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Managing for Success in Health Care Delivery. What can we do?. Ruth A. Anderson RN, PhD, FAAN Duke University School of Nursing. Purpose of Presentation. Demonstrate how we are applying the complexity science concepts to studies of management practices in health care
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Managing for Success in Health Care Delivery What can we do? Ruth A. Anderson RN, PhD, FAAN Duke University School of Nursing
Purpose of Presentation • Demonstrate how we are applying the complexity science concepts to studies of management practices in health care • Show evidence base for complexity science derived hypotheses
Self Organization • Naturally occurring system property • Arises through relationship patterns • Works for or against goals
System Parameters • Rate of new information flow • Nature of connections among people • Cognitive diversity Ralph Stacey, 1996
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
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
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
RN Participation & Improvement in Resident Outcomes • 190 Nursing Homes • Survey methods • Administrators and Directors of Nursing • Minimum Data Set • Improvement in Resident Outcomes • Anderson, R. A., & McDaniel, R. R., Jr. (1999). RN participation in organizational decision making and improvements in resident outcomes. Health Care Management Review., 24(1), 7-16.
What are the differences between most improved and least improved? • Controlling for: • Size • Change in Cost • RN Staffing Anderson & McDaniel, 1999
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
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
Participation of Clinical Professionals (MD and RN) = Lower Cost/admission in Hospitals Participation of MDs/RNs Participation of Middle Managers Ashmos, D. P., Huonker, J. W., & McDaniel, R. R. (1998). Participation as a complicating mechanism: The effect of clinical professional and middle manager participation on hospital performance. Health Care Management Review, 23(4), 7-20.
Complexity & Turnover Study • 164 Nursing Homes • Survey methods • Administrator, Director of Nursing, RNs, LPNs, CNAs (n~3500) • Medicaid Cost Reports-Turnover Anderson, R. A., Corazzini, K. N., & McDaniel, R. R. (2004). Complexity science and the dynamics of climate and communication: Reducing nursing home turnover. The Gerontologist, 44(3), 378-388.
Laissez-faire Climate Conflict prevents accomplishment Adm doesn’t care who gets hurt Little concern for employee relations No room for new ideas It’s who you know Unclear goals Little effort to constantly improve 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
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
LPNs Climate, Communication & Turnover • DON tenure • Number of RNS • LPN Workload • Reward climate x Communication openness Anderson, Corazzini & McDaniel, 2004
Nurse Assistants Climate, Communication & Turnover • CNA Workload • Reward climate x Communication openness • Reward climate x Communication accuracy Anderson, Corazzini & McDaniel, 2004
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
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.
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
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
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
Problem Behaviors • Context • Size ( – ) • Mgmt Practice • RN Participation in decision making (–) Anderson, Issel & McDaniel, 2003
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
Leadership & Fracture (N=164) • Mgmt Practice • Relationship-oriented leadership (–) Anderson, Issel & McDaniel, 2003
Management Practice • Formalization • Centralized control using job descriptions, surveillance, and procedures and rules to ensure predictability • System Parameters • Rate of information flow • Nature of interconnections • Diversity within/between cognitive schema
Anderson, Issel & McDaniel, 2003 Leadership, Formalization & Complications of Immobility • DON Characteristics • DON Experience (–) • Mgmt Practice • Relationship-oriented leadership (–) • Formalization (+) N=164 Anderson, Issel & McDaniel, 2003
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
Things to Think About for Effectiveness • Connection • Diversity • Information exchange