Directing and Organizing Patient Care

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Directing and Organizing Patient Care
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Historical Overview

• 1800s the great awakening
• Late 1800s advances in medical knowledge led to
  the need for organizations, personnel and
  systems
  
• 1900s- advances in technology, need to control
  costs
  

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Differentiated Practice

• Maximizes Nursing Resources by Creating Distinct
  Levels of Nursing Practice Based on Education,
  Experience and Competence
  
• Scope of Nursing Practice and Level of
  Responsibility Are Specified for Each Level

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Goals for Managing and Organizing Patient Care

• Ensure Quality of Care
• Patient and Family Satisfaction
• Staff/Employee Satisfaction
• Appropriate staffing of nursing units
• Resolution of scheduling issues
• Cost - Effectiveness

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Functional Method - Division of Labor Structure
to Give Care

• Advantages
• Efficient
• Clearly defined roles
• Cost effective
• Less time needed to coordinate team work of staff

• Disadvantages
• Fragmentation of care
• Impersonal care
• Boring for staff
• less communication between the patient , nurse
  other health care providers
  
• Poor patient satisfaction

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Figure 3-1 Functional nursing
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Team Nursing

• Team Leader is an assigned role with delegated
  authority to supervise the team providing total
  care for a number of assigned patients.
  
• Requires good communication among team members
  for planning and implementing quality care.

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Team Nursing

• Advantages
• Comprehensive
• Holistic nursing care
• Patient and staff satisfaction is higher.
• Recognition of staff members abilities are
  possible.
  

• Disadvantages
• If team work poor then
• care is fragmented continuity of care ?
• care lacks accountability
• poor communication
• delegation poor
• Increased time in supervision by team leader.

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Figure 3-2 Team/modular nursing
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Total Patient Care or Case

• One nurse is assigned to complete the total care
  to a specific number of patients.
  
• Model used in intensive specialty care units,
  home health care, private duty nurse and for
  student nurse assignments.
  
• Is holistic and comprehensive with clear lines of
  responsibility.
  
• Least efficient and costly- uses RNs

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Figure 3-3 Total patient care
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Primary Nursing Care

• Each patient has a Primary Nurse responsible for
  the outcomes of care.
  
• Assessing needs of patient
• Developing plan of care in collaboration with
  other health care provides
  
• Implementing plan of care using non-licensed
  staff to assist in completing tasks
  
• Evaluating the outcomes of the nursing care
  given
  

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Primary Care

• Advantages
• Increased autonomy for the R.N.
• Able to provide more direct care
• Accountable, for outcomes
• Satisfaction for staff patients

• Disadvantages are implementation issues
• Cost of high ratio R.N. staff needed
• Not all nurses skilled in assessments and
  developing plans implementing plans of care
  
• Role confusion of other staff

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Figure 3-4 Primary nursing
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Practice Partnerships

• RN and Assistant Work as Practice Partners to
  Provide Care to Same Patients
  
• Advantages
• Less expensive
• More satisfying professionally for partners
• Disadvantages
• Decreased ratio of professional to
  nonprofessional nursing staff
  
• Potential for inappropriate delegation to
  assistant
  
• (See Figure 3-5)

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Figure 3-5 Practice partnerships
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Case Management

• Organizes Patient Care by Major Diagnoses and
  Focuses on Attaining Predetermined Patient
  Outcomes Within Specific Time Frames
  
• Advantages
• All professionals are equal members of team
• Emphasis is on managing interdisciplinary
  outcomes
  
• Disadvantage
• Requires essential base-line data be available to
  team members
  
• (See Figure 3-6)

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Figure 3-6 Case management
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Nursing Care Management

• Nurse is responsible for clinical and economic
  outcomes of patient care.
  
• Care is organized around the patient.
• Improved continuity and coordination of care.
• Uses Critical Pathways.
• Holistic approach

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Critical Pathways

• Refers to the Expected Outcomes and Care
  Strategies Developed by Collaborative Team
  
• Provides a Daily Outline of Outcomes to Be
  Achieved for Each Patient
  
• Alterations in Expected Outcomes Are Categorized
  as a Variance to Be Analyzed by the Case Manager
  
• Examples of Outcomes Include Length of Stay and
  Expected Time Frame for Specific Interventions

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Patient Focused Care

• Services are brought to the patients. Requires
  specific structure of the physical plant of the
  facility. High start up costs.
  
• Extensive cross -training of Care provider
• Goal is to streamline complex health care and to
  decrease the cost of health care.
  
• Organization wide, not just for nursing.

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Patient-Centered Care

• Role of Nurse Is Broadened to Coordinate a Team
  of Multifunctional Unit-Based Caregivers
  
• Focus of This Model Is Decentralization and the
  Promotion of Efficiency, Quality, and Cost
  Control
  
• Responsibilities of Caregivers Are Increased So
  That Service and Waiting Times Are Decreased

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Staffing Considerations

• Patient Census
• Patient Acuity
• Skill mix of staff needed
• Budget
• Needs of staff
• Education and training
• Nonproductive time

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Patient Classification and Acuity

• Acuity Index
• complex needs of the patient
• number of nursing hours requires per shift
• type of care needs will determine skill level
  needed to provide for the care

• Classifications
• DRGs - diagnosis related groups relate to
  reimbursement
  
• Prototype - patient categories
• Factor Evaluation - amount of time to complete a
  task (RVUs)

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Role of Patient Classification Systems

• To assist in planning the type and number of
  staff needed
  
• Right staff mix
• Maintain quality of patient care
• Maintain high satisfaction levels for patients
  and staff
  
• To determine the cost of nursing care provided

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Requirements for Scheduling

• FTE - 40 hrs per week or 2080 hrs per year.
• Productive time - actual time worked
• Nonproductive time includes benefit time
• Need for staff development/education
• Non-direct patient care tasks charting, report,
  communicating to allied health care
  professionals, supervising of unskilled staff

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Supervision of Unlicensed Staff

• Requirements for education and training vary from
  one organization and state to another.
  
• What is the skill level of the individual?
• Job description for the role.
• Limitations and responsibilities
• Reports to whom
• Your accountability

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Staffing Concerns

• Cross-training is a formal orientation to two or
  more like units.
  
• Increases individual skills
• More flexible staff
• Concern - nursing becomes more generalized .

• Floating - assigned where needed.
• Clarification - what is expected of the nurse
• Assessment - skill knowledge base to function
• Option identification -legally responsible