Clinical Corner : Leadership

Health care reform and LTC: Part IV

Carol Kleinman — Fri, 06 Nov 2009 16:47:00 GMT

Health care reform is not possible without health insurance coverage. It comes as no surprise that health insurance decisions are not always made in the best interest of the patient. As Michelle Obama related, in some states it is still legal to deny a woman coverage because she's been the victim of domestic violence. Health care premiums have doubled since 2001 and the cost of care for the uninsured has skyrocketed.

We should consider supporting public policy initiatives that:

Achieve universal coverage through market-based solutions while avoiding a one-size fits all approach
Encourage patient responsibility and financial accountability for lifestyle and health care decisions
Provide employers and individuals with access to affordable, high quality coverage options
Establish the expectation that each American will maintain some form of insurance coverage

Role Conflict and the Nurse, Part II

Carol Kleinman — Thu, 16 Oct 2008 16:42:00 GMT

An organizational environment that provides open communication and joint problem solving between staff and managers is associated with less role conflict among nurses. Job dissatisfaction and turnover are the primary significant negative organizational outcomes of role conflict. Other negative outcomes include absenteeism, less professional behavior, lack of commitment to the organization, psychological strain, emotional exhaustion, depersonalization toward patients while providing nursing care, stress, and burnout. These negative employee and organizational outcomes provide the basis upon which to develop strategies for reducing role conflict.

Leadership behaviors should provide the following: an organizational environment that supports open discussion of ideas among all levels of staff, articulation of clear goals, visibility and availability to staff, reasonable standards for high performance, and emphasis on team relationships. Support from managers and administrators as well as peers is an effective mediator of role conflict.

Initiating a supportive discussion format for staff in which they are able to meet both informational and emotional needs is an important strategy. This might be implemented through separate meetings or by allowing staff meetings to evolve into a dialogue that not only communicates pertinent information but includes discussions among and with staff regarding their emotional needs. This strategy should also be implemented between managers and staff during one-to-one interactions.

Of great importance is role clarity and feedback regarding job performance expectations and the understanding of reciprocal role expectations of nursing and non-nursing work group members. Sharing job descriptions across disciplines may be an effective strategy that will allow staff to articulate expectations for themselves and others in specific patient care situations.

It appears the real crux of the issue for managers and administrators in reducing role conflict is the need to facilitate team-building across all members of the health care team. Team development exercises play an important role; these exercises might involve role playing, practicing effective communication techniques, and interactive assignments to enhance team work. Certainly, all nurses would benefit from learning team-building strategies in continuing education programs provided by long term care organizations.

Part 11: Creative strategies for revenue generation: an example

Carol Kleinman — Tue, 12 Aug 2008 17:26:00 GMT

Not long ago, I helped one of our local hospitals develop an enhancement to an existing program. I had been asked to consult with a wound care program from a psychiatric perspective on the relatively high percentage of patients who were noncompliant with their treatment regimens.

I became fascinated with the issue as I wondered why patients would not want their wounds to heal! I implemented a pilot study and gave simple psychological tests to patients, discovering that many were clinically depressed and this is what accounted for their lack of compliance, based on their belief their wounds would never heal. he findings allowed the department to develop an psychiatric intervention component to the program and to bill for services rendered by the psychiatrist and psych NP who began to work with the program.

Can any of you think of a similar idea for generating revenue?

There are many opportunities for money-making ventures that we never think about. Often we are allowing other businesses to make money on our efforts and that represents giving money away. One great example is home health. For years we referred patients to external home health agencies until, one day, someone said, "Why don't we do it ourselves?" and the hospital-based home health agency was born!

Not all new ideas will make money or even have revenue attached to them. Often the new ideas we come up with and implement will serve other purposes. Some will improve patient care significantly, others will save money though not generate any, still others will enhance the image of the organization, while some are "loss leaders" and get people in the door who will then avail themselves of our other services.

Unhappily, generating revenue and making money are not usually considered a bonus. Most of our programs, products, and services need to have positive cash flow and at least some profit margin as the excess of revenue after expense is needed to grow the organization, to support those services that lose money, and to offset bad debt. Nonetheless, making money is a collaborative effort and the "idea" person is just as important as the "implementation" person.

All new initiatives are important to the business-minded nurse leader and there are projects that are important and viable but do not make much money-though certainly most will need at least to break even if you wish to have them supported by administration!

Part 10: More Budget Secrets

Carol Kleinman — Thu, 31 Jul 2008 17:31:00 GMT

Budgets are done initially as computer-modeled projections based on previous performance. What that means is that the computer looks at what was spent and models a budget for the next cycle based on that amount. Thus, if you spend less, you will get less. It's pretty weird, but it reflects the belief that you do not need as much as was allocated.

In the real world, while all budget line items are examined, the greatest focus is placed on staff costs, followed by supply costs. I work very hard to keep those two in line. But for other line items, I have a policy of not only spending every penny, but of going over five to ten percent every year. That is often not enough of a variance in these areas to attract much attention and it allows me to be allocated just a little more next year. This strategy allowed me, over several years, to develop a few subaccounts with money I could use in various ways to the benefit of my staff and the unit. I call this "creative accounting..."

Believe me, I learned this strategy the hard way by being very attentive to budget limits and staying just under budget across the board...only to be allocated less the following year! In general, as managers you should spend up to...and even slightly over...the limit for line items (other than salaries and patient supplies, of course). I even suggested to my managers when I was the CNE (though I deny I ever said it!) that they do so as it helps all the nursing units. Sometimes, there will even be money left over in various subaccounts.

Whether or not you will be able to use the money left over toward something else is a question you will need to find out from your organization. Some allow the transfer of funds from one subaccount to another and this should certainly be explored as it will allow you to spend the money where it is most needed. Even if this is not possible, I would spend all I could on, for example, journal subscriptions, because it will tell your staff you are interested in their growth as professionals. Using the funds for books and creating a unit-based library of reference books is often another way to use subscription funds. There are truly many ways to develop creativity in managing the budget!

In most of my facilities I was able to move money from one account to another through an interaccount transfer and that helped me pool funds for different purposes. I also worked directly with finance to create new subaccounts and transferred money into them from other subaccounts. For example, there was no account for journals and books and I was able to create one so staff could have resource books and current journals available on the units.

Another example was the staff request for new lockers, to which I believed they were entitled to keep their things safe. However, in total the lockers would have cost much more than $1000, putting them in the category of a capital request, which I knew would never be approved. The cost was also more than I could authorize at the time as a nurse manager, as my signing authority was limited to $1000 and my director would have had to approve the purchase, which she would not have done. So I ordered them but used the subaccount of minor equipment (which was for beepers and cell phones and the like), ordering six at a time and doing that every couple of months until everyone had a new locker.

Managers (and even administrators) have spending limits on what they can purchase on their signature alone. Going above that figure requires the signature of a higher-level manager. As I have no interest in bringing some of my activities to their attention, I am always below that number. So, if my limit is $1000, I may have three or four orders for $900. I share this with the vendors and ask for bills or invoices for those numbers and they always comply...they also know the game!

Part 9: The Courage to Lead

Carol Kleinman — Mon, 28 Jul 2008 16:11:00 GMT

As I developed the recent blog entries, I was led to reflect on what is required of our leaders in the current health care environment. It seems to me that so many of those who allege to lead us suffer from a failure or fear to act. I think courage is one of the key elements required of true leaders, though I am not sure how much you will read about it in the literature. I know it is scary, but we must gird our loins and face the demons for the sake of the patients and our staff.

Are all of you ready to do that?

You might be interested in what I was able to come up with in the literature on the subject of courage in leadership. I think courage and a willingness to take risks instead of playing it safe is a key characteristic of great leaders.

-Clancy, T. (2003). Courage and today's nurse leader. Nursing Administration Quarterly, 27, 128-132.

-Hader, R. (2007). Leadership anxiety? Choose courage over complacency. Nursing Management, May, 6.

-Fifer, J. (2006). Courage in leadership: like a long distance runner? Healthcare Financial Management, November, 32.

-Fifer, J. (2006). Courage to lead in the revenue cycle. Healthcare Financial Management, September, 200.

Thinking about courage in leadership led me to reflect upon how management/administration is viewed by the rank and file. So often, administration is regarded with suspiciousness and doubt as staff believe they are not being told everything and think there is a hidden agenda that explains management's actions. However, once we are on the other side of the fence, it is so much different. Of course I would prefer transparency, just as I prefer complete honesty in personal relationships. But we all know that we must balance such honesty with tact and compassion. If we said everything we thought and felt to our spouses, significant others, parents, children, and friends...we would likely be voted off the island! The same is true for openness and honesty in management. How do we balance openness with the need to know? What if I need to be deceptive, but for a good reason?

Part 6: Management Tip - Staff Buy In

Carol Kleinman — Thu, 05 Jun 2008 20:24:00 GMT

One of the things I had ongoing on all my units was a wish list in the staff lounges on which anyone could put a request for something they wished to have purchased. I always did my best, at every administrative level, to acquire as much as I could of what staff wanted and needed. It is one form of support for their efforts that recognized their value.

One of the most interesting things to me about this strategy is that staff did not ask for raises or longer breaks or fewer patients, which I could not grant. They asked for things like reference books, lockers (that could actually lock), educational classes about clinical topics, a water cooler, and so on. These things required little money and made a huge impact as I was the first director who had every asked what they wanted or needed and then provided them with their requests. If affirmed their value and let them know I was listening and really cared.

Change, Part 4

Carol Kleinman — Tue, 19 Feb 2008 19:25:00 GMT

I thought I would share an online article by Rosabeth Kanter called "The Enduring Skills of Change Leaders." The abstract in the Harvard Business Review states, “Leaders use seven leadership skills in conceiving and managing change projects, whether innovations in established organizations, culture and process changes, or entrepreneurial ventures for industry or social change. The skills leaders need are different at various phases of change projects. Offers details and also discusses the rhythm of change and resistance to change.”

Ms. Kanter says that leaders can order change, but the kind of change that is long lasting is built slowly throughout the organization with input from many people. People cannot be forced to change. Change comes from people using their imaginations and working together. People from many levels need share goals. She outlines seven classic skills useful for leaders.

1. Tuning in to the environment.

2. Challenging the prevailing organizational wisdom.

3. Communicating a compelling aspiration.

4. Building coalitions.

5. Transferring ownership to a working team.

6. Learning to persevere.

7. Making everyone a hero.

Leadership Development in Long-Term Care

Carol Kleinman — Thu, 06 Dec 2007 22:56:00 GMT

The long term care industry reflects the rapid changes experienced by the entire healthcare industry. A new generation of nurse leaders is desperately needed, leaders who are able to respond as we are being asked to become more cost-conscious and understand the financial realities that drive care. Nurse managers are responsible for cost centers and staff nurses have become care coordinators. All nurses must be sensitive to the costs of providing care as managed care initiatives force a focus on resource management and staff nurses are expected to be knowledgeable about cost-driven clinical pathways and variances from them. How are we to cope with this avalanche of increased responsibility?

As a great nurse, you possess a sound knowledge of patient needs but clinical skills are of even greater value when combined with an understanding of the "business" of nursing practice. Do you have an idea for a new product or service? Have you found a new piece of equipment that will facilitate better resident care? Are you responsible for staffing and scheduling on your shift? Are you comfortable delegating to and supervising unlicensed assistive personnel?

You may have already been asked by your manager or director to write up a proposal, develop a budget, or create a justification for one of your initiatives. Do you feel poorly prepared for the task? If you have not been asked yet, chances are you soon will be, especially if you seek to move up the ladder into a position of increased responsibility. These tasks are now commonplace in a health care environment in which nurses are the new care managers. These concepts and skills were never taught in our basic nursing programs and many of us are unprepared for the demands upon us. It is clear the long term care market has changed and educational preparation for leadership roles within our organizations must mirror the new demands.

What is the answer?

One solution is through formal educational programs. Preparation in integrated nursing and business programs results in a grounded understanding of the business principles that drive health care today and provides the tools for patient management that are now required at all levels of nursing. Alternatively, leadership development and business knowledge can be acquired through inservice education, attendance at conferences, participation in certificate programs, online courses, and many more.

What is the conclusion that may be reached? A broad array of educational offerings is available to enhance professional viability in an increasingly demanding work environment and in an increasingly competitive job market. So whether they ask you to do a budget or a business plan...you'll be ready!