managing for success in health care delivery what can we do? ruth a. anderson rn, phd, faan duke...
TRANSCRIPT
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
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 Self OrganizationOrganization
Naturally occurring system property Arises through relationship patterns Works for or against goals
System ParametersSystem Parameters
Rate of new information Rate of new information flowflow
Nature of connections Nature of connections among peopleamong people
Cognitive diversityCognitive diversity
Ralph Stacey, 1996
Conceptual Model
Nursing Mgmt Practices
•Rate of information flow thru systemNumber & intensity of interconnections between agentsLevel of diversity within & between cognitive schema of system agents
Behaviors for
Quality Outcomes
Self-Organization
System Control Parameters
Process Outcomes
ManagementPractices Alter
Self
Organization
Management Practice
• Work Environment
• Participation in decision making
• Communication Openness
• Leadership behaviors
• Workforce diversity
System Parameters
• Rate of information flow
• Nature of interconnections
• Diversity within/between cognitive schema
Better & IMPROVED
Outcomes
Agents & information diversity:
|
Scope
Agents & information diversity:
|
Scope
Participation in Decision MakingParticipation in Decision Making
Agent connection & interaction:
|
Intensity
Agent connection & interaction:
|
Intensity
Depth|
Information “Richness”
Depth|
Information “Richness”
Breadth|
Information Diversity
Breadth|
Information Diversity
Decision Activities
Raising the IssueClarifying the IssueGenerating AlternativesEvaluating AlternativesChoosing Alternative
Decision Activities
Raising the IssueClarifying the IssueGenerating AlternativesEvaluating AlternativesChoosing Alternative
Decision Mechanisms
Established Com.Specially Created Com.Informal MeetingsChance EncountersOther
Decision Mechanisms
Established Com.Specially Created Com.Informal MeetingsChance EncountersOther
RN Participation & Improvement in Resident Outcomes
190 Nursing Homes Survey methods Administrators and Directors of Nursing Minimum Data Set
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?
Size23%
Group 20%
Unexplained
57%
Controlling for:
• Size
• Change in Cost
• RN StaffingAnderson & McDaniel, 1999
Do Nurses Influence Final Choices Through Participation?
Participation in Decision MakingParticipation in Decision Making
Agent connection & interaction:
|
Intensity
Agent connection & interaction:
|
Intensity
Decision Activities
Raising the IssueClarifying the IssueGenerating AlternativesEvaluating AlternativesChoosing Alternative
Decision Activities
Raising the IssueClarifying the IssueGenerating AlternativesEvaluating AlternativesChoosing Alternative
Decision Mechanisms
Established Com.Specially Created Com.Informal MeetingsChance EncountersOther
Decision Mechanisms
Established Com.Specially Created Com.Informal MeetingsChance EncountersOther
Anderson, R. A., & McDaniel, R. R., Jr. (1998). Intensity of registered nurse participation in nursing home decision making. Gerontologist., 38(1), 90-100. Survey of 125 Nursing Homes
Participation in Decision MakingParticipation in Decision Making
Agent connection & interaction:
|
Intensity
Agent connection & interaction:
|
Intensity
Decision Activities
Raising the IssueClarifying the IssueGenerating AlternativesEvaluating AlternativesChoosing Alternative
Decision Activities
Raising the IssueClarifying the IssueGenerating AlternativesEvaluating AlternativesChoosing Alternative
Decision Mechanisms
Established Com.Specially Created Com.Informal MeetingsChance EncountersOther
Decision Mechanisms
Established Com.Specially Created Com.Informal MeetingsChance EncountersOther
Survey of 68 Public Health Agencies
Issel, L. M., & Anderson, R. A. (2001). Intensity of case managers' participation in organizational decision making. Research in Nursing & Health., 24(5), 361-372.
Error100%
Explained0%
Error87%
Explained13%
Participation of Clinical Professionals (MD and RN) =
Lower Cost/admission in Hospitals
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.
Complexity & Turnover Study
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.
Laissez-faire Climate 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
Reward Climate 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
Accuracy Accuracy is the extent
to which one believes that the information conveyed by other parties is correct
Openness Openness is the
extent to which one can speak clearly and directly without fear of repercussions or misunderstanding
Climate, Communication & Turnover
Work Env X Open
Commun.27%
Unexplained73%
LPNs
Anderson, Corazzini & McDaniel, 2004
DON tenure Number of RNS LPN Workload Reward climate x
Communication openness
Climate, Communication & Turnover
Work Env X Open & Accurate Commun.
25%
Unexplained75%
Nurse Assistants
Anderson, Corazzini & McDaniel, 2004
CNA Workload Reward climate x
Communication openness
Reward climate x Communication accuracy
Laissez-faire Climate 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
Anderson, Corazzini & McDaniel, 2004
Communication Openness Openness is the extent
to which one can speak clearly and directly without fear of repercussions or misunderstanding
Complexity, Management Practices & Resident Outcomes
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.
Theoretical Model
Nursing Mgmt Practices
+
–
–
–Communication Openness
Participation in Decision Making
Relationship Leadership
Formalization
Control Variables
Contextual FactorsSizeOwnership Type
DON CharacteristicsTenure in positionDON Experience
Resident Outcomes
Prevalence of:Resident Behaviors ProblemsRestraint UseComplications of ImmobilityFractures
Anderson, Issel & McDaniel, 2003
System Parameters
• Rate of information flow
• Nature of interconnections
• Diversity within/between cognitive schema
Management Practice
• Communication Openness
People can say what they mean without fear of repercussion—during vertical and horizontal information exchanges.
Anderson, Issel & McDaniel, 2003
Error79%
Explained21%
Communication Openness & Restraint Use (N=164)
Context•Size ( – )
DON Characteristics•DON Tenure (–)•DON Experience (–)
Mgmt Practice• Communication
Openness (–)
Anderson, Issel & McDaniel, 2003
Anderson, Issel & McDaniel, 2003
Error85%
Explained15%
Problem Behaviors
Context•Size ( – )
Mgmt Practice•RN Participation in decision making (–)
Anderson, Issel & McDaniel, 2003
System Parameters
• Rate of information flow
• Nature of interconnections
• Diversity within/between cognitive schema
Management Practice
• Leadership behaviors
Relationship-oriented—product of human interaction and communication between manager and worker
Anderson, Issel & McDaniel, 2003
Error89%
Explained11%
Leadership & Fracture (N=164)
Mgmt Practice• Relationship-oriented
leadership (–)
Anderson, Issel & McDaniel, 2003
System Parameters
• Rate of information flow
• Nature of interconnections
• Diversity within/between cognitive schema
Management Practice
• Formalization
Centralized control using job descriptions, surveillance, and procedures and rules to ensure predictability
Error85%
Explained15%
Leadership, Formalization & Complications of Immobility
DON Characteristics• DON Experience (–)
Mgmt Practice• Relationship-oriented
leadership (–)• Formalization (+)
Anderson, Issel & McDaniel, 2003
N=164
Anderson, Issel & McDaniel, 2003
New Behaviors
Management Practices
• Work environment
• Communication
• Participation in decision making
• Leadership behaviors
• Workforce diversity
System Parameters
• Rate of information flow
• Nature of interconnections
• Diversity within/between cognitive schema
Self
Organization
Things to Think About for Effectiveness
Connection Diversity Information
exchange
MANAGE THE SYSTEM