Management Of Care

NCM 105

Management Process Madeline N. Gerzon, RN, MM Clinical Instructor Davao Doctors College [email protected]

According to Machiavelli…. “There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things”

Management Process Consists of achieving organizational objectives through planning, organizing, directing, and controlling human and physical resources and technology

Management Process INPUT

HUMAN RESOURCES Medical Nursing Allied health Patients/clients Significant others

OUTPUT

PHYSICAL & TECHNICAL RESOURCES

REALIZATION OF GOALS

Buildings Grounds Supplies Equipment

Delivery of Quality Nursing care

Nursing Management Process • • • •

Planning Organizing Directing Controlling

Planning: a fundamental process Definition

Planning is having a specific aim or purpose and mapping out a program or method beforehand for accomplishment of the goal (Douglas) Making a plan of action to provide for the foreseeable future (Fayol) Planning is deciding in advance what to do, how to do it, when to do it, and who to do it (Alexander)

Planning: a fundamental process • Basic function of management • Systematic process • Facilitates wise use of resources and approaches to achieve objectives • Bridges the gap between where you are and where you want to go

Planning Planning is determining in advance: b) What is to be done? c) How it is to be done? d) When it is to be done? e) Who will do it?

Reasons for Planning • Planning leads to success in achievement of goals and objectives • Planning gives meaning to work • Planning provides for effective use of available resources and facilities • Planning helps in coping with crisis • Planning is cost effective • Planning based on the past and future helps reduce the elements of change • By planning, one can discover the need for change • Planning is necessary for effective control

Planning Process Planning Process is consists of five steps • • • • •

Assessment of work situation Need identification and priority setting Management by objectives Implementation of the plan Evaluation or controlling of the plan

Steps in Planning Process Assessment of work situation • Tangible elements (buildings, grounds, equipment) • Intangible elements (cognitive, affective) • Environment (source of income, family/community mores, geographical location, etc) • Government vs private control (capitation plans) • Standards (structure, process, outcome) • Professional standard of care (qualification)

Steps in Planning Process Need identification and priority setting • Listing things • Placing needs in order of priority (depends on level of management)

• Criteria for determining priority (must and want)

Steps in Planning Process Management by objectives • Goals and Objectives (broad, organizational VMG) • Process of management by objectives (departmental planning according to objectives)

• Guidelines for MBO (SMART, resources, etc)

Steps in Planning Process Implementation of the plan • Developing alternative courses of action • Nursing care planning (written)

Steps in Planning Process Evaluation or controlling of the plan • Results of evaluation or controlling process • Employee participation ensures control activities of people to meet objectives

What needs to be planned? • • • • • •

Budget (finances) Organization Structure Change Implementation of change Decision-making

What needs to be planned? Budget • Plan or a schedule adjusting expenses during a certain period to the estimated or fixed income for that period (webster) • Is an operational management plan, stated in income and expense terms covering all phases of activity for a future division of time

What needs to be planned? Key concepts in Budget • Revenue – income from sale of products or services • Expenses – cost of providing services • Patient days – used to project revenue • Fiscal Year – financial year or calendar year • Product line – units of service

What needs to be planned?

Change According to Machiavelli…. “There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things”

What needs to be planned?

Change • Need for change – profit, improve human

work, satisfy economic goals, individual satisfaction • Change theory – Lewin’s theory (unfreezing change, moving change, refreezing change) • Resistance to change – plan changes, manage change

Organizing Process • Is the grouping of activities for the purpose of achieving objectives, the assignment of such groupings to a manager with authority for supervising each group, and the defined means of coordinating appropriate activities with other units (horizontally, vertically) that are responsible for accomplishing organization objectives

Organizing Process • Involves deciding the necessary levels of organization needed to accomplish the objectives • Involves putting people where they will be most useful • According to Urwick….. Process of designing the machine

Organizing Organizing is the establishment of relation ship between the

• Activities • Persons • Physical factors

Organizing • or we can say that organizing includes: – What tasks are to be done? (Activity) – Who is to do them? (People) – What physical resources are required? (Resources) – And who reports to whom. (Structure)

Organizing

Principles of Organizing • The principle of Chain of Command (authority and accountability)

• The principle of Unity of Command (1S+1L+plan=meet objectives)

• The principle of Span of Control (supervise in terms of number, functions, and geography)

• The principle of Specialization (perform single leading function)

Organizing

Five steps in Organizing process  Division of Labor (assigning amount of task, time-element, rotation)

 Departmentalization (segmentation of work, kind of activities)

 Staff positioning (Staff mix, classification of patient, staff scheduling)

 Assigning authority or Delegation of power (substitutes, performance of special task)  Equalizing authority and responsibility

Organizing Staffing • Placing right people at the right time • Assigning competent people to fill the roles designed for the organizational structure through recruitment, selection, and development of personnel • Matching job with the people

Staffing Employment procedure • Recruitment • Responsibility for selection of nursing personnel • Induction and orientation

Staffing Staff Projection • Projecting number of nurses needed to provide care to patients – Data collection – patient census, ave length of stay, types of patients, admissions/discharges – Patient classification – – Staff mix – Staff scheduling – work schedule and off meet organizational goals with fairness and equity among personnel – centralized or decentralized

PATIENT CLASSIFICATION Number of patients

1 2 3 21 22 23 24

Minimal

Partial

Total

Day

PM

Night

Day

PM

Night

Day

PM

Night

0.17 0.34 0.51 3.57 3.74 3.91 4.08

0.14 0.28 0.42 2.94 3.08 3.22 3.36

0.10 0.20 0.30 2.10 2.20 2.30 2.40

0.27 0.54 0.81 5.67 5.94 6.21 6.48

0.15 0.30 0.45 30.15 3.30 3.45 4.00

0.07 0.14 0.21 1.47 1.54 1.61 1.68

0.36 0.72 1.08 7.56 7.92 8.28 8.64

0.30 0.60 0.90 6.30 6.60 6.90 7.20

0.20 0.40 0.60 4.20 4.40 4.60 4.80

Day shift 3 required minimal care 14 required partial care 5 required total care Total # of nursing personnel Needed to staff day shift

3 x 0.17 14 x 0.27 5 x 0.36

= = =

0.51 3.78 1.80 6.09

Modes of Organizing Patient Care • Total Patient Care Nursing or Case Method Nursing • Functional Nursing • Team and Modular Nursing • Primary Nursing • Case management

Modes of Organizing Patient Care Total Patient Care Nursing or Case Method Nursing • Nurse assumes total responsibility • Requires highly skilled personnel • Disadvantage: if nurse is inadequately prepared

Modes of Organizing Patient Care Functional Nursing • Evolved because of shortage • Care through others • Economical • Allow care to be provided with min registered nurses • May lead to fragmented care and overlooking patient priority needs

Modes of Organizing Patient Care Team and Modular Nursing • To decrease problems in FN • Ancillary personnel collaboration • Communication is important • Associated with democratic leadership

Modes of Organizing Patient Care Primary Nursing • Relationship-based nursing • Brought back nurse to bedside • Also useful in other health hospices • Requires high degree of responsibility and autonomy • Disadvantage: inadequately prepared nurse

Modes of Organizing Patient Care Case management • Latest work design • Collaborative process

Nurse Scheduling Challenges • • • • • • •

24/7 coverage needed Workload varies by shift by skill level by unit Rotation to off-shifts? Multiple skill levels (RN, LPN, aide, etc.) Covering weekends Shortage of personnel Dealing with daily fluctuations in supply & demand – OT, agency, part-time, float on/off unit, contingent, send home, call-in

Directing • Directing is the issuance of assignments, orders, and instructions that permit the worker to understand what is expected of him/her, and the guidance and overseeing of the worker so that he or she can contribute effectively and efficiently to the attainment of organizational objectives

Directing • Interpersonal relationships and communication are functions of directing • “Command” and “coordination”

Directing and Nursing Management • Directing is a physical act of nursing management, the interpersonal process by which nursing personnel accomplish the objectives of nursing • Process of applying the management plans to accomplish nursing objectives

Elements of Directing • Motivation • Leadership • Communication As a nurse manager…..

Delegating • A major component of directing • Managers get the work done through the employees • A solution to prevent overwork – stress, anger, and aggression

Reasons for Delegating • Assigning routine tasks • Assigning tasks for which the nurse manager does not have time • Problem solving • Changes in nurse manager’s own job emphasis • Capability building

Techniques for Delegating • Prepare list of duties to be delegated • Duties ranked according to time required to perform them • Delegate one duty at a time

What not to delegate • • • • • •

Power to discipline Responsibility for maintaining morale Overall control “hot potato” Too technical jobs Duties involving trust and confidence

Controlling • Verifying if everything occurs in conformity with the plan adopted, the instructions issued, and principles established (Fayol)

Controlling • Seeing that everything is being carried out in accordance with the plan • Measurement and correction of the performance in order to make sure that the organization meets its objectives and plans

Controlling In controlling function “Administrative reviews, regulates and controls performance to ensure that it confirms to certain standards”

Principles of controlling • Principle of uniformity • Principle of comparison • Principle of exception

Controlling and Nursing management • Major function of nursing management (Dovovan)

• Includes coordination of numerous activities, decision-making r/t planning and organizing of activities

Controlling and Nursing management • Also refers to records, reports, organizational progress towards aims and effective use of resources

Controls as management tools • Observations, patient charts, patients sources of data • Corrective actions can be corroborative, disciplinary or educational • Communication as information is essential to control

10 characteristics of good control system • • • • • • • • • •

Must reflect the nature of activity Must report errors promptly Should be forward-looking Should point out exceptions at critical points Should be objective Should be flexible Should reflect organizational pattern Should be economical Should be understandable Should indicate corrective action

Controlling mechanisms • • • • • • •

Accreditation procedures Consultants Evaluation devices Rounds Reports Inspections Nursing audits

Methods of measurements • Task analysis – nurse manager studies process of giving nursing care • Quality control – concerns measurement of quality and effects of nursing care

Control - Standards • System of evaluation • Yardsticks to measure the quantity and quality of service

Control - Standards • Performance standards • Performance evaluation and quality assurance

Controlling techniques • Nursing rounds • Nursing operating instructions • Gantt charts (show on board)

Controlling Approaches • TQM – Total quality management standards • Nursing audits • QMS, QA – quality management system, quality assurance

Controlling In controlling function “Administrative review, regulates and controls performance to ensure that it confirms to certain standards”

Leading In leading function guide and supervise subordinates to fulfill objective established in planning function

Leading is divided into five steps 1. 2. 3. 4. 5.

Supervision Motivation Communication Bringing about change Managing conflict

Mistakes Managers Make 1. Insensitive to others 2. Cold, aloof, arrogant 3. Betrayal of trust 4. Overly ambitions 5. Specific performance problems with the business 6. Overmanaging: unable to delegate or build a team 7. Unable to staff effectively 8. Unable to think strategically 9. Unable to adapt to boss with different style 10. Overdependent on advocate or mentor 6

The First Year Management Transition Initial Assumptions

7

Reality

 Exercise formal authority

 Cannot be “bossy”

 Manage tasks, not people

 Manage people, not tasks

 Help employees do their jobs

 Coach employee performance

 Hire and fire

 Fast pace, heavy workload

Conflict Management • Relates to feelings, including feelings of neglect, of being viewed as taken for granted, of treated like a servant, being ignored, being overloaded… • Results in overt behavior like brooding, arguing or fighting • In itself is neither functional (beneficial) or dysfunctional (harmful)

Conflict management • Can threaten harmony and balance in the organization • Can also be desirable and useful depending on how it is managed

Attitudes toward Conflict Bureaucratic or conservative • Conflict is unnecessary and harmful • Reflects failure in planning and control • Equates it to trouble, fight, unpleasant argument, pain and tension • Treat it with repressive and disapproving climate

Attitudes toward Conflict Human relations approach • Normal and frequent (human needs) • Some conflict is desirable – search for solution = effectiveness • Concerned with human communication – resolve conflict • Recognize and minimize conflict to minimize harmful aspects and maximize its benefits

Kinds of Conflict • Conflict within individual • Conflict between health organizations • Conflict within health organizations

Kinds of Conflict Conflict within individual • Uncertainty about work expectations • When confronted with ethical issues • Role conflict • Work overload • Personal independence and conformity to demands of organization • Expectations exceed capability – “bluff”

Kinds of Conflict Conflict between health organizations • Completion of buildings • Kinds of services • Kinds of facilities

Kinds of Conflict Conflict within health organizations • Differences between management and staff • Shared resources • Work interdependence • Differences in goals and values

Consequences of Conflict • Issues as recognized and brought out in the open • Rise in group cohesion and performance • Poor performance • Constructive or destructive results • Rise of leaders or new leaders

Conflict resolution • • • • • • •

Dominance and suppression Restriction Smoothing Avoidance “mutual admiration society” Majority rule Compromise “settling differences” Integrative problem solving

Passive, aggressive and assertive behaviors Passive behavior • Submissive, second-class employees • Unable to exert influence • Apologetic • Avoids direct confrontation • Feelings of helplessness and powerlessness • Engages in self-pity

Passive, aggressive and assertive behaviors Aggressive behavior • Bold, attacking, hostile manner • Accomplish purpose at expense of others • Disagreeing, unpleasant • Blaming, shaming, refusing to take “no”, belittling remarks • Humiliating and embarrassing others • Stomping feet, banging doors, cursing, slamming phone and crying

Passive, aggressive and assertive behaviors Assertive behavior • Maintaining balance between passive and assertive • Expressing positive and negative beliefs • Makes choices about how, when, where, how, who and why actions were taken • Initiate and terminate conversation with confidence, acts in best interest of self, patient and members of health team

Figure: Management Skill Mixes Different

Organizational Levels Conceptual Skills

Diagnostic Skills

Top Managers Middle Managers First-line Managers

Technical Skills

interpersonal Skills