What is health policy?
Policy: the principles that govern action directed towards given ends.
public health policy
refers to local, state, and federal legislation; regulation; and court rulings that govern the behavior of individuals and organizations in the provision of health care services
o Local health policy
0
oState health policy
governs nursing practice through the Nursing Practice Act
�Provides "invisible services" through regulatory activities
�Maintaining a safe meat supply through livestock inspections, ensuring safe food storage and preparation in restaurants, ensuring that
oFederal health policy
� Funds health-related research and education for health professionals
� Pays for health care through Medicare, Medicaid, SCHIP, and the Veterans Administration Health Care system
� Plays a monumental role in shaping nursing practice
What are current issues of health care policy?
�Nursing shortage, lack of access to care, cost of care, etc
.� Lack of access to health care and the uninsured and underinsured:
o Primarily reflects a lack of health insurance coverage
o In 2009, 47 million people in the U.S. were uninsured.
o Working p
3. Factors that have lead to increased costs of health care?
� Social consciousness and economic factors
� Lack of cost consciousness contributed to increased costs.
� Patients were not aware of the costs
� Providers had little incentive to be concerned about costs, received more income for using more services, and
4. What are DRGs?
� System used by Medicare to determine payment rates for an inpatient hospital stay based on admission diagnosis.
� Each DRG represents a particular case type for which Medicare provides a flat dollar amount of reimbursement.
o This set rate may, in actua
5. Problems of access to health care for uninsured and underinsured.
� Estimates that 1/3 of these are in US illegally
� Underinsured and uninsured generate uncompensated care and "bad debt" for health care providers, who must then increase charges to paying customers (cost-shifting)
� Reasons some groups advocate for nati
6. How healthcare is paid for?
private insurance, health maintenance organization, preferred provider organization
private insurance
accounts for the largest percentage of coverage for health care
o Cost of providing health insurance to employees passed on by the employer to the consumer
o Everyone pays part of the country's health care cost in every purchase made.
o Individuals also p
health maintenance organization
o Unlike traditional indemnity insurance, an HMO covers only care rendered by those doctors and other professionals who have agreed to treat patients in accordance with the HMO's guidelines and restrictions in exchange for a steady stream of customers.
preferred provider organization
o A managed care organization of medical doctors, hospitals, and other health care providers who have covenanted with an insurer or a third-party administrator to provide health care at reduced rates to the insurer's or administrator's clients.
o The idea
8. What are primary areas on UTMBs legislative agenda?
� Obtain debt service for $150M TRB (Replacement Hospital)
� Maintain UTMB's GR Base
� Maintain UTMB's Ike Recovery Funds ($150M)
� Obtain new Correctional Health Care contract � Designated as Certified Application Coordinator organization
� Financial cou
�The Patient Protection and Affordable Care Act - 2010 Provisions
oYoung adults can stay on parents insurance until age 26
oChildren under 19 with pre-existing condition cannot be denied coverage
o10% tax on tanning services
oMedicare drug plan beneficiaries will get $250 rebate
oInsurance companies can't drop people wh
� The Patient Protection and Affordable Care Act - 2011 Provisions
o Medicare will cover full cost of annual wellness visits
o Employers required to disclose actual cost of health care on W-2
o Annual fee to pharmaceutical companies based on market share
o Payments to Medicare Advantage companies are frozen at 2010 level
� The Patient Protection and Affordable Care Act - 2012 Provisions
o CMS (Center for Medicare and Medicaid Services) begins tracking hospital readmission rates
o HCAP Survey (Hospital Consumer Assessment of Healthcare Providers and Systems)
� The Patient Protection and Affordable Care Act - 2013 Provisions
o Threshold for claiming medical expenses on income tax raised to 10% from 7.5%
o The Federal Insurance Contributions Act tax (FICA) is raised to 2.35% from 1.45% for individuals earning more than $200,000 and married couples with incomes over $250,000.
o
� The Patient Protection and Affordable Care Act - 2014 Provisions
o State health insurance exchanges open for small businesses and individuals
o Individuals with up to 133% of federal poverty level qualify for Medicaid
o Health care tax credits become available for people up to 400% poverty level to help pay for insuran
� The Patient Protection and Affordable Care Act - 2015 Provisions
o Medicare creates system of rewarding physicians based on quality of care rather than volume of services
� The Patient Protection and Affordable Care Act- 2018 Provisions
o Excise tax on high cost employer-provided plans is imposed
Know that in 2014, everyone will be required to have health insurance.
just remember
Know that the ACA will start rewarding providers based on quality rather than volume of services in 2015.
just remember
What are HCAPs? How will HCAPs affect reimbursement?
� Hospital Consumer Assessment of Healthcare Providers and Systems
� Centralized Staffing
o Staffing decision are made by personnel in a central office or staffing center
o The manager's role is limited to making minor adjustments and providing input
� The manager would communicate special staffing needs and assist with obtaining staff coverag
� Decentralized Staffing
o The unit manager is often responsible for covering all scheduled staff absences, reducing staff during periods of decreased patient census or acuity, adding staff during periods of high patient census or acuity, preparing monthly unit schedules, and pre
How does acuity affect staffing levels?
� Need more staff for more acutely ill patients
16. What are nurse-patient ratios?
� Amount of patients assigned to one nurse
17. What are patient classification systems, and how are they used in staffing?
� Aka workload management, patient acuity tools
� A PCS groups patients according to specific characteristics that measure acuity of illness in an effort to determine both the number and mix of the staff needed to adequately care for those patients
� PCSs
Know that some states have legislated these.
must have patient classification systems.
What is self-scheduling?
� Allows nurses in a unit to work together to construct their own schedules rather than have schedules created by management
20. What are reasons for staff development?
� Nurses must have proven competencies in order to perform their duties, many of which are not learned in nursing school
� As healthcare evolves, we are faced with new technologies, new procedures and evolving evidence-based practice that we must learn
�
21. What are some general components of a staff development program?
� Free CEUs, time off to get CEUs, tuition reimbursement
22. What is negotiation?
� Resembles compromise when used as a conflict negotiation strategy, emphasis on accommodating differences between the parties
� Each party must consider trade-offs and the bottom line to negotiate successfully
� Before = be prepared mentally by having do
23. What is delegation?
� Getting work done through others, directing the performance of one or more people to accomplish organizational goals
25. Why might a nurse manager under delegate?
� Fear that delegation may be interpreted as a lack of ability to do the job completely or correctly
� A desire to complete the whole job himself or herself
� Fear that subordinates will resent delegated work.
� Lack of experience in the job or with deleg
26. Why are UAPs used more now than in the past?
�UAPs can free professional nurses from tasks and assignments that can be completed by less well-trained personnel at a lower cost
27. What does the nurse need to know about the UAP before delegating a task?
� Job description, knowledge base, and demonstrated skill
28. What is correct technique for hand hygiene?
� Wash hands for 40-60 seconds when hands are visibly soiled.
� Wash hands at the beginning of shift and when caring for a patient with C dif
� Alcohol rub between patients
� Contact
o Private room, wear gloves and gown when entering room, wash hands, wash all pt care equipment, limit transport if possible
o MRSA, varicella
Airborne
o Negative flow room if possible, keep door closed and pt in room, wear N95 mask, limit transfer if possible
o Measels, anthrax, TB, varicella
� Droplet
o Private room, surgical mask on pt, surgical mask when going into room
o Meningitis, influenza
� Neutropenic
chemo pts
� All Barrier
o Combo of airborne and contact precautions, plus eye protection and standard precautions
� Severe Acute Respiratory Syndrome (SARS), hemorrhagic disease, and all known and suspect avian and pandemic influenza patients
30. What is a tall or bureaucratic structure?
� Tight control of bureaucracy
bureaucratic or line structures:
� Common in healthcare organizations
� Works well with large organizations
� Responsibilities are clearly defined
� Unity of Command
� Lots of rules, policies and procedures
� Disadvantages:
31. What is a flat structure?
�More democratic, > number of administrative levels in an organization.
� Reduces layers
� Decision making done at lower levels
� Advantages:
� Mangers have greater autonomy
� Disadvantages:
� Mangers have greater work load
32. How is decision making done in these type of structures?
�Scalar chain:
� The decision-making hierarchy
� Centralized decision making:
� A few people at the top make the decisions
� Decentralized decision making:
� Decisions made throughout the organization
Formal structure:
? Provides framework for defining ma
34. What's shared governance?
� An organizational framework based on the idea of decentralized leadership that fosters autonomous decision making and professional nursing practice
� Founded on the philosophy that employees have both a right and responsibility to govern their own work
35. What are factors to consider when forming committees?
� Should be composed of people who want to contribute in terms of commitment, energy, and time.
� Members should have a variety of work experience and educational backgrounds, composition should ensure expertise sufficient to complete the task
� Enough me
36. Know the following types of power.
� Legitimate = given because of the position in the organization
� Expert = based on special skill or ability of the person
� Reward = based on the ability to control & administer rewards
� Coercive = based on the manager's ability to use punishment
� Ref
37. What is authority?
� The right to command that comes with a management position
? Authority: power to act
? Responsibility: duty related to a job
? Accountability: internalizing responsibility for the job
38. What are the techniques to use to build power?
� Pay your dues = do your assignments, seek extra duties, and contribute,
� Identify the power structure (formal, informal)
� Dress for success, present yourself well
� Understand the organization's mission and goals
� Maintain knowledge and skills
� Incr
39. What is the authority-power gap and what happens when it increases?
� The gap between the manager and the employee
� The more power an employee thinks the manager has, the smaller the authority gap
o Visible exercise of authority in decision making
� A narrow gap tends to make the employees more dependent on the manager
�
40. Know what functional, team, primary methods of organizing patient care.
� Functional = emphasis on getting task accomplished and procedures done
o RNs: assess, starts IVs, do orders, chart, complex skills
o LVNs: give meds, treatments
o CNAs, UAPs: baths, beds, VS
� Team = care provided by a team lead by RN responsible for kn
41. Know what is case management and why was it started?
� Case manager coordinates care done by all who have contact with the patient
� Focus is on individual clients, not patient population
� The medical world now revolves around managed care entities (MCEs) instead of patients
� MCEs want to save money and s
Benner's stages of professional development.
� Stage 1 = Novice
o No experience of the situations in which they are expected to perform
o Novices are taught rules to help them perform, and don't like to stray from what they've been taught
o "Just tell me what I need to do and I'll do it"
o "Please G
How does a nurse increase her emotional intelligence?
� Self awareness, self regulation, motivation, empathy, social skills
What is transactional and transformational leadership?
� Transactional = traditional manager, concerned with day-to-day operations
o Focus on tasks and getting work done
o Uses trade-offs to meet goals
o Examines causes
� Transformational = manager who is committed, has a vision, and is able to empower others
What is strategic planning?
� Focuses on purpose, mission, philosophy, and goals related to the external organizational environment
� Helps to separate daily management activities and operations from initiatives that can take an organization to the next level
� Forecasts the future
What are the steps of strategic planning?
� Define organization purpose, establish realistic goals and objectives, identify external constituencies and determine their assessment of the organizations purpose and operations, communicate goals to constituents, develop sense of plan ownership, devel
McClelland's theory of motivation.
� People are motivated by achievement, affiliation, and power
� Achievement oriented people are actively focus on improving what is
o They transform ideas to action, judiciously and wisely, taking risks when necessary
� Affiliation oriented people focus t
Herzberg's 2-factor theory.
� Motivators/job satisfiers are present in work itself, give people the desire to work and work well
o Achievement, recognition, responsibility, advancement, work itself, possibility for growth
� Hygiene/maintenance factors keep employees from being dissa
What are strategies to use when collaborating to manage conflict?
� An assertive and cooperative means of conflict resolution whereby all parties set aside their original goals and work together to establish a common priority goal
� What are grassroots political strategies?
� Registering to vote and voting in all elections
� Joining a professional nursing organization
� Working in candidates' campaigns
� Attending a "meet the candidates" town hall meeting
� Visiting personally with policy makers or their staff
� Communicatin
unity of command
Unity of command:
� Solid lines on chart indicate formal relationships
� Unity of Command = one person - one boss
� Max Weber - Bureaucracy:
� Lack of unity of command leads to conflict, confusion, and decreased productivity
span of control
# of People Reporting to a Supervisor
Ideal Span: Depends on philosophy
� Narrow span = Many levels, pyramid shaped
� Tall Structure = tight control of bureaucracy
� Wide Span = Fewer levels, rectangular shaped
� Flat structure = more democratic
Know what functional, team, primary methods of organizing patient care.
Be able to recognize the types when descriptions are given.
Total care assignment:
Requires highly skilled nurses
Advantages:
� More satisfying for nurses than functional nursing
� Nurses have high autonomy
� Patients have holistic care while nurse on duty
Disadvantages:
� Expensive
� Lack of teamwork is safety is
case management
Case Manager coordinates care done by all who have contact with the patient
Focus is on individual clients, not populations of clients.
The medical world now revolves around managed care entities (MCEs) instead of patients.
Patients' role has shifted to t
central and decentralized
What is centralized and decentralized staffing?
Centralized staffing - staffing decisions made by personnel in a central office
May or may not be staffed with RN's
Usually have protocols/matrixes off which to staff. Usually considered to be fairer to empl
how does acuity affect staffing levels
Adequate levels of RN in staffing mean safe patient care. Growing body of research links BSN prepared nrueses to lower mortality and failure to rescue rates. AACN Nursing Shortage Fact Sheet
Impact of Nurse Staffing on Patient Care - March 2011 - NEJM - r
what are nurse patient ratio
Mandatory Nurse-Patient Ratio: very controversial! Was driven by the state of California with the passage of California Assembly Bill 394 in 1999 which mandated nurse-patient ratios. The final bill was to be implemented in 2004 however Gov. Schwarzenegger
What are patient classification systems and how are they used in staffing?
Unit of Service - or nursing care hours per patient day. Standard formula that I used --- ADC at midnight with � credit being given for discharges/admissions multiplied by a set number by personnel engineer. NICU - I got 11 hours - covers everything!
Used
self scheduling
Self scheduling - Nurses create their own schedules. Guidelines are set and the schedule is developed. Difficult to implement. Greatest control over the schedule by the staff. Management must ensure that guidelines are met so that the schedule is determin
reasons for staff development
. Nurses must have proven competencies in order to perform their duties, many of which are not learned in nursing school.
2. As healthcare evolves we are faced with new technologies, new procedures and evolving evidenced based practice that we must learn.
chicken pox
...
measles
Airborne
anthrax
airborne
�Powdery substance, inhalation anthrax- fever, muscle aches, meningitis, shock. Fatal complications with respiratory
MRSA
contact
meningitis
droplet
tuberculosis
negative pressure airborne. night sweats, wt loss, persistent cough
what is delegation
� What is delegation?
- Getting work done through others or directing the performance of one of more people to accomplish tasks.
� Essential element of the directing phase
� What is delegation? Basically is it getting work done through others or directing
why delegate
It frees the manager to handle problems that are more complex or require a higher level of expertise
Someone else may be better prepared or have greater knowledge/expertise to do the task
Can be a learning or "stretching" opportunity for others
Can be a m
how do you delegate effectively
Five Rights of Delegation:
Right Task
Right Circumstance
Right Person
Right Direction/Communication
Right Supervision
step one in delegating
RN takes responsibility and accountability for the provision of nursing practice. Are there laws and rules that support the delegation?
RN directs care and determines the appropriate utilization of any assistant involved in providing direct patient care
C
step two in delegating
Communication is a two-way process
The RN needs to assess the UAP's understanding
Of the task to be accomplished
When and what information is to be reported
Observations to report and record
Specific client concerns that would require prompt recording
Com
why might a nurse manager underdelegate
Because delegation is a skill that we must learn - we can make errors. Common errors include:
overdelegation
Burdens subordinates, Poor management of time, spend too much time getting organized, Insecurity in performing task
underdelegating
Wrong assumption that delegation means that the manager does not have the ability to do the job correctly or completely
Desire to complete the job personally due to a lack of trust in others
Do not have the skills in delegation itself, Fail to anticipate
improper delegating
Delegate at the wrong time, Delegate to the wrong person, Delegate for the wrong reason, Delegating tasks that beyond the capability of the person (should be done by the manager)
Don't want to "satisfice" want to "maximize" What is satisfice? Aiming to ac
resistance to delegation
common response, the delegator must determine "why" this is happening and take appropriate action to eliminate the factors causing the resistance. Should see the situation from the viewpoint of the individual be delegated to
issues
Individual believes that they are "incapable" of completing the task
Resistance to authority - testing the boundaries
Tasks are resisted because they are too "specific" - Allow creativity and independent thinking, Mix routine with more challenging tasks a
emotional intelligence
Self awareness, self regulation, motivation, empathy, social skills
thought leadership
...
transformational leadership
...
strategic planning and its steps
...
legitimate power
...
referent power
...
mcLelland
achievement, affiliation & power
o McCllland argued that people are motivated by three basic needs:
� Achievement
� Affiliation
� Power
o Achievement oriented people are actively focus on improving what is; they transform ideas to action, judiciously and
Herzberg theories
motivators and hygiene factors and examples of these.
o Motivators or job satisfiers are present in work itself; they give people the desire to work and do that work well. Hygiene or maintenance factors keep employees from being dissatisfied or demotivate
strategies to use when collaborating to manage conflict
o Compromising:
� Each party gives up something it wants.
o Competing:
� One party pursues what it wants, regardless of the cost to others
o Accommodating:
� One party sacrifices his or her beliefs and wants to allow the other party to win
o Smoothing:
�
What is correct technique for hand hygiene?
o Wash hands for 40-60 seconds when hands are visibly soiled. At the beginning of shift and when caring for a patient with c difficile. Alcohol rub between patients.
flu
droplet