Patient%20Care%20Delivery

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Patient Care Delivery

• Chapter 5- Colleen Person

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Patient Care Delivery System

• A template for organizing and providing care to
  patients.
• The delivery system used is one of the most
  powerful tools a manager has in creating an
  environment of stability, with increased
  predictability and decreased uncertainty being
  by-products. (Marie Manthey)
• The purpose is to establish a therapeutic
  relationship between nurses and
  patients/families.
• The most effective care delivery systems are
  those designed with the patient always held in
  the highest regard.

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Bureaucratic Nursing vs. Professional Nursing

• Nation wide movement from a task based view of
  care delivery to a principles-based, holistic
  view.
• Bureaucratic nursing tasks drives activities,
  cure of disease, focus is on physical,
  diagnosis-centered care, policies and procedures
  drive decision making, rules, habits and routines
  determine nurses behavior

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Professional Nursing

• Knowledge based, healing is the goal, focus is on
  holistic care, professional standards and current
  research drive decision making, critical thinking
  and innovation determine nurses behavior.
• Studies show that nursing care is the most
  important predictor of overall patient
  satisfaction with their hospital care

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Designing Delivery Systems

• The authors base care delivery design on the
  following
• Purpose- caring for patients/families
• Most effective when we know what matters most to
  each patient/family
• Patients share more when they feel safe
• Continuity of care improves productivity,
  efficiency, and patient and staff satisfaction
• Each element needs to be clearly defined

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Elements of Care Delivery Systems

• Nurse/patient relationship and decision making
  clearly define RAA
• How long does a relationship last between nurse
  and patient?
• Work allocation/patient assignments
• How are staff scheduling, patient assignments,
  and delegation of care activities achieved?

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Elements cont.

• Communication between members of the health care
  team standards of communication
• Addresses values, beliefs, and group norms
• Management of unit /environment of care unit
  manager creates the culture of care
• When all four elements are clearly defined a
  delivery system can function efficiently and
  effectively

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Four Care Delivery Systems and When They Started.

• Functional nursing (50s-60s)
• Team nursing (mid 60s mid 70s)
• Total patient care (late 60s)
• Primary nursing (Univ. of Minn. 1968-69)

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Functional Nursing

• Decision making occurs over a single shift and
  made by charge nurse/nurse mgr.
• Tasks are divided among members
• Med adm, treatments, ADLs, vital signs
• Focus was on getting tasks done, not on
  establishing relationships
• Communication is hierarchical, nurses report to
  charge nurse and charge nurse communicates with
  other team members.
• Mgrs. Function as overseers. Are tasks completed?

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Team Nursing

• Decision making over a single shift, by team
  leader or nurse mgr.
• Role of the RN is to carry out more complex
  tasks, while delegating and supervising team
  members who are given other tasks.
• Focus is on completion of tasks, assignments
  change based on pt location, acuity, and
  complexity.
• Communication is hierarchical, nurses report to
  team leader who reports to physicians and team
  members.
• Nurse mgr. supervises team leader.
• Was very useful when LPNs also work the unit

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Total Patient Care

• Decision making occurs over a single shift- by RN
  after being assigned by the nurse mgr.
• Assignments are patient based with RN providing
  activities of care.
• Assignments may vary by shift based on location,
  pt acuity, does not support continuity of care.
• Communication is usually direct but is sometimes
  done through a charge nurse.
• Mgrs. Serve as a resource and promote stronger
  role of RN in care decisions.
• RN does not have responsibility for creating or
  implementing a plan for the continuity of the
  patients care over time.

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Primary Nursing

• RN makes the decision for patients based on
  therapeutic relationship.
• Relationship is sustained for length of stay
• Assignments ensure continuity of care.
• Associate nurse takes care of pt when primary is
  not there.
• Communication is direct. Primary nurse is
  responsible for integrating information and
  coordinating care.
• Mgrs. Promote nurse/pt relationship. Create a
  healthy work environment and empower staff.

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Role of RN in Primary Nursing

• RNs clearly accept responsibility for decision
  making regarding pt care, authority, and
  accountability.
• Determine and prioritizes needs of the pt/family,
  establishes an individualized plan of care,
  delegates tasks.
• Communicates and coordinates needs with other
  members of the health care team.
• RBC has evolved from the basic tenet of Primary
  nursing.

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Partners in practice-New Concept

• RN, LPN, CNA agree to partner with one another
  in the provision of the activities of care.
• They choose to work together with consistent
  scheduling, building relationship, and focused
  around patient needs.
• RN is responsible for developing the knowledge
  and skill of his/her team
• It can work with the 12 hour shift, and supports
  continuity of care
• Reduces turnover of RNs, improves patient
  quality, promotes professional nursing.

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Myths about Primary Nursing

• It requires an All RN staff nurse extenders play
  a vital role in meeting needs of
  patients/families.
• The primary nurse does all the bedside care
  their role is to accept RAA. It is not practical
  for RN to do all of bedside care.
• Primary nursing eliminates teamwork. You only
  know your patients this model is based on a
  shared commitment to all patients. The nurse must
  work collaboratively.
• Complex scheduling requirements prohibit
  continuity of the nurse-patient-relationship
  central to the primary care model scheduling
  must be creative. Nurses report perceived
  increase in productivity when continuity of care
  is supported.

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Are all primary nursing models the same?

• Systems must be customized to what works for that
  individual organization.
• Each organization determines the best terminology
  with which to clarify RAA.
• The organization identifies key principles of
  each of the four elements

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Role of the Consumer

• Health care consumers are becoming increasingly
  educated about nursing care and staffing issues.
• Find out the RN to patient ratio is managed by
  the acuity of the patients (Some suggest no
  greater than 14)
• Check also the ratio of RNs to LPNs
• Study the facilitys report card. (Leepfrog,
  JCAHO reports)
• Locate the nearest Magnet Hospital

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Magnet Status

• Magnet hospitals have demonstrated Ability to
  retain well qualified nursing staff provide
  higher quality care decrease error rates
  decrease morbidity and mortality Improved
  pt/family satisfaction (Aiken, Clarke, Sloane,
  Sochalski, Silber, 2002 Ingersoll, Schultz,
  Hoffart, Ryan, 1996 Prescott, 1993 Scott et
  al., 1999)
• Three goals of the Magnet Program
• Promoting quality in a setting that supports
  professional practice
• Identifying excellence in the delivery of nursing
  services to patients/residents and
• Disseminating best practices in nursing
  services.

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Forces of magnetism

• Evolved out of a study conducted by the American
  Academy of Nursings Task Force
• ANCC provides programs and credentialing services
  to hospitals desiring to achieve Magnet Status
  http//www.nursecredentialing.org/
• All of the standards are grounded in therapeutic,
  continuous relationship between the RN and
  patient.

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Forces of Magnetism

• Quality of Nursing Leadership
• Organizational Structure
• Management Style
• Personal Policies and Programs
• Professional Models of Care
• Quality of Care
• Quality Improvement
• Consultation and Resources
• Autonomy
• Community and the Hospital
• Nurses as Teachers
• Image of Nursing
• Collegial Nurse-Physician Relationships
• Professional Development

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Transformational Leadership

• Forces 1 3
• today's leaders are required to transform their
  organization's values, beliefs, and behaviors.
• This requires vision, influence, clinical
  knowledge, and a strong expertise relating to
  professional nursing practice. It also
  acknowledges that transformation may create
  turbulence and involve atypical approaches to
  solutions.
• The organization's senior leadership team creates
  the vision for the future, and the systems and
  environment necessary to achieve that vision.
  They must enlighten the organization as to why
  change is necessary, and communicate each
  department's part in achieving that change.

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Structural Empowerment

• Forces 2, 4, 10, 12, 14
• Staff need to be developed, directed, and
  empowered to find the best way to accomplish the
  organizational goals and achieve desired
  outcomes.
• This is accomplished through the organization's
  strategic plan, structure, systems, policies, and
  programs
• This may be accomplished through a variety of
  structures and programs one size does not fit
  all.

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Exemplary Professional Practice

• Forces 5, 8, 9, 11, 13
• This entails a comprehensive understanding of the
  role of nursing the application of that role
  with patients, families, communities, and the
  interdisciplinary team and the application of
  new knowledge and evidence.
• The goal of this Component is more than the
  establishment of strong professional practice it
  is what that professional practice can achieve.

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New Knowledge, Innovation, Improvements 

• Force 7
• Magnet organizations have an ethical and
  professional responsibility to contribute to
  patient care, the organization, and the
  profession in terms of new knowledge,
  innovations, and improvements.
• This Component includes new models of care,
  application of existing evidence, new evidence,
  and visible contributions to the science of
  nursing.

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Empirical Quality Results

• Force 6
• Magnet-recognized organizations are in a unique
  position to become pioneers of the future and to
  demonstrate solutions to numerous problems
  inherent in our healthcare systems today.
• They may do this in a variety of ways through
  innovative structure and various processes, and
  they ought to be recognized, not penalized, for
  their inventiveness.
• clinical outcomes related to nursing workforce
  outcomes patient and consumer outcomes and
  organizational outcomes