Analyze Staffing and Controlling Issues

User Generated

Vafngvnoyrjbzna

Business Finance

Description

Week 3 - Assignment: Analyze Staffing and Controlling Issues

Instructions

Personnel are the single greatest and largest resource available to healthcare administrators. As a group, personnel and staffing represent the largest cost, but are also the means by which a healthcare organization can fulfill its mission.

Imagine that you are a clinical department manager for a large hospital system. Leadership has decided that a service line is needed in a new medical area. One example of a newer medical field is medical genetics, but others exist. Select one or create your own for this assignment. Regardless of the field, leadership is anxious to better understand the staffing needs—including management, physicians, nursing, support staff, and others—that will be needed for this new area of service.

Prepare a PowerPoint presentation for leadership that reviews the overall role of staffing and for specific needs, such as those mentioned above. Explain how you will determine what and how many staff members will be required. Note that you do not need to provide actual numbers, but an understanding of your approach is needed. Describe the staff reporting structure in the new department and why you feel the proscribed structure will be effective. Finally, indicate how you will recruit for these new positions.

Incorporate appropriate animations, transitions, and graphics as well as speaker notes for each slide. The speaker notes may be comprised of brief paragraphs or bulleted lists.

Support your presentation with at least three scholarly resources. In addition to these specified resources, other appropriate scholarly resources may be included.

Length: 12-15 slides (with a separate reference slide)

Notes Length: 100-150 words for each slide

Be sure to include citations for quotations and paraphrases with references in APA format and style where appropriate.

Please watch following videos:

Nursing Shortage

produced by Nancy Kramer, fl. 2001, Columbia Broadcasting System; interview by Lesley Stahl, 1941-, in 60 Minutes (New York, NY: Columbia Broadcasting System, 2003), 12 mins

Building a Magnetic Culture: How to Attract Top Employees, Engage Them, and Make Them Want to Stay

produced by Briefings Media Group, in Retaining Great Employees: Tactics for Hanging on to Your Best Talent (Bethesda, MD: Columbia Books, 2013, originally published 2013), 1 hour 26 mins

Week 3 Assignment Title: Analyze Staffing and Controlling Issues

Grading Rubric

CriteriaContent (12 points)

Characterized an example of a clinical service line (2 points).

Analyzed the staffing model to be used in an understandable manner (4 points).

Illustrated the proposed staff reporting structure (4 points).

Reviewed the manner of recruitment for the various roles (2 points).

Included speaker notes for each slide, animations, transitions, and graphics. Included a minimum of three scholarly references, with appropriate APA formatting applied to citations and paraphrasing. Presentation is 12-15 slides long (3 points).

(Total points 15)

Unformatted Attachment Preview

inter v ie w Interview With Wayne M. Lerner, DrPH, FACHE, Past President and Chief Executive Officer, Holy Cross Hospital W ayne M. Lerner, DrPH, FACHE, was president and CEO of Holy Cross Hospital in Chicago, Illinois, from 2006 to 2013. He spent the first 17 years of his career at Rush–Presbyterian–St. Luke’s Medical Center, where he rose to the position of vice president for administrative affairs and chair of the Department of Health Systems Management. During the early 1990s, Dr. Lerner served as president of Jewish Hospital of St. Louis, Missouri, and as a senior executive officer within the BJC Health System, where he was a key executive behind the merger of Jewish and Barnes hospitals as well as the creation of the BJC Health System. From 1997 to 2006, Dr. Lerner was president and CEO of the Rehabilitation Institute of Chicago, an organization distinguished by its designation as the best rehabilitation hospital in the United States since 1991 by U.S. News & World Report. In 2006, Dr. Lerner became interim president and CEO of Holy Cross Hospital, an inner-city, faith-based, disproportionate-share hospital in Chicago. In 2007, he assumed the role on a full-time basis and stepped down from that position in 2013. Dr. Lerner is a Fellow of the American College of Healthcare Executives and of the Institute of Medicine of Chicago. He holds a bachelor’s degree from the University of Illinois and MHA and DrPH degrees from the University of Michigan. In 2013 he was the recipient of ACHE’s Gold Medal Award in the healthcare delivery organization category. The Gold Medal Award is the highest honor bestowed by the American College of Healthcare Executives on outstanding leaders who have made significant contributions to the healthcare profession. Dr. O’Connor: Congratulations on receiving the 2013 Gold Medal Award! The variety of organizations (academic medical center; rehabilitation facility; large, integrated system; inner-city, faith-based hospital) in which you have worked and the breadth of activities you have managed are noteworthy. Similarly, you have filled many different types of leadership roles. How have you been able to adapt to the different role demands and differences in organizational context, culture, governance, resources, and so on, as you moved among these various settings? What did you learn from working in these different types of organizations and roles? Dr. Lerner: First, we should establish a contextual baseline for this question. The delivery system roles were important, but so were the many external roles in which I also participated. I always tell people that I’ve had an atypical career, in that it has not followed any type of linear trajectory. I have always been motivated by opportunities that are intellectually demanding and professionally exciting. If an opportunity meets those criteria, then I tend to say yes. Those are the qualities that have driven Photocopying or distributing this PDF is prohibited without the permission of Health Administration Press, Chicago, Illinois. 245 For permission, please contact the Copyright Clearance Center at www.copyright.com. For reprints, please contact hapbooks@ache.org. Journal of H ealt hcare M anage ment 58:4 J uly /A ugust 2013 me to follow a career path not considered to be the norm for someone with my background. I’m not sure I have a great secret here. I first became a hospital president when I was about 40 years old. It was the biggest transition I had ever made. I tell students that the best job you will ever have is when you’re number two or three in an organization, because you can be yourself, you don’t have ultimate responsibility for the direction of the institution, and you can relate to people on a more humanto-human basis than you can in a higher position. When you become number one, you assume a role for which you may have been prepared but you’re not really ready for, as it can be very isolating in terms of personal interrelationships. People look to you to provide the last word on whatever is going on in the institution. I finally realized the true implications of being a CEO when I understood the need to change my approach slightly. I had to modify my sense of humor, and in general I didn’t feel free to relate to people in exactly the same way I had previously—I began playing the role of president. That adjustment included acknowledging that now I’m responsible for, say, 10,000 lives, 1,200 staff, 100,000 people in my community, and the strategic direction of the organization. The other major insight I gained from shifting roles or positions, whether staying within an institution or moving on outside of it, was that the lens through which you see things changes. For example, when I became chair of the Illinois Hospital Association board, all of a sudden, how I perceived and related to situations and people, and how I managed my personality within the context of these organizations, changed, because I now had a responsibility and an obligation to people outside of my organization, or outside of my immediate circle. As my situation changed by becoming a CEO, so did my orientation to the position and to those with whom I interacted. Ultimately, if you assume that you can apply a single template that will work in all organizations and role responsibilities encountered in a career, you have made a big mistake. Culturally and strategically, every organization is different. The one constant is who you are. Dr. O’Connor: Born and raised in Chicago, you spent most of your professional career there (with the exception of six years in St. Louis). Could you have achieved the same level of success and variety of activities if you had moved to a different city for each subsequent professional position? In other words, are there unique career path prospects and opportunities embedded within a city such as Chicago that are not available in other places? Dr. Lerner: I think it’s happenstance or serendipity that I ended up spending my whole life in Chicago except for the time in St. Louis. It never was my plan to stay; in fact, I was more than willing to move for an opportunity. I started at Rush– Presbyterian–St. Luke’s Medical Center working with Gail Warden, LFACHE, which was a great way to begin a career, and ended up having five different jobs there over 17 years. I decided to leave Rush because there was no place for me to grow at that point and I didn’t know if I had the wherewithal to be a president. I was not the kind Photocopying or distributing this PDF is prohibited without the permission of Health Administration Press, Chicago, Illinois. 246 For permission, please contact the Copyright Clearance Center at www.copyright.com. For reprints, please contact hapbooks@ache.org. I nterv iew of person who always wanted to be a president. There is no camp to attend to see if you can or should become a president. You have got to do it, decide if you like it, and see if the expectations of the position are those that you can meet or exceed. For personal reasons, I drew an hour’s flight time around Chicago. I was lucky enough to get an interview at The Jewish Hospital in St. Louis and even luckier to be selected as its president. Six years later, after essentially merging myself out of a job, I became a consultant back in Chicago, reinvigorated myself with my family, and started to consider whether I wanted a lifelong career in consulting or other possible opportunities. Again, serendipity or karma was at play when I learned of a unique opportunity in Chicago: serving as president and CEO of a specialty hospital—the Rehabilitation Institute of Chicago—whose specialty was the same area in which my wife worked. I never really thought about location, perhaps because the societal demands and cultural differences between the roles I had at Rush and Jewish were very different than those at the Rehabilitation Institute, which was a very high-profile role. I don’t believe location makes much difference when considering job opportunities for healthcare executives. The key factor is how well you adapt to the demands of a particular job, how well you relate to the people for whom you work, and how well you relate to your employees and the community. For example, despite their relative proximity, St. Louis is very different than Chicago in terms of culture, local dynamics, politics, and other factors. If you are attuned to such factors, you are likely to make those transitions easier. I have always maintained that it doesn’t matter where you go for your job. What makes the difference is what the environment is like where you are going to work and learn, and who your boss is. The job could be located in Alaska, Antarctica, or Chicago; if you have a great environment, good support and people, and a supportive boss or board, then theoretically you should be able to apply your talents anywhere. Dr. O’Connor: The need for clinicians and administrators to work effectively together has never been greater, yet the majority of today’s physicians, nurses, and administrators are educated in isolation from each other—in silos, if you will, that don’t address the roles or functions of other hospital occupations. What can our educational programs do to begin overcoming this problem? Dr. Lerner: This issue is near and dear to my heart. I had never taken an epidemiology course until I was working on my doctoral degree at the University of Michigan. I had been working at Rush, whose organizational structure was based on a tripartite relationship among doctors, nurses, and administrators. In other words, each operating unit had a doctor, a nurse, and an administrator at the top, who were expected to work together. I was always amazed to think how we were all educated differently, how we talked differently, how we didn’t even relate to the variable of time in the same way and were then thrown together around this entity called the patient where we were expected to make everything better. And this occurred in an organization that employed a matrix management model, which by its nature is the most difficult model to operate within. Photocopying or distributing this PDF is prohibited without the permission of Health Administration Press, Chicago, Illinois. 247 For permission, please contact the Copyright Clearance Center at www.copyright.com. For reprints, please contact hapbooks@ache.org. Journal of H ealt hcare M anage ment 58:4 J uly /A ugust 2013 Organizational behavior and organizational theory have always been my great interests, and it is always fun for me to think about these topics. So when I went to Michigan, I wrote a paper that my professor called turgid and irksome. I still have it; she was right, my writing was not great. But the theory was good. The paper examined how we have no common language among doctors, nurses, and administrators and how we are educated in silos and then thrown together and expected to work together effectively. I thought it would be nice if we at least had a common language. I wrote that we all ought to be forced to take epidemiology, and we all should conduct a joint epidemiologic project as a way to break down barriers and find at least one core vehicle by which to communicate with one another. I believe our educational programs should reach across the campus and find ways to get students together and collaborate, not just from medicine, nursing, and administration but from the other health professions as well. With the Affordable Care Act in place, we have to deliver services across a continuum to a defined population in an effort to maximize both individuals’ health and their functional status. If you don’t incorporate an understanding of primary prevention with the acute and postacute models, how do you intervene to ensure this population is healthy? Now add to the mix patient navigators, ombudsmen, insurance professionals, lawyers, and others, all of whom are engaged in this effort to maximize health. Some may see a complex morass that will never come together. But wouldn’t it be fun to work collaboratively on a project that helps a community achieve its potential? Dr. O’Connor: What is the future for urban, safety net hospitals in the United States? Dr. Lerner: Over the next 7 to 10 years, the entire healthcare landscape will change. That transformation is one reason the Sisters of St. Casimir at Holy Cross Hospital were encouraged to look at such options as selling the hospital to a forprofit firm, merging with one of the bigger Chicago-area systems, or becoming part of a new initiative by creating a private safety net system. I worry that stand-alone safety net hospitals will not survive once patients have more choices that come with their new health insurance. It is likely that we will begin to see unusual affiliations and relationships develop for both public and private safety net hospitals, as I do not see the need for safety nets ever going away. In the end, the safety nets remaining will need to find ways to reduce expenses, control costs, and increase revenue while improving the health of their populations, which will be a most challenging task, indeed. I believe that over the next decade, the roles and points of focus of the private practice of medicine, the stand-alone community hospital, and the urban and rural safety net hospitals all will change. Those changes will come about not so much by what the institutions choose to do as by what happens with the other entities they work with. In fact, we may find these hospitals participating in multi-institutional systems that include federally qualified health centers, private clinics, medical groups, and perhaps even insurance companies. Photocopying or distributing this PDF is prohibited without the permission of Health Administration Press, Chicago, Illinois. 248 For permission, please contact the Copyright Clearance Center at www.copyright.com. For reprints, please contact hapbooks@ache.org. I nterv iew Dr. O’Connor: What topics and issues would you like to see addressed by authors in the Journal of Healthcare Management? Dr. Lerner: I would like to see authors address the changing face of healthcare leadership in terms of education, experience, and background. What does it mean for our field and those we serve if the traditional master’s degree–prepared individual no longer is the gold standard for CEO positions? How will clinically educated executives change the way care is provided to populations—not just patients—and what does this change in orientation mean for the graduate education system? What roles will be assumed in the future by those coming from graduate programs? Who will mentor them if the CEO does not have that orientation in her background? How will the role, function, and expectations of the governing boards change as we migrate our system to one that maximizes a population’s health and links payment to health and functional status outcomes? Finally, how should our educational system change in recognition of the contributions of clinical and nonclinical executives in the organization and delivery of health services? If we are to assume risk for a population’s health, then we will need expertise across a wide continuum. Leading such a multidisciplinary team while engaging the community will present our field’s leadership with new and daunting challenges. Photocopying or distributing this PDF is prohibited without the permission of Health Administration Press, Chicago, Illinois. 249 For permission, please contact the Copyright Clearance Center at www.copyright.com. For reprints, please contact hapbooks@ache.org. Copyright of Journal of Healthcare Management is the property of American College of Healthcare Executives and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. Developing a Pediatric Burn Treatment Program in a Community Hospital Pamela Jennings, Marc Cullen, Roseanne Mark, Mary Ellen Meloche, Sandra Jaeger, and Tammy Lile T here are 120,000 pediatric burn injuries annually in the United States (Center for Research Injury and Policy [CRIP], 2010). According to CRIP (2010), pediatric burns result in 2,500 deaths and over 100,000 emergency room visits every year. Burns are the fourth leading cause of death in children under the age of 15 years and the number one cause of accidental death occurring in the home. Burn injuries are also a major source of pediatric disability and are associated with significant national health care resource utilization (CRIP, 2010). Serious burns are resource intensive, costing hundreds of thousands of dollars per patient (Miller, Latenser, Jeng, & Lentz, 2009). Many pediatric thermal injuries are not severe; however, referral to a burn unit for any burn regardless of depth, size, location, or severity is common. These patients are routinely transported long distances and at great expense for treatment (Vercruysse, Ingram, & Feliciano, 2011). Pamela Jennings, DNP, PNP, RN, is a Pediatric Clinical Nurse Specialist, St. John Hospital, Detroit, MI. Marc Cullen, MD, MPH, FACS, is Division Chief–Pediatric Surgery, St. John Hospital, Detroit, MI. Roseanne Mark, MA, RN, is a Clinical Nurse Manager, St. John Hospital, Detroit, MI. Mary Ellen Meloche, BSN, RN, is a Pediatric Surgery Nurse, St. John Hospital, Detroit, MI. Sandra Jaeger, BSN, RN, is a Pediatric Nurse, St. John Hospital, Detroit, MI. Tammy Lile, ADN, RN, is a Nurse Preceptor, St. John Hospital, Detroit, MI. Acknowledgment: The authors would like to thank Susanna M. Szpunar, PhD, Senior Medical Researcher, for providing statistical analysis. There are 120,000 pediatric burn injuries annually in the United States (Center for Research Injury and Policy [CRIP], 2010). Although many pediatric thermal injuries are not severe, referral to a burn unit for any burn regardless of depth, size, location, or severity is common. Many patients with smaller burns can be effectively managed in a community hospital, which allows children and their families to remain close to home, reducing costs and some stress associated with hospital stays. This article describes the process of creating a community pediatric burn care program at St. John Hospital in Detroit, Michigan, and initial outcomes of the program. Patients with large burns (greater than 15% body surface area for young children, and greater than 20% for older children and adolescents) develop systemic responses to vasoactive mediators released from damaged tissue after a burn injury (Joffe, 2010). These patients are likely to require aggressive, resource-demanding management available in a regional burn center. However, most burns treated in burn units within the United States are superficial, partial thickness burns that would heal without burn unit referral (Vercruysse et al., 2011). Many patients with smaller burns (less than 15% body surface area) can be effectively managed in a community hospital when a knowledgeable and experienced staff establish and maintain a coordinated burn program. When Vercruysse et al. (2011) considered the problem of overutilization of regional burn centers for pediatric patients, they noted that communitybased care eliminates the need for children with less-severe burn injuries to be transferred, and allows children and their families to remain close to home, reducing costs and some stress associated with hospital stays. St. John Hospital in Detroit, Michigan, part of St. John Providence Health System (SJPHS), is an 800-bed, not-for-profit community hospital with a 40-bed pediatric unit, an 8-bed pediatric intensive care unit, and a pediatric emergency room, and holds a Level 2 Pediatric Trauma Certi- PEDIATRIC NURSING/September-October 2015/Vol. 41/No. 5 fication. In keeping with attaining pediatric trauma certification, the pediatric surgery department, in collaboration with the inpatient units, began a pediatric burn pilot program in April 2009. The pilot program would verify which patients can safely and effectively be cared for in a community setting and establish the basis for a permanent pediatric burn unit in the hospital. St. John Hospital pediatric services chartered the Pediatric Burn Care Multidisciplinary Committee to examine standards of care for children with burn injuries throughout SJPHS, evaluate the need for and create burn care guidelines for patients treated in a community hospital, and educate staff on the principles of pediatric burn care. The committee established its mission to provide uncompromising, compassionate care for children who have sustained less-severe burn injuries. A multidisciplinary team committed to spiritually focused, holistic healing was assembled to provide physical, emotional, social, and spiritual support to injured children and their families. The team was dedicated to giving the highest standard of care, extending beyond the healing of the skin to restoring a sense of wholeness, acceptance, and reintegration into the community. The committee conducted a literature search for information about pediatric burn care outside of regional burn centers. PubMed and CINAHL search 219 Developing a Pediatric Burn Treatment Program in a Community Hospital engines were utilized in January of 2009 and again in August 2011. There was a plethora of articles describing the medical and nursing care of children with burn injuries (Death, 2005; Joffe, 2010); however, there was little information about pediatric burn programs (Brignall & Death, 1999; Death 2005). There were no publications addressing burn care programs in community hospitals. This paucity of information demonstrated the need for the development of a model for a community burn care program. The committee used the American College of Surgeons (ACS) (2006) Guidelines for the Operation of Burn Centers as a framework to evaluate their current standard of care for pediatric trauma patients. The committee found most of the elements required for a burn center were already in place at St. John Hospital as components of maintaining a level 2 Pediatric Trauma Center. The areas in which the current program did not meet the guidelines included admission and census levels of a burn center hospital, one or more employees that are Advanced Burn Life Support (ABLS) instructors, and a specialized nursing unit dedicated to acute burn care. Organization of Pediatric Burn Care Program A burn team was identified and was composed of the many services required for the complex management of thermal injuries. Team members included surgeons, intensivists, resident physicians, advanced practice and staff nurses, clinical pharmacists, nutritionists, social workers, physical and occupational therapists, chaplains, and a child life specialist (see Table 1). The team reviewed and revised existing policies and procedures, developed a burn care supply cart, and established procedures for burn wound management and guidelines for the use of procedural sedation for dressing changes. Standard physician orders and prescriptions established consistency. A comprehensive program of lectures and hands-on workshops provided education to achieve health care professional competence consistent with national standards. The ACS (2006) burn center referral criteria were used as a guideline to establish admission and transfer criteria for the burn program (see Table 2). 220 Program Development The team reviewed and addressed the many aspects needed to create and implement the program, including policy development, supply organization, documentation, processes for pain management and burn dressing changes, processes for follow-up care, staff competency validation, education tools, and program evaluation. Policy The existing pediatric burn care policy was revised to reflect the current evidence-based practice guidelines established by the ACS (2006). The policy now includes admission criteria, mandatory consults, laboratory studies to be drawn, and medications to be given. It also includes a list of equipment needed and a step-bystep procedure list. A portable burn care cart was assembled to organize all equipment and burn wound dressing supplies. Burn Care Communication Tool A burn care communication tool was developed to convey which dressings and medications were applied to each burn site to pass this critical information on to subsequent caregivers. The tool is used for family home care instructions as well, and a copy is included in the patient’s discharge folder. The staff also uses the tool as a checklist to restock the burn cart in readiness for the next dressing change. Procedural Analgesia And Sedation A procedural sedation protocol was developed from evidence-based guidelines (Mason, 2011). It specifies medication set up, preparation, and administration, and includes both pharmacologic and non-pharmacologic pain management interventions. Non-pharmacologic interventions used include relaxation, guided imagery, distraction, therapeutic touch, music therapy, and aromatherapy. Most initial dressing changes where debridement is needed are performed while the patient is under moderate to deep sedation. Medications are generally given in combination, according to the age of the patient: a) for children less than 2 years old, ketamine and midazolam are given; b) children 2 to 5 years may be given either ketamine and midazolam, or propofol and fentanyl; and c) for children older than 5 years, propofol and fentanyl are used. When less debridement is required and initial healing has begun, intravenous analgesia (morphine) and sedation (midazolam [Versed®]) are given 10 to 15 minutes before the dressing change. Dressing changes just prior to discharge are usually done with oral analgesia (acetaminophen [Tylenol®] with codeine) and sedation (diphenhydramine [Benadryl®]). Burn Wound Dressing Change Process The process for changing burn dressings was developed for inpatient and outpatient care, and a written guideline was created. Pictures are taken before and after debridement and/or dressing change with parental consent. The pictures are shown during the monthly multi-disciplinary pediatric burn care meeting while case reviews are presented. A portable surgery cart is used to assemble supplies. Burn Wound Care Competency A process to validate burn wound care competency for nurses and resident physicians was developed. The process starts by attending a pediatric burn care presentation, reading the contents of the patient education folder, and reviewing the contents of the burn cart. The learners subsequently observe a burn dressing change, assist with a dressing change, and finally, perform a dressing change, first under supervision and then independently. The final step in the competency validation process is teaching burn wound care under supervision, then independently, to staff and parents. The clinical nurse specialist, pediatric burn care nurse, nurse preceptors, and lead burn care nurses validate staff burn wound care competency. Orders and Prescriptions The burn program medical director and the clinical nurse specialist wrote standard physician orders and prescriptions. Orders include consults, dressing changes, laboratory and diagnostic studies, diet, activity, and inpatient medications. Prescriptions include outpatient medications, analgesics, and antipruritics, as well as dressing change supplies. PEDIATRIC NURSING/September-October 2015/Vol. 41/No. 5 Table 1. Multidisciplinary Team Members Medicine • Burn program director is a pediatric surgeon with 30 years of pediatric burn care experience. • Pediatric intensivists provide fluid management, monitoring, and procedural sedation. • Pediatric emergency medicine physicians provide the initial assessment and urgent care to patients who arrive in the emergency department with burn injuries. • Pediatric child abuse program director is a board-certified pediatrician with specialty training in child abuse prevention, recognition, and treatment; and is consulted for all patients with suspected abuse or neglect. Nursing • Clinical nurse specialist (CNS) coordinates the program, develops the parent and staff education programs, standard orders, and prescriptions; and assists with staff education. The CNS meets with patients with burn injuries and their families and coordinates their inpatient care. The CNS also leads a pediatric burn research project and mentors staff nurses in nursing research. • Pediatric surgery/burn care (PS/BC) nurse works in direct collaboration with the Burn Surgeon, and leads the nursing education program, providing lectures and workshops demonstrating burn wound care. The PS/BC nurse provides direct patient care, both inpatient and outpatient, develops patient’s plan of care, and coordinates the patient’s outpatient care with other team members. • Pediatric trauma coordinator rounds on all pediatric patients with burn injuries and collects all data needed for the National Burn Repository (NBR). The National Burn Repository is a database summarizing some of the clinical characteristics and course of burn treatment for cases submitted to the NBR from specialized burn care facilities (Miller et al., 2009). • Pediatric and pediatric intensive care unit nurse preceptors mentor and support nursing staff while they learn burn care. • Lead burn care nurses from each unit (pediatric and pediatric intensive care unit) serve as a burn care resource and mentor staff nurses as they develop burn care competence. • Nurse case managers assist with issues involving insurance, home care, dressing supplies, and equipment. • Nurse managers provide administrative support for the development and maintenance of the burn care program. • Home care nurses provide education, assessment, and support once the patient returns home. Social Work • Social workers provide emotional support to families, assist with problem solving and decision making, financial and transportation needs, and language barriers. They are liaisons with child protective services in suspected child abuse cases. Pharmacy • A pediatric clinical pharmacist provides information on all medications used for treatment and symptom management. Nutrition • Dietitians make nutritional recommendations and educate the child and family regarding a diet to promote burn wound healing. Spiritual Care • Chaplains visit patients and families daily and are available to provide spiritual and emotional support. Child Life • Child life specialists are teachers as well as counselors that are specially trained in caring for ill children. They provide communication with schools, assess educational needs, and assist children in developing coping skills (relaxation, imagery, etc.) for use in managing the anxiety and/or pain associated with burn care. Occupation and Physical Therapy • An occupational or physical therapist is present at burn dressing changes to improve the range of motion of involved joints, as this can be done with less discomfort while the child is sedated. They demonstrate to the patient and parents the exercises that will need to be done at home. Patient and Parent Education A broad patient and parent education program was developed, including information regarding burn classification, pain, and pruritis management at home. The home dressing change process is reviewed. Parents are involved from the first inpatient dressing change and have ongoing participation in all subsequent dressing changes. This helps assure that by the time the child is ready for discharge, parents are proficient at burn wound care. The dietician reviews the patient’s nutritional needs and a meal plan. Occupational and physical therapists explain strategies to prevent contractures and scarring. The child life specialist, social worker, and nurses address psychological adjustment and school issues. Parents often struggle with the guilt associated with an accidental injury, and they receive support from chaplains, nurses, the child life specialist, and social workers during PEDIATRIC NURSING/September-October 2015/Vol. 41/No. 5 the healing process. Finally, prevention of burn injuries is reviewed. A burn injury education record developed for the program is used to document the education provided. Costs of Instituting The Program The costs associated with instituting the burn program at SJPHS were primarily construction and training costs. The cost of reconstructing an existing storage space into a burn 221 Developing a Pediatric Burn Treatment Program in a Community Hospital Table 2. Criteria for Admission and Transfer Admission Criteria Transfer Criteria 1. Partial thickness burns less than 15% total body surface area (TBSA). 1. Partial thickness burns greater than 15% TBSA. 2. Burns that involve the face, hands, feet, genitalia, perineum, or major joints. 2. Electrical burns. 3. Minor burn injuries that could be managed outpatient but exist in patients who will require special social, emotional, or rehabilitative intervention requiring inpatient care. 3. Complex thermal, chemical and inhalation burns. 4. Non-complex (not requiring intubation and mechanical ventilation) inhalation burns. 4. Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality. 5. Non-complex (partial thickness) chemical burns. 5. Any patients with burns and concomitant trauma in which the burn injury poses the greatest risk of morbidity or mortality. treatment room was approximately $120,000. This cost included architectural drawings, demolition, construction, and installation of the burn tub, along with heating and lighting options to create a more serene and comfortable treatment space for dressing changes. The construction costs were covered entirely through donations from the local community and the SJPHS philanthropic and fund-raising foundation. The approximate cost of staff training was $2,000, using an average salary of $30.70 per hour, multiplied by the 48 registered nurses who attended the training. This cost was also covered through donated community funds. The training cost for other staff, including physicians, nurse specialists, social workers, dietitians, and therapists, was part of the operating budget. Program Evaluation Three quality metrics and two financial metrics were established to evaluate the burn program. The three quality metrics are length of stay, infection rate, and readmission rate. The two financial metrics are charges per case and net revenue per case. Quality measures were selected because they are part of the core measures SJPHS has established. SJPHS selected the core measures based on the Centers for Medicare and Medicaid Services (CMS) and The Joint Commission recommendations to focus efforts on the use of data to improve the health care delivery process (The Joint Commission, 2013). The financial metric, charges 222 per case, was chosen based on the American Burn Association (ABA) (2012) report, which provides mean total and daily charges for patients with burn injuries. The second financial metric, net revenue per case, is a standard financial indicator used at SJPHS. Staff and patient satisfaction data are collected as part of the overall pediatric program evaluation at SJPHS. Data specific to staff caring for patients with burn injuries and data regarding patient satisfaction with care were collected as part of this routine survey. Although staff and patient satisfaction were not established program evaluation indicators, data collected are reported in this article. Barriers to the Burn Care Program and Solutions Barriers to putting the burn care program in place included lack of staff participation and unfamiliarity with burn care processes, lack of a reliable and appropriate physical space for procedures, the need to change established burn patient referral patterns, lack of engagement and support from the operating room and other multidisciplinary services, and availability of a process for outpatient follow up and management. These barriers to implementation were analyzed, and strategies to address each of these were devised and implemented by the team. Staff Participation The principal barrier to implementation of the burn program was the reluctance of pediatric staff to care for children with burn wounds. They expressed discomfort with burn care and fear of causing pain. Many experienced staff members recalled caring for children with burns 15 to 20 years ago. They remembered how the children suffered during “burn baths” during that time. A comprehensive program was designed to address the nurses’ concerns. Education and grand rounds addressing pediatric burn management was provided for staff in the operating room, emergency department, pediatric unit, pediatric intensive care unit, and family practice areas. Teaching guidelines were developed to ensure consistency and comprehensiveness of patient education. Staff education regarding burn patient-specific pharmacologic and non-pharmacologic pain and anxiety management was provided, to ease staff concerns regarding patient comfort. Burn Treatment Room Another barrier to the burn program was the lack of appropriate facilities. The existing treatment room was too small to accommodate the staff and supplies required for burn wound dressing changes. Initially, the burn wound dressing changes were done in the pediatric intensive care unit (PICU) when moderate to deep sedation was required. The child’s hospital room was used when moderate to deep sedation was not needed. Problems with providing care in the PICU included an increased risk of infection and a lack of privacy; diffi- PEDIATRIC NURSING/September-October 2015/Vol. 41/No. 5 Figure 1. Burn Treatment Room 15% burn injuries. The hospital website was updated to include information about pediatric burn injury prevention and treatment, as well as adding an easy-access process for families and community physicians to refer children for assessment, treatment and follow up. Operating Room Support The operating room staff lacked experience with temperature control or transfusion management in children with burn injuries. Operating room and anesthesia personnel had no experience doing skin grafts or burn excisions, and were unprepared for rapid blood loss and hypothermia related to exposed burn patients. Equipment like dermatomes and hemostatic agents, as well as wound care supplies, had to be stocked. Anesthesia and operating room staff were in-serviced on temperature and transfusion management for burn excision. Equipment was purchased and inventory managed to support skin grafting. culties with in-patient room care were lack of space and infection control. In addition, performing wound treatment in the patient’s room violated a space that should be reserved for the safe, quiet, and comfortable convalescence from the injury. Funding was obtained for a new burn treatment room located within the pediatric unit. This allows the staff to provide appropriate care for children with burn injuries in a secure and appropriate environment. The new burn treatment room has two patient therapy areas: a monitored treatment bay for dressing changes and procedures, and an ARJO Rhapsody Tub for cleaning and debriding burn wounds (see Figure 1). The spacious treatment room was specifically designed to accommodate parent participation in the burn dressing, if appropriate, to promote a holistic and family-centered approach. The space is child-friendly, with soothing murals, adjustable and color-changing LED lighting, and distraction activities, such as television and music. It is climate-controlled, and there are two keypad locked entry doors, both with electronic occupancy alerts exterior to the room, to ensure privacy. Referral Patterns The established pattern of care was to transfer children with burn injuries from our health system sites to a metropolitan children’s hospital. Despite the high level of interest in the program, it has been difficult to change referral patterns. Changing patterns requires informing all system sites that a pediatric burn care program exists. It also requires support from all system leaders. Burn program success depends on a culture change within the health system and constant attention to each triage opportunity for all burned children seen within the organization. The emergency room staffs of the four referral hospitals within the health system were targeted for outreach marketing. The pediatric medical education department held a conference at an area system hospital to increase awareness of our pediatric subspecialties, including surgery and burn management. The medical director presented the comprehensive burn program to community and professional groups, emphasizing the advantages of caring for these children within their own community rather than at a regional hospital some distance away. The pediatric/ PICU clinical nurse specialist visited referral hospitals to educate emergency room and pediatric unit staff on initial burn wound care, providing information for the units to easily and directly contact St. John Hospital for transfer of children with less than PEDIATRIC NURSING/September-October 2015/Vol. 41/No. 5 Outpatient Follow Up Traditional physician office resources and availability are not conducive to patients with burn injury needs. Having a burn program required that there be outpatient services available within 24 hours to see patients that were sent home from the emergency room. Reviewing care and ensuring the patients had the proper supplies within 24 hours of being discharged was challenging. Office scheduling in the surgery department was restructured to provide same-day or next-day appointments for children with burn injuries. Children with thermal injuries are followed in the office burn clinic at regular intervals for wound evaluation, dressing changes, physical/occupational therapy assessment and treatment, appraisal for potential complications, and ongoing education regarding home care strategies. A staff member from Care Transitions, a patient satisfaction program, contacts families by telephone after inpatient and outpatient visits. Care Transitions data show families report great satisfaction with the ease of access, prompt attention, and individualized care they receive from the office team. Multidisciplinary Engagement The occupational and physical therapists were unfamiliar with posi223 Developing a Pediatric Burn Treatment Program in a Community Hospital tioning, exercise, range of motion, and scar management for children with burn injuries. Social services and nurse case managers were challenged by length of stay and discharge requirements. Occupational and physical therapy staff received instruction on burn management, emphasizing positioning, edema reduction, range of motion, and scar management. Monthly multi-disciplinary pediatric burn care meetings are held, which include the pediatric social worker and nurse case managers. Staff nurses who cared for the child with the burn injury lead case reviews, which include patient demographics, burn type (pre- and post-treatment wound pictures are shown), cause, length of stay, wound care, use of sedation and analgesia, symptom management, complications, patient and family education, consults, and discharge. Care in the emergency room, pediatric or pediatric intensive care unit, outpatient clinic, and patient home are reviewed. Recommendations for changes in the burn program based on findings from case reviews are discussed and implemented. Outcomes Burn Care Provided The pediatric burn program was instituted in April 2009. From this time until March 2011, 123 pediatric patients with burn injuries were cared for at St. John Hospital. Sixty-four patients (52%) were seen in the emergency room only. Thirteen patients (10.6%) were seen in the clinic only. Forty-six (37.4%) were admitted to the pediatric or pediatric intensive care units. The mean age at the time of the burn injury was 6.5 years. The mean total body surface area burned was 2.9%. The ABA National Burn Repository (Miller et al., 2009) indicates that for all pediatric patients with burn injuries, 66% are male and 34% are female. At St. John Hospital (51.2%) were male and (48.8%) were female (see Table 3). National statistics indicate scalds account for 60% to 80% of burn injuries in young children, while older children are more likely to be injured from flames (ABA, 2009). Consistent with national statistics, the St. John patient population demonstrated the most common burn type was scalds (50.8%) (see Table 4), 224 Table 3. Gender Frequency Female Percentage 60 48.8 Male 63 51.2 Total 123 100 Table 4. Burn Type Frequency Chemical Contact Percentage 2 1.6 42 34.4 Electrical 1 0.8 Flame 11 9.0 Friction 4 3.3 62 50.8 Scald Missing data 1 Table 5. Age and Body Surface Area (BSA) by Burn Type Total (n) Mean Age Mean BSA 42 4.9 1.49 Flame 11 14.7 3.91 Scald 62 6.3 3.71 Other 7 5.9 1.86 Missing data 1 Contact Table 6. Mechanism of Injury Frequency Chemical Percentage 4 3.3 20 16.5 Food 4 3.3 Liquid 56 46.3 Metal 30 24.8 Friction/Plastic/Unknown 7 5.8 Missing data 2 Electrical/Fire and the mean age for children with scald injuries was 6.3 years (see Table 5). The mean age for flame burn type was 14.7 years. Flames also caused the largest mean body surface area burned (3.91%) (see Table 5). The most frequent mechanism of burn injury was liquid (46.3%), followed by metal (24.8%) and electrical (16.5%) (see Table 6). Quality Metrics The three quality metrics used were length of stay, readmission rate, and wound infection rates. None of the 46 patients were readmitted, and there were no infections. Although not published, a widely used clinical standard for expected length of stay for a patient with a burn injury is one day for each 1% percent of burn sur- PEDIATRIC NURSING/September-October 2015/Vol. 41/No. 5 Table 7. Patient Satisfaction Results (N = 28) References Do you feel that your emotional and spiritual needs were met? Yes – 100% No – 0% Are you doing well today? Yes – 100% No – 0% Is there anything we could have done differently during your stay? Yes – 10% No – 90% On a scale of 0 to 10, how likely is it that you would return to this facility for your future health care needs? Scale: 10 – extremely likely, 0 – not at all likely (10) 80% (9) 10% (8) 10% (0-7) 0% face involved. To meet this standard and provide the most efficient care, a one-day per 1% burn surface goal was established and met for all 46 hospitalized patients. Meeting these three quality metrics demonstrate that for the 46 hospitalized patients, the program was safe and effective. Financial Metrics St. John Hospital Pediatric Burn Program provides care for children with less than 15% BSA burns. Analysis of the St. John Hospital pediatric patients with burn injuries from April 2009 to March 2011 shows mean total charges per case is $10,266, and mean daily charges per case is $2,704. It is significant to note that while charges are relatively low on these lower-acuity burns, the net revenue per case is $4,230. Patient and Staff Satisfaction Although patient and staff satisfaction were not established evaluation indicators, some preliminary patient and staff satisfaction data were collected. Positive inpatient satisfaction scores were obtained through discharge surveys (see Table 7). Continued support and education for the staff involved in caring for children with burn injuries has encouraged participation. Anecdotal reporting and staff interest in burn care suggests the fear of caring for children with burn injuries and their families has slowly dissipated. Work environment survey results demonstrate that the successes in managing patients in the pediatric burn program are building staff efficacy, confidence, and satisfaction. munity setting is needed. Additionally, Vercruysse et al (2011) reported community-based care reduces some stress associated with hospital stays. The pediatric burn pilot program did not evaluate the level of stress for patients or their families. This is an important area that should be addressed in future research. Conclusions The pediatric burn treatment program at SJPHS demonstrates that quality burn care can be provided in a community setting. Based on the successes experienced, St. John Hospital is considering expanding the pediatric burn program to become a burn center in the future. There are census criteria and physical space requirements that must be satisfied to meet the guidelines for the operation of a burn center. If those criteria can be successfully met, the change to burn center status will allow communitybased care not only for minor burns, but more severe ones as well. American Burn Association (ABA). (2012). National Burn Repository. Retrieved from http://www.ameriburn.org/2012 NBRAnnualReport.pdf American College of Surgeons (ACS). (2006). Resources for optimal care of the injured patient. Guidelines for the operation of burn centers. Chicago: American College of Surgeons Committee on Trauma. Brignall, J., & Death, A. (1999). Back to normal: Children’s care after burn injury. Nursing Times, 95(39), 54-56. Center for Injury Research and Policy (CIRP). (2010). New national study finds decrease in rate of pediatric burns. Retrieved October 5, 2010, from http://www.nationwidechildrens.org/ news-room-articles/new-national-studyfinds-decrease-in-rate-of-pediatricburns?contentid=49195 Death, A. (2005). Caring for children with burn injuries. Nursing Times, 101(1), 76-77. Joffee, M.D. (2010). Emergency care of moderate and severe thermal burns in children. Up to Date. Retrieved from http://www.uptodate.com/contents/ emergency-care-of-moderate-andsevere-thermal-burns-in-children Mason, K. (2011). Pediatric sedation outside the operating room: A multispecialty international collaboration. New York, NY: Springer. Miller, S., Latenser, B., Jeng, J., & Lentz, C. (2009) National Burn Repository 2009 report. Retrieved from http://www.ameri burn.org/2009NBRAnnualReport.pdf The Joint Commission. (2013). Core measure sets. Retrieved from http://www. jointcommission.org/core_measure_ sets.aspx Vercruysse, G. Ingram, W., & Feliciano, D. (2011). Overutilization of regional burn centers for pediatric patients-a healthcare system problem that should be corrected. The American Journal of Surgery, 202(6), 802-809. Future Research Further study of patient and staff satisfaction with burn care in a comPEDIATRIC NURSING/September-October 2015/Vol. 41/No. 5 225 Copyright of Pediatric Nursing is the property of Jannetti Publications, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. Healthcare Management Ethics Moral Management as a Leadership Priority Frankie Perry, RN, LFACHE Treating employees well and managing ethically is a business imperative. In the June 6, 2013, cover story in Bloomberg Businessweek, “The Cheapest, Happiest Company in the World: Costco, where toilet paper—and ecstatic employees—can both be found in bulk,” Costco CEO Craig Jelinek attributes much of the company’s financial and market success to treating its employees well. In a 2013 letter to Congress addressing raising the federal minimum wage Jelinek wrote: “We know it’s a lot more profitable in the long term to minimize employee turnover and maximize employee productivity, commitment and loyalty.” Putting employees first must be working because all indicators show Costco outpacing its competitors. The Costco experience about the value in treating employees well and managing them in an ethically responsible way draws considerable parallels to healthcare. In its Code of Ethics, ACHE provides clear guidelines for healthcare executives’ ethical and professional obligations to employees. Most center on creating and contributing to a work environment and culture that promotes and supports ethical conduct within the organization. Organizational culture, ethical standards and a safe and healthy work environment are essential in fulfilling one’s ethical responsibilities to employees. 58 Healthcare Executive JAn/FEB 2014 But while the “right” policies and procedures and the “right” culture and work environment may be in place to promote the ethical treatment of employees, it is the day-to-day management actions that determine whether managers are fulfilling their ethical responsibilities to the employees they supervise. Maintaining an Ethical Culture Creating an infrastructure that includes such things as a code of ethics, standards of conduct and an ethics committee may be the easy management task; making ethical conduct the norm throughout the organization from the boardroom to housekeeping is a much more difficult task. More than anything, managers who role model ethical conduct in the treatment of their employees send a clear message about what is acceptable behavior in the organization. Employees who are treated with honesty, fairness and respect are more likely in turn to treat patients, clients, vendors and co-workers in this same way, thus contributing to the success of the organization in its many business and professional relationships inherent in healthcare delivery. Recruitment and Hiring Practices Competent, ethical clinical and nonclinical employees want to work for an ethical organization with leaders who inspire and challenge them to achieve high levels of ethical performance. A culture where staff and employees are treated ethically and are expected to treat others in a like manner will attract and retain a workforce that will enhance the image of the institution. When recruiting staff, it is sometimes tempting to oversell your organization and its position in the marketplace. This is understandable in your desire to attract highly qualified people. But it is not fair to the recruit to paint an unrealistic picture of the organization and its viability or of the position, its authority and responsibilities, especially if the recruit will be relocating his or her family and committing considerable investment in relocation. When making a job offer to a new hire, it is a questionable practice to offer more compensation to a new hire than what an existing employee who has tenure and experience in your organization and who is doing a good job at the same level with the same responsibilities is receiving. Caution must be exercised to ensure equitable compensation, benefits and support for staff members. In addition, hiring or promoting a staff person into a position, giving him or her clear expectations of the job to be done and then failing to provide the resources or the authority needed for the employee to meet those required expectations is unfair to both the employee and the organization. Managing Diversity Failure to understand the importance of having a cross-cultural Healthcare Management Ethics workforce will increasingly thwart the achievement of organizational goals and set the stage for discrimination of employees based on factors such as race, ethnicity, national origin, gender, religion, age, marital status, sexual orientation, gender identity or disability. To avoid derailment of organizational goals and the threat of potential litigation, healthcare leaders must create, embrace and sustain a culture of diversity that serves the needs of the workforce and patients. A recent legal action charging a hospital with employee discrimination based on race made national news. A parent demanded that nursing staff of a different race than himself not be assigned to care for his child. The parent’s demand was met in spite of a hospital policy to the contrary. This case points out the need for staff education, especially of front-line workers, related to anti-discrimination laws and policies and their application to the workforce. Much has been written in academic literature and in the media about sexual harassment, and yet these cases continue to make news. In an ethical organization, management will establish a zero tolerance policy for sexual harassment, make certain employees are well educated in the law, and assign designated staff members to investigate and handle complaints and answer questions other employees may have. Performance Evaluations In an ethical organization, performance evaluations will be fair, honest, objective, timely and focused on the work. Consistent standards of performance will be applied to all staff. Employees will not be expected to perform beyond their job descriptions or beyond what can reasonably be expected of them given the resources they have been provided. Managers will not imply that poor performance may be the result of such factors as aging, health or family issues that may be viewed as discriminatory and open the organization up to litigation or disability claims. Develop a Postgraduate Fellowship Creating future leaders benefits you, your organization and the profession. It’s an opportunity to teach others, groom talent and invest in the next generation. Building a program is easy! ACHE’s Fellowship Development Guide will assist you, and Natalie Lencioni, operations coordinator in the Division of Member Services, is available to answer your questions at (312) 424-9374 or nlencioni@ache.org. Learn more at ache.org/PostGrad Healthcare Executive 60 Develop_PostGradDir_horz.indd JAn/FEB 2014 1 5/20/13 9:05 AM Managers often view performance evaluations as a bureaucratic necessity—not a high priority on their to-do list. They may even allow considerable time to lapse beyond the due date for the review. This can be especially unfair to the employee if a pay raise is contingent upon the completion of a satisfactory performance evaluation. Even if this is not the case, employees deserve to know if they are doing a good job, if there are areas of their job performance that require improvement and how improvements might be facilitated and measured. Communication Ethical managers practice two-way communication with their workforce. They seek employees’ opinions and ideas, encourage civil debate and avoid the practice of listening only to those who agree with their position. Ethical managers recognize that any threat to the status quo or existing stability of the organization such as workforce reduction, mergers or acquisitions will have a direct impact on the job security of individual employees. Employees need sufficient information to mobilize personal resources to plan or take action if needed. It is unfair to withhold information from employees that may allow them to make necessary adjustments for themselves or their families. Managers must not lose sight of the fact that employees’ job satisfaction, loyalty, commitment and productivity are in large part directly related to how they are treated by their “boss”—not primarily by the organization or human resources department—but by their manager. It is the day-to-day decisions imbedded in routine management functions that reflect the moral treatment of the workforce, which in turn reflects the character of the leadership and, in turn, the character and image of the organization. s Frankie Perry, RN, LFACHE, is an ACHE faculty member and author of several articles and books, including the 2013 book The Tracks We Leave: Ethics and Management Dilemmas in Healthcare, Second Edition (Health Administration Press). She can be reached at frankieperry@comcast.net. Find New Vision at With a strong commitment to raising the bar for healthcare in our community, Nassau University Medical Center is a Level I Trauma Center and a 530-bed teaching hospital affiliated with the North Shore/LIJ Health Care System and Stony Brook University. NuHealth is fully accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and has been the recent recipient of many awards, such as the 2013 American Heart Association’s Gold Plus Quality Achievement Award for Stroke and 2013 US News & World Report Best Nursing Homes in New York. NuHealth System also includes a 589-bed Extended Care Facility and five Community Health Centers.We are located in East Meadow, New York, a suburb of New York City. President and Chief exeCutive OffiCer NuHealth is currently seeking a Chief Executive Officer. As a member of the Hospital’s senior management team, the Chief Executive Officer (CEO) will participate in operational decision-making processes necessary for the successful attainment of the hospital’s mission, in addition to maintaining an awareness of changes in healthcare matters that could have an impact on the success of the hospital. The ideal candidate will have the responsibility for working with the Board of Directors in leading our management team and staff toward our goal of excellence and quality in patient care. The ideal candidate will possess: • Financial management knowledge. • Proven leadership skills and strong decision making capability. • Knowledge of current health care regulations and requirements. • Must have proven ability to establish and maintain effective working relationships with physicians, hospital staff and community. • Ability to maintain confidential information concerning personal, financial, or medical matters. For more information on the NuHealth System, please view our website at www.NuHealth.net Qualified candidates should forward a CV or resume to: jsoffel@numc.edu Nassau University Medical Center 2201 Hempstead Turnpike, East Meadow, NY 11554 Equal OppOrtunity EmplOyEr Client: NuHealth Publicaton: Healthcare Exec Date: January 2014 Size: 4.74 x 7” Healthcare Executive JAn/FEB 2014 61 Copyright of Healthcare Executive is the property of American College of Healthcare Executives and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. Management Managing the Accountability of Your Staff By Ronald B. Pickett In this article… Explore ways to improve accountability among your staff members by first assessing individual levels of maturity. You have a wonderful staff. You have given all the assignments, and now it’s time to sit back and wait for the results to roll in. Sadly, that’s not my world. There is a lot more to getting things done than assigning tasks. Personal accountability is a vital, necessary ingredient. But it’s not your job to follow your staff around, checking to see that tasks are accomplished. So what can you do to enhance the level of accountability of your staff? Managing accountability of individuals One fact you will have observed is that each member of your staff demonstrates a different level of maturity or responsibility. A good definition of an adult is someone who takes full responsibility for his or her actions. As a manager you need to assess the maturity level of each member of your staff and provide the appropriate degree of direction, coaching and guidance. This does not imply a detailed, formal assessment, but more of an observation of what works and what each person wants and needs to be effective on the job. For new staff members it may be necessary to provide very specific direction on what has to be done, how to do it, and to monitor the results with frequent coaching. This is the entry level of maturity. With time and experience, the employee will be able to take on additional responsibility and will require less specific direction. Your role shifts during this development process from providing specific guidance and close monitoring to ultimately describing the desired outcomes and providing an environment in which the employee can select the best way to achieve those outcomes. There are intermediate steps as 20 PEJ JULY•AUGUST/2014 the person assumes greater responsibility. The manager’s role is to be less directive and more participative, seeking more input from the person as he or she assumes increased responsibility. This process may sound complicated, but it quickly becomes second nature and is the essence of what managing people is all about. An employee’s maturity level is a combination of ability or skill and willingness or motivation. He or she can have a high level of ability, but lack a willingness to actually do the work. Additional training would be useless in this situation. Maturity levels are also task specific. A person could be generally skillful, confident and motivated in most aspects of their job but would have a low level of maturity when asked to perform a task requiring skills they don’t possess. Understanding this concept is especially important in the transition process when one of your staff is given additional responsibilities. It does little good to provide training when the person already has the skills but lacks the motivation to do the job — able, but not willing. High levels of maturity guarantee personal accountability. Developing people and self-motivation A good leader develops the competence and commitment of their people so they’re self-motivated rather than dependent on others for direction and guidance. A leader’s high but realistic expectations lead to high performance of followers. A leader’s low expectations lead to low performance. Think about how often those statements have been borne out in your personal experience. In order to develop an effective staff, a manager needs to motivate followers, and to do that the management style and the rewards must be individualized and appropriate. Not understanding and using the concept of variable levels of maturity is one of the major contributors to poor personal accountability and low morale. Effective leaders need to be flexible and must adapt themselves to the individual situation and personality of each staff member. High S k i l l s Motivate! Clone! Fire! Train! Low Low Motivation High This model is used for coaching, but it is also useful in building accountability. The role of performance appraisals The best and first tool for developing and enhancing accountability is the performance appraisal. Set and agree on high standards that can and will be monitored jointly. This may seem like a primitive method, but all the necessary elements are there — expectations jointly arrived at, monitoring measures and consequences. Simple steps to take: • Schedule periodic update meetings. • Provide the appropriate level of detail for each individual. • Ask “What do you need from me to be successful?” • Become less involved in specifics, or the “how to,” and more involved in the “what if.” • Set objective, “self-measuring” standards or metrics. Assist staff with incorporating measurements that will help them get on track and stay on track to achieve their goals. Effective leaders need to be flexible and must adapt themselves to the individual situation and personality of each staff member. Things you can do Here are some more mature, longer-range steps you can take to achieve a climate of accountability: • Move intentionally toward a more participative climate. • Get input from your staff — frequently and openly. • Nurture involvement in decisionmaking, goal setting and performance monitoring. • Lead through collaboration. • Spot and reward individual initiative. An important issue to resolve is whether to focus on the accountability of teams or individuals. The answer to this question will change depending on the projects you are working on. When that is established, set accountability standards that recognize and reward the appropriate achievements. So if your practice has large projects and success is dependent on the aggregate outcome of the work of several contributors, ensure that your monitoring and reward systems shape team contributions, not individual ones. In one of my jobs there were three peers. While each of us wanted to stand out from the others, we wanted to be highly effective as a team. It was the only time I recall that if you didn’t do something, it would be done for you. This was a great environment: competitive, and yet mutually supportive — not a cutthroat setting, simply everyone dedicated to getting the job done quickly and efficiently. How did that climate evolve? Each of us had a strong personal commitment to an important and challenging goal. ACPE.ORG 21 Consider this checklist for assessing personal accountability: 1. Does your staff feel like they have a positive role in the management of the organization? 2. Are things that need to be done identified and resolved on the spot? 3. Is your staff given the appropriate, individualized level of responsibility and support? 4. Does a climate of mutual support and teamwork exist? 5. Is there clarity and focus on the organization’s goals? 6. Do people focus on team outcomes rather than individual contribution (assuming you need a team focus)? 22 PEJ JULY•AUGUST/2014 If your answers to this short checklist are negative, or if you don’t know the answers, you may want to begin a purposeful effort at raising the level of accountability. Significant improvements can be achieved by a shift in attitude (yours) and minor changes in communication patterns. What will you gain as a result of an environment with enhanced accountability? • High morale. Ronald B. Pickett is an organizational effectiveness consultant based in Escondido, CA. ronp70000@aol.com Resources: 1. Cook I. “How to Build Accountability in Your People,“ http://www. evancarmichael.com/Leadership/4354/ How-to-Build-Accountability-in-YourPeople.html 2. Eden D. Leadership And Expectations: Pygmalion Effects And Other SelfFulfilling Prophecies In Organizations, Leadership Quarterly, 3(4), 1992, 271-305. 3. MacAdam M. “Ten Steps to Promoting Staff Accountability,“ http://www. bizymoms.com/business/Article/ Ten-Steps-to-Promoting-StaffAccountability/400 4. Pickett RB. “Performance Appraisals,“ Lab Manager Magazine, October 2010. http://www.labmanager. com/?articles. view/articleNo/3840/ • Greater productivity. • Staff maturity. • Excellent retention. • Improved recruiting of new staff. Copyright of Physician Executive is the property of American College of Physician Executives and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. F R A M IN G HEALTH M ATTERS A Framework for Describing Health Care Delivery Organizations and Systems | lleana L. Pina, MD, MPH, Perry D. Cohen, PhD, David B. Larson, MD, MBA, Lucy N. Marion, RN, PhD, MN, Marion R. Sills, MD, MPH, Leif I. Solberg, MD, and Judy Zerzan, MD, MPH D escribing, e v a lu a tin g , and conducting research on th e questio n s raised by c o m p a ra tiv e effectiveness research and characterizing care d e liv e ry o rg a n iza ­ tion s o f all kinds, fro m in d e p e n d e n t in d iv id u a l p ro v id e r units to large in teg rated health system s, has b ecom e im p e ra tiv e . R ecognizing this c h alleng e, th e D elivery S ystem s C o m m itte e , a s u bg ro u p o f th e A g e n c y fo r H ealth care Research and Q u a lity 's E ffective H ealth Care S takeh old ers G ro u p , w h ich represents a w id e d iversity of perspectives on health care, created a d raft fra m e w o rk w ith d o m a in s and ele m e n ts th a t m a y be useful in characterizing variou s sizes and typ es o f care d e liv e ry o rg anization s and m a y co n trib u te to key o utcom es of interest. T he fra m e w o rk m a y serve as th e d o o r to fu rth e r studies in areas in w h ich clear d e fin itio n s and descriptions are lacking. [Am J Public Health. 2 0 1 5 ;1 0 5 :6 7 0 -6 7 9 . d oi:1 0 .2 1 0 5 /A J P H .2 0 1 4 .3 0 1 9 2 6 ) Recent and ongoing innovation in systems for the delivery and reimbursement of health care in the United States have broadened stakeholders’ need for standardized methods to describe, measure, compare, and evaluate delivery system changes. A common taxonomy of delivery system characteristics would allow for improved communication and transparency regarding these changes, potentially enhancing the quality of decisions and care for patients, providers, researchers, policymakers, payers, and other stakeholders.1-5 The comparative effectiveness of delivery system characteristics is ranked as a top priority by the Institute of Medicine, which has defined comparative ef­ fectiveness research (CER) as “the generation and synthesis of evidence that compares the benefits and harms of alternative methods to prevent, diagnose, treat, and monitor a clini­ cal condition or to improve the delivery of care.”6^ 203) Yet, there is no standard way to describe care delivery units or systems that encompasses their breadth, ranging from in­ dependent individual provider units to large integrated health systems.7 Thus, the absence of a common parlance for describing delivery systems hinders stakeholders from determining the generalizability of a study or an innovation introduced in 1 setting. The effectiveness of an intervention may be quite different depending on whether the setting is a large integrated care system or a small independent practice and whether providers are paid on production or salaried. W e propose a preliminary framework for description of health care delivery systems that will allow health care stakeholders to better understand, evaluate, disseminate, and imple­ ment delivery system innovation in a more informed, transparent, and stakeholder-centered fashion and permit comparisons among them. Our objective is to present the domains and elements of the framework, the methods that were used to derive i t and examples of its potential application in diverse settings. M ETHODS Our proposal builds on previous taxonomic descriptions of the US health care system. In response to the increasing complexity and het­ erogeneity of health care deliveiy systems, the Agency for Healthcare Research and Qualify (AHRQ) funded development of a taxonomy of organizations, categorized by shared structural and strategic elements.8 The resulting taxon­ omy8 categorized 70% of health networks and 90% of health systems into clusters using 3 dimensions—differentiation, integration, and centralization—and applied the same dimensions to hospital services, physician arrangements, 6 7 0 I Framing Health M atters | Peer Reviewed | Pina et al. and provider-based insurance activities. In 2004, the taxonomy was updated to include a redefinition of centralization and updated descriptors of health care systems because of the continued evolution of organizations.91,1 In 2006, Luke11 noted that taxonomies de­ rived from local systems were not appropriate for large multihospital systems and recom­ mended that further taxonomic studies were needed. Subsequent taxonomic approaches broadened the role of a systems approach, giving primacy to the interrelationships, not to the elements of the system alone.12,13 The pieces (elements) of the framework we describe will certainly become further complex as organizations other than medical care groups (e.g., public health agencies) enter the arena of health care delivery. Rather than describe the lack of an element in a specific organization, one must consider the integration of other organizations bringing the missing elements with them. In parallel to the work of Bazzoli et al.10 and Luke,11 Mays et al.14 concurrently described methodology to classify and com­ pare public health systems on the basis of elements of organization and defined 7 configurations with 3 tiers on the basis of their level of dif­ ferentiation. Also paralleling Bazzoli et al.,10 Mays et al.14 found that public health systems were in a state of fluidity from 1998 to 2006. F rag m e n ta tio n The escalating complexity and heterogeneity of health care delivery systems has led to in­ creased fragmentation of how and where health care is delivered and has created new and often ill-defined relationships between fragments. The Commonwealth Fund Commission on a High Performance Health System has described traditional health care in the United States as a cottage industry wherein fragmentation oc­ curs at the federal, state, and local levels.15 Fragmentation can contribute to unnecessary, American Journal of Public Health | April 2 0 1 5 , Vol 10 5, No. 4 FRAMING HEALTH MAHERS redundant utilization and poorer quality of care. representatives, policymakers, researchers, and research institutions. Recognizing the challenges of a complex, dynamic, and often fragmented health care delivery system, the AHRQ’s Effective Health Care Stakeholders Group (SG) decided to draft an updated framework for describing health care delivery systems, with domains and elements that might be useful for characterizing various sizes and types of care delivery organizations. The SG was a part of AHRQ’s Community Forum initiative, funded by the American Re­ covery and Reinvestment Act, to formally and broadly engage stakeholders and to enhance and expand public involvement in its entire The Delivery Systems Committee (DSC), a subgroup of the SG, consisted of 7 members including clinicians, policymakers, patient ad­ vocates, and researchers who were involved with a variety of care delivery organizations and represented diverse perspectives. The DSC convened to address a specific objective of interest to AHRQ: to develop guidance for AHRQ on how to approach CER on health Effective Health Care Program. Nomination of individuals for the SG occurred via a public process (a Federal Register notice) and was broadly inclusive. A committee composed of representatives from AHRQ reviewed all nominations and selected stakeholders to rep­ resent a diversity of perspectives, expertise, geographical locations, gender, and race/ethnidty. The group represented broad constituencies of stakeholders including patients, caregivers, and advocacy groups; clinicians and profes­ sional associations; hospital systems and med­ ical clinic providers; government agencies; purchasers and payers; and health care industry delivery organizations and systems by devel­ oping a framework that could be used to char­ acterize potentially important differences in structure and function. DSC discussions were facilitated by 2 members of the AHRQ Com­ munity Forum. All meetings were attended by at least 1 AHRQ staff member who provided feedback. The charges of both the SG and the DSC are detailed in the box below. The DSC’s initial work focused on defining the basic unit of consideration: the health care organization or system. Common definitions for health care delivery systems generally refer to all the components providing health care in a country or locality. For example, the World Health Organization16 has defined a health system as all organizations, people and actions whose primary intent is to promote, restore or maintain health. The framework presented here is meant to be broadly descriptive. To­ ward that end, the DSC developed an elements framework with 28 key elements grouped by 6 domains that characterize organizations and delivery systems and may contribute to key outcomes of interest. The DSC tested the framework for face validity among SG stake­ holders representing a broad variety of systems of care. For the purposes of this article, we defined a health care delivery system as the organiza­ tion of people, institutions, and resources to deliver health care services to meet the health needs of a target population, whether a single­ provider practice or a large health care system. A pproach For each step in the development of the framework, the DSC used 2 approaches: review of the literature and the Delphi method, in­ cluding facilitated group discussions and itera­ tive rounds of individual written feedback on successive drafts of the framework. Descrip­ tions of conflict and resolution were recorded in detailed meeting notes and in framework drafts, preserving an audit trail. Although the DSC (at face-to-face meetings) did prioritization exercises, substantial discussion Charges of the Stakeholder Group and the Delivery Systems Committee in Developing a Framework to Describe Health Care Delivery Organizations and Systems S ta ke ho ld e r Group Provide g u idance on program im p le m e nta tio n , including Delivery System s C om m ittee How to c om pare diffe re nt ways o f delivering care , including to subpopulations 1. Q uality im provem ent, 2 . O p p o rtun itie s to m axim ize im p a ct and expand program reach, 3 . Ensuring s ta ke h olde r interests are considered and included, and 4 . Evaluating success Provide inp u t on im p le m e ntin g Effective H ealth Care Program reports and findings in p ractice W h a t a re the ingredients o r e lem en ts needed for com parison o f ways to deliver care? and policy settings. Identify o ptions and recom m end solutions to issues identified by Effective H ealth Care Program staff. Provide input on c ritical research inform ation gaps for p ractice a nd policy, as well as research Can those e lem en ts be exam ined across delivery organizations and system s to get a sense o f w h a t works b est fo r patients? W h at com ponents o f delivery organizations and systems do researchers need to m ethods to address th e m . Specifically, 1. Inform ation needs and types o f products m ost useful to consum ers, clinicians, 1. Identify and e lab o ra te , and and policym akers; 2 . Feedback on Effective H ealth Care Program reports, reviews, and sum m ary guides: 2 . R elate to th e p atie n t-ce n te re d outcom es th a t are m ost im p o rtan t? 3 . S cientific m ethods and applications; and 4 . C ham pion objectivity, accountability, a n d transparency in the Effective H ea lth Care program . April 2015, Vol 105, No. 4 | American Journal of Public Health Pina et a/. | Peer Reviewed | Framing Health Matters | 671 FRAMING HEALTH MAHERS examples of possible measures are presented in Table 1, and summarized here. FIGURE 1-D eliv e ry systems methods flowchart of the creation of a draft framework to describe health care delivery organizations and systems. occurred by e-mail and in conference calls, which resulted in additional edits and revisions to the framework. The richness of those dis­ cussions contributed significantly to the final product. Each step of the process involved all 3 methods: literature review, facilitated group discussions, and synthesis of individual written feedback. P rocess The DSC initially constructed a framework consisting of elements of health care organiza­ tions, focusing on outcomes of interest broadly defined as quality, cost, equity, and patient centeredness. Next, it identified several com­ mon medical conditions, for example, diabetes, as basic examples for developing the list of elements relevant to outcomes for the selected conditions. These elements were grouped into domains on the basis of commonalities, with the resulting framework initially consisting of 30 elements categorized according to 4 domains: structure, resources, culture, and function-process. A reiterative process initially resulted in 35 elements housed in 7 domains: physical assets, human assets, the customer, financial aspects, culture, process-function-system structure, and integration, with each element assigned to 1 domain only. Each member applied the framework to the delivery system with which they were most familiar to test its goodness of fit. Comments from this validation exercise were used to further reorganize the framework into 26 elements in 6 domains: capacity, organizational structure, finances, patients, care processes and infra­ structure, and culture. The model of these processes is shown in Figure 1. The full SG was subsequently asked to pro­ vide feedback regarding the domains, elements, and definitions and to prioritize the elements. Feedback from the SG included 2 primary re­ commendations. First, it was valuable to have the full set of elements available rather than to eliminate elements or designate a core set of measures. On the basis of this feedback, the DSC decided to allow future users of the framework to select elements relevant to their individual application of the framework. Sec­ ond, the SG recommended including both ex­ amples of the application of each element and information about measurability of each ele­ ment. The DSC responded to these suggestions by adding more information about measur­ ability, including (1) whether the element is feasible to measure and, if so, providing ex­ amples of instruments or formats for this mea­ surement and (2) whether the measure of the element involves description or increasing value (i.e., is more better?). The DSC decided to use both generic and specific instruments, when possible, for measurement of the elements, with the understanding that additional instruments may currently exist or be developed. R ESU LTS The elements of the framework were divided into 6 domains and their respective elements. Descriptions of the elements and potential 6 7 2 I Framing Health M atters | Peer Reviewed | Pina et at. 1. Capacity: the physical assets and their own­ ership, personnel, and organizational char­ acteristics of a delivery system that determine the number of individuals and breadth of conditions for which the system can pro­ vide care. Elements include size, capital assets, and comprehensiveness of services. 2. Organizational structure: the components of an organization, both formal and in­ formal, that describe functional operations in terms of hierarchy of authority and the flow of information, patients, and re­ sources. Elements include organizational configuration; leadership, structure, and governance; research and innovation; and professional education. 3. Finances: mechanisms by which a health care delivery system is paid for its services and the financial arrangements and prac­ tices of the system and organizations within the system to allocate those funds, as well as the system’s financial status. Elements include payment received for services, provider payment systems, own­ ership, and financial solvency. 4. Patients: demographic characteristics, as well as wants, needs, and preferences of individuals and families of individuals who receive health care services from a health care delivery system. Elements include patient characteristics and geo­ graphic characteristics. 5. Care processes and infrastructure: the meth­ ods by which a health care delivery system provides health care services to its cus­ tomers and patients as well as the degree of coordination of those methods. Elements include integration, standardization, per­ formance measurement, public reporting, quality improvement, health information systems, patient care teams, clinical de­ cision support, and care coordination. 6. Culture: The long-standing, largely implicit shared values, beliefs, and assumptions that influence behavior, attitudes, and meaning in an organization.21 Elements include patient centeredness, cultural competence, competition-collaboration continuum, community benefit, and inno­ vation diffusion and working climate. American Journal of Public Health | April 2 0 1 5 , Vol 10 5, No. 4 FRAMING HEALTH MAHERS April 2015, Vol 105, No. 4 | American Journal of Public Health Pina et a/. | Peer Reviewed | Framing Health Matters | 673 FRAMING HEALTH MATTERS 674 | Framing Health Matters | Peer Reviewed | Pina et al. American Journal of Public Health | April 2015, Vol 105, No. 4 FR A M IN G HEALTH M ATTERS The selected domains were chosen in an effort to cluster those elements that describe similar aspects of the delivery system. By its nature, an element may not fit perfectly within a domain or, conversely, may be related to aspects of multiple domains. Rather than repeat elements in multiple domains, committee members placed each element in the single domain that the majority felt best represented that element. Many of the elements are simply descriptive rather than normative, such as organizational size, configuration, or type of payments received. In other words, no or little inherent value is generally ascribed to having a large versus small staff, employment versus partnership model, or receiving payment on a fee-for-service versus capitation basis, for example. The descriptive nature of these elements is expected to result in relative ease of mea­ surement and protection from manipulation. However, some elements are inherently normative or value based, such as care co­ ordination, patient centeredness, and cultural competence. In other words, it is inherently desirable for a health care delivery system to effectively coordinate care, be patient centered, and be sensitive to patients’ cultural back­ ground. These elements also tend to describe less tangible characteristics of the organization and are thus less easily measured and poten­ tially more subjective and vulnerable to bias. Furthermore, they tend to describe charac­ teristics that are more structural, cultural, or longitudinal. Nevertheless, the DSC decided to include these elements despite their ac­ knowledged limitations because they represent important aspects of care delivery, with the expectation that objective measures may al­ ready be accessible or will evolve over time. One such example is organizational culture—a domain that is easier to describe than to measure. Yet, various instruments are already available, albeit with some limitations, as reviewed by Scott et al.22 and Zazzali et al.,23 who surveyed physician culture and found great variability within groups. Another less tangible element, but equally as essential, is care coordination. The Care Coordination Measures Atlas 24 pub­ lished by AHRQ introduces a framework for structure and processes that influence care coordination and can be used today. Although many of the value-based measures are directional (i.e., “more is better”), improving April 2015, Vol 105, No. 4 | American Journal of Public Health Pina et al. | Peer Reviewed | Framing Health Matters | 675 FRAMING HEALTH MATTERS 1 desirable attribute may come at the expense of another desirable attribute, such as financial solvency versus comprehensiveness of services and community benefit or standardization versus patient centeredness and research and innovation. The framework as a whole is meant to be used in such a way as to balance such competing values. Elements were chosen as aspects of health care delivery systems that, in the stakeholders’ opinion, were likely to contribute to a delivery organization’s ability to fulfill its mission. The DSC acknowledged that the elements do not necessarily capture every important aspect of a care delivery system but include enough to serve as a basis for a framework describing health care organiza­ tions. Conversely, not all elements are neces­ sarily needed to describe a given organization. In addition, the DSC intentionally focused on elements and domains rather than specific measures or measurement systems; measures staff-model health maintenance organizations. From the aspect of specialties, 79% were in single-specialty practices, and only 21% were in multispecialty groups.27 Therefore, creating this framework only for large health care orga­ nizations would be myopic. The DSC’s inten­ tion has been to provide domains and elements that could also be applied to organizations of all sizes, from very large to very small, from single providers to groups of providers. Fur­ thermore, this work was intended to bring an organized set of domains and elements that have been created by all stakeholders (i.e., providers, administrators, policymakers, and health care consumers) under the auspices of AHRQ. The inclusion of this diverse group of stakeholders is in accordance with the In­ stitute of Medicine report, which emphasizes their inclusion in CER to ensure its relevance to health care delivery.6 Health care delivery systems also include those responsible for the among these apparently similar organizations. Solberg et al.18 created a set of measures of functional, structural, and financial aspects of integration from the organizational point of view, whereas Singer et al.34 instead built measures from the patient’s perspective. In spite of these measures, no consensus has been reached on how best to measure integration. Less controversial than integration is the importance of team care as an essential com­ ponent of better quality, although whether it also decreases costs is less clear. For example, the collaborative care model for major depres­ sion has clearly been demonstrated to produce higher quality, although it takes 3 to 4 years to have any impact on costs.35 38 This model is based not only on having a care manager in the primary care practice but also on regular consultation visits by a psychiatrist. The de­ velopment of effective team care for quality improvement in chronic illness has been ex­ included in Table 1 serve only as examples. public health. The Commonwealth Fund Commission re­ port15 has described the characteristics of high- plored by Shortell et al.39 and suggests the importance of patient satisfaction. Similarly, the chronic care model by W agner et al.40 presents the importance of patient engagement as part of the team for chronic care, such as in diabetes. Team care is also a key feature of many of the elements of the medical home. Hence, it seems an important component of this framework (see DISCUSSION In this article, we present a draft framework created for describing important differences in health care delivery organizations of all sizes and types, one that might facilitate under­ standing as we study and move from traditional models of care to a system-oriented approach while maintaining a patient-centered focus. In the process, the DSC considered the current status of the health care sector, medical prac­ tices in the United States, and current innova­ tive models of care and the overall importance of patient centeredness, which traverses all of the domains. C u r re n t H e a lth C a r e S e c to r The number of single-physician practices dropped from 69% in 20 0 3 and 11% with 2 physicians to 33% in solo or 2-physician practices in 20 08.25 In 2008, 92% were single specialty and 8% multispecialty; 15% were in practices of 3 to 5 physicians, and 19% were in groups of 6 to 50 physicians. Thirteen percent practiced in hospital settings, with 44% of hospital-based physicians working in office practices or clinics and the remainder split evenly between emergency rooms and hospital staff.26 Of the physicians, 3% worked in com­ munity health centers and 4% in group- or performing systems, which include access to information, active management, interdepen­ dent accountability, patient access to care, and continuous innovation. The reader may find several of these attributes among the domains and elements we present that can serve re­ searchers as a roadmap to add definitions and borders to their work. Consequently, the cur­ rent fragmentation of care further highlights the need for the draft framework presented here. One of the key and controversial features of care delivery organizations, primarily large ones, is the extent to which the care they provide is integrated.28-30 This observation is especially true because many studies of care delivery redesign and qualify have been conducted in large integrated organizations such as the Veteran’s Health Administration, Group Health, Kaiser Permanente, and Health Partners, among others. T here are many definitions of integration, b u t we have chosen the one developed by Shortell et al.31 and Gillies et al.32 (see Table 1, Domain V). Using this definition, Solberg et al.18,33 demonstrated that, among 100 large medical groups nationally, there was a positive correlation between functional integration and the presence of practice systems that have been associated with higher quality of care and, yet, a lot of diversity existed in integration 6 7 6 I Framing Health Matters | Peer Reviewed | P/na et a t Table 1, Domain V).41"43 In n o v a tiv e C a r e M o d e ls In fight of the creation of innovative care systems, the DSC believed that it was important to make this framework capable of describing the key features of organizations of all sizes so that organizational structure and function can more consistently be incorporated into re­ search design, publication, and policy decisions. In addition, the DSC’s intent has been to help compare health care organizations across dif­ ferent settings and provide a framework that will facilitate CER of care delivery functions and outcomes. There is no better example of distinct and different settings than the current care delivery reform emphasis on the medical home and accountable care organizations, encompassing both large and small care orga­ nizations.42 Much of the research on these and other care redesign topics is being conducted among dimes of varying size and ownership, often members of practice-based research net­ works.44 The Kaiser Permanente system, as American Journal o f Public Health | April 2 0 1 5 , Vol 10 5, No. 4 FRAMING HEALTH MATTERS compared with independent traditional prac­ tices, offers a model of a physician organization that has adopted value- and quality-oriented, system-level care tools to deliver more effective care.45 To understand whether the results apply to any particular practice, it is essential to understand whether the clinics involved are similar or, if they are not, to decide whether the differences affect generalizability. R o le o f P u b lic H e a lth in C o m p a r a tiv e E ffe c tiv e n e s s R e s e a r c h Health issues that have the greatest impact at the population health level and how to com­ pare them should also be part of CER. Teutsch and Fielding46 argued that comparative effec­ tive assessments of public health interventions can positively influence health at all levels—that is, the individual and the population as a whole—and that studies should also focus on the develop­ ment of research methodology applied to public health. However, most of the current published CER work has centered on the comparison of 2 or more interventions focused on or targeted to disease management or therapies. Other studies, however, must explore the relevance of this work to public health efforts so that in­ terventions can and should be studied not only within systems of care but at the population level. Certainly, the application of CER meth­ odology to public health will present challenges because, for example, randomization as in con­ trolled clinical trials may not always be possi­ ble. However, these challenges may lead to more innovative statistical techniques, such as propens...
Purchase answer to see full attachment
User generated content is uploaded by users for the purposes of learning and should be used following Studypool's honor code & terms of service.

Explanation & Answer

Attached.

Introduction
➢This presentation provides an understanding on important aspects
involved in management of a new service line the will be integrated
within the healthcare. The presentation takes into focus

➢A clinical service line
➢Staffing model
➢Proposed staff reporting structure
➢Recruitment for various roles

The new service line
➢The healthcare is considering developing mobile integrated healthcare
(MIH) to improve the quality of healthcare specialized in
pharmacology field.

➢It is based on the increasing demand for healthcare
➢Will be developed based on a patient-centered approach
➢It will also target clients from far regions as well as individuals who
require frequent healthcare review and are unable to afford regular
medical attention due to increased cost.

Roles of staffing
➢Staffing involves activities like hiring, job descriptions, job analysis
recruitment and others.

➢Staffing plays a crucial managerial role-staffing process is very
important as it combines with planning, organizing a den direction in
conjunction with controlling.

➢Staffing ensures that the right people are in the right job. That through
staffing the right candidates is sele...


Anonymous
Nice! Really impressed with the quality.

Studypool
4.7
Trustpilot
4.5
Sitejabber
4.4

Related Tags