Complex Health Care Organizations Research Articles

Evaluation of leadership practices: how to develop a vision

Leadership competencies and more specifically a strategic vision are essential to managing increasingly complex healthcare organisations and change. However, Switzerland, like many other countries, has identified a lack of leadership skills among nurse leaders. Therefore the Royal College of Nursing’s (RCN) Clinical Leadership Programme has been adapted, implemented and evaluated in the Swiss nursing context. The aim of this qualitative study was to evaluate the Leadership Programme’s support for vision development. In-depth interviews with six nurse leaders, who were purposefully selected according to the quantitative results of the overall mixed-methods evaluation project were included. Interviews were audio-recorded and transcribed prior to qualitative content analysis. Findings showed the different approaches used in the process of vision formation. Some used cognitive-analytical techniques and proceeded very methodically and systematically, whereas others described a more intuitive approach. Some also used a combination of both approaches. Participants experienced fostering and hindering factors on different levels – personal as well as organisational. The identified factors in vision development may be helpful in the planning of educational programmes to facilitate visionary skills among nurse leaders. Vision formation requires time for reflection and the ability of creative thinking, which is distinct from day-to-day management tasks.

The Need for Effective Management in African Health Systems

Effective health management is critical at every level of African health systems in order to improve services and in turn the current poor health situation in many countries. Specialized professional training equips health-care workers for clinical services, but is limited in preparing them for the management of complex health care systems and organizations. Health management involves technical and social processes for achieving health objectives through effective and efficient use of health resources in view of social, economic, political and cultural realities. Basic functions expected of African health managers include health policy analysis and formulation, health planning, organizing, implementing, leading, coordinating, controlling, monitoring and evaluating services. Health managers at primary, secondary and tertiary levels require additional specialist training in health management to acquire knowledge and skills needed for effective and efficient management of complex health-care organizations. This, in turn, facilitates application of tested theories, systematic approaches and best practices in addressing the health needs of the people. Objective This article advocates effective health-care management in order to achieve the Millennium Development Goals, health goals of the New Partnership for Africa’s Development, national health goals and to promote quality in health care, equity and justice. These culminate in improving health of the people and changing the poor health indices. It also outlines, in brief, the basic functions expected of African health managers and concludes by advocating health-management training for strategic, departmental and operational managers at different levels in the health system. Method I wrote this article based on literature review, experience working with federal and state ministries of health in Nigeria and anecdotal reports from senior health officials and public health students.

Many Large Medical Groups Will Need To Acquire New Skills And Tools To Be Ready For Payment Reform

Federal and state policy makers are now experimenting with programs that hold health systems accountable for delivering care under predetermined budgets to help control health care spending. To assess how well prepared medical groups are to participate in these arrangements, we surveyed twenty-one large, multispecialty groups. We evaluated their participation in risk contracts such as capitation and the degree of operational support associated with these arrangements. On average, about 25 percent of the surveyed groups' patient care revenue stemmed from global capitation contracts and 9 percent from partial capitation or shared risk contracts. Groups with a larger share of revenue from risk contracts were more likely than others to have salaried physicians, advanced data management capabilities, preferred relationships with efficient specialists, and formal programs to coordinate care for high-risk patients. Our findings suggest that medical groups that lack risk contracting experience may need to develop new competencies and infrastructure to successfully navigate federal payment reform programs, including information systems that track performance and support clinicians in delivering good care; physician-level reward systems that are aligned with organizational goals; sound physician leadership; and an organizational commitment to supporting performance improvement. The difficulty of implementing these changes in complex health care organizations should not be underestimated.

Re-Engineering the Post-Discharge Appointment Process for General Medicine Patients

Patients are vulnerable to issues that emerge after discharge from the hospital, and this susceptibility is compounded as patients attempt to navigate complex healthcare organizations. Post-discharge clinic appointments may provide the opportunity to mitigate risks posed to patients during this vulnerable time. Our aim was to determine whether actively engaging patients in scheduling post-discharge appointments before leaving the hospital affects the rate of patients seeing an ambulatory care physician. This was a prospective cohort pilot study from May to July 2007 with a historical convenience control from 2003. The setting was an inpatient academic tertiary care referral center in the US. Study participants had been discharged from a general medicine hospitalist service during the study time period. Patients, or their designated caregivers, were contacted in hospital rooms to schedule a post-discharge appointment before discharge. The primary outcome was rate of attendance at post-discharge appointments, determined a priori. Eighty-three patients with 115 scheduled appointments in the intervention group were compared with 306 patients with 398 appointments in the historical control group. The attendance rate was 59.5% in the control group versus 78.3% in the study group (p < 0.0001). Patients received 1.3 discharge appointments per discharge in both the historical and study group. In a limited evaluation, the study group had a trend towards a lower return rate to the emergency department within 3 days of discharge (1.2% vs 3.8%, nonsignificant), and a lower readmission rate within 14 days of discharge (10.8% vs 11.8%, nonsignificant). Our patient-centered process for helping patients arrange their post-discharge appointments before discharge improved the attendance rate at those appointments.

Management knowledge and skills required in the health care system of the Federation bosnia and herzegovina.

Extremely complex health care organizations, by their structure and organization, operate in a constantly changing business environment, and such situation implies and requires complex and demanding health management. Therefore, in order to manage health organizations in a competent manner, health managers must possess various managerial skills and be familiar with problems in health care. Research, identification, analysis, and assessment of health management education and training needs are basic preconditions for the development and implementation of adequate programs to meet those needs. Along with other specific activities, this research helped to determine the nature, profile, and level of top-priority needs for education. The need for knowledge of certain areas in health management, as well as the need for mastering concrete managerial competencies has been recognized as top-priorities requiring additional improvement and upgrading.

Ontology-driven execution of clinical guidelines

Clinical guidelines (CG) contain general descriptions, defined by health care organisations, of the way in which a particular pathology should be treated. Their adoption in daily care offers several benefits to both patients and practitioners, such as the standardisation of the delivered care and the reduction of errors, but, at the same time, there are several issues that limit their application. CGs are designed to cover a disease taking into account the available evidence but are not designed to be deployed in a particular hospital or healthcare institution. CGs include general recommendations that should be translated according the particular settings before adoption in daily care. This adoption should also specify accountable information about the responsible actors of performing actions in healthcare teams in order to avoid errors arising during delegation/assignment of tasks. In addition, this enactment is not performed taking into account a central knowledge base or a single actor. This paper proposes the combination of a multi-agent system modelling complex healthcare organisations and knowledge representation techniques in order to build a general framework for enabling the enactment of CGs in the context of a medical centre. As a main contribution, the ontological paradigm and the expressiveness of modern ontology languages are used to design, implement and exploit a medico-organisational ontology aimed to provide the semantics required to support the execution of clinical guidelines. The knowledge-driven guideline enactment is managed by a multi-agent system modelling in a distributed fashion the clinical entities involved in the care delivery.

Reclaiming time for nursing practice in nutritional care: outcomes of implementing Protected Mealtimes in a residential aged care setting

To improve nutritional care and the mealtime experience of older people in a residential aged care setting by assisting nurses to create change to their practice and to the mealtime environment. Despite being preventable and treatable, inadequate nutrition remains a problem for many older people in residential aged care and tertiary health care settings. Nevertheless, many organisations are uniquely positioned to implement solutions that will lead to better care. The study used a qualitative, action research approach, grounded in the participatory worldview. The multimethod approach of data and between-method triangulation were chosen to assist in understanding the multidimensional issues associated with resident mealtimes and the provision of nutritional care. The collection of non-participant observations was informed by aspects of the Developmental Research Sequence. Action group meetings and non-participant observations were qualitatively analysed using the Analytic Hierarchy. Protected Mealtimes was tailored for the residential aged care unit. The most significant change involved the transformation of system processes by creating the space in nurses' busy schedules and thus reclaiming time for nurses to reconnect with nutritional care. Fixed role boundaries were made flexible by assisting individuals to understand and extend their roles in nutritional care. Most importantly, sustainability of Protected Mealtimes was achieved and long-term changes around nutritional care continued to be resident focused. This study demonstrates that lasting changes to nursing practice in nutritional care can be achieved by applying the principles of a participatory worldview and action research. CHANGE is challenging to achieve in complex health care organisations. This study bridges the gap between theory and practice and has shown that nurses can create change by employing a participatory worldview and action research as part of their toolkit for problem solving.

New graduate nurse practice readiness: Perspectives on the context shaping our understanding and expectations

Workforce shortages, fiscal restraint, complex healthcare organizations, increasing patient acuity, the explosion of knowledge and technology and the ever expanding role of nurses in healthcare have reinforced the importance of new graduates arriving in the work setting with the ability to move seamlessly into practice. This idea of moving seamlessly into practice is often referred to as practice readiness. Differing perspectives exist between nurses in the practice and education sector about the practice readiness of new graduates. The aim of this study was to understand the perspectives of nurses about new graduate nurse practice readiness and the underlying context shaping these perspectives. Focus groups involving 150 nurses with varying years of experience in the practice, education and regulatory sector were conducted. The findings revealed that participants' expectations and understandings of new graduate practice readiness were influenced by the historical and social context within which nursing education and professional practice is grounded. These differences centered around three main areas: the educational preparation of nurses (diploma or degree), the preparation of the technical versus the professional nurse, and the perceived responsibilities and accountabilities of the education and practice sector for the educational preparation of nurses. To shift the discourse around practice readiness, nurses from all sectors must focus on unique, innovative and cooperative solutions to ensure the seamless transition of all nursing graduates in the 21st century healthcare system.

Core Competencies of the Entrepreneurial Leader in Health Care Organizations

The purpose of this article is to discuss core competencies that entrepreneurial health care leaders should acquire to ensure the survival and growth of US health care organizations. Three overlapping areas of core competencies are described: (1) health care system and environment competencies, (2) organization competencies, and (3) interpersonal competencies. This study offers insight into the relationship between leaders and entrepreneurship in health care organizations and establishes the foundation for more in-depth studies on leadership competencies in health care settings. The approach for identifying core competencies and designing a competency model is useful for practitioners in leadership positions in complex health care organizations, so that through the understanding and practice of these 3 areas of core competencies, they can enhance their entrepreneurial leadership skills to become more effective health care entrepreneurial leaders. This study can also be used as a tool by health care organizations to better understand leadership performance, and competencies can be used to further the organization's strategic vision and for individual improvement purposes.

Nursing Faculty Mentors as Facilitators for Evidence-Based Nursing Practice

Increasing use of evidence-based practice (EBP) within complex healthcare organizations requires the identification of individuals who will support and facilitate new practice patterns. In a large Midwestern hospital, a diverse group of academic nursing faculty functioning as mentors to develop clinical nurses' skills in the use of EBP has demonstrated early success. This article highlights the context, challenges, and successes of faculty mentors for developing nursing staff's involvement in and use of EBP.

Administrative Decision Making

Today's health care organizations face tremendous challenges and fierce competition. These pressures impact the decisions that managers must execute on any given day, not to mention the ever-present constraints of time, personnel, competencies, and finances. The importance of making quality and informed decisions cannot be underestimated. Traditional decision making methods are inadequate for today's larger, more complex health care organizations and the rapidly changing health care environment. As a result, today's health care managers and their teams need new approaches to making decisions for their organizations. This article examines the managerial decision making process and offers a model that can be used as a decision making template to help managers successfully navigate the choppy health care seas. The administrative decision making model will enable health care managers and other key decision makers to avoid the common pitfalls of poor decision making and guide their organizations to success.

The enactment of dynamic leadership

The purpose of this paper is to empirically examine how clinical team leadership can facilitate a collaborative team and, in doing so, drive change in a health service. Ethnographic field work was conducted with a clinical team, comprised of 13 health professionals, in community health, in Sydney Australia. Utilising semi-structured interviews, data were collected and then analysed using Goleman's leadership typology as an analytic lens. Leadership can facilitate a team to realise high levels of collaboration, trust and respect. This creates an environment in which collective learning and increased responsibility thrives. Together, these elements enable front-line staff to take ownership of their services, to integrate the organising and delivery of services, and, in doing so, improve health care practice. The leadership empirically observed here confirms qualities, behaviours and approaches that have been argued as important in the literature. For health professionals in a clinical team leadership role Goleman's typology can be instructive. Many leaders in complex health care organisations are engaged in, and needing to respond to, unfolding situations to ensure positive improvement. At such times the typology offers a range of leadership styles to draw upon. The application of the typology to health care clinical team leadership is a new development.

Nurse/Physician Conflict Management Mode Choices

In today's complex healthcare organizations, conflicts between physicians and nurses occur daily. Consequently, organizational conflict has grown into a major subfield of organizational behavior. Researchers have claimed that conflict has a beneficial effect on work group function and identified collaboration as one of the intervening variables that may explain the relationship between magnet hospitals and positive patient outcomes. The purpose of this study was to identify and compare conflict mode choices of physicians and head nurses in acute care hospitals and examine the relationship of conflict mode choices with their background characteristics. In a cross-sectional correlational study, 75 physicians and 54 head nurses in 5 hospitals were surveyed, using the Thomas-Kilmann Conflict Mode Instrument. No difference was found between physicians and nurses in choice of the most frequently used mode in conflict management. The compromising mode was found to be the significantly most commonly chosen mode (P = .00) by both. Collaborating was chosen significantly more frequently among head nurses (P = .001) and least frequently among physicians (P = .00). Most of the respondents' characteristics were not found to be correlated with mode choices. The findings indicate a need to enhance partnerships in the clinical environment to ensure quality patient care and staff satisfaction.

Taking Aim at Fall Injury Adverse Events: Best Practices and Organizational Change

Fall injuries represent a huge healthcare, social and financial burden to the Canadian population. In 2004, the McGill University Health Centre (MUHC) was awarded recognition as a National Spotlight Organization for Implementation of the Registered Nurses Association of Ontario Best Practice Guidelines (BPGs). That same year, the author and co-leader of the Best Practice Guideline Program began the CHSRF Executive Training in Research Application (EXTRA) Program with the goal of reducing falls injuries, one of the most common adverse events in the MUHC and in acute care in Canada. This demonstration project used multiple strategies to strengthen a culture of safety and improve performance relating to adverse events, including: pilot testing several evidence-based falls prevention interventions (autumn 2005), training teams of champions to work across multiple sites, developing an infrastructure to support organizational change, modifying existing quality indicators to become benchmarkable, conducting a cost analysis of falls prevention, evaluating pre- and post-pilot surveys of organizational climate and obtaining initial baseline measures of the safety climate within the organization. Positive patient, practitioner and organizational outcomes suggest that falls safety prevention is feasible in large, complex healthcare organizations--and that safety is both a moral and a financial imperative. Next stages of the BPG program include full rollout, and measuring sustainability via a formal outcome evaluation study.

Leadership development in healthcare: a qualitative study

AbstractChallenges associated with leading a $1.7 trillion industry have created a need for strong leaders at all levels in healthcare organizations. However, despite growing support for the importance of leadership development practices across industries, little is known about leadership development in healthcare organizations. An extensive qualitative study comprised of 35 expert interviews and 55 organizational case studies included 160 in‐depth, semi‐structured interviews and explored this issue. Across interviews, several themes emerged around leadership development challenges that were particularly salient to healthcare organizations. Informants described how the relative newness of leadership development practices in a majority of healthcare organizations contributes to an overall perception of haphazard practices throughout the industry. In addition, respondents noted challenges associated with developing leaders who would be representative of the patient community served, and commented on the pressure to segregate different professional groups for leadership development. Framed by these challenges, I propose a conceptual model of commitment to leadership development in healthcare organizations as influenced by three factors—strategy, culture, and structure. These, in turn, influence program design decisions and can impact organizational effectiveness. In the context of inherently complex healthcare organizations where leaders must respond to multiple stakeholders and meet performance goals across multiple dimensions of effectiveness, addressing these reported challenges and considering the importance of organizational commitment to leadership development can help ensure that programs are effectively designed, delivered, and sustained. Copyright © 2006 John Wiley &amp; Sons, Ltd.

Effective people: leadership and organisation development in healthcare Stephen Prosser Effective people: leadership and organisation development in healthcare Radcliffe 208 £27.95 1857756940 1857756940

Effective People: Leadership and organisation development in healthcare examines the challenging area of achieving effectiveness with people and within complex health care organisations. Although it is specifically nursing focused, it asks if the actions of leaders have positive effects on others and the organisation’s effectiveness and thus is highly relevant to current nursing practice and leadership.

Nurses’ information management across complex health care organizations

The purpose of this study was to describe the information management used by hospital and home care nurses for patients in need of continuing care after an episode of hospitalization. A prospective descriptive design was used. In total 287 hospital nurses and 220 home care nurses were asked to complete a questionnaire before and after the hospital implemented nursing documentation integrated in the electronic patient record (EPR). Discrepancies between the policies expressed by the health care organizations and the authorities in formal documents and the information management used by the nurses were identified. Differences were also found between nurses in hospital and home care with regard to how they assessed the information management during patient admission, throughout the patient's hospital stay and at the patient's discharge. The perceived differences decreased, however, after the hospital introduced electronic nursing documentation. The study shows a need to contextualize and customize the information that nurses exchange. In addition technological problems with the lack of integrated EPR systems between the hospital and the home health care as well as different practice models in the two organizations entail complex information handling during a patient's trajectory through the health system.

The organizational and performance effects of nurse practitioner roles.

Most studies evaluating the roles of Nurse Practitioners have compared the care delivered by individual Nurse Practitioners with that provided by other professionals. These studies should be complemented by research focusing on a higher unit of analysis, namely the organization of the care process for a specific patient group. The most important reason is that Nurse Practitioners are increasingly involved in direct, multiprofessional care in complex health care organizations and networks. In these work settings, their roles may, in both positive and negative ways, lead to changes in the organization of the entire care delivery system. The aim of this paper is to stimulate awareness and evaluation of these organizational changes and their potential impact on the effectiveness of the care process. A conceptual model based on patterned systems contingency theory is proposed. With the help of this model, attention is drawn to issues at the level of the organization and the effectiveness of the care processes that merit attention when Nurse Practitioner positions are being introduced. These issues are derived from case studies in Dutch hospitals. According to the model, a Nurse Practitioner position will change the work structure of the care process involved. Therefore, the effectiveness of a Nurse Practitioner position will be dependent on the changes realized in the work structure. The resulting structure should fit the task characteristics of the care services demanded by the specific patient group. On the basis of this model and the examples presented, questions for further study are formulated. Nurse Practitioner roles can only enhance the effectiveness of care processes when embedded in a work structure that is internally consistent and adjusted to the task environment and available skill-mix. A structural contingency framework may be helpful in identifying relevant organizational issues. To determine the effects of Nurse Practitioner roles, cross-sectional as well as longitudinal studies are needed.

Continuous quality improvement for radiologists 1: critical thinking skills symposium

Continuous quality improvement methods provide a relatively new way to improve quality in healthcare by using a systems approach with key features of customer-mindedness, data collection, experimentation, and teamwork. CQI is not meant to solve simple problems but is increasingly applied in our complex healthcare organizations. In fact, CQI is as much philosophy as it is both a qualitative and quantitative method to assess quality. This review describes the general methods and potential application for radiologists.

Managing change: an overview.

As increasingly powerful informatics systems are designed, developed, and implemented, they inevitably affect larger, more heterogeneous groups of people and more organizational areas. In turn, the major challenges to system success are often more behavioral than technical. Successfully introducing such systems into complex health care organizations requires an effective blend of good technical and good organizational skills. People who have low psychological ownership in a system and who vigorously resist its implementation can bring a "technically best" system to its knees. However, effective leadership can sharply reduce the behavioral resistance to change-including to new technologies-to achieve a more rapid and productive introduction of informatics technology. This paper looks at four major areas-why information system failures occur, the core theories supporting change management, the practical applications of change management, and the change management efforts in informatics.