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Leadership & Management in Hospitals & Healthcare Agencies

Martha Highfield, PhD, RN, AOCN

Associate Professor Nursing

California State University, Northridge, USA

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Presented at the invitation of the Guangzhou Municipal Health Bureau

Guangzhou, China

August 2001

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Driving Forces

• Professional scope & standards of nursing practice

• Legal requirements

• JCAHO

• Fiscal solvency

• Ideals of compassionate care & valuing the individual

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ANA Administration Standards

NURSE EXECUTIVE1. Leading

2. Collaborating & integrating nursing in interdisciplinary environment

3. Facilitating effective, efficient, compassionate care.

4. Evaluating

MANAGER

1. Report to executive

2. Defined area

3. Allocate resources for compassionate care

4. Upward & downward communication

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Differences: Leader & Manager

• Leaders– Informal or formal

– More roles

– Focus on group process

– Emphasize relationships

– Direct willing followers

– Goals

• Managers– Assigned formal position

– Delegated authority

– Specific functions, duties, responsibilities

– Emphasize control, decision-making, analysis & results

– Manipulate resources

– Direct willing & unwilling followers

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Both Executives & Managers...1. Promote vertical & horizontal

communication

2. Inspire critical thinking for proper decision-making

3. Efficient & effective: highest possible individualized care at the lowest possible cost

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Standards

• Standards: “Statements that describe a level of care or nursing performance by which the quality of nursing practice can be judged.”

(p. 38-9)

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Standards of Nursing Administration

1. Standards of Care = statement of a competent level of clinical nursing practice, such as identifying problems and planning & taking action to correct them

2. Standards of Performance = statement of competent role activities, such as collaboration & quality of care

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Standards of Care

Standard 1: Assessment

Standard 2: Diagnosis

Standard 3: Identification of Outcomes

Standard 4: Planning

Standard 5: Implementation

Standard 6: Evaluation

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Standards of Care

1. Assessment: Develops, maintains, & evaluates patient/client and staff data collection systems and processes to support the practice of nursing and delivery of patient care.

2. Diagnosis: Develops, maintains, & evaluates an environment that supports the professional nurse in analysis of assessment data and in decisions to determine relevant diagnoses

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Standards of Care (cont.)

3. Identification of Outcomes: Develops, maintains, & evaluates information processes that promote desired client-centered outcomes

4. Planning: Develops, maintains, & evaluates organizational planning systems to facilitate the delivery of nursing

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Standards of Care (cont.)

5. Implementation: Develops, maintains, & evaluates organizational systems that support implementation of the plan

6. Evaluation: Evaluates the plan and its progress in relation to the attainment of outcomes.

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Standards of Professional Performance

• Standard 1: Quality of care

• Standard 2: Performance appraisal

• Standard 3: Education

• Standard 4: Collegiality

• Standard 5: Collaboration

• Standard 6: Research

• Standard 7: Resource utilization

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Standards of Performance1. Quality of Care & Administrative Practice:

Systematically evaluates the quality and effectiveness of nursing practice & nursing services administration

2. Performance Appraisal: Evaluates own performance based on professional practice standards, relevant statutes & regulations & organization criteria

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Standards of Performance (cont.)

3. Education: Acquires & maintains current knowledge in administrative practice

4. Collegiality: Fosters professional environment

5. Ethics: Decisions & actions are based on ethical principles

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Standards of Performance (cont.)8. Collaboration: Collaborates with nursing staff at

all levels, interdisciplinary teams, executive officers, and other stakeholders

9. Research: Supports research & integrates it into the delivery of nursing care & administration

10. Resource Utilization: Evaluates & administers the resources of organized nursing services

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Standards met incarrying out Decision-Making

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Decision-Making

• Fundamental skill for all aspects

• Traditional decision-making starts with identifying problem

• Management decision-making starts with writing objectives--fixed end goals

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Decision-Making Grid• List alternatives down

the first column on left• For each write out

– Financial effect– Political effect– Department effect– Time

• Last column write decision about each alternative

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Standards met incarrying out Planning

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Roles & Functions: Planning

• Mission

• Philosophy

• Goals & objectives

• Strategies to achieve goals & objectives: programs, policies, procedures

• Time management

• Delegation

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Overcoming Barriers to Planning

• Goals & objectives increase effectiveness

• Plan is a guide & must be flexible

• Include all stakeholders in planning

• Plans should be simple, specific, realistic

• Planned change

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Planning: Managing Change

• STAGE 1-UNFREEZING

• STAGE 2 - MOVEMENT

• STAGE 3 - REFREEZING

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Planning: Emotional Stages of Change

1. Equilibrium

2. Denial

3. Anger

4. Bargaining

5. Chaos

6. Depression

7. Resignation

8. Openness

9. Readiness

10. Reemergence

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Planning: Time Management

1. Prioritizes day-to-day planning to meet short-term & long-term unit goals

2. Schedules time for planning

3. Analyzes others’ use of time

4. Eliminates environmental barriers

5. Handles paperwork promptly & efficiently

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Time management (cont.)

6. Breaks down large tasks into smaller achievable ones.

7. Uses technology for documentation & communication

8. Discriminates between inadequate staffing & inadequate time

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Planning: Examples of Specific Strategies

• Use last 30-60 minutes of day to plan next & clean desk

• Plan what you will do in each 30-60 minute block

• Number tasks in order of priority• Start with most difficult priority task & work

for set time• Plan communication with staff

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Standards met incarrying out Organizing

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Roles & Functions:Organizing Delivery of Nursing Care

• Organizational structure

• Authority & power in organizations

• Nursing systems

• Organizing client care

• Committees

• Nursing informatics

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Organizing: Management Functions

1. Understand agency’s structure & personal responsibility & authority within it

2. Informs staff of unit organizational chart

3. Maintains & clarifies unity of command as possible

4. Follows subordinate complaints upward

5. Establishes proper span of control

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Organizing: Management Functions

6. Knowledgeable about agency culture

7. Uses informal organization to meet agency goals

8. Uses committee structure for quality & quantity of work

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Organizing: Decision-Making

• Centralized: Few managers at the top

• Decentralized: At the lowest level possible

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Organizing: Assessing Culture1. How does the organization view physical

environment?

2. What is the organization’s social environment?

3. How supportive is the organization

4. What is the organizational power structure?

5. How does the organization view safety?

6. What is communication environment?

7. What are organization taboos & heroes?

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Organizing: Span of Control

• “The appropriate number depends on the organization, the maturity of the subordinates, and the type of work to be done. An inappropriate span of control can result in inefficiency.”

(p. 161, Marquis & Huston, 2000)

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Organizing: Committees

• Groups who want to work on a project

• Manager must give parameters--A clear assignment with deadlines

• Written agendas & chairperson

• Large enough to do task; small enough to talk

• Discourage “group think”

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Organizing: Patient CareC ase M ethod OR

Total Patient C are Structure

Patients

R N

Patients

R N

Patients

R N

C harge N urse for each sh ift

R N M anagerde legates to

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Organizing: Patient Care

Functional Nursing O rganizaton

M edication R N Treatm ent R NType title here

N ursing AssistantsType title here

C lerical &H ousekeeping

Patients

C harge R NType title here

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Organizing: Patient CareTeam Nursing O rganization

Patients

R N , LVN ,N ursing Assistant

R N staffType title here

Patients

R N , LVN ,N ursing assistant

R N staffType title here

C harge R Neach shift

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Organizing: Patient Care

• Primary Nursing– 1 RN plans & manages care for the patient in

collaboration with Associate RNs– Interfaces with MD, Charge RN, & resources

• Case Management – All RNs use resources to expedite health; OR– A special nurses monitors & facilitates use of

resources in the agency for many patients in collaboration with their nurses

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Organizing: Informatics

• Data recording & retrieval used to– Manage care– Monitor care

• Computer/technology

• RNs must be educated

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Standards met incarrying out Staffing

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Roles & Functions: Staffing

1. Personnel

2. Fiscal planning/budgeting

3. Staffing & scheduling

4. Staff Development

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Staffing: Management Functions1. Ensures adequate, skilled workforce to meet agency

goals

2. Shares recruitment responsibility

3. Interviews with proper techniques

4. Develops selection criteria

5. Places based on agency needs & employee strengths

6. Interprets employee handbook

7. Participates in employee orientation.

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Staffing: Personnel• Recruiting: Actively seeking out and hiring

those who can best do job• Interviewing:

– Based on specific job criteria– Best predictor of future performance is past

performance– Give person clear information about job– Try to contradict your first impressions– More than 1 interviewer is ideal

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Staffing: Structured Interview• Motivation• Physical• Education• Work experience• Present work• Previous work• Personal characteristics & goals• Anticipated contributions to this agency

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Staffing: Orientation & Socialization

• Orientation --> Competence --> Quality

• Socialization– Introduce to others & their roles– Coach as take on role responsibilities– “Carrot & stick”– Recognize current skills & knowledge & build

on these

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Staffing: Scheduling

• Scheduling should – Meet agency need– Be fair to all

• Policies should include, for example– Lateness, absence, illness, emergencies– Vacations & regular time off; Special requests– Expectations for working in other areas of the

agency

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Staffing: Scheduling & Budgeting

NCH/PPD = Nursing hours in 24 hour period

Patient census

• Acuity of patients calculated to adjust RNs

• Cost controlled

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Staffing: Staff Development

• Interface with educators• Own role in orientation & motivation• Preceptor program

– Identification of clinical & teaching expertise– Education of preceptor– Adjustment in assignments of preceptor & new

staff– Competence checklists

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Standards met incarrying out Directing

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Roles & Functions: Directing1. Use authority to provide reward system

2. Use positive feedback as reward

3. Unit goals that integrate agency & employee needs

4. Environment that – Reduces job dissatisfiers

– Focuses on employee motivators

5. Maintain tension for productivity along with job satisfaction

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Roles & Functions: Directing (cont.)

6. Clear communication of expectations

7. Communicates sincere respect, concern, trust, & sense of belonging to subordinates

8. Assigns work appropriate to employee competence

9. Identifies what motivates subordinates, and develops motivational strategies to meet these.

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Directing: Communications1. Understand & use agency formal communication

network

2. Uses appropriate communication mode for distribution of information

3. Prepares appropriate written communication

4. Consults/coordinates with others who have overlapping functions

5. Differentiates between information & communication and recognizes need for both.

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Directing: Communications

6. Protects subordinate confidentiality

7. Prepares self & staff for use of technology

8. Uses group dynamics knowledge to achieve agency goals

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Directing: Delegation

1. Creates & follows specific job descriptions that conform to national/professional standard of care

2. Understands legal liabilities of management

3. Delegates based on abilities/limits of staff

4. Delegates authority appropriately to achieve goals

5. Maintains periodic review of delegated task

6. Recognition & rewards for task completion

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Directing: Managing Conflict

1. Anticipates & minimizes sources of conflict on unit

2. Uses authority when quick, unpopular decision must be made

3. Facilitates conflict resolution between employees

4. Accepts mutual responsibilities for reaching goals

5. Effectively negotiates for needed resources

6. Compromises unit needs only on the noncritical

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Directing: Labor Issues

1. Uses union contract appropriately

2. Administers policies fairly

3. Works cooperatively with administration & personnel when dealing with unions

4. Understands laws relating to manager’s work

5. Safe work environment

6. Alert for discrimination

7. Ensures licensing requirements met

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Standards met incarrying out Control

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Leadership & Management

• Leader focus more on – Agency system for quality control– Maximizing employee potential

• Manager focus more on control– Unit criteria for quality control– Controlling employee behavior to meet

standards

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Roles & Functions: Controlling1. In collaboration with others, “establishes clear-cut

measurable standards of care & determines the most appropriate method for measure [whether] those standards have been met.

2. Selects & uses process, outcome & structure audits as quality control

3. Gathers data from appropriate sources

4. Determines discrepancies between performance & standards & determine why

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Roles & Functions: Controlling

5. Uses quality findings for performance review, rewards, & development of employees

6. Educates self about state & accrediting regulations that define quality

7. Participates in “benchmarking” efforts and “best practices” initiatives.

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Controlling: QualitySTEPS

1. Identify standards & expected outcomes

2. What information would objectively measure these standards/outcomes?

3. Determine how & where to collect the information

4. Gather information

5. Compare information to standards/outcomes

6. Make a judgment about quality

7. Share information & take corrective action prn

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Controlling: Quality

Audits

1. Structure

2. Process

3. Outcomes

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Controlling: Quality

• Total Quality Improvement (TQI or QI or QAI or CQI) is a different philosophy

• “Identifying doing the right things, the right way, the first time, and problem-prevention planning--NOT inspection and problem-solving--lead to quality outcomes”

(p. 402, Marquis & Huston, 2000)

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Controlling: Performance Appraisal1. Uses formal, established system of appraisal

2. Gathers fair & objective data

3. Uses to determine staff education & training needs

4. Based on written standards that have been communicated

5. Documents process

6. Follows up on deficiencies

7. Conducts appraisal in way that promotes positive outcome

8. Provides continuous feedback to employees.

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Example• Part of an oncology nurse performance evaluation tool

for Professional Performance Standard 3: Education The oncology nurse acquires and maintains current knowledge in oncology nursing practice.

• Rating scale used: – 1. Performance below standards– 2. Performance meets standard– 3. Performance exceeds standard

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Professional Performance Standard 3:Education: The oncology nurse acquires andmaintains current knowledge in oncologynursing practice.Criteria: Rating 1 2 31. Participates in ongoingeducational activities (includinginservices, continuing education,formal education, andexperientatil learning) to expandoncology knowledge ofprofessional issues2. Seeks experiences to develop& maintain clinical skills

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Promoting Professionalism

• Professional standards

• Professional relationships & commitment

• Patient advocate

• Staff education & career planning