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PROFESSIONAL PRACTICE CARE
DELIVERY MODELS EMERGING
PRACTICE MODELS- CHAPTER
Accountable Care Organization (ACO) - a collaboration of hospitals, doctors, and other providers who work accept joint responsibility for the quality and cost of care provided to patients. Care delivery system - a system for the delivery of care that delineates the nurses authority and accountability for clinical decision making and outcomes; it is integrated with the professional practice model and promotes continuous, consistent, efficient, and accountable nursing care. medical home - a mechanism to provide patients with a central primary care practice or provider who cooridnates the patients' care across settings and providers professional practice model - a schematic description of a theory, phenomenon, or system that depicts how nurses practice, collaborate, communicate, and develop professionally to provide the highest level of care that meets the 3 aims of effectiveness, efficiency, and patient experience. what is at the center of the professional practice model? - the patient and family What guides the professional practice model? - The practice model is guided by the nursing vision, mission, and values of the organization. The professional practice model also: -Describes the environment in which the professional nurse practices -Determines the expectations for the nurse within a care environment -Provides nurses with opportunities for autonomy, accountability, and control over the care that they provide what is integrated into the professional practice model? - The care deliverym system. It is Continually improved to adjust to: -National patient safety goals -Value-based outcomes -Regulatory requirements -Current best evidence
•Describes the manner in which care is delivered, the context of care, and the expected outcomes of care Five key dimensions of the care delivery model (Dubois et al.) are? - -Staffing intensity -Skill and nursing education mix -Professional scope of practice -Nursing practice environment -Unit level capacity for innovation Positive outcomes achieved in models with what? - -Rich skill and education mix -High staffing intensity -Practice environment more supportive of professional practice -Investments in innovation Six domains of professional practice include what? - assessment and planning, teaching, communication, supervision, quality of care, and knowledge updating. Five criteria for innovation include what? - -expanded RN roles -sharpened focus of care on the patient -attention to patient transitions -leveraging of technologies -performance monitoring and feedback. Information considered in the development of a delivery care model should include the following: - -Population served -Age, ethnic, cultural and spiritual patient characteristics -Scope and complexity of patients -Admission characteristics -Assessment/reassessment practices and standards -Staffing ratios and staff mix -Standards for assignment of patients -Required competencies of staff -Nursing philosophy, mission, vision, and values -Interprofessionals who support care delivery -Standards to ensure continuity of care -Professional nursing standards -Use of evidence to drive innovation -Performance improvement indicators Three emerging models include? - -Accountable care organization -Medical or health home -Nurse-managed health center
FTE (full time equivalent) - equal to a full time employee nursing hours per patient - total paid hours for nursing personnel for a specific time period divided by the number of patient days in the same period patient acuity - measure of nursing workload that is generated for each patient permanent shifts - Personnel working the SAME hours repeatedly rotating work shifts - alternating work hours among days, evening, and nights self-scheduling - staff coordinating their own work schedules staffing pattern - plan that articulates how many and what kind of staff are needed by shift and day to staff a unit or department staffing ratios - number of nursing staff per patient staffing schedules - Work schedules for personnel variable staffing - Determining the number and mix of staff based on patient needs variance reports - noting differences in budgeted or planned staffing costs The Joint Commission (TJC) surveys hospitals on what? - the quality of care provided TJC does not mandate staffing levels BUT does assess what? - an organization's ability to provide the right number of competent staff to meet the needs of patients served by the hospital (TJC, 2007) The ANA Principles for Nurse Staffing are organized into five (5) sets according to what topics? - -The characteristics and considerations of the health care consumer -The characteristics and considerations of the registered nurses and other interprofessional team members and staff -The context of the entire organization in which the nursing services are delivered -The overall practice environment that influences the delivery of care -The evaluation of staffing plans in 1999, the ANA advocated a work environment that supports nurses in providing what? - -the best possible care by budgeting enough positions -administrative support -good physician-nurse relations
-career advancement options -work flexibility -personal choice in scheduling Daily staffing - refers to filling in open shifts on the current work schedule Scheduling - refers to making work assignments for the next work period. It is done from 4 to 8 weeks in advance depending on the institution -The staffing process culminates with a schedule (organized plan) of personnel to provide patient care services Scheduling variables: - -The number of patients, complexity of patients' conditions, and nursing care required -The physical environment in which nursing care is to be provided -The nursing staff members' competency levels, qualifications, skill range, knowledge or ability, and experience level -The level of supervision required -Availability of nursing staff members for the assignment of responsibilities The staffing plan consists of four (4) different elements that MUST be addressed: - 1. The health care setting
- The care delivery model
- Patient acuity
- Nursing staff Centralized scheduling - - Decision making occurs in a "centralized" location for the entire institution Decentralized scheduling - - Decision making occurs with the nurse manager on the unit Mixed scheduling - - Blends aspects of items 1 and 2. Individual units may manage staffing, but if they cannot fill open shifts, they might forward their needs to a centralized office Self-scheduling - - Individual staff members schedule themselves. The nurse manager then works with staff members to fill empty slots Pros and Cons of Centralized Scheduling - Pros: Fairness to employees through consistancy/Cost containment through better use of resources Cons: Lack of individualized treatment Pros and Cons of Decentralized Scheduling - Pros: Managers have authority/Staff get personalized attention/Staffing is easier and less complicated
•Provide ego satisfaction •Maintain nursing skills •Continue education Benefits for Institution include: •Having a flexible work pool; and •Decreased benefit costs •Note: 2 Nurses can share 1 full-time position Disadvantage for Institution: •Educational & administrative expenses higher r/t orientation Disadvantage for Nurses: •No full-time benefits (vacation & sick time) external temporary agencies - •Usually a last resort •The staffing agency is a business that has a registry of nurses who have highly flexible schedules •Matching of nurses' credentials with the position is sometimes daunting •Replacement staff from agency pools are expensive (most hospitals prefer to minimize the use of agency nurses because of the extra cost to the institution) Travel nurses - "Travelers" are per diem nurses working for a business that places them in contracted hospitals Unlike agency nurses, travelers usually sign longer-term contracts with hospitals (3 to 6 months or longer) options used for sick calls - -use a float, per diem, or agency nurse -ask a nurse to work for the sick person and cancel a shift for that person later in the week -ask a park-time person to work an extra shift, substituting one type of classification for another, such as a LPN for an RN -ask one staff member to work a few hours of overtime and another to come in a few hours early. -do without a substitute -manager covers the shift overtime - •Length of time that the nurse will be working •The nurse manager must be careful to evaluate the exhaustion level of the staff •There are documented instances of increased errors when the staff is exhausted (Garrett, 2008) •On a budget end, overtime may increase the dollars spent on care provided
•State labor law will need to be reviewed as well as union guidelines (where unions are utilized) Patient outcomes related to staffing: - -Accreditation standards and National Patient Safety Goals -Patient Satisfaction survey results -National Database of Nursing Quality Indicators (NDNQI) nursing sensitive indicator outcomes -Unit scorecards -The NDNQI Staff RN Satisfaction Survey -Centers for Medicare and Medicaid Services (CMS) core measures -Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) results -Unit-based surveys -Note: As a nurse manager, you will be evaluated in areas of patient outcomes and budget performance. Direct patient care activities - activities such as hygienic care, feeding pts, taking VS, and so on that are performed on the pt Indirect patient care - routine activities of the patient unit that deal with the day to day functioning of the unit, such as restocking supplies. deligation - Allows the transfer of responsibility to another person to complete a task or activity while the initial person retains the accountability for the outcome. ~The person that is entrusted the delegated task must be qualified, competent and able to perform the task. ~The RN takes responsibility and accountability for the provision of nursing practice. ~The organization/agency is accountable to provide sufficient resources to enable appropriate delegation. deligation is based upon what? - the RNs judgement concerning the care complexity of the patient, the avalibility and competance of the individual accepting the delegation, and the type of intensity of supervision required. who is responsible for ensuring the RN has access to documented competency information for staff to whom the RN is delegating tasks? - the organization/agency Unlicensed Assistive Personnel (UAP) - Also known as: •Noncredentialed assistive personnel •Nursing assistant (NA) •Patient care associate (PCA)
-skin care: perform back care, prepare skin for procedure, perform skin prep for operative procedure -Activity and mobility: assist in ambulating patient, perform passive and active ROM, positioning, transfers -respiratory support: set up oxygen, assist with using an incentive spirometer, assist with coughing and deep breathing exercises -procedures: set up patient room (suction canisters, cables for continuous cardiac monitoring, tubing for chest tubes), Orient patient to room environment, obtain necessary supplies for sterile procedure, perform postmortem care indirect patient care activities that may be delegated include? - -cleaning: cleaning equipment, environment, refrigerators , patient care areas, remove meal trays, cleaning supply carts, clean and restart procedure rooms, make unoccupied beds -errands : deliver meal trays, obtain and deliver supplies, equipment, and blood products , check laboratory specimens for appropriate labeling, deliver specimens to clinical laboratory -clerical tasks: place and answer phone calls, symbol, disassemble, and maintain patient charts, transcribes physician Anne nursing patient care orders, scheduled diagnostic tests and procedures, order necessary office supplies and forms, sort and deliver Mail, keep unit log books up-to-date with patient admissions, transfers, and discharges -stocking & maintenance: stock patient bedside supplies, stock unit supplies, utility rooms, treatment, examination, and procedure rooms, nourishment and kitchen supplies, linen cart, check electrical equipment for inspections due dates questions to ask yourself when accepting a delegated assignment? - •Is act consistent with your defined scope of practice? •Is there a valid order? Is it in accordance with the agency protocols, policies, and procedures? •Is the act supported by research data or a position statement? •Are you competent to perform it safely? •Is the act to be performed with the acceptable "standards of care"? Would another nurse with similar education and clinical skills perform similarly? •Are you prepared to assume accountability for the provision of safe care? Note: The nurse who is accepting a delegated task should know whether a national nursing organization has issued a position statement on the specific practice. It is for you to know the nurse practice act of the state in which you are practicing and to be aware of what? - the delegation regulation within your state.
The requirement of the right person means that you must know what? - the competency level, job description, individual level of skill, and standard of education of the individual to whom you are delegating. When delegating tasks, directions should be...? - clear, concise, and complete. nursing activities that may not be delegated include? - •Patient assessments •Nursing diagnosis •Planning and evaluation of nursing care •Developing, updating plan of care •Health teaching and health counseling (unless it is reinforcement of previously taught material) •Discussing patient with physician •Communicating with or implementing orders from physician •Documenting assessment •Administering medications •Providing direct nursing care barriers to delegation include? - Barriers in the delegator(RN): lack of confidence in subordinates, perfectionism, and inability to explain tasks, fear of being disliked, uncertianty over tasks Barriers in the delegate (AP/LPN): lack of experience, disorganization, and overload of work, Situational/environmental barriers: urgency, understaffing, and lack of toleration for mistakes Levels of expertise (Benner) - •Novice •Advanced beginner •Competent nurse •Proficient nurse •Expert has limited experiance with tasks and needs rules to guide actions - novice nurse has enough experience to recognize patterns in work but continues to need help in setting priorities; relies on rules and protocols - Advanced Beginner Nurse has been practicing for 2-3 years; can prioritize and cope with various contingencies; requires assistance working through various situations not yet experienced - Competent nurse has enough experiance to see the "big picture" rather than a series of individual actions; decision making is more efficient and accurate; is able to prioritize and plan even more challenging more patient care. - proficient nurse
-Other elements of orientation can occur when staff is providing care, treatment, and services -All employees, regardless of level of competence, are required to attend orientation -New-employee orientation covers organization-specific functions, policies and expectations, such as mission, vision, values, stakeholder expectations, performance improvement, basic skill evaluation, and a mandatory policy review The time frame for new nurse socialization to the role, or the process of developing clinical judgment in practice, has been suggested to be as follows (Ferguson, Day, Anderson, & Rohatnsky, 2007): - -Orientation (0 to 20 days) -Learning practice norms (orientation 4 to 6 months) -Developing confidence (6 to 12 months) -Consolidating relationships (12 to 18 months) preceptor functions include? - Assist new nurse to acquire knowledge and skills Tailor program specifically 2 needs orient two unit socialize within group Orient to unit functions teach unfamiliar procedures assistant development of skills act as a resource person familiarize with policies and procedures act as a counselor and role model act as a time management coach delegate tasks an assist with priority setting mentor to shared governance A preceptor is an experienced staff member who possesses... - excellent clinical skills and facilitates learning through caring, respect, compassion, understanding, nurturing, role modeling, and the excellent use of interpersonal communication (Speers, Strzyzewski, & Ziolkowski, 2004) -Experienced nurses are frequently required to serve as preceptors as part of their normal responsibilities Peer review in nursing is the process by which practicing registered nurses systematically - access, monitor, and make judgments about the quality of nursing care provided by peers as measured against professional standards of practice. •Peer review forms the basis of nursing accountability for current practice and the continual improvement of practice. Peer review six principles: - 1. A peer is someone of the same rank
- Peer review is practice-focused
- Feedback is timely, routine, and a continuous expectation
- Peer review fosters a continuous learning culture of patient safety and best practice
- Feedback is not anonymous
- Feedback incorporates the nurse's developmental stage performance appraisal - An evaluation that measures employee performance against established standards in order to make decisions about promotions, compensation, training or termination. The formal evaluation is part of the employee record and is usually a competency- based assessment of the performance of the employee during the past year. The performance appraisal should include: - -Strengths and weaknesses -Accomplishment of last year's goals -Future goals -Specific examples of performance should be included -There should be a correlation between the evaluation, the job description and the goals of the institution As a nurse being evaluated during a performance appraisal you want to: - -Know what you are being rated on -Acknowledge the peer review results -Before the review, carefully think about the period since your last review -Review the previous year's goals -Keep track of your performance and accomplishments along the way -Use examples to illustrate how you met the standard -Remain positive; acknowledge errors and show how you learned from them -Receive criticism well -Clarify expectations -Accept praise What is mandated by The Joint Commission (2014) - Ongoing education, and includes in-services, training, and other activities. •Occurs when job responsibilities change •Increases knowledge of work-related issues •Is appropriate to the needs of the population(s) served and complies with law and regulation •Emphasizes specific job-related aspects of safety and infection prevention and control •Incorporates methods of team training •Informs when and how to report adverse and sentinel events •Is offered in response to identified learning needs •Results in documented outcomes •Is documented
