NUR3114 Consolidated Notes (2) PDF

Overview of Singapore’s Healthcare System Health promotion promotes healthy living and healthy lifestyles by initiatives based on indiv and community responsibility ○ Empowers individuals to make healthy choices and lifestyle decisions for self MOH Mission, Vision and Philosophy...

Overview of Singapore’s Healthcare System Health promotion promotes healthy living and healthy lifestyles by initiatives based on indiv and community responsibility ○ Empowers individuals to make healthy choices and lifestyle decisions for self MOH Mission, Vision and Philosophy Mission Vision Philosophy Promote good health and reduce For a healthy nation with people to [Based on Affordable HC in 1993 White Paper] illness live well, live long and with a peace Ensure access to good and of mind 1) Nuture healthy nation by promoting good affordable HC that is appropriate to health needs 2) Promote personal responsibility for own Pursue medical excellence health, avoid over-reliance on welfare/insurance 3) Provide good and affordable basic medical services 4) Relying on competition and market forces → improve services and increase efficiency 5) Intervene directly in HC sector when needed if market fails to keep HC cost low [Based on Finance] Affordability and accessibility ○ Heavy subsidies for HC services Indiv responsibility ○ Co-payment ○ Risk-pool for catastrophic illness Enabling markets to work ○ Reduce market distortions (reduce abuse and moral hazard) ○ Rely on market mechs when possible Evolution in Healthcare Moving from institutional based care → population based care ○ Improve health promotion and education → reducing (re)hospitalization Integration of services ○ Inclusivity of public and private care Developing innovative models of care across care centers ○ Seamless transition ○ Based off the needs required Beyond Healthcare 2020 3 main clusters: 1) West → NUHS 2) Central → NHG 3) East → SHS (Singhealth services) Challenges Faced 1) Rapid ageing Increased consumption of HC Reduced manpower 2) Changes in chronic disease patterns 3) Changing social compact Smaller families and singlehood Economic instabilities (income inequality) Increased expectations 4) Rising HC $$ Future Ready Focus points to increase: Accessibility ○ Increasing capacity and access ○ Enhanced transport senior subsidies Quality ○ Enhancing primary and aged care quality ○ Introduction of Enhanced Nursing Home Standards (focus on dignity and psychosocial care) ○ Guidelines for homes, community and palliative care services ○ Nursing home design ○ Leveraging on info technology (e.g. NHMR and within facilities) Affordability (especially for low SES) ○ CHAS, Pioneer Generation, Merdeka Generation, MediShield/Save/Care, CareShieldLife, ElderFund 3 Key Shifts in SG’s HC System a) Beyond hospital to community ○ Integrating care across providers and settings ○ Transforming primary care ○ Developing aged care in community b) Beyond quality to value 𝑂 (ℎ𝑒𝑎𝑙𝑡ℎ 𝑜𝑢𝑡𝑐𝑜𝑚𝑒𝑠 𝑜𝑓 𝑝𝑎𝑡𝑖𝑒𝑛𝑡) 𝑉 (𝑣𝑎𝑙𝑢𝑒) = $ (𝑐𝑜𝑠𝑡 𝑜𝑓 𝑑𝑒𝑙𝑖𝑣𝑒𝑟𝑖𝑛𝑔 𝑜𝑢𝑡𝑐𝑜𝑚𝑒𝑠) Ensuring appropriate care and treatments Efficient usage of resources and manpower More productive HC delivery ○ Using data to guide decisions ○ Productivity improvements → reviewing rules and processes ○ Care and drug guidances → aiding clinical outcomes ○ Moderate fee escalation (private sectors) → overcharging behaviours, reasonable fees c) Beyond healthcare to health Initiatives across different age groups (upstream health) ○ Children → good habits ○ Adults → health maintenance, screening and early diagnosis ○ Elderly → active aging Healthcare Manpower Build future skills in existing HC workforces Grow strong local core ○ Investing in fresh grads ○ Supporting mid-career changes ○ Community support Utilizing technology ○ Improve work environment ○ Improve patient experiences Reaching out to young ○ Social media ○ Outreach programs to schools Nursing branding campaigns Retaining current staff ○ Strengthening career pathways in the nursing sectors ○ Appreciation days Health Policies: Impact on Healthcare Operations What is a healthcare policy? Decision/plan to achieve specific healthcare goals within or for a society Why have a healthcare policy? Defines vision for future Outlines priorities and expected roles of different groups; builds consensus for stakeholders Informs people (aiding in decision-making) Importance of healthcare policies: Resources are scarce and limited hence there is a need to prioritize and focus on resources available ○ Better optimization of limited resources and capabilities ○ Increased comprehensive and patient-centered care to meet evolving HC needs MOH’s Roles: Regulator System design and governance Service planning Healthcare financing Agency for care effectiveness Key principles of SG’s healthcare policy: 1) Allowing markets to function– preserve $$, no free HC 2) Individuals to be responsible for their own health 3) Transparency with information– promoting competition and reduce information asymmetry 4) Public providers focuses on social mission Shifts under Healthier SG enrolment: Past Present Episodic care Holistic patient-centered care Centre of gravity in tertiary settings Centre of gravity in primary care setting High volume acute workload Team-based care Ad hoc collaborations Private primary care as integral to wider HC system Fragmented care across settings Coordinated and seamless care Integration of GPs/family physicians to aid in supporting community health Holistic and integrated care throughout life course Preventive health → better outcomes + better sustainability Impact of HC Policies on Developments in Nursing Shift on approach to healthcare: Due to aging population and increased number of residents living with frailty, dementia and complex needs More support for aging seniors at home and community Acute sector → primary and community sectors ○ Hospital → community and homes ○ Integrated community and home-based care with health and social services Increase care integration and coordination across institutes Increased number of primary and community nurses 3C’s to transform nursing workforce: Care → enable nurses to focus on patient care Community → strengthen community nursing Competency → developing competencies to prepare for the future Advancing and developing nursing leadership: Equip with deep understanding of healthcare landscape and community sectors Imparting knowledge and skills to lead care across different facilities (acute and community) Nurses to be change agents with strong leadership and policy perspectives Organizational Structure, Culture and Values What are Organizations? Structured process where people interact and work together to achieve goals Vision, Mission, Values and Goals Vision Direction/aims for future Mission Why the organization exists Values Guides behaviour of people in the organization Goals What the organization wants to achieve Organization Structure Structure of an organization: Lines of communication and authority Allocation of rights and duties Alignment with needs and responses to environmental changes How should an organization chart be established? Chain of command Span of control Managerial level/line of communication Centrality Important Concepts Culture Climate Values Power Organizational culture: Set of shared values, beliefs and assumptions Expectations, experiences, philosophy Holds indivs together Provides direction Organizational climate: Indiv employee’s own perception towards organization Might be accurate/inaccurate Organizational value: Importance attached to something that acts as an influence and guide for behaviour E.g. Teamwork, Respect, Integrity, Honesty, Patient-centeredness What is Power? Capacity to produce/prevent change ○ Potential ability to influence to achieve goals/change attitudes and behaviour Types of power: Position Personal Reward Expert ○ Incentive offers ○ Skills, knowledge, competency and experiences Coercive ○ Penalties imposed if not Referent complying with authorities ○ Admiration/respect for another Legitimate Charismatic ○ Right to make requests (due to ○ Personal attractive one’s authority/hierarchy) characteristics Informational Self ○ Individual access to data/info ○ Individual strength and confidence Patient Safety and Risk Management In Healthcare 6 Domains of Quality Care Safe Providing safe care 0 harm to patients Timely Prevent delays– timely diagnosis and treatment Efficient Using the right resources for the right patient and time Equity Standard of practice of delivering care to patients - Regardless of type of patient - Prevent variations in giving care Effective Evidence-based results Patient-centered Based on patient’s needs and requirements Why do medical errors occur? Planned action fails to be completed OR as intended ○ Error of execution of intervention Using the wrong plan to achieve an aim ○ Error of planning ○ Due to wrong/inaccurate assessment → affects diagnosis/error Swiss Cheese Model of Safety (by James Reason) Explains how errors happen and how to prevent them Defences against hazards in systems: (no holes in the cheese): Good documentation Clear communications Regular training Effective supervision Thorough inspections But defences in the real world has ‘holes/gaps’ → allowing hazards to still pass through: Incomplete documentation Poor communication Lack of supervision for new staff Active failures and latent failures: Active failures → unsafe acts directly linked to the accident/harm ○ Usually involves frontline staff Latent failures → contributory factors that remains unseen over a period of time, contributing to the accident ○ E.g. lack of service maintenance of monitoring equipment Each ‘slice of cheese’ represents → parts of a system that defends against errors (e.g. protocols/checks) ‘Holes’ → failures/gaps in system where errors passes through Example: Evolution of Safety Culture Blame → accountability Accountability for one’s behavioural choices (just culture– giving the benefit of doubt to the person who has caused the error) Human Error At-risk Behaviour Reckless Behaviour Product of current system Unintentional risk-taking Intentional risk-taking design How it can be managed: How it can be managed: How it can be managed: Processes Remove incentives Remedial action Procedures Creating incentives for Disciplinary action Training healthy behaviours Design Increase situational Environment awareness Console Coach (to be more risk aware) Punish Risk Management in Healthcare Consideration of: ○ Patient safety ○ Quality assurance ○ Patient rights There is potential for risk in all aspects of HC Risks should always be controlled before harm can occur Fundamental steps of risk management: 1) Risk identification 2) Risk analysis 3) Risk mitigation/control 4) Risk monitoring/review Risk identification Identify potential risk factors from the incident Root cause analysis (RCA) ○ Retrospective review of past incidents ○ Establish root causes for problems and solutions ○ Minimize risk of recurrences of similar incidents Healthcare failure mode and effective analysis (HFMEA) ○ Looks at steps in a process (esp new/high risk ones) ○ Predicts where risks or failures will exist → redesign process to eliminate risks Risk analysis To determine the risk levels Patterns/frequencies of events and system defects Patient traits that are susceptible to high risks Contributing environmental elements Risk mitigation/control Formulating intervention strategies Gathering suggestions and observations from variety of sources → formulating alternative approaches to mitigate identified risks Engages end-users from the start in planning strategies and action plans Strategies to mitigate risks: 1) Risk avoidance/removal - Remove risk by doing thing differently if possible 2) Risk reduction/control - Development and implementation of policies/standards/procedures to reduce risk of AEs 3) Risk transfer - Switch responsibility/burden to another party by contract/insurance 4) Risk acceptance - Tolerating the risk → no feasible solutions at the moment and impact of risk is at an acceptable level Common strategies to consider: Reduce reliance on memory ○ visual aids/checklists Improve access to information ○ utilizing IT Error-proof processes ○ to change human behaviours Standardize tasks ○ protocols, guidelines Reducing the number of hand-offs ○ POCT  How to implement the solution: Utilizing an action plan Developing process and outcome measurements Baseline measures Implement action plan → conduct pilot test in selected area first Risk monitoring/review Communicate high alert risks to stakeholders Following up on risk treatment options ○ Analysis of risk with data collected → assess effectiveness of action Yearly review of risks register to evaluate impact Risk management and quality improvement: Risk management focus Quality improvement focus To decrease probability of incurring adverse Increase probability of achieving desired outcome outcome Better patient outcome and safety How to contribute to risk management: Effective communication Good documentation Incident management How can nurses help to build a safety culture: Report incidents timely and accurately Help to identify and assess risks Provide additional information on risks Practice risk management in daily operations Speak up on any patient-safety issues Leadership Theories and Styles Definitions Leader: Empowers and influences others Manager: Guides, directs and motivates others Management alone ≠ good leader Leadership Theories Theory 1: Trait theories (1950-1980) > Great Man Theory Some were born to lead, others were born to be led Some have certain personality traits and skills → better leaders Characteristic of successful leaders: ○ Intelligence ○ Adaptable ○ Effective communicator ○ Emotional intelligence ○ Creativity Theory 2: Behavioural theories (1940-1980) > Lewin’s and White & Litppitt suggested 3 leadership styles 1) Authoritarian → high productivity, low creativity and self-motivation 2) Democratic → high autonomy, long decision-making 3) Laissez-faire → low direction, high creativity Leaders can be made and trained Assume that there are distinctive leadership styles regarding behaviours Emphasis on what leaders do rather than qualities and characteristics Theory 3: Situational and Contingency theories > Fiedler’s Contingency Model Based off 3 situational factors 1) Leader-member relationship 2) Task structure 3) Position power Effectiveness of a leader depends on match btw leadership style and situation No one-size-fits all leadership style > Blake and Mouton’s Managerial Grid Understanding different leadership styles based on: ○ Concern for people → how much a leader prioritizes needs, well-being and development of the team ○ Concern for production → how much a leader focuses on achieving tasks, goals and productivity 5 primary leadership styles: Impoverished leadership Minimal effort (low people and production) Team and tasks are not a priority Leader is disengaged Country club leadership Focus on r/s and creating (high people, low production) comfortable environment Neglecting achieving goals Authority-compliance leadership Priority on efficiency and results (low people, high production) Little regard for team members  Middle-of-the-road leadership Tries to balance team needs (medium people, medium and tasks achievements production) Still lacking strong results Team leadership Ideal style (high people, high production) Emphasizes on collaboration, trust and high performance Values both team and tasks > Hersey & Blanchard’s Situational Model Leaders should adapt their styles to follower development style ○ How ready and willing followers are to perform tasks Based off their competence and motivation ○ 4 leadership styles (s1-4) to match development levels (d1-4) S1 DIRECTING High directive, low support D1 (Developing) Leaders giving instruction + close Inexperienced/ supervision unmotivated Good for teams that need clear guidance S2 COACHING High directive, high support D2 Leaders provide direction + Willing but lacks ability encouragements Good for teams that need both support and direction S3 Low directive, high support D3 SUPPORTING Leaders focus on building r/s and Capable but insecure sharing decision-making Good for teams that need more confidence + emotional support S4 Low directive, low support D4 (Developed) DELEGATING Leaders entrust tasks fully to Skilled and self-reliant team Good for teams that are highly capable and independent > Tannenbaum and Schmidt Continuum of Leadership How leadership styles vary depending on how much authority the leader uses vs hos much freedom the team is given ○ R/s between freedom given and amt of authority used Need for leaders to adapt their style based on situation ○ Balance control and team involvement to achieve best results ○ Using participatory style more Leader-centered → subordinate-centered leadership styles (model) Change, Innovation and Design Thinking Design thinking: Having a design action plan with a set of thinking mindsets Problem-solving, solution-based approach User-centered, centric approach Innovation When to use? Volatility Uncertain Complex Ambiguous Utilize a bottom up approach Reframe problem Validity and reliability Non-linear process  Always try to understand the problem 1) Empathize Understand or feel user Placing self in another’s position 2) Define Defining the problem before tackling it (possible solutions) Problem-statement ○ Who is the user ○ What is their needs and goals 3) Ideate Thinking of possible ideas and sketch Avoid looking for the perfect idea Cluster idea → identifying key values and group them  4) Prototype and test Creating a climate for change Engaging and enabling organization Implementing and sustaining change Lewin’s Theory of Change Force field analysis ○ Driving forces → goal ← restraining forces Theory of change (unfreeze, change, refreeze) Kotter’s 8 Steps Change Model 1) Establish sense of urgency 2) Create guiding coalition 3) Develop clear shared vision 4) Communicate the vision 5) Empower people to act on vision 6) Create short term wins 7) Consolidate and build on gains 8) Institutionalise changer Conflict Management and Building Resilience Organizational Conflict and Effectiveness Too little conflict → organizational stasis Too much conflict → reduce organizational effectiveness Types of Conflict 1) Intrapersonal → self internal conflict 2) Interpersonal → within other individuals 3) Intergroup Conflict Process Antecedent condition ○ Something that sets the scene for conflicts to happen (e.g. miscommunication, lack of resource)  Perceived conflict ○ Parties recognizing that conflict is occurring Felt conflict ○ Emotions, felt responses arises due to conflict Manifest behaviour ○ Conflict is being expressed openly ○ Arguments/disagreements Conflict resolution/suppression ○ Conflict is either addressed through resolution (problem-solving) OR ○ Through suppression (ignorance) Resolution aftermath ○ How the conflict is handled affects future r/s and interactions ○ +ve/-ve Leadership vs Management Leadership roles Management functions Self-awareness Using appropriate legitimate power Accept individual differences Facilitate conflict resolution Addressing conflicts ASAP Prepared to negotiate unit resources Supportive, role model Compromising, win-win situation Conflict Management and Resolution Win-win situation is most ideal Working together more effectively, not to defeat other person Conflict Management Techniques Confrontation → conflict is surfaced and attempted to resolve it via knowledge and reasoning Negotiation → conflicting parties give and take Conflict Resolution Strategies Avoiding Denying that the conflict exists Competing Desire to win regardless of the cost Accommodating/cooperating Neglecting own concerns, favouring others Smoothing Complimenting one’s opponent and focusing on minor areas of agreement Compromising Rewards divided equally Collaborating Everyone works together Preventing Further Conflict Assess both +ve and -ve traits and determine personality types Reviewing past conflicts Assessing communication skills of those involved Reading body language of participants Being neutral, good comms skills and eliminating external interruptions Utilize good communication skills and basic rules for mediation Value Based Healthcare Recap on the 3 Key Shifts: 1) Hospital → Community 2) Quality → Value 3) Healthcare → Health What is Value Based Care 𝑂𝑢𝑡𝑐𝑜𝑚𝑒𝑠 𝑉𝑎𝑙𝑢𝑒 = 𝐶𝑜𝑠𝑡 Value → health outcome per $1 Outcomes → health outcomes Cost → $$ it takes to reach the outcomes Value Provider value Customer value Health system Community HC system Resident Provider-institution Patient Provider-team Clinician Outcome - Must define the outcome according to the desired value definition Customer health: Community/country Resident Patient National level Provider level National Trends towards Value-Based Payment Models 1) Fee for service Providers pay specific amount for each service provided 2) Pay for performance Incentives for achieving quality targets 3) Bundled payments Single payment for clinically defined episodes of care 4) Capitated payments Single payment to manage the patient across the whole healthcare system The greater the risk, greater the opportunity National Initiatives to Enable Value Based Care Outcomes: Driving factors National initiatives to raise value/protect loss Patient health factors Beyond healthcare to health Clinician factors Clinician trainings Healthcare system factors HC facilities, infection control, manpower development Environmental factors Government– HDB, SportsSG Costs: Driving factors National initiatives to raise value/protect loss Over-prescription of services ACE Care guidelines, national value HC workgroup value driven outcomes New medical technologies ACE technology guidance Patients seeking inappropriate care ACE guidelines for insurance and other benefit plans Profit motives of providers MOH fee guidelines, MOH audits Initiatives that are key to manage $$ and protecting against loss of value: National Agency for Care Effectiveness (ACE) Value-Based Payment Provider Initiatives to Enable Value Based Care Standardization, measurement and continuous improvement are important to value enhancement E.g. Patient value compass (PVC) score methodology, Optimal care index (OCI) methodology Patient value compass: Functional outcomes Physical function Perceived well-being Mental health Social role Experience outcomes Quality of HC delivery Perception of health benefit received Delights and disappointments Costs-to-patient outcomes Direct $$ Indirect $$ Clinical outcomes Mortality Morbidity Complications Signs and symptoms Side effects SOSI (steps of systematic improvement) methodology: Systematic improvements → utilizing tools Accountability → facilitating meetings, initiating inputs/processes Measurement → building ‘dashboards’ based on best available data Purpose → team works together on concept of service Resource Management: Time and Nursing Staff 3 Basic Steps for Time Management 1) Planning and setting priorities 2) Completing tasks 3) Reprioritizing tasks Strategies Setting priorities ○ Eisenhower matrix ○ 5-right delegation ○ Important-urgent chart SMART goals ○ Specific ○ Measurable ○ Achievable ○ Realistic ○ Timely Overcoming procrastination Avoiding interruptions  a) Eisenhower matrix Urgent Not urgent Important Crisis Building r/s Deadlines Personal development Pressing issues Planning and preparation DO IT PLAN TO DO IT Not important Interruptions (e.g. TV movies meetings) Time wasters Phone calls DELEGATE DROP b) 5 right delegation 1) Right task 2) Right circumstance 3) Right person 4) Right direction/communication 5) Right supervision  c) Important-urgency chart Category of time use Examples Important and urgent Ensure sufficient staffing for next shift Important but not urgent Drafting educational program Urgent but not important Update and submitting census Time wasters Sitting and waiting for return calls Overcoming Procrastination ≠ laziness Concerning one’s attitudes and mindsets ○ Breakdown tasks ○ To do lists ○ Deadline setting Avoiding interruptions Don’t make yourself overly accessible Avoid promoting socialization Brief and precise Appointments Learning how to say ‘no’ professionally and politely Management and Motivation Management Process Step 1: Planning Determine philosophy, goals, objectives, policies, procedures and rules Step 2: Organizing Who do what Establish structure and work flow to carry out the plan Step 3: Staffing Recruitment, interviews, hiring, staff development, team building Step 4: Directing Motivating, managing conflict, delegating, communicating, facilitating collaboration Step 5: Controlling Monitoring activities to ensure tasks are done as planned Performance appraisals, quality control, legal and ethical control Henry Mintzberg’s Managerial Roles and Functions (1973) 1) Interpersonal 2) Informational 3) Decisional Interpersonal roles: a) Figurehead → perform routine duties of legal/social nature b) Leader → responsible for motivation and direction of employees c) Liaison → expands outside information sources and networks Informational roles: Monitor → internally seek information about organization Disseminator → sharing information within organization Spokesperson → sharing information with individuals outside of organization Decisional roles: Entrepreneur → seeking ways to problem solve or improve organization Disturbance handler → reponds to problems Resource allocator → manages time and coordinates efforts Negotiator → mediates resources or decisions with outside forces Theories involved: 1) Maslow Hierarchy of Needs 2) Alderfer’s EFG 3) Skinner’s Reinforcement theory 4) Hezberg’s 2-factor theory 5) McClelland’s acquired needs 6) McGregor’s Theory X and Y Maslow Hierarchy of Needs Alderfer’s ERG (similar to MHN) Skinner’s Reinforcement Theory +ve reinforcement Praising employees +ve behaviour followed by +ve consequences -ve reinforcement Stops nagging at employees +ve behaviour followed by removal of negative consequences Punishment Demotion of employee -ve behaviour followed by -ve consequences Extinction Ignoring behaviour -ve behaviour followed by removal of +ve consequences Hertzberg 2 Factor Theory McClelland’s Theory of Needs Need for power Need for affiliation Need for achievement McGregor X-Y Theories