1. Managing for Success in Health Care Delivery What can we do? Ruth A. Anderson RN, PhD, FAAN Duke University School of Nursing

2. Purpose of Presentation Demonstrate how we are applying the complexity science concepts to studies of management practices in health care Show evidence base for complexity science derived hypotheses

3. Self Organization Naturally occurring system property Arises through relationship patterns Works for or against goals

4. System Parameters Rate of new information flow Rate of new information flow Nature of connections among people Nature of connections among people Cognitive diversity Cognitive diversity Ralph Stacey, 1996

5. Conceptual Model Nursing Mgmt Practices Rate of information flow thru system  Number & intensity of interconnections between agents  Level of diversity within & between cognitive schema of system agents Behaviors for Quality Outcomes Self- Organization System Control Parameters Process Outcomes Management Practices Alter

6. Self Organization Management Practice Work Environment Participation in decision making Communication Openness Leadership behaviors Workforce diversity System Parameters Rate of information flow Nature of interconnections Diversity within/between cognitive schema Better & IMPROVED Outcomes

7. Agents & information diversity: | Scope Agents & information diversity: | Scope Participation in Decision Making Agent connection & interaction: | Intensity Agent connection & interaction: | Intensity Depth | Information “Richness” Depth | Information “Richness” Breadth | Information Diversity Breadth | Information Diversity Decision Activities  Raising the Issue  Clarifying the Issue  Generating Alternatives  Evaluating Alternatives  Choosing Alternative Decision Activities  Raising the Issue  Clarifying the Issue  Generating Alternatives  Evaluating Alternatives  Choosing Alternative Decision Mechanisms  Established Com.  Specially Created Com.  Informal Meetings  Chance Encounters  Other Decision Mechanisms  Established Com.  Specially Created Com.  Informal Meetings  Chance Encounters  Other

8. RN Participation & Improvement in Resident Outcomes 190 Nursing Homes Survey methods Administrators and Directors of Nursing Minimum Data Set  Improvement in Resident Outcomes Anderson, R. A., & McDaniel, R. R., Jr. (1999). RN participation in organizational decision making and improvements in resident outcomes. Health Care Management Review., 24(1), 7-16.

9. What are the differences between most improved and least improved? Controlling for: Size Change in Cost RN Staffing Anderson & McDaniel, 1999

10. Do Nurses Influence Final Choices Through Participation?

11. Participation in Decision Making Agent connection & interaction: | Intensity Agent connection & interaction: | Intensity Decision Activities  Raising the Issue  Clarifying the Issue  Generating Alternatives  Evaluating Alternatives  Choosing Alternative Decision Activities  Raising the Issue  Clarifying the Issue  Generating Alternatives  Evaluating Alternatives  Choosing Alternative Decision Mechanisms  Established Com.  Specially Created Com.  Informal Meetings  Chance Encounters  Other Decision Mechanisms  Established Com.  Specially Created Com.  Informal Meetings  Chance Encounters  Other Anderson, R. A., & McDaniel, R. R., Jr. (1998). Intensity of registered nurse participation in nursing home decision making. Gerontologist., 38(1), 90- 100. Survey of 125 Nursing Homes

12. Participation in Decision Making Agent connection & interaction: | Intensity Agent connection & interaction: | Intensity Decision Activities  Raising the Issue  Clarifying the Issue  Generating Alternatives  Evaluating Alternatives  Choosing Alternative Decision Activities  Raising the Issue  Clarifying the Issue  Generating Alternatives  Evaluating Alternatives  Choosing Alternative Decision Mechanisms  Established Com.  Specially Created Com.  Informal Meetings  Chance Encounters  Other Decision Mechanisms  Established Com.  Specially Created Com.  Informal Meetings  Chance Encounters  Other Survey of 68 Public Health Agencies Issel, L. M., & Anderson, R. A. (2001). Intensity of case managers' participation in organizational decision making. Research in Nursing & Health., 24(5), 361-372.

13. Participation of Clinical Professionals (MD and RN) = Lower Cost/admission in Hospitals Participation of MDs/RNs Participation of Middle Managers Ashmos, D. P., Huonker, J. W., & McDaniel, R. R. (1998). Participation as a complicating mechanism: The effect of clinical professional and middle manager participation on hospital performance. Health Care Management Review, 23(4), 7-20.

14. Complexity & Turnover Study 164 Nursing Homes Survey methods Administrator, Director of Nursing, RNs, LPNs, CNAs (n~3500) Medicaid Cost Reports-Turnover Anderson, R. A., Corazzini, K. N., & McDaniel, R. R. (2004). Complexity science and the dynamics of climate and communication: Reducing nursing home turnover. The Gerontologist, 44(3), 378-388.

15. Laissez-faire Climate  Conflict prevents accomplishment  Adm doesn’t care who gets hurt  Little concern for employee relations  No room for new ideas  It’s who you know  Unclear goals  Little effort to constantly improve Reward Climate  Adm does the right thing  Adm looks out for worker  Concern for relationships  Learning encouraged  What you do–not who you know  Clear goals & expectations  Constructive feedback  Always looking for a better way

16. Accuracy  Accuracy is the extent to which one believes that the information conveyed by other parties is correct Openness  Openness is the extent to which one can speak clearly and directly without fear of repercussions or misunderstanding

17. Climate, Communication & Turnover LPNs Anderson, Corazzini & McDaniel, 2004 DON tenure Number of RNS LPN Workload Reward climate x Communication openness

18. Climate, Communication & Turnover Nurse Assistants Anderson, Corazzini & McDaniel, 2004 CNA Workload Reward climate x Communication openness Reward climate x Communication accuracy

19. Laissez-faire Climate  Conflict prevents accomplishment  Adm doesn’t care who gets hurt  Little concern for employee relations  No room for new ideas  It’s who you know  Unclear goals  Little effort to constantly improve Anderson, Corazzini & McDaniel, 2004 Communication Openness  Openness is the extent to which one can speak clearly and directly without fear of repercussions or misunderstanding

20. Complexity, Management Practices & Resident Outcomes 164 Nursing Homes Survey methods Directors of Nursing & RNs Minimum Data Set-Resident Outcomes Medicaid Cost Reports-Control Variables Anderson, R. A., Issel, L. M., & McDaniel, R. R. J. (2003). Nursing homes as complex adaptive systems: Relationship between management practice and resident outcomes. Nursing Research, 52(1), 12-21.

21. Theoretical Model Nursing Mgmt Practices + – – – Communication Openness Participation in Decision Making Relationship Leadership Formalization Control Variables Contextual Factors  Size  Ownership Type DON Characteristics  Tenure in position  DON Experience Resident Outcomes Prevalence of:  Resident Behaviors Problems  Restraint Use  Complications of Immobility  Fractures Anderson, Issel & McDaniel, 2003

22. System Parameters Rate of information flow Nature of interconnections Diversity within/between cognitive schema Management Practice Communication Openness People can say what they mean without fear of repercussion—during vertical and horizontal information exchanges. Anderson, Issel & McDaniel, 2003

23. Communication Openness & Restraint Use (N=164) Context Size ( – ) DON Characteristics DON Tenure (–) DON Experience (–) Mgmt Practice Communication Openness (–) Anderson, Issel & McDaniel, 2003

24. Problem Behaviors Context Size ( – ) Mgmt Practice RN Participation in decision making (–) Anderson, Issel & McDaniel, 2003

25. System Parameters Rate of information flow Nature of interconnections Diversity within/between cognitive schema Management Practice Leadership behaviors Relationship-oriented— product of human interaction and communication between manager and worker Anderson, Issel & McDaniel, 2003

26. Leadership & Fracture (N=164) Mgmt Practice Relationship-oriented leadership (–) Anderson, Issel & McDaniel, 2003

27. System Parameters Rate of information flow Nature of interconnections Diversity within/between cognitive schema Management Practice Formalization Centralized control using job descriptions, surveillance, and procedures and rules to ensure predictability

28. Leadership, Formalization & Complications of Immobility DON Characteristics DON Experience (–) Mgmt Practice Relationship-oriented leadership (–) Formalization (+) Anderson, Issel & McDaniel, 2003 N=164 Anderson, Issel & McDaniel, 2003

29. New Behaviors Management Practices Work environment Communication Participation in decision making Leadership behaviors Workforce diversity System Parameters Rate of information flow Nature of interconnections Diversity within/between cognitive schema Self Organization

30. Comparative, multiple- case study Design: ~Six months in each nursing home Large interdisciplinary team involved in all aspects of study to provide checks and balances Example Case: Non-profit, suburban, ~125 beds

31. Data Sources Data Sources Administrators, supervisors, department heads, RNs, LPNs, CNAs, other clinical and support staff 14 shadowed 29 interviewed at least once 98 in direct observation 91 documents

32. Upper Level Management Middle Management LPNs The CNAs The Residents Nursing Home Case Study Relationship Patterns

33. Child rearing is CNAs’ model for resident care Cry baby Attention seeking “Spoiled” Resident problems unaddressed Poor quality of life Outcome RN clinical expertise to identify symptoms of depression CNA Guiding Philosophy CNA Sensemaking Interpretation Nursing Home Case Study Interaction Patterns

34. Things to Think About for Effectiveness Connection Diversity Information exchange

35. MANAGE THE SYSTEM