Management and Organisation of Nursing Care - Essay Example

Management and Organization of Nursing Care Financial Management of Healthcare & Emerging Issues Healthcare, the field concerned with the restoration or maintenance of health of the mind or the body, is an industry which involves much more than just doctors and hospitals. Although the latter two entities form the major part of the expenditures in the industry there are other healthcare providers too which have a fair share of the remainder. The industry is almost as large as $ 1.9 trillion and expected to go up to $ 2.5 trillion by the year 2009 which means tremendous resources are available to companies that serve patients and hence tremendous opportunities too. This large sum of money should lead to the best possible outcomes, at the least possible cost and in the most consumer-friendly manner that is possible. Before we look at what is financial management it is imperative to look at what is management by itself. In a managed venture which is profit oriented and investor owned, management could be observed in terms of its standard objectives that is to maximize the shareholder’s or owner’s wealth. Towards achieving this goal, management skills like planning, organizing, coordinating, motivating and controlling are essential to execute the management roles and responsibilities that lay ahead. Even though this management philosophy is not applicable to healthcare industry directly since it is a not-for-profit set up under section 501(c) (3) of the Internal Revenue Code. Still the healthcare industry management has to deliver the best possible bottom line even though the employers are not-for-profit. For this they have to carry out optimal patient care which is both satisfying and most efficient. In a profit oriented organization, management has to administer the assets owned by the enterprise in order to maximize wealth for the owner. Here therefore the primary goal of the management is to identify that combination of earnings and risk associated with generating those earnings to yield the highest possible value. Margin is the term associated with profit or earnings in a not-for-profit organization. In both the above type of organizations what remains after expenses, or costs, are deducted from revenues is the margin or profit generated. So emphasizing again, the role of management is to generate the best possible financial returns, while reducing the associated risk to the organization to the minimum level. Although there is an emphasis on social goals in not-for-profit organizations both type of organizations meet with success or failure as dictated and decided by the board of directors based on the quality of the bottom-line. Financial management can be viewed as initiating and executing a strategy for the financial direction and day to day financial operations of the organization. Thus there are two management functions or tasks which are usually handled at the executive level by two designated individuals namely (1) the Chief Financial Officer (CFO), who takes care of strategizing the financial direction by getting the financial plan of the organization endorsed by the board and implementing their recommendations as to the nature of investments as per policy drawn on various assets and the other (2) the Financial Controller who manages the day to day financial operations ranging from departmental payroll to banking activities etc. The major issue involved in this financial management activity is the management of information. Management Function / Activity in Delivery of Patient Care A case by case analysis and exploration. Healthcare workforce can be efficiently used by means of introducing skill mix changes which can in turn act as a potential contributor for the same. ‘Skill mix’ in a broader sense depicts the mix of workforce staff and the distinguishing activities and roles of multiple categories of staff. Skill mix can also be referred to as “the mix of posts in the establishment; the mix of employees in a post; the combination of skills available at a specific time; or the combinations of activities that comprise each role, rather than combination of different job titles” (Buchan et al. 2001:233). The main focus on the use of introducing skill mix, to the improvement of healthcare system and hence the delivery of patient care is the mix of physicians and nurses. Development in the skill mix changes might include getting a specific group of staff to enhance their skills, substitution among multiple groups, delegation from top to bottom in a single disciplined hierarchy, and role innovation. The motivation behind such changes could be several including innovation in service, improvement of quality, improving the cost-effectiveness of service delivery transpiring as a desire, and more especially in rural areas and inner cities an acute shortage of workers belonging to a specific category. The use of nurse as an advance practitioner cannot be ignored when it comes to evaluation of the role in terms of its cost effectiveness, overall effectiveness and others. The substitution of nurses for doctors in most cases of delivery of patient care has been encouraged. Literature reviews of most of the Advanced Practice Nurses (APN) have indicated that the equivalent care provided by a doctor can be provided by these nurses too under similar settings. Even the patients were more heartened by the consultations undertaken by nurses than the one undertaken by doctors. In fact more tests were being ordered by nurses during their long consultations with patients than the doctors themselves. Also in the treatment of minor injuries the role of nurses were found to be neither better nor worse than the house officers present. Though the substitution of doctors by advanced nurses is encouraged once the diagnosis for the patient is established it is still an untried experiment if the patients has undifferentiated diagnosis and the extent to which nurses can detect rare illnesses or side effects of treatments is still a big question mark. Staff shortage and substitution have been found to be the key drivers for requirement of skill mix in the delivery of patient care. However a major issue in staff mixes still prevailing in the UK is the definition and institutionalization of advanced roles for nurses, for instance seeking a legal recognition, and provisions in educational and training programs, accessibly readily for direct reimbursements and being specified in career paths. Although the Royal College of nursing in UK has spelt out certain educational qualifications and competencies for ‘nurse practitioners’, such roles still have not been legislatively defined yet. There still prevails some divided opinion in UK about defining and regulating the roles of advanced nurses with a skill mix than the advanced practitioners themselves to evolve locally. Integrated case management can help meet the common or joint goals such as minimum lengths of stay in hospitals, decreased rates of admission or readmission, while increasing satisfaction of the patient. Both the payers and providers should design and integrate their case management services to accommodate wider resource sharing and integration of incentives and goals of patient care. Traditionally, a fragmented system of management of episodes of illness existed. Each department and the provider essentially laid down its own priorities to manage all its operations by itself. Payers did not provide any incentive to the department for coordinating care among facilities or department and hence it did not contribute to reduce costs although cost-based reimbursement was sill being made by payers. However the traditional trend is being changed by managed care. Now the payers and providers are keenly engaged in the process of reducing costs of patient care. The use of case management, as a tool towards this effort, stops not only at the review of utilization and discharge planning alone but also pays focused attention on clinical and operational issues too. Problems and bottlenecks in the delivery of patient care that affect the associated costs and more importantly the patient outcome are clearly identified by case managers and necessary steps initiated towards data collection and analysis leading to resolution of the problem. For example any lagging in operational arrangement which has direct clinical implications are detected by case managers with proper analysis of a prevailing anomaly in the delivery of patient care. An example case in point here is the detection by the case manager that the undue delay in the recovery of patients who have had total knee replacement operation is attributed to the operational failure of providing the requisite weekend therapy or ambulation services to the patient. By collecting continuously data on such patients whose therapy is interrupted and the data of those patients who had received uninterrupted therapy, effective inputs can be made to a multidisciplinary team who in turn can decide on the optimum provision of weekend therapies thereby improving patient outcomes and / or reducing associated costs. Although it is a well known fact that a MCP can provide better and more comprehensive health care at a lower cost (Trinh B.Pifer 2003) their main disadvantage is their approaches to healthcare management that is of a restrictive nature. For instance patients who always desire a flexible health care plan often meet with displeasure and dissatisfaction when asked to restrict themselves to a specific set of healthcare providers. Particularly in end stage renal disease (ESRD) maintaining and improving patient satisfaction and quality of life have become quite important goals of delivery of patient care. Measured patient quality of life has testified to morbidity, hospitalization and mortality in dialysis patients. The patient satisfaction and quality of life were the two parameters being addressed by the patient care management function of ESRD managed care demonstration. Case managers were responsible for all the coordination between the nephrologists and the multidisciplinary team. Also included in their responsibilities were monitoring patient care and promoting quality improvement, coordinating and managing patient needs, providing early intervention if needed, and educating patients. The other Kaiser case management team was involved with providing case management for all the transplant patients ensuring immediate attention to obtaining transplants for qualified patients. Further the coordinator responsible also ensured long-term-post-transplant follow up and patient education. Application of Management Theories to Decision Making in Delivery of Patient care The availability of nursing staff 24 hours at healthcare facilities is inevitable and highly indispensable. This means that working in shifts has become absolutely essential. However considering the staff morale, the nursing staff cannot be arbitrarily assigned to shifts. Constraints such as entitlement of staff to vacations and other such absences have to be taken into account while rostering nurses for shifts. Also nurses with the right skill mix have to be present during the shift failing which the delivery of quality patient care will suffer. At the same time too many staffs, increasing the costs beyond acceptable limits, cannot be deployed to take care of all emergencies. Hence it is through an effective system of roster management of nurses that objectives set forth for both quality and costs can be met. The role of ward managers in the delivery of patient care is also to be considered in detail here. They have to implement the use of nursing care quality metrics on the wards. To ensure adequate confidence in patient care and its delivery improvements have to be made in practice on the wards. The ward manager has to monitor patient safety and report incidents on the wards. It is incumbent on the ward managers to develop leadership and management skills and creating time for education and training. Together he has to manage problems on the ward and support frontline ward staff. Ensuring of medication safety also falls under the responsibility of ward managers in the absence of a regular duty nurse. The ward manager has to further ensure cleanliness of the area to preclude any infection associated with healthcare and take the lead in improving overall patient care. Last but not the least the ward manager has to implement Lean and Productive ward which would increase the time nurses have for direct delivery of patient care. It is the changes in nursing structure and the policy of healthcare which has led to the transformation of nurses to ward managers invested with enough independence and empowerment to improve the efficacy and quality of delivery of patient care. Effective change management is highly essential under the above circumstances to ensure clinical effectiveness and quality of patient care delivery. While looking at the scenario that whether these nurses undergoing change had the time, knowledge, resources, preparation and support it has been majorly found that the change was inevitable and absolutely necessary and the requirement for development of role as widely acknowledged. However according to some the change process was itself managed poorly and that while there were insufficient consultations that were made, preparation and support to effect changes were grossly inadequate. Even the lack of supernumerary status had led to a role conflict and resultant confusion. Consequently the changed role of ward managers from nurses could not be fulfilled to its true potential although it was demanding yet an exciting one. Sometimes bank nurses, who are NHS employees, contracted to work at short notices are employed to cover unplanned or planned shortfalls in the availability of nurses. Paid at NHS rates they are recruited and trained by the NHS employers. Also commercial nursing agencies depute agency nurses who are employed on an ad hoc basis for which a fee is paid by NHS. Reports made during late 1990s and its publication in 2002 suggests that NHS management should review the use of bank and agency nurses to address the pegging concerns of cost and quality. It has been ascertained that an increasing proportion of temporary needs for nursing staff are met by bank nurses. It has been rather astonishingly found that managers, while applying the theory of management, struggle in resource allocation and allocation of efforts in managing a complex service delivery system abounding in hospitals. Their decisions and action focus on two broad aspects namely, health care which is categorized as clinical and technical with more emphasis on what actually the patient receives, and performance of process, wherein emphasis is laid on how healthcare services such as delivery of patient care is conducted (Kathryn A.Marley 2004). In some of the top management group decision-making process, organizational issues play a key role through affecting information processing and finally the decisions that the team makes. Earlier research has also shown that issue interpretation also affects the decision making process. Current studies focus on the fact that interpretation of organizational issues can be a pivot point for decision making and subsequent action in organizations (Christopher L.Shook 2005). Starting with an issue defined by a collective set of top managers, such focuses lead to finding relevant processes and actions of the organization going forward. Issues are nothing but events, trends and developments that the organization’s members collectively recognize as a consequence to the organization. In fact organizations do respond to their environments by interpreting and acting on issues. Always it has been found that top management is busy focusing on key issues that bear the potential to impact organizational performance or its very survival itself. Since such issues are highly uncertain and ambiguous, interpretation to a substantial extent is felt as essential by the decision-makers. Interesting findings from a wider UK Department of Health funded evaluation of English Primary Care Groups (PCGs) and Trusts (PCTs) present qualitative research into the experience of General Practitioners in decision making related to delivery of patient care. The findings focus on the fact whether individual GPs feel a loss of control over decisions and their own clinical practice. The concern of GPs that clinical decisions are sometimes overridden by cost control was also taken into account. Though there was skepticism around the belief that to what extent primary care professionals leading PCGs and PCTs could fend off managerial control the GPs, who had perceived a threat which was more an anticipatory one than real, were ready to accept a degree of standardization if they felt that it was consistent with good clinical care. The stratification theory to management of doctors and healthcare professionals involved in delivery of patient care believes in the fact that some individual doctors are losing freedom and status. But the medical profession has so far managed to maintain its power and authority. Medicine has become more hierarchical within itself (Goodwin N 2004). Though it has responded to the need for management control it has also fended it off by ensuring doctors themselves take up responsible management positions. The stratification management theory though suggests that professionals are now acquiring organizational assets or power which was previously controlled by managers the distribution of these assets varies within the profession resulting in the division of previously homogenous united group into those with a wider organizational stake and those who are without it. 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