Managing for Success in Health Care Delivery

1. Managing for Success in Health Care Delivery What can we do? Ruth A. Anderson RN, PhD, FAAN Duke University School of Nursing

2. Purpose of Presentation • Demonstrate how we are applying the complexity science concepts to studies of management practices in health care • Show evidence base for complexity science derived hypotheses

3. Self Organization • Naturally occurring system property • Arises through relationship patterns • Works for or against goals

4. System Parameters • Rate of new information flow • Nature of connections among people • Cognitive diversity Ralph Stacey, 1996

5. Conceptual Model Nursing Mgmt Practices System Control Parameters Process Outcomes • Rate of information flow thru system • Number & intensity of interconnections between agents • Level of diversity within & between cognitive schema of system agents Management Practices Self- Organization Behaviors for Quality Outcomes Alter

6. System Parameters • Rate of information flow • Nature of interconnections • Diversity within/between cognitive schema Self Organization • Management Practice • Work Environment • Participation in decision making • Communication Openness • Leadership behaviors • Workforce diversity Better & IMPROVED Outcomes

7. Agents & information diversity: | Scope Agent connection & interaction: | Intensity Depth | Information “Richness” Breadth | Information Diversity • Decision • Activities • Raising the Issue • Clarifying the Issue • Generating Alternatives • Evaluating Alternatives • Choosing Alternative • Decision • Mechanisms • Established Com. • Specially Created Com. • Informal Meetings • Chance Encounters • Other Participation in Decision Making

8. RN Participation & Improvement in Resident Outcomes • 190 Nursing Homes • Survey methods • Administrators and Directors of Nursing • Minimum Data Set • Improvement in Resident Outcomes • Anderson, R. A., & McDaniel, R. R., Jr. (1999). RN participation in organizational decision making and improvements in resident outcomes. Health Care Management Review., 24(1), 7-16.

9. What are the differences between most improved and least improved? • Controlling for: • Size • Change in Cost • RN Staffing Anderson & McDaniel, 1999

10. Do Nurses Influence Final Choices Through Participation?

11. Agent connection & interaction: | Intensity • Decision • Activities • Raising the Issue • Clarifying the Issue • Generating Alternatives • Evaluating Alternatives • Choosing Alternative • Decision • Mechanisms • Established Com. • Specially Created Com. • Informal Meetings • Chance Encounters • Other Participation in Decision Making Anderson, R. A., & McDaniel, R. R., Jr. (1998). Intensity of registered nurse participation in nursing home decision making. Gerontologist., 38(1), 90-100. Survey of 125 Nursing Homes

12. Agent connection & interaction: | Intensity • Decision • Activities • Raising the Issue • Clarifying the Issue • Generating Alternatives • Evaluating Alternatives • Choosing Alternative • Decision • Mechanisms • Established Com. • Specially Created Com. • Informal Meetings • Chance Encounters • Other Participation in Decision Making Issel, L. M., & Anderson, R. A. (2001). Intensity of case managers' participation in organizational decision making. Research in Nursing & Health., 24(5), 361-372. Survey of 68 Public Health Agencies

13. Participation of Clinical Professionals (MD and RN) = Lower Cost/admission in Hospitals Participation of MDs/RNs Participation of Middle Managers Ashmos, D. P., Huonker, J. W., & McDaniel, R. R. (1998). Participation as a complicating mechanism: The effect of clinical professional and middle manager participation on hospital performance. Health Care Management Review, 23(4), 7-20.

14. Complexity & Turnover Study • 164 Nursing Homes • Survey methods • Administrator, Director of Nursing, RNs, LPNs, CNAs (n~3500) • Medicaid Cost Reports-Turnover Anderson, R. A., Corazzini, K. N., & McDaniel, R. R. (2004). Complexity science and the dynamics of climate and communication: Reducing nursing home turnover. The Gerontologist, 44(3), 378-388.

15. Laissez-faire Climate Conflict prevents accomplishment Adm doesn’t care who gets hurt Little concern for employee relations No room for new ideas It’s who you know Unclear goals Little effort to constantly improve Administrative Climate • Reward Climate • Adm does the right thing • Adm looks out for worker • Concern for relationships • Learning encouraged • What you do–not who you know • Clear goals & expectations • Constructive feedback • Always looking for a better way

16. Accuracy Accuracy is the extent to which one believes that the information conveyed by other parties is correct Communication • Openness • Openness is the extent to which one can speak clearly and directly without fear of repercussions or misunderstanding

17. LPNs Climate, Communication & Turnover • DON tenure • Number of RNS • LPN Workload • Reward climate x Communication openness Anderson, Corazzini & McDaniel, 2004

18. Nurse Assistants Climate, Communication & Turnover • CNA Workload • Reward climate x Communication openness • Reward climate x Communication accuracy Anderson, Corazzini & McDaniel, 2004

19. Laissez-faire Climate Conflict prevents accomplishment Adm doesn’t care who gets hurt Little concern for employee relations No room for new ideas It’s who you know Unclear goals Little effort to constantly improve Explanation • Communication Openness • Openness is the extent to which one can speak clearly and directly without fear of repercussions or misunderstanding Anderson, Corazzini & McDaniel, 2004

20. Complexity, Management Practices & Resident Outcomes • 164 Nursing Homes • Survey methods • Directors of Nursing & RNs • Minimum Data Set-Resident Outcomes • Medicaid Cost Reports-Control Variables Anderson, R. A., Issel, L. M., & McDaniel, R. R. J. (2003). Nursing homes as complex adaptive systems: Relationship between management practice and resident outcomes. Nursing Research, 52(1), 12-21.

21. Control Variables • Contextual Factors • Size • Ownership Type • DON Characteristics • Tenure in position • DON Experience Nursing Mgmt Practices Communication Openness • Resident Outcomes • Prevalence of: • Resident Behaviors Problems • Restraint Use • Complications of Immobility • Fractures – Participation in Decision Making – – Relationship Leadership + Formalization Theoretical Model Anderson, Issel & McDaniel, 2003

22. System Parameters • Rate of information flow • Nature of interconnections • Diversity within/between cognitive schema • Management Practice • Communication Openness • People can say what they mean without fear of repercussion—during vertical and horizontal information exchanges. Anderson, Issel & McDaniel, 2003

23. Anderson, Issel & McDaniel, 2003 Communication Openness & Restraint Use (N=164) • Context • Size ( – ) • DON Characteristics • DON Tenure (–) • DON Experience (–) • Mgmt Practice • Communication • Openness (–) Anderson, Issel & McDaniel, 2003

24. Problem Behaviors • Context • Size ( – ) • Mgmt Practice • RN Participation in decision making (–) Anderson, Issel & McDaniel, 2003

25. Management Practice • Leadership behaviors • Relationship-oriented—product of human interaction and communication between manager and worker • System Parameters • Rate of information flow • Nature of interconnections • Diversity within/between cognitive schema Anderson, Issel & McDaniel, 2003

26. Leadership & Fracture (N=164) • Mgmt Practice • Relationship-oriented leadership (–) Anderson, Issel & McDaniel, 2003

27. Management Practice • Formalization • Centralized control using job descriptions, surveillance, and procedures and rules to ensure predictability • System Parameters • Rate of information flow • Nature of interconnections • Diversity within/between cognitive schema

28. Anderson, Issel & McDaniel, 2003 Leadership, Formalization & Complications of Immobility • DON Characteristics • DON Experience (–) • Mgmt Practice • Relationship-oriented leadership (–) • Formalization (+) N=164 Anderson, Issel & McDaniel, 2003

29. Management Practices • Work environment • Communication • Participation in decision making • Leadership behaviors • Workforce diversity • System Parameters • Rate of information flow • Nature of interconnections • Diversity within/between cognitive schema Self Organization New Behaviors

30. Things to Think About for Effectiveness • Connection • Diversity • Information exchange

31. MANAGE THE SYSTEM