Leadership

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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 EXECUTIVE
• 1. 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

• Managers
• Assigned formal position
• Delegated authority
• Specific functions, duties, responsibilities
• Emphasize control, decision-making, analysis
  results
• Manipulate resources
• Direct willing unwilling followers

• Leaders
• Informal or formal
• More roles
• Focus on group process
• Emphasize relationships
• Direct willing followers
• Goals

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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 Performance

• 1. 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 FunctionsOrganizing 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 agencys 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 Culture

• 1. How does the organization view physical
  environment?
• 2. What is the organizations 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 Care
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Organizing Patient Care
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Organizing Patient Care
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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 Functions

• 1. 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 --gt Competence --gt 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 Directing

• 1. 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 Communications

• 1. 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 managers 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 Controlling

• 1. 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 Quality

• STEPS
• 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 Appraisal

• 1. 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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Promoting Professionalism

• Professional standards
• Professional relationships commitment
• Patient advocate
• Staff education career planning