Transcript Journal of Nursing Management

Clinical Excellence: A Leadership
Framework
14-E
Jacqueline Vance, RNC, BSN,
CDONA/LTC, FACDONA
Disclosure
• Ms. Vance has disclosed that she has no
relevant financial relationship(s).
Objectives
• Discuss best practices to improve care outcomes
and the leadership attributes required to
successfully carry them out
• Recognize the role of clinicians in leading and
sustaining meaningful improvement in quality
and resident safety
• Discuss ways to foster a person-centered culture
that values transparency, communication and
teamwork
Characteristics of an Effective Leader
• The true task of leadership involves
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having a positive mental attitude
the ability to make change happen
being dynamic, passionate and visionary
having a motivational influence on other people
being solution-focused
seeking to inspire others
fostering potential
A Positive Mental Attitude
• Whether or not you realize it… everyone IS watching
you
• Working in LTC can be a negative, high stress
environment. The IDT and practitioners hear the
negative all day long. Your role is to be the antidote.
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Focus on the success
Celebrate the small things
Demonstrate the ability to overcome
Learning to trust yourself is as important as your team
learning to trust you
Ability to Make Change Happen
• Understand it is a people initiative
• Most business leaders have come to understand
the importance of the people component in
implementing and embedding change
• According to a survey conducted by Booz &
Company of 350 global executives charged with
leading major transformation programs, senior
leaders now recognize that people initiatives
usually spell the difference between success and
failure
Dynamic, Passionate and Visionary
• This type of leader attracts commitment and
energizes people, creates meaning in workers' lives,
establishes a standard of excellence, bridges the
present to the future, and transcends the status quo
• A shared vision causes commitment that bond leader
and worker together in a common cause in order to
meet a common goal
About Passion
• According to Forbes, true passion requires honestly
committing to something about which you feel
deeply, and staying committed through difficult
circumstances
Motivational Influence on Other People
• If you expect your team to work hard, you’re
going to need to lead by example
– There is no greater motivation than seeing the leader
down in the trenches working alongside everyone
else, showing that hard work is valued and being
accomplished on every level
– By proving your commitment to the, you will not only
earn the respect of your team, but also instill that
same hardworking energy among your staff
– It is important to show your commitment not only to
the work at hand, but also to your promises
Being Solution-focused
• The solution-focused approach is a process in which leaders
invite their staff to envision their preferred future
F
Focus
Focus on what you want to be different
O
Outcomes
Describe the desired outcome in detail
R
Realized
Describe results already realized
W
When
When did similar successes already happen
A
Action
One small step forward
R
Results
Monitor for achievement of new results
D
Desire
Make desire for further change explicit
Seeking to Inspire Others
• Inspiring your team to see the vision of the successes
to come is vital
• Make your team feel invested in the
accomplishments of the community
• The ability to inspire your team is not only great for
focusing on the future goals, but it is also important
for the current issues
Seeking to Inspire Others
• Acknowledge the work that everyone has
dedicated and commend the team on each of
their efforts
• It is your job to keep spirits up, and that begins
with an appreciation for their hard work
• Being a leader is about developing, encouraging,
and preparing your team to do their very best
work, all the while feeling good about it
Fostering Potential
• Recognizing potential is a skill in and of itself
• Potential that is not fostered and not acted upon is a waste
• Truly effective leaders not only recognize potential, they
feed it, prepare it, and allow the holder to exercise it
• An effective leader is one who possess the ability to:
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Spot potential
Encourage potential
Develop potential
Liberate potential
Mentorship
• Different people are motivated in different ways
• Leaders should use strategies that individuals find
motivating to empower them and highlight the
importance of their clinical role
• One method of achieving this is through
structured mentorship
– fosters ongoing role development and based on the
acquisition and mastery of new skills
Leadership Models
• The two most common models are
– transformational and
– transactional
Adair’s 3 Circle Model of Strategic Leadership
A group of
people that the
leader is
responsible for
and who have to
work together in
order to achieve
the task
Task
Team
The Job that
needs to be
done at a
particular time
Individual
The individual
people who
make up the
team who have
different
personalities,
motivations and
skills
Professional Socialization
• Effective leaders will generate opportunities which create
potential for professional self-development for junior
staff
• It is during this socialization period that junior staff
develop opinions, attitudes and beliefs about their role
which form the basis of professional growth
• The role of modelling behavior from clinical leaders
during this process is critical in transmitting appropriate
professional values from one generation to the next
• This includes clarifying role expectations and developing
a professional identity
Developing a Professional Identity
• Involves:
– Developing competency
– Managing emotions
– Developing autonomy
– Establishing identity
– Developing purpose
– Developing integrity
Understanding Why
• Why people do what they should and why
people don’t do what they should do
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Accountability
Knowledge
Skills
Have or don’t have the resources they need to
accomplish the task
Recognize the Role of Clinicians
• In leading and sustaining meaningful improvement in
quality and resident safety
– Principles of a high reliability organization
– The healthcare organization as a system
– Clinicians leading a healthy work environment
– How clinicians can use evidence-informed practice
with the objective of managing uncertainty and
the goal of improvement
Principles of a High Reliability Organization
• What is a HRO?
– HROs are defined as organizations that function
daily under high levels of complexity and hazards.
Reliable organizations have procedures and
attributes that make errors visible to those
working in the system so that they can be
corrected before causing harm and produce
consistent results.
Principles of a High Reliability Organization
• Applying the theory behind high reliability
organizations and normal accident theory (e.g.,
understanding how health system factors affect
safety), patient safety improvements has been linked
to high-reliability safety interventions, including
double checking, and improving the validity of rootcause analyses
HUDSON RIVER PLANE
LANDING
January 15, 2009
Five Characteristics of High Reliability
Organizations
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Preoccupation with failure
Reluctance to simplify interpretations
Sensitivity to operations
Commitment to resilience
Deference to expertise
Preoccupation with Failure
• HROs are focused on predicting and eliminating catastrophes
rather than reacting to them
• These organizations constantly entertain the thought that
they may have missed something that places patients at risk
• Near misses are viewed as opportunities to improve current
systems by examining strengths, determining weaknesses,
and devoting resources to improve and address them
• Near misses are viewed as opportunities to better
understand what went wrong in earlier stages that could be
prevented in the future through improved processes
Reluctance to Simplify Interpretations
• HROs refuse to simplify or ignore the explanations for
difficulties and problems that they face
• They understand that their systems can fail in ways that
have never happened before and that they cannot
identify all the ways in which their systems could fail in
the future
• This means that all staff members are encouraged to
recognize the range of things that might go wrong and
not assume that failures and potential failures are the
result of a single, simple cause
Sensitivity to Operations
• HROs recognize that manuals and policies constantly
change and are mindful of the complexity of the systems in
which they work
• HROs work quickly to identify anomalies and problems in
their system to eliminate potential errors
• Sensitivity to operations encompasses more than checks of
patient identity, vital signs, and medications
• It includes awareness by staff, supervisors, and
management of broader issues that can affect patient care,
ranging from how long a person has been on duty, to the
availability of needed supplies, to potential distractions
Commitment to Resilience
• HROs pay close attention to their ability to quickly contain errors
and improvise when difficulties occur
• An HRO assumes that, despite considerable safeguards, the system
may fail in unanticipated ways
• They prepare for these failures by training staff to perform quick
situational assessments, working effectively as a team that defers to
expertise, and practicing responses to system failures
• A good boater never leaves the dock without preparing for many
situations that are unlikely but possible
• Oars in case the motor fails, pump in case they take on water,
lifejacket, and fire extinguisher ensure that the boater can quickly
respond to unexpected system failures
Deference to Expertise
• HROs cultivate a culture in which team members and organizational
leaders defer to the person with the most knowledge relevant to
the issue they are confronting
• The most experienced person or the person highest in the
organizational hierarchy does not necessarily have the information
most critical to responding to a crisis
• A high reliability culture requires staff at every level to be
comfortable sharing information and concerns with others—and to
be commended when they do so. (It takes a strong leader to be
able to do this)
• Different staff members as well as the patient and family may have
information essential to providing ideal care
• Deference to expertise entails recognizing the knowledge available
from each person and deferring to whoever’s expertise is most
relevant to the choices being made
HRO Common Features
• Auditing of risk—to identify both expected and
unexpected risks
• Appropriate reward systems—for safety-related
behaviors
• System quality standards—evidence-based practice
standards
• Acknowledgment of risk—detecting and mitigating
errors; and
• Flexible management models—promoting teamwork
and decentralized decision-making
Healthy Work Environments
• In a healthy work environment
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staff feel valued by their organization
have standardized processes in place
have empowerment
acknowledge strong leadership
feel a sense of community
are places where safe and high-quality care is
expected and rewarded
Evidence-Informed Practice vs EvidencedBased for the LTC Setting
• Combines clinical expertise with the best available
external evidence, expert knowledge and patient
preference
– Without clinical expertise, practice risks becoming
tyrannized by evidence
– Without current best evidence, clinical practice becomes
out of date
• The combination of the scientific evidence base with
expert opinion contextualized to local clinical practice
is referred to as evidence-informed practice
Evidence-Informed Practice vs Evidenced-Based
for the LTC Setting
• Pure evidence-based medicine requires the inclusion of 3
different perspectives:
– Efficacy – it works in the idealized patient
– Efficiency – It works in the usual patient
– Effectiveness – It has benefit at a reasonable cost.
• This current basis of evidence is not structured for the type
of patient we see in the LTC setting
• The usual patient would be eliminated by attempting to
extrapolate the randomized control trial results to the real
world of clinical practice we live in
– as they would not meet the criteria for the study
• So our best practice would be to apply evidence informed
practice
Using Evidence-Informed Practice
• Adverse events are caused by the cumulative
effects of smaller errors within organizational
structures and processes of care
• Focusing on the systemic approach of change
means looking at factors in the chain of events
leading to errors and adverse events
• One such approach to apply would be
evidence-informed practice
Person-centered Culture vs Traditional
• In traditional nursing home care:
– Decision control over daily practices is held tightly by
management staff;
– Residents and direct-care workers are largely excluded
from decision-making about care and daily routines;
and
– Care is organized around a medical model in which
care practices are driven by diagnoses, organized by
tasks, and carried out by specifically trained personnel
Person-centered Culture vs Traditional
• Person-centered care:
– Seeks to eliminate the assembly line approach to care
and embraces a philosophy of residents as individuals;
– Seeks to improve quality of care and quality of life for
residents and leads to a more satisfied life;
– Means residents are given choices and are able to
make decisions;
– Requires staff to alter work routines to accommodate
resident preferences; and
– Requires staff to have relevant knowledge and
decision-making authority.
Person-centered Care
• The focus had been on doing what is “in the best
interest of the person” as defined by the healthcare
professional staff, rather than as defined by the person
• The whole process was been based on a historical
medical model that assumes the “patient” is the
passive and “compliant” recipient of care directed and
provided by professionals
• Person-centered care is based upon a fundamentally
different perspective, which places particular value on
an individual’s right to make decisions concerning
every aspect of her or his life
Principles of Person Centered Care Approach
Recognizing that the responsibility to respect resident
rights for self-determination is equal to the
responsibility for resident safety concerns.
• How to balance?
1. Weigh -with the resident - the potential outcomes
(positive and negative) of both respecting and
facilitating the resident acting on his or her choices,
and
2. Review – with staff and practitioner - the potential
outcomes (positive and negative) of preventing the
resident from acting on his or her choices
Principles of Person Centered Care Approach
• Guidelines for implementing this process
include:
1. a detailed description of the process for honoring
resident choice and mitigating risk
2. a flow chart of the process
3. an outline that a care community can use to
guide and document the process if they choose
4. sample process scenarios to guide care planning
Principles of Person Centered Care
Approach
• According to CMS regulations, the resident has the right to:
– Choose activities, schedules, food/beverages, and health care
consistent with his or her preferences and interests
– Interact with members of their interdisciplinary team, friends and
family both inside and outside the care community
– Make choices about aspects of his or her life in the care community
that are important to him or her
– Participate in care planning
– Refuse treatment
– Both quality of care and quality of life that recognizes each individual
and enhances dignity
The assessment of risk in LTC is often an unbalanced exercise
• It generally only takes into consideration potential negative
consequences, primarily with respect to quality of care issues
• Insufficient consideration is given to either possible positive
consequences or to how choices might impact quality of life
• In the healthcare arena, safety - particularly physical safety and
protection from illness - has been more valued than the positive
psychological and emotional outcomes that may result from behaviors
or activities which may have some level of risk attached
• Traditionally, care communities consider risk management to mean
keeping residents safe
– but this view does not take into account that the potential loss of quality of
life is equally important.
• CMS regulations, as well Person Centered Care approaches, recognize
that the responsibility to respect resident rights for self-determination is
equal to the responsibility for resident safety concerns
Principles for Assessing and Care Planning
• To optimize opportunities for resident choice and
mitigate risk
• in order to attain each resident’s highest practicable level
of well-being
• The interdisciplinary team along with the resident
uses a care planning process to plan for each
resident’s choice when the choice carries risk
– balancing resident choice while mitigating risks and
benefits
The Process
1. Identifying and clarifying the resident’s choice
2. Discussing the choice and options with the resident
3. Determining how to honor the choice (and which
choices are not possible to honor)
4. Care planning the choice
5. Monitoring and make revisions to the plan
Identifying and Clarifying the Resident’s Choice
Interview, observe, and review the resident’s history to obtain
detailed information about the nature and extent of the choice
that the resident wishes to make.
1. What is the choice the resident would like to make?
2. Does this choice present a perceived risk or safety challenge
to the resident, other residents, or the community?
3. Are there other alternatives (safer or easier to
accommodate) that might be more readily implemented that
are acceptable to the resident?
4. If the resident has named a representative, has that person
been included in discussing options?
Discussing the Choice and Options with the
Resident
• Discuss with/educate the resident about the potential
outcomes of respecting and facilitating the resident acting on
his or her choices, as well as the potential outcomes of
preventing the person from acting on his or her choices.
Consider potential positive outcomes as well as potential
negative consequences.
– (Use the matrix shown in a few slides to be sure you have considered
all options.)
Discussing the Choice and Options with the
Resident
• Identify and discuss alternative actions that might satisfy the
resident but involve less risk of negative outcomes. Again, use
the matrix to be sure all potential outcomes are considered.
• As appropriate, have conversations with the representative
about the resident’s preferences and alternatives that have
been offered
Resident Choice Matrix
Describe Resident Choice:
Respecting Resident Choice
Potential Positive Consequences
Potential Negative Consequences
Refusing Resident Choice
Determining How to Honor the Choice
From the various alternatives discussed in Step II, identify the
option (or rank order the options) that most closely respects
the resident’s choice while balancing any safety concerns.
1. What is the decision that has been reached?
2. What are the plans for mitigation of risk?
3. What are the plans for monitoring and reassessment?
4. What alternatives were offered?
5. (If the request cannot be honored) What is the reason for
denial of the request?
6. Who was involved in this decision making process?
Care Planning the Choice
If a mutual decision is reached as to how the team will
accommodate the choice to maximize the resident’s
well-being, the team will work out with the resident
the specific steps the staff will take to support the
resident’s requested/preferred choice.
1. List the steps the staff will take to assist the resident and
mitigate potential negative outcomes to the extent possible,
and the monitoring that the staff will conduct about
outcomes of the choice
Monitor and Make Revisions to the Plan
• The interdisciplinary team will monitor the progress of
the plan and its effects on the resident’s well-being, as
well as the ongoing desire of the resident to continue
with the choice.
• The team will work with the resident to revise the plan as
needed and desired by the resident.
• This may occur daily or weekly, especially at the
beginning, but should occur at least quarterly.
1. The ongoing discussion will be documented in the chart.
The resident’s plan of care and/or chart notes will be
updated as needed to reflect these changes
In Summary
• Strong and effective clinical leadership skills can
bring about significant and positive change in any
setting
• Meaningful improvement in quality and resident
safety can be brought about and sustained by
effective clinical leadership
• Implementing a person-centered culture that
values transparency, communication and
teamwork mitigates risk while improving quality
of resident and staff lives
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