• listen intently

• take self care seriously

delegation

transferring authority and responsibility to perform a specific activity from their own practice, to an individual qualified to perform that task but retains accountability for the task

delegation benefits

• allows time to focus initiatives

• increases flexibility

• gain trust in staff performance

• earn respect from staff

• improves communication

• achieves goals in cooperative group effort

• balances workload and time

• decreases stress

• increased productivity

• more ideas/creativity/solutions

• better use of human resources

• builds on leadership skills

delegation staff benefits

• improves the level of trust and communication

• achieves goals that require cooperative group effort

• personal and professional development

• increased job satisfaction

• know-how, experience

• increased productivity

delegation organization benefits

• saves money for the organization because it makes the best use of organization resources since it increases overall productivity and efficiency

• ensures tasks are assigned to the right person at the right level

• more motivated staff and improved retention

effective delegation

identify the necessary skills/education level to complete task

• NPA — determines RNs’ scope in each state

• RN must understand scope of practice of others on nursing team

• different rules apply in each state and organization for delegation to unlicensed personnel

nurse pracice act

• state’s definition of delegation

• items that can’t be (routinely) delegated

• guidelines for RNs about tasks that can be delegated

• description of professional nursing practice

• description of RN, LPN/LVN, UAP scope

• degree of supervision required for task

• guidelines for lowering delegation risks

• warnings about inappropriate delegate

• if there is a restricted use of the word “nurse” to licensed staff

RNs in NYS

• RNs are independent practitioners and don’t require supervision when providing care

• prepared to assess, diagnose, plan, implement, evaluate

LPN scope

• dependent practitioners that must practice under supervision of RN or other licensed provider

• RN needs to be on premises or immediately available by telephone when professional services are rendered

• degree of supervision should be appropriate to the circumstances

• home care → RN available by phone

• LTC → RN on site at least 8 hours per day and available by phone at other times

UAP scope

unlicensed healthcare provider permitted to perform in a limited manner some activities that fall within nursing scope

• supervising RN still responsible for assessment, evaluation, judgment

UAP functions

• non nursing: housekeeping, clerical, transportation, dietary

• health related:

  • doesn’t require professional judgment/critical thinking and can be completed using standard procedure

  • NOT within legally protected scope

  • must have demonstrated competency

scope exceptions

permits nursing activities/tasks to be performed by non-nurses under very specific conditions

• family members

• nursing students

• OMH/OMRDD attendants

• caregivers for self-directing individuals in special state-authorized home care programs

delegation in NYS

Rule of Board of Regents states

• delegating professional responsibilities to a person when the license delegating such responsibilities knows/has reason to know that such person is not qualified = unprofessional conduct

• crime to permit unauthorized practice

• class E felony

• violations reportable to State Education Department, Office of Professions, State Attorney General

what can be delegated

LPNs/UAPS must be supervised by RN or other authorized licensed professional

• RNs can delegate to RNs/LPNs

• LPNs can delegate to LPNs

• non-nursing tasks can be assigned to UAPs

RN must

• be familiar with job descriptions

• know competency level

• have supervisory authority

delegation - potential for harm

the greater the potential for harm, the more necessary it may be to have a professional nurse render care

delegation - condition/stability

an UAP should be assigned no more than minimal health-related activities for unstable patients

delegation - complexity of task

• activities involving complex psychomotor skills and requiring expert nursing assessment/judgment should only be performed by professional nurse

• as required skills increase in complexity, greater consideration must be given to prior training and demonstrated competency

delegation - problem solving/innovation

adapting an activity and evaluating its outcome is professional nurse’s responsibility

delegation - unpredictability

when a patient’s response is unpredictable or unknown, it is advisable to delegate activity to RN/LPN

delegation - coordination/consistency

the nurse’s ability to plan, coordinate and evaluate a patient’s care is restricted when support personnel engage in most of direct patient contact

delegation - 1. define the task

complexity and components

• what areas of authority or what resources must the person control to achieve expected results

• what are the limits, boundaries, or parameters for each area of authority or resource to be used?

• NEVER delegate: discipline, situation that involves confidentiality, controversy

delegation - 2. decide on delegate

match task to individual

• who has requisite capabilities?

• who is allowed to do the task legally and by organizational policy?

• who is willing to accept responsibility?

delegation - 3. determine the task

clearly define expectations

• describe the task, provide a reason for the task, inform about standard of evaluation and how often, identify constraints as well as risks, validate understanding by eliciting questions and providing feedback

delegation - 4. reach agreement

empower delegate

• anticipate areas of negotiation, identify what you are prepared and able to provide

delegation - 5. monitor performance and provide feedback

reward accomplishment

• mechanism for feedback and control that ensures tasks are carried out as agreed

right of delegation

successful delegation

• define task

• select individual

• assess ability and training needs

• explain why

• state required results

• agree on schedule

• support and communication

• provide feedback on results

• repeat process

effective delegation - plan ahead

• delegate before you get overwhelmed

• assess situation to identify tasks that can be delegated

effective delegation - select/empower

• identify the right individuals for the task

• be aware of job descriptions and allowed tasks per hospital

• delegate authority and responsibility to complete the task

effective delegation - communicate goals

• purpose of task, any limitations or qualifications imposed on task including a timeline, expectations for reporting

effective delegation - set deadlines

monitor progress

• shows interest of delegator, provides review of progress and encourages ongoing communication

• final responsibility belongs to delegator but delegate accepts responsibility for completing task appropriately and is accountable

effective delegation - be a role model

provide guidance

• as a resource to delegate to identify alternate solutions

• be willing to answer questions, clarify desired outcomes

• reassuming task is a last resort as it fosters sense of failure and demotivates

effective delegation - evaluate

provide feedback including positive and negative

• ask what you could have done differently to help

effective delegation - reward

• reward successfully completed accomplishment

• leaders are often measured by successes of those on their teams

can delegate to UAP

• feeding w/o swallowing precautions, drinking, ambulating/turning, grooming, toileting

• collecting vitals, I/O, glucometer (not in NYS)

• apply clean dressings

• perform oral suctioning/mouth care

• taking EKGs

• giving enemeas

• doing venipuncture

• carrying out non-nursing functions

• reporting to RN/LPN

cannot delegate to UAP

• assessing, evaluating, problem solving

• determining nursing dx

• developing nursing plan of care

• providing patient education or health counseling

• performing sterile or invasive procedures

• feeding through NG tube

• admin O2

• trach suctioning or resp care

• admin meds

appropriate tasks to assign to UAP

• non-invasive/nonsterile tx

• collecting, reporting, documenting data (VS, height/weight, I/O, urine tests)

• ambulation, positioning, turning, transfers

• transportation of patient within facility

• personal hygiene, elimination (vaginal irrigations and cleansing enemas)

• feeding, cutting up food, placing of meal trays

• socialization activities

• activities of daily living

RN to LPN - can delegate

• monitoring client findings as input to RN’s ongoing assessment

• reinforcement of client teaching from standard care plan

• routine dressing changes

• tracheostomy care

• suctioning

• checking NG tube patency

• admin of enteral feedings

• ostomy care

• insertion of urinary cath

• med admin (excluding IVs)

RN to LPN - cannot delegate

• assess, evaluate, problem solve

• independently develop nursing care plan

• admin chemo

• admin direct IV push except saline/heparin flushes

• admin IV fluid bolus for plasma volume

• access any form of central line or venous chest or arm port line device (except in outpatient chronic hemodialysis)

• triage, case management, mental health teaching

under delegation

• “i like to have things done my way”

• “my staff will resent the additional work”

• “my staff expect me to be the problem solver and decision maker”

• “i can do this better and quicker than my staff”

• “i don’t have confidence in my staff”

• “it’s easier to do it myself than organize, explain and monitor it”

over delegation

• poor time management

• unorganized

• insecure in ability to do task

• do not know laws/regulations

• assignment too heavy

improper delegating

• delegating at wrong time

• to the wrong person

• for the wrong reason

• delegating tasks/responsibilities beyond capabilities of delegate

• delegating w/o providing adequate information

resistance to delegation

• current workload is overwhelming

• believe they are incapable of performing task or lacks confidence

• inherent resistance to authority

• tasks are overdelegated in terms of specificity

performance appraisal

• determines how well employee carries out duties

• should encourage/motivate staff

• objective manner

• determines area for professional growth, strength, projects, committee involvement

• how is employee working toward organizational goals

motivate through appraisal

• have a positive outcome

• have a standardized process

• shows accountability

• appraisal tool must accurately assess the performance

• employee input

• known standards

• should be completed with direct supervisor

appraisal - accuracy/fairness

• be objective

• be aware of personal biases

• seek other managers’ input as needed

• gather and keep accurate data

• obtain positive data about performance, growth, achievement

• note areas of improvement

• self appraisal needed

• work toward goals

appraisal day

• employee should know reason for meeting

• choose a time not rushed and provide advanced notice

• be ready to give unbiased appraisal

• watch body language

• begin positive, have employee give self-assessment

• listen and give full attention, avoid distraction

• be specific

• set goals

• agree/disagree on terms

peer review

• provides feedback and growth opportunities

• must orient staff to process

• standard tools available

• ongoing support, resources

• how should the information be used

• increase professionalism

performance appraisal components

how to manage employee problems

• understand personalities

• communication is key

• adequate employee training

• regularly scheduled performance evaluations

• be constructive vs. destructive

• support mental health of overworked

• employee understands expectations and manager needs them to develop skills/job performance

• self discipline - values/beliefs, self worth, integrity, emotional intelligence

• does employee fit in with the group, is there social pressure

• mutual trust among colleagues, with management, with administration

McGregor’s Hot Stove Rules

1. forewarning

2. immediate consequences

3. consistency

4. impartiality