Clinical Management Nutr 564: Management Summer 2007

Objectives: Contrast the functions of management as presented previously to the functions of clinical management Analyze tools available for clinical management Review the Nutrition Care Plan Review Care Pathways Clinical Management

Concept Discussion Review the major topics we have covered this quarter and be prepared to discuss examples from clinical management.

Functions of Management Leadership / Management Information Management Time Management Systems Management

Why? Puckett ‘04

Management Activities 1) Planning Strategic Planning: Setting Goals Operational Planning Defining Objectives Designing the organization to achieve the goals and objectives Assigning responsibilities Allocating resources Designing organizational controls

Planning Examples from the reading Policies, Procedures and Standards (Also see p. 251 Puckett) Planning for facility goals and objectives Planning for program goals and objectives Personnel needs (education, travel) Planning for services – patient care Marketing Opportunities

Policies and Procedures Purpose: Documentation Internal purposes JCAHO requirements Standardization Consistency between personnel / Communication Establishes plan for revision and evaluation

Examples Polices

Examples Procedures

Procedure Name:Review of interns records prior to start of program Origination Date:July 13, 2004 Authorization:L Peck, B Bruemmer Status:Active Procedure Objective:Assure compliance with CADE guidelines Personnel InvolvedNS Program Assistant/ DI Director Schedule of ActivityYearly 4 th week of August PersonnelNS Program Assistant will: Review documentation for incoming Dietetic Interns for: One original complete transcript DPD verification form Submit these completed forms to the DI for review DI Director will: Confirm documentation Note in DI log that records were reviewed and completed Revision Status:Bi-annual (August) References:CADE Accreditation Handbook Definitions: Distribution List:L Peck, B Bruemmer, B Winter-Eben, C Purnell Forms & Resources:

Procedure Name: Student RD Exam Registration Eligibility Frequency of ActivityYearly Schedule of Activity:June Procedure Objective:Identify DI graduates to CDR for eligibility to take RD exam Procedure DI Director  Two weeks before the end of spring quarter the eligible interns will be identified.  Distribute Name/Address verification form to the interns NS Program Secretary  Prepares the CDR disk: Intern – name, social security number  Prepares the DI verification forms – 5 per student: DI Verification forms include: Code xxx; Title = ‘Director, Dietetic Internship’; Date; Student Name, SS number, date of completion of internship Interns:  Complete name/address verification form (sign and date in blue ink)  Retain student copy  Return CDR copy to Program Secretary DI Director:  Signs 5 original verification forms (blue ink) per intern 1 form to intern file; 4 forms given to intern at completion of DI  Signs cover sheet for CDR NS Program Secretary/ At completion of DI  Copies CDR materials  Sends disk to CDR Sends name/address verification forms and cover sheet to CDR

2)Controlling 2)Controlling Management control Designing project controls Motivating/ Monitoring Reviewing Progress Solving Problems Leadership, coaching and counseling Performance appraisal Measuring productivity Management Activities

Puckett ‘04 Measuring Productivity

Determine the estimated variability in the time spent on each task. Evaluate patient acuity relative to staff services Measuring Productivity

Acuity: Decisions about acuity are based on sensitivity and specificity models not on universal principles. May be determined by: Diagnosis Screening Clinical Status

Match staffing to appropriate skill level Include estimates of cost-effectiveness/ quality assurance Avoid the pitfall of only monitoring processes and not outcomes Measuring Productivity

2) Controlling Operational control Scheduling Establishing procedures Measuring Productivity

Screening Puckett ‘04

Objectives: Contrast the functions of management as presented previously to the functions of clinical management Analyze tools available for clinical management Review the Nutrition Care Plan Review Care Pathways Clinical Management

Definition The ADA Nutrition Care Process is…. A systematic problem solving method tha dietetics professionals use to critically think and make decisions to address nutrition related problems and provide safe, effective, high quality nutrition care.

Nutrition Care Plan A means of communication among all members of the treatment team A resource to be used in treating the patient’s illness A means of providing continuing patient care in different health care settings. An important tool in utilization management and quality assessment programs. A constant and valuable source of information for research and educational and statistical studies Proof of services provided (for reimbursement documentation) A document that can afford legal protection to the health care facility, its employees and its patients. Puckett ‘04

Nutrition Care Plan What are the advantages to using the pathway? Standardized language Link to EBM Focus is on delivery of quality care Systematic documentation for reimbursement

Objectives: Contrast the functions of management as presented previously to the functions of clinical management Analyze tools available for clinical management Review the Nutrition Care Plan Review Care Pathways Clinical Management

Clinical Pathways

Also known as: Critical paths Critical pathways Care paths

Clinical Pathways “Management plans that display goals for patients and provide the sequence and timing of actions necessary to achieve these goals with optimal efficiency” Every NR et al. Circulation 2000;101:461-5.

Clinical Pathways  Select the best practice when practice varies unnecessarily  Defining the standards for the expected duration of hospital stay and for the use of tests and treatment  Examining the interrelations among the different steps in the care process to find ways to coordinate or decrease the time in the rate- limiting step

Clinical Pathways  Giving all hospital staff a common game plan from which to view and understand their various roles in the overall care process  Providing a framework for collecting data on the care process so that providers can learn how often and why patients do not follow an expected course during their hospitalization  Decreasing documentation burdens  Improving patient satisfaction with care by educating patients and their families about the plan of care

Clinical Pathways Care delivery tool similar diagnoses Identify level of care Members of Health Care Team Specifies time of intervention Incorporates discharge planning & education

Clinical Pathways Benefits Uniform care / reduces variation in care Improves communication Facilitates documentation Supports quality assurance efforts

Clinical Pathways Limitations Only useful if properly used in a timely fashion Flexibility Often many of the processes have not been tested Not all variation is negative Not an end in itself Allow for identification of problems

Clinical Pathways Examples: Information on patient’s nutritional care Admission: Screening - Baseline data - Ht, Wt, IBW, Nutritional Assessment - at risk statement During hospitalization: Interactions * Diet Instruction * Nutrition Support

Clinical Pathways Examples: Information on patient’s nutritional care Discharge Planning: Education Plan for follow-up

Clinical Pathways Sabo ‘05

Clinical Pathways

Steps in developing a care pathway Select a topic Select a team Evaluate the current process of care Evaluate medical evidence and current practice Determine the critical pathway format Develop the algorithm Include documentation on the pathway Document and analyze variance Pathway implementation Continuous Quality Improvement

Fuss: J Trauma Nursing; ‘98

Clinical Management Examples McMahon ‘06

Clinical Management Challenges Organizational Structure Health Care Ancillary service