2. Managing Client Care

3. OBJECTIVES Describe the economic climate of the health- care system. Describe the economic climate of the health- care system. Compare and contrast the traditional and contemporary models of client care delivery system. Compare and contrast the traditional and contemporary models of client care delivery system. Discuss the role of the nurse in continuous quality improvement and risk management Discuss the role of the nurse in continuous quality improvement and risk management Discuss how CQI affects care. Discuss how CQI affects care. Explain how a critical pathway can be used to measure client outcomes. Explain how a critical pathway can be used to measure client outcomes.

4. In the 1800’s, Florence Nightingale wrote…to be in charge is certainly not only to carry out the proper measure yourself but to see that every one else does so too; to see that no one either willfully or ignorantly thwrats or prevents such measures…to ensure that each does that duty to which he is appointed. In the 1800’s, Florence Nightingale wrote…to be in charge is certainly not only to carry out the proper measure yourself but to see that every one else does so too; to see that no one either willfully or ignorantly thwrats or prevents such measures…to ensure that each does that duty to which he is appointed.

5. Today administrators try to find a balance between “lean and mean” efficiency and high-quality care Today administrators try to find a balance between “lean and mean” efficiency and high-quality care Economic climate today-looks at key to health care success; Lean, flexible, high productive work forces, better management of clients “high risk” and satisfied customers Economic climate today-looks at key to health care success; Lean, flexible, high productive work forces, better management of clients “high risk” and satisfied customers

6. Models of Care Delivery Decision making Decision making Care allocation Care allocation Communication Communication Management Management

7. Managing Client Care What are the ways care is delivered in the healthcare settings? What are the ways care is delivered in the healthcare settings? Traditional Models Traditional Models Total Care Total Care Functional Functional Team Team Primary Care Primary Care Contemporary Models Contemporary Models Case Management Case Management Client-focused Care Client-focused Care Product Line Management Product Line Management

8. Traditional Models of Care Delivery Total Care-Percursor of Primary Care Total Care-Percursor of Primary Care Home Health Home Health Private Duty Private Duty Intensive Care Intensive Care Nursing Students Nursing Students Advantage of being client focused-yet, not the most efficient use of staff

9. Functional Models of Care Delivery Grew in the 1950’s Manager assigns a medication nurse, treatment nurse Manager assigns a medication nurse, treatment nurse Communication is clearly defined Communication is clearly defined Efficient model in getting the work done. Also economical Negative factor is “care is fragmented” and emotional needs of staff an clients are overlooked in the interest of time management and task completion

10. Team Nursing Popular in the 1950’s and 1960’s Moved from task focus to group dynamics to promote job satisfaction Moved from task focus to group dynamics to promote job satisfaction Each team has a mix of staff Each team has a mix of staff Emphasis on holistic care Emphasis on holistic care The completion of tasks are checked by the Team Leader. This model is time consuming and expensive

11. Modular Nursing More Current version of team nursing Allows nurses to located nearer to clients Allows nurses to located nearer to clients RN’s delegate tasks to team members RN’s delegate tasks to team members Emphasis on efficiency with shortage of RN’s Emphasis on efficiency with shortage of RN’s

12. Primary Nursing Popular in the 1960’s and 1970’s over nurses concern of fragmented patient care RN assigned to patient for 24 hours a day from admission to discharge RN assigned to patient for 24 hours a day from admission to discharge RN develops care plans, manages associate nurses RN develops care plans, manages associate nurses Decreases the number of persons in contact with patient Decreases the number of persons in contact with patient Positive is this form of care increases patient satisfaction. However, it severely limits the number of clients each nurse can serve and may place the client in jeopardy

13. Contemporary Models of Care Delivery Restructuring and Redesigning appeared Case Management Case Management Describes a variety of healthcare delivery systems in acute, long-term and community settings Describes a variety of healthcare delivery systems in acute, long-term and community settings This is not new…Public Health has used this since the early 1900’s and Mental Health since 1960’s This is not new…Public Health has used this since the early 1900’s and Mental Health since 1960’s

14. ANA defines Case Management as Provision of quality care along a continuum, decreasing fragmentation of care across many settings, enhancing the quality of life, and cost containment (1998) Provision of quality care along a continuum, decreasing fragmentation of care across many settings, enhancing the quality of life, and cost containment (1998) Case management usually involves one on one nurse patient assignments Case management usually involves one on one nurse patient assignments

15. Primary functions of a case manager involve Negotiation of Services and or Treatments Negotiation of Services and or Treatments Communication-service providers Communication-service providers Coordination of care to avoid duplication Coordination of care to avoid duplication Clinical expertise-technical knowledge Clinical expertise-technical knowledge Holistic approach to meet biologic, social, and behavioral needs Holistic approach to meet biologic, social, and behavioral needs Ethics of Caring advocate for client Ethics of Caring advocate for client Coaching Coaching

16. Nursing Management involves coordination of monitoring of patient care coordination of monitoring of patient care A system for delivering nursing care that is based on the philosophy of case management A system for delivering nursing care that is based on the philosophy of case management Designed to decrease fragmentation of care, decrease hospital days and cost Designed to decrease fragmentation of care, decrease hospital days and cost Nursing care management is a system for delivering nursing care Nursing care management is a system for delivering nursing care

17. Goals of Nursing Care Management Outcomes based on standards of care Outcomes based on standards of care Well-coordinated continuity of care through collaborative practice Well-coordinated continuity of care through collaborative practice Efficient use of resources to reduce wasted time, energy an materials Efficient use of resources to reduce wasted time, energy an materials Timely discharge with prospective payment guidelines Timely discharge with prospective payment guidelines Professional development and satisfaction Professional development and satisfaction

18. Client-Focused Care Organized around client needs, not around a department approach Organized around client needs, not around a department approach Place similar client together Place similar client together Disciplines are placed together Disciplines are placed together Emphasizes cross training Emphasizes cross training May blur lines of distinction between professionals May blur lines of distinction between professionals Mixed feelings about this model. New all purpose technicians are used

19. Product Line Management used in businesses to create central plan, manage and market product Drug Abuse Treatment Drug Abuse Treatment Pain Management Pain Management Women’s Health Women’s Health Pediatric Pediatric Cancer Center Cancer Center Product Line Manager directs operations. Nurse may not be the manager

20. Differentiated Practice Structure based on Education, Experience, and Competence Structure based on Education, Experience, and Competence 1965 Entry into Practice Bill is still raging 1965 Entry into Practice Bill is still raging ADN looks at meeting physiologic and comfort needs ADN looks at meeting physiologic and comfort needs BSN looks at continuity of care BSN looks at continuity of care MSN extends beyond acute setting to integration MSN extends beyond acute setting to integration

21. Monitoring and Evaluating the Quality of Care Guidelines Guidelines Protocols Protocols Algorithms Algorithms Standards of Care Standards of Care Critical Pathways Critical Pathways

22. Quality Improvement JCAHO established in 1951 JCAHO established in 1951 They looked at structural measure, physical plant, client beds per nurse ratio, credentialing They looked at structural measure, physical plant, client beds per nurse ratio, credentialing Now we have CQI- Continuous Quality Assessment Now we have CQI- Continuous Quality Assessment

23. Is this like drowning in alphabet soup???? QA- Quality Assurance to Quality Assessment QA- Quality Assurance to Quality Assessment QI- Quality Improvement QI- Quality Improvement CQI- Continuous Quality Improvement CQI- Continuous Quality Improvement PI- Performance Improvement PI- Performance Improvement

24. Purpose is to improve capability of all involved in primary care Purpose is to improve capability of all involved in primary care Industrial aspect relate to quality is TQM Industrial aspect relate to quality is TQM Aspects to evaluate in quality improvement program Aspects to evaluate in quality improvement program

25. Structure- setting an resources Structure- setting an resources Facilities-comfort Facilities-comfort Equipment Equipment Staff Qualifications, credentials Staff Qualifications, credentials Finances-Salaries, sources Finances-Salaries, sources

26. Process Process Activities of staff that are carried out Activities of staff that are carried out Teaching Teaching Counseling Counseling Physical care Physical care

27. Outcome Outcome Results of activities Results of activities Measures and evaluates the effectiveness of activities Measures and evaluates the effectiveness of activities

28. Continuous Quality Improvement Continuous Quality Improvement Data collection is everyone’s responsibility QI should be interdisciplinary 1. Standard- what the nurse will do- what the client can expect to receive 2. Indicators- a measurable objective 3. Criterion- threshold

29. Purpose is to continuously improve the capability of everyone involved in providing care, including the organization…to provide the highest quality health care Purpose is to continuously improve the capability of everyone involved in providing care, including the organization…to provide the highest quality health care

30. Quality Improvement and Organizational and Unit Level Strategic Planning Strategic Planning Framework for decisions Framework for decisions Basis for detailed planning Basis for detailed planning Informs, involves and motivates others Informs, involves and motivates others Stimulates change Stimulates change

31. Structured Care Methodologies (SCM’s): Structured Care Methodologies (SCM’s): Guidelines to assist in making appropriate health care decisions Protocols: Protocols: Specific, formal documents to outline how a procedure or intervention is to be conducted Algorithms: Algorithms: systematic procedure that follows a logical progression

32. Standards of Care: Standards of Care: discipline related to operationalize client- care processes

33. Critical Pathways or Clinical Pathways Critical Pathways or Clinical Pathways A multidisciplinary map- designed to describe the course of events that lead to a successful outcome with DRG (Diagnostic Related Group) A multidisciplinary map- designed to describe the course of events that lead to a successful outcome with DRG (Diagnostic Related Group) Includes discharge planning, patient education, and medication Includes discharge planning, patient education, and medication Are considered an outgrowth of nursing care plans Are considered an outgrowth of nursing care plans Many disciplines develop it Many disciplines develop it Able to focus on problem Able to focus on problem Provides framework for communication Provides framework for communication

34. Risk Management A process of identifying, analyzing, treating, and evaluating real and potential hazards A process of identifying, analyzing, treating, and evaluating real and potential hazards Risk events categorized according to severity Risk events categorized according to severity Service occurrence Service occurrence Serious incident Serious incident Sentinel event Sentinel event

35. Any Questions???