Nursing Leadership &
Management
Patricia Kelly-Heidenthal
0-7668-2508-6
Delmar Learning
Copyright © 2003 Delmar Learning, a Thomson Learning company
Chapter 14
First-Line Patient Care
Management
Delmar Learning
Copyright © 2003 Delmar Learning, a Thomson Learning company
Objectives

Upon completion of this chapter, the reader should be
able to:
• Define first-line patient care management.
• Discuss elements of strategic planning—philosophy,
mission, vision.
• Define nursing shared governance.
• Identify Benner’s concepts of novice, advanced beginner,
competent, proficient, and expert nursing practice.
• Identify accountability-based care delivery systems.
• Identify measures of a unit’s performance.
Chapter 14
Copyright © 2003 Delmar Learning, a Thomson Learning company
3
Introduction


First-line patient care management is the coordination
of resources and clinical processes at the point of
service delivery.
First-line patient care management uses the nursing
process to plan, implement, and evaluate the outcomes
of care for populations of patients as opposed to
individual groups of patients.
Chapter 14
Copyright © 2003 Delmar Learning, a Thomson Learning company
4
Strategic Planning

Strategic planning is a process designed to achieve
goals in dynamic, competitive environments through
the allocation of resources.
Chapter 14
Copyright © 2003 Delmar Learning, a Thomson Learning company
5
Unit Strategic Planning


Unit or departmental strategic planning begins with
examination of the external environment, both
independent of and through the lens of the larger
organizational system of which the unit/department is
a member.
The group developing the unit strategic plan must
examine the impact that the external environment will
have on the particular unit.
Chapter 14
Copyright © 2003 Delmar Learning, a Thomson Learning company
6
Unit Strategic Planning


The group must also examine the internal
environment that supports the work unit to determine
the state of the human resources, clinical systems,
support services, information infrastructure, and
finances available to deliver care.
Unit strategic plans should be consistent with and
support the mission, vision, strategic plan, and annual
operating plan of the organization of which they are a
part.
Chapter 14
Copyright © 2003 Delmar Learning, a Thomson Learning company
7
Philosophy Based on Values That Drive
Unit Practice



A philosophy is a statement of beliefs based on core
values—inner forces that give us purpose.
A unit’s mission and vision is most authentic if it is
developed based on the philosophy or core beliefs of
the work team.
A unit’s core beliefs or values should be incorporated
into the unit’s mission and vision statements.
Chapter 14
Copyright © 2003 Delmar Learning, a Thomson Learning company
8
Mission Statement



Mission is a call to live out something that matters or
is meaningful.
An organization’s mission reflects the purpose and
direction of the health care agency or a department
within it.
A mission statement has three elements:
• A mission statement is no longer than a couple of sentences.
• It states the unit’s purpose using action words.
• It should be simple and from the heart.
Chapter 14
Copyright © 2003 Delmar Learning, a Thomson Learning company
9
Vision Statement


A unit vision statement describes how the mission of
the unit within an organization will be actualized.
A vision statement includes four elements:
• A vision statement is written down.
• It is written in present tense, using action words, as if it
were already accomplished.
• It covers a variety of activities and spans broad time frames.
• It addresses the needs of providers, patients, and
environment in a balanced manner that anchors it to reality.
Chapter 14
Copyright © 2003 Delmar Learning, a Thomson Learning company
10
Goals and Objectives



The work unit develops broad strategies that span the
next three to five years, and then develops annual
goals and objectives to meet each of these strategies.
Goals are written as specific aims or targets that the
unit wishes to attain within the time span of one year.
Objectives are the measurable steps to be taken to
reach each goal.
Chapter 14
Copyright © 2003 Delmar Learning, a Thomson Learning company
11
Structure of Professional Practice

In an organization where professional nursing practice
is valued, development and implementation of
strategic initiatives is most effectively carried out
through a structure of shared governance and shared
decision making between management and clinicians.
Chapter 14
Copyright © 2003 Delmar Learning, a Thomson Learning company
12
Shared Governance


Shared governance is an organizational framework
based on the idea of decentralized leadership that
fosters autonomous decision making and professional
nursing practice.
It implies the allocation of control, power, or authority
(governance) among mutually (shared) interested
vested parties.
Chapter 14
Copyright © 2003 Delmar Learning, a Thomson Learning company
13
Shared Governance

In most health care settings, vested parties in nursing
fall into two distinct categories:
• Nurses practicing direct patient care, such as staff nurses
• Nurses managing or administering the provision of that
care, such as managers
Chapter 14
Copyright © 2003 Delmar Learning, a Thomson Learning company
14
Shared Governance




Clinical Practice Council: the purpose is to establish
the practice standards for the work group.
Quality Council: the purpose is to credential staff and
to oversee the unit quality management initiatives.
Education Council: the purpose is to assess the learning
needs of the unit staff and develop and implement
programs to meet these needs.
Research Council: At the unit level, this council
advances research application with the intent of
incorporating research-based findings into the clinical
standards of unit practice.
Chapter 14
Copyright © 2003 Delmar Learning, a Thomson Learning company
15
Shared Governance


Management Council: this council ensures that the
standards of practice and governance agreed upon by
unit staff are upheld and that there are adequate
resources to deliver patient care.
Coordinating Council: the purpose is to facilitate and
integrate the activities of the other councils. This
council usually facilitates the annual review of the
unit mission and vision, and develops the annual
operational plan.
Chapter 14
Copyright © 2003 Delmar Learning, a Thomson Learning company
16
Competency/Professional Staff
Development



Competency is defined as possession of the required
skill, knowledge, qualification, or capacity.
Competency of professional staff can be ensured
through credentialing processes developed around a
clinical or career ladder staff promotion framework.
Clinical ladders acknowledge that staff members have
varying skill sets based on their education and
experience.
Chapter 14
Copyright © 2003 Delmar Learning, a Thomson Learning company
17
Benner's Novice to Expert

There are five progressive stages of Benner’s model
of nursing practice:
• Novice: task-oriented and focused
• Advanced beginner: demonstrates marginally acceptable
independent performance
• Competent: has been in the same role for two to three years;
demonstrates conscious, deliberative planning
• Proficient: perceives situations as wholes as opposed to a
series of tasks
• Expert: intuitively know what is going on with patients
Chapter 14
Copyright © 2003 Delmar Learning, a Thomson Learning company
18
The Process of Professional Practice:
Situational Leadership


Situational leadership maintains that there is no one
best leadership style, but rather that effective
leadership lies in matching the appropriate leadership
style to the individual’s or group’s level of taskrelevant readiness.
Readiness refers to how able and motivated an
individual is to perform a particular task.
Chapter 14
Copyright © 2003 Delmar Learning, a Thomson Learning company
19
The Process of Professional Practice:
Situational Leadership

A leader should help followers grow in their readiness
to perform new tasks by adjusting leadership behavior
through four styles along the leadership curve:
· Telling
· Selling
· Participating
· Delegating
Chapter 14
Copyright © 2003 Delmar Learning, a Thomson Learning company
20
Accountability-based Care Delivery


Accountability-based care delivery systems focus on
roles, their relationship to the work to be done, and the
outcomes they are intended to achieve.
Competence is evidenced not by what a person brings
to the work, but instead by the results of the
application of the person’s skills to the work.
Chapter 14
Copyright © 2003 Delmar Learning, a Thomson Learning company
21
Primary Nursing



In a primary nursing model, one nurse is accountable
for the care a patient receives during a given episode
of care.
She functions through associate nurses during the
hours of the day when she is not present in the
workplace.
The hallmark of primary nursing is that one nurse
maintains 24-hour accountability for a specific
patient’s care.
Chapter 14
Copyright © 2003 Delmar Learning, a Thomson Learning company
22
Patient-focused Care


Patient-focused care is a model of differentiated
nursing practice that emphasizes quality, cost, and
value.
The first-line patient care manager takes on an
expanded role, assuming accountability to manage
nurses and staff from other departments. The focus
has expanded to include overseeing the coordination
of all care activities required by patients and their
support systems.
Chapter 14
Copyright © 2003 Delmar Learning, a Thomson Learning company
23
Case Management


The primary goal of case management is to deliver
high-quality patient care in the most cost-effective
way by managing human and material resources.
Secondary goals are to:
•
•
•
•
•
•
Manage the delivery of care within a given time frame
Decrease length of stay for inpatient care
Ensure appropriate use of services and resources
Improve continuity of care
Standardize the care delivered for a given diagnosis
Improve patient outcomes from a given episode of care
Chapter 14
Copyright © 2003 Delmar Learning, a Thomson Learning company
24
Measurable Quality Outcomes


Regular evaluation of a unit’s performance to ensure
that the outcomes of care delivery are meeting the
objectives of professional practice as outlined in the
unit’s annual operational plan is an important
component of first-line patient care management.
The development of process improvement measures in
today’s health care organizations is driven by the
standards of quality required by the Joint Commission
on Accreditation of Healthcare Organizations
(JCAHO) and the National Council for Quality
Assurance (NCQA).
Chapter 14
Copyright © 2003 Delmar Learning, a Thomson Learning company
25
Unit-based Performance Improvement

To develop a comprehensive unit-based quality
improvement program, the first-line patient care
manager should track outcomes from four domains:
•
•
•
•
Access
Service
Cost
Clinical quality
Chapter 14
Copyright © 2003 Delmar Learning, a Thomson Learning company
26
Population-based Quality Improvement


In today’s health care environment, organizations are
able to track their aggregate performance in caring for
select populations of patients against evidence-based
standards of care.
Quality compass:
•
•
•
•
Functional status
Clinical outcomes
Cost and utilization
Patient satisfaction
Chapter 14
Copyright © 2003 Delmar Learning, a Thomson Learning company
27