Transcript Managing for Success in Healthcare Delivery

Managing for Success in
Health Care Delivery
What
can
we
do?
Ruth A. Anderson
RN, PhD, FAAN
Duke University
School of Nursing
Purpose of Presentation
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Demonstrate how we are applying
the complexity science concepts to
studies of management practices in
health care
Show evidence base for complexity
science derived hypotheses
Self
Organization
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Naturally occurring system property
Arises through relationship patterns
Works for or against goals
System Parameters
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Rate of new information
flow
Nature of connections
among people
Cognitive diversity
Ralph Stacey, 1996
Conceptual Model
Nursing Mgmt
Practices
Management
Practices
System Control
Parameters
Alter
•Rate of
information flow
thru system
Number &
intensity of
interconnections
between agents
Level of diversity
within & between
cognitive schema
of system agents
Process Outcomes
SelfOrganization
Behaviors
for
Quality
Outcomes
Management
Practice
System Parameters
• Work Environment
• Rate of information flow
• Participation in decision
making
• Nature of interconnections
• Communication
Openness
• Diversity within/between
cognitive schema
• Leadership behaviors
• Workforce diversity
Better & IMPROVED
Self
Outcomes
Organization
Participation in Decision Making
Agents &
information
diversity:
Agent
connection &
interaction:
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Scope
Intensity
Depth
Breadth
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Information
“Richness”
Information
Diversity
Decision
Activities
Raising the Issue
Clarifying the Issue
Generating Alternatives
Evaluating Alternatives
Choosing Alternative
Decision
Mechanisms
Established Com.
Specially Created Com.
Informal Meetings
Chance Encounters
Other
RN Participation & Improvement
in Resident Outcomes
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190 Nursing Homes
Survey methods
Administrators and Directors of Nursing
Minimum Data Set
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Improvement in Resident Outcomes
Anderson, R. A., & McDaniel, R. R., Jr. (1999). RN participation in
organizational decision making and improvements in resident
outcomes. Health Care Management Review., 24(1), 7-16.
What are the differences between
most improved and least improved?
Unexplain
ed
57%
Size
23%
Controlling for:
Group
20%
Anderson & McDaniel, 1999
• Size
• Change in Cost
• RN Staffing
Do Nurses
Influence
Final Choices
Through
Participation?
Participation in Decision Making
Agent
connection &
interaction:
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Intensity
Decision
Activities
Raising the Issue
Anderson, R. A., &
McDaniel, R. R., Jr. (1998).
Intensity of registered nurse
participation in nursing
home decision making.
Gerontologist., 38(1), 90100.
Clarifying the Issue
Generating Alternatives
Evaluating Alternatives
Choosing Alternative
Decision
Mechanisms
Established Com.
Specially Created Com.
Informal Meetings
Chance Encounters
Other
Survey of 125 Nursing Homes
Participation in Decision Making
Agent
connection &
interaction:
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Intensity
Decision
Activities
Raising the Issue
Issel, L. M., & Anderson,
R. A. (2001). Intensity of
case managers'
participation in
organizational decision
making. Research in
Nursing & Health., 24(5),
361-372.
Clarifying the Issue
Generating Alternatives
Evaluating Alternatives
Choosing Alternative
Decision
Mechanisms
Established Com.
Specially Created Com.
Informal Meetings
Chance Encounters
Other
Survey of 68 Public Health Agencies
Participation of Clinical Professionals
(MD and RN) =
Lower Cost/admission in Hospitals
Error
87%
Participation of
MDs/RNs
Participation of
Middle Managers
Ashmos, D. P., Huonker, J. W., & McDaniel, R. R.
(1998). Participation as a complicating mechanism:
The effect of clinical professional and middle manager
participation on hospital performance. Health Care
Management Review, 23(4), 7-20.
Explained
13%
Error
100%
Explained
0%
Complexity & Turnover Study
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164 Nursing Homes
Survey methods
Administrator, Director of Nursing,
RNs, LPNs, CNAs (n~3500)
Medicaid Cost Reports-Turnover
Anderson, R. A., Corazzini, K. N., & McDaniel, R. R. (2004).
Complexity science and the dynamics of climate and
communication: Reducing nursing home turnover. The
Gerontologist, 44(3), 378-388.
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Reward Climate
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Adm does the right thing
Adm looks out for worker
Concern for relationships
Learning encouraged
What you do–not who you
know
Clear goals & expectations
Constructive feedback
Always looking for a better
way
Laissez-faire Climate
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Conflict prevents accomplishment
Adm doesn’t care who gets hurt
Little concern for employee
relations
No room for new ideas
It’s who you know
Unclear goals
Little effort to constantly improve
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Openness
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Openness is the
extent to which one
can speak clearly
and directly without
fear of
repercussions or
misunderstanding
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Accuracy
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Accuracy is the extent
to which one believes
that the information
conveyed by other
parties is correct
Climate, Communication & Turnover
Unexplained
73%
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Work Env X
Open
Commun.
27%
LPNs
Anderson, Corazzini & McDaniel, 2004
DON tenure
Number of RNS
LPN Workload
Reward climate x
Communication
openness
Climate, Communication & Turnover
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CNA Workload
Reward climate x
Communication
openness
Reward climate x
Communication
accuracy
Nurse Assistants
Unexplained
75%
Work Env X
Open &
Accurate
Commun.
25%
Anderson, Corazzini & McDaniel, 2004
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Communication
Openness
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Laissez-faire Climate
Openness is the extent
to which one can speak
clearly and directly
without fear of
repercussions or
misunderstanding
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Anderson, Corazzini & McDaniel, 2004
Conflict prevents accomplishment
Adm doesn’t care who gets hurt
Little concern for employee
relations
No room for new ideas
It’s who you know
Unclear goals
Little effort to constantly improve
Complexity, Management
Practices & Resident Outcomes
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164 Nursing Homes
Survey methods
Directors of Nursing & RNs
Minimum Data Set-Resident Outcomes
Medicaid Cost Reports-Control Variables
Anderson, R. A., Issel, L. M., & McDaniel, R. R. J. (2003).
Nursing homes as complex adaptive systems: Relationship
between management practice and resident outcomes.
Nursing Research, 52(1), 12-21.
Control Variables
Theoretical
Model
Contextual Factors
Size
Ownership Type
DON Characteristics
Tenure in position
DON Experience
Nursing Mgmt Practices
Communication
Openness
–
Participation in
Decision Making
–
Relationship
Leadership
Formalization
Anderson, Issel & McDaniel, 2003
–
+
Resident
Outcomes
Prevalence of:
Resident
Behaviors
Problems
Restraint Use
Complications of
Immobility
Fractures
Management
Practice
• Communication
Openness
People can say what
they mean without fear
of repercussion—during
vertical and horizontal
information exchanges.
Anderson, Issel & McDaniel, 2003
System Parameters
• Rate of information flow
• Nature of interconnections
• Diversity within/between
cognitive schema
Anderson, Issel & McDaniel, 2003
Communication Openness &
Restraint Use (N=164)
Context
•Size ( – )
Error
79%
DON Characteristics
•DON Tenure (–)
•DON Experience (–)
Explained
21%
Mgmt Practice
• Communication
Openness (–)
Anderson, Issel & McDaniel, 2003
Problem Behaviors
Context
•Size ( – )
Error
85%
Mgmt Practice
•RN Participation in
decision making (–)
Anderson, Issel & McDaniel, 2003
Explained
15%
Management
Practice
• Leadership
behaviors
Relationship-oriented—
product of human
interaction and
communication between
manager and worker
Anderson, Issel & McDaniel, 2003
System Parameters
• Rate of information flow
• Nature of interconnections
• Diversity within/between
cognitive schema
Leadership & Fracture (N=164)
Mgmt Practice
Error
89%
• Relationship-oriented
leadership (–)
Explained
11%
Anderson, Issel & McDaniel, 2003
Management
Practice
• Formalization
Centralized control
using job descriptions,
surveillance, and
procedures and rules to
ensure predictability
System Parameters
• Rate of information flow
• Nature of interconnections
• Diversity within/between
cognitive schema
Anderson, Issel & McDaniel, 2003
Leadership, Formalization
& Complications of Immobility
DON Characteristics
Error
85%
• DON Experience (–)
Mgmt Practice
• Relationship-oriented
leadership (–)
• Formalization (+)
Explained
15%
N=164
Anderson, Issel & McDaniel, 2003
Management
Practices
System Parameters
• Work environment
• Rate of information flow
• Communication
• Nature of interconnections
• Participation in decision
making
• Diversity within/between
cognitive schema
• Leadership behaviors
• Workforce diversity
Self
New Behaviors
Organization
Things to Think About for
Effectiveness
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Connection
Diversity
Information
exchange
MANAGE THE SYSTEM