Care Delivery Systems (10)

Goals for Successful Client Care – IOM, JACHO, etc says we need to be doing these things
Successful client care = good patient outcomes
– high quality care
– low cost care
– positive client outcomes
– Strong satisfaction levels (HCAHPS)
Workforce Management – 5 core processes necessary to deliver safe, quality care
1. patient care delivery systems/models
2. patient classifications (determines how much your patient requires of you, giving the patient acuity level a number)
3. core scheduling (adjusted to patient population changes)
4. staffing assignments
5. evaluation of staffing effectiveness
T/F: There is no one best way to organize patient care
T – need to look at the unit itself, the type of care delivered and other factors to decide the best way to do this
Why are patients in the hospital?
for nursing care
Choosing the most appropriate organizational model to deliver patient care for each unit or organization depends on the (5)
1. skill mix and expertise of the staff
2. availability of RNs
3. economic resources of the organization
4. acuity of the patients
5. complexity of the tasks to be completed
An element of assignment is
Overview of Pt Care delivery system
– Assigning nursing and multidisciplinary staff to clients needing care is a basic activity of health care systems
– Assignment must be within the individual’s scope of practice
– Both assignment and delegation are methods used by managers to delivery patient care within the structure of the HC system
– the determination of the structure and method by which assignments are made is a managerial responsibility
The determination of the structure and method by which assignments are made is a ______ responsibility
Importance of nursing care delivery system
– the model of care delivery has a direct relationship on the allocation of control over decisions about client care
– care delivery systems are the means through which nurse managers delegate effectively and thereby free up and manage time as a scarce resource
– autonomy over practice is determined largely by the care model
Autonomy over practice is determined largely by
the care model
the model of care delivery has a direct relationship on the
allocation of control over decisions about client care
Total Patient Care
-oldest model of organizing pt care
– nurses assume total responsibility for meeting the needs of all assigned its during their time on duty – no efficient use of time/qualifications
Team Nursing
Ancilliary personnel collaborate in providing care to a group of patients under the direction of a professional nurse
– requires extensive team communication and regular team planning conferences
Functional Nursing
– care is assigned by task rather than patient
– charge nurse –> nurse assistants/hygienic care –> RN med nurse, tx nurse, wound care nurse –> patients
– not very safe
Case management
-Collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual’s health needs through communication and available resources to promote quality, cost-effective outcomes
– coordinates care throughout an episode of illness
– the focus in case management is on individual patients, not populations of patients
The focus of case management
individual patients, not populations of patients
Pros and Cons of functional nursing
Pro: efficiency is increased, inexpensive
Cons: nurses do managerial work, nurse assistants perform pt care, poor client satisfaction
Pros and Cons of team nursing
Pros: Care is provided through team effort
– pt care coordinator is freed to manage the unit
– nursing care conferences help problem solve and develop staff
– nursing care plan is developed
Cons: time is needed to coordinate delegation, bad leader = non functional team
Pros and Cons of private duty nursing
Pros: total patient care is provided by one nurse on each shift
– fosters closeness in nurse-client relationship
– increase RN and client satisfaction
Cons: different nurses provide care on difference shifts and different days
– costly with low efficiency
– isolated from colleagues
Pros and Cons of primary nursing
Pros: RNs give total patient care
Cons: nurses’ talents are confined to a limited number of patients
– associate nurse may change care plan without discussing with primary nurse
Pros and Cons of case management
Pros: entire episode of illness is focus
– achievement of outcomes emphasized
– care coordinated by case manager
– care provided by second generation primary nursing
– critical pathways used
– variation analysis conducted
– intershift reports create
– HC team meetings held
– interdisciplinary approach used
Cons: coordination requires effort
Pros and Cons of total patient care
Cons: lack of coordination, communication, continuity of care
Clinical Pathways
Tools used to achieve patient outcomes
– AKA multidisciplinary care pathway/critical path/collaborative pathway
– patient focused
Clinical pathways describe (4)
1. clinical standards
2. interventions
3. expected outcomes at each stage
T/F: Are clinical pathways appropriate for all patients?
F – no
Disease management
– population based health care and continuous health improvement
– a comprehensive, integrated approach to the care and reimbursement of high-cost, chronic illnesses
Disease management is used for
chronic illnesses
Goal of disease management
address the illness or condition with max efficiency regardless of treatment settings or typical reimbursement patterns
Common features of disease management programs
1. provide comprehensive, integrated approach to the care and reimbursement of common, high-cost, chronic illness
2. focus on prevention as well as early disease detection and intervention to avoid costly episodes but provide comprehensive care and reimbursement
3. target population groups, rather than individuals
4. employ a multidisciplinary HC team, including specialists
5. use standardized clinical guidelines – clinical pathways – reflecting best practice research to guide providers
6. use integrated data management systems to track patient progress across care settings and allow continuous and ongoing improvement of treatment algorithms
7. frequently employ professional nurses in the role of case manager or program coordinator
Multidisciplinary action plan (MAP)
– a combination of a critical path and a nursing care plan
– defines times when nursing interventions should occur
– defines variances (alteration in the progress through a clinical pathway)
Medical Home Model
-A place where somewhere will receive primary care – may be no difference between this and a doctor’s office
-Comprehensive primary care
– came about in rural areas where people didn’t have clinics and sued the ER for primary care, so these came out to reduce this
Medical Home Model benefits
1. allows better access to care
2. improves health – decreases travel time and increases compliance with therapy
3. better patient care
IOM’s report states that the design of care delivery models must meet the objectives of (4)
1. cost containment
2. patient satisfaction
3. quality
4. safety outcomes
Chief Nursing Officer
– Over every nursing function in the organization; usually 2nd to CEO
– almost always report to CEO buyt they are the ones who really run the employees – they look at pt satisfaction, employee satisfaction, etc.
– strong influence on direction of the organization
– monitors standards or pt care, strategic planning, nursing budgets
– sets performance goals in nursing
– member of the facility’s executive team
– participates in decisions impacting the facility and operational performance
– oversees direct patient care activities and clinical education and development
Nurse Manager
– supervises and evaluates employees for a specific unit
– responsible for the unit budget
– disciplinary actions against employees
– process paperwork such as problems with patients’ medical records
– hires and fires all personnel assigned to the unit
– handle the operations and staffing of a unit
– deterines the educational needs of the unit and individual staff members
– assures members have the proper equipment to provide safe pt care
– assures member of the unit are meeting pt standards
– creates work schedule
– ultimately responsible for the performance of all members working on the unit and for the care provided to the patients
Nurse/House Supervisor
– Reports direction to the CNO director and/pr VP of nursing
– collaborates with the nurse managers
– coordinates bed management and staff mix to assure that effective nursing services are provided
-assures the satisfaction of internal and external customers
– provides leadership, direction and guidance to staff during their assigned shift
– effectively addresses personnel issues “just-in-time” in order to promote a productive and healthy work environment
– serves as initial point of contact for hospital emergencies
-validates and maintains accurate patient census
– performs hospital rounds during shift
-effectively intercede with family/patients and resolve concerns related to the delivery of health care services
– ensures level of staffing for the level of acuity is appropriate for shift worked
Charge Nurse/Team Leader
-responsible for the directing of patient care for a designated shift
– reports to the nurse manager and coordinates with all related departments within limits of patient care issues for a designated shift
– receives a report from the previous shift of all patients and identifies special patient care needs
-adjusts staffing according to pt acuity
Ensures level of staffing for the level of acuity is appropriate for shift workload
nurse/house supervisor
Is the charge nurse/team leader an administrative position?
Staff Nurse
– Provides direct delivery of care: educates, collaborates, develops plan of care, may be a “team Leader” for the rest of the staff
– have advanced knowledge
– proven you are an expert in that practice
Patient Classification System (PCS)
– giving the patient a number that defines how sick they are
– groups patients according to specific chars that measure acuity of illness
– helps determine both the number and mix of the staff needed to care for the patients
– attempts to quantify patients’ needs for care to match these to the corresponding activities and efforts nurses will need to contribute in service delivery
Core elements of PCS (2)
1. Time
2. Activities
Patient Acuity
– the patients and cases that nurses manage and provide care for differ with respect to how intensively and extensively they require nursing services
– acuity matters in the work of nurses, but measuring acuity is complicated
– to manage human resources, both patients’ needs for nursing care (patient acuity) and the amount of nursing time that is required to meet patients’ needs for care (nursing intensity) needs to be specifically and more accurately measured
To manage human resources, both patients’ needs for nursing care (aka _____) and the amount of nursing time that is required to meet patients’ needs for care (aka ______) needs to be specifically and more accurately measured
1. patient acuity
2. nursing intensity
a combination of a critical path and a nursing care plan; defines times when nursing interventions should occur and variances
Multidisciplinary Action Plan (MAP)

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