cnml review agenda

CNML Review Course

Agenda

Jointly Provided by Baptist Health and Little Rock Critical Care Program

Baptist Health Training Center Auditorium – 900 John Barrow Road, Little Rock

June 21, 2019 8:00am – 4:30pm

TOPIC DURATION

FINANCIAL MANAGEMENT A. Recognize the impact reimbursement on revenue

B. Anticipate the effects of changes on reimbursement programs for patient care

C. Maximize care efficiency and throughput

D. Understand the relationship between value‐based purchasing and quality outcomes with revenue and reimbursement

E. Create a budget

F. Monitor a budget

G. Analyze a budget and explain variance

H. Conduct ongoing evaluation of productivity

I. Forecast future revenue and expenses

J. Capital budgeting

0800‐0930

HUMAN RESOURCE MANAGEMENT A. Staffing needs

B. Manage human resources within the scope of labor laws

C. Apply recruitment techniques

D. Staff Selection

E. Scope of practice

F. Orientation

G. Performance management

H. Staff Development

I. Staff retention

J. Manage conflict

K. Situation management

L. Relationship management

M. Influence others

N. Promote professional development

0945‐1100 Lunch 1100‐1200

1200‐1400

CNML Review Course

Agenda

TOPIC DURATION

PERFORMANCE IMPROVEMENT A. Performance improvement

B. Customer and patient engagement

C. Patient safety

D. Maintain survey and regulatory readiness

E. Monitor and promote workplace safety requirements

F. Promote intra/interdepartmental communication

1415‐1445

STRATEGIC MANAGEMENT AND TECHNOLOGYA. Facilitate change

A. Project management

B. Contingency plans

C. Demonstrate written and oral presentation skills

D. Manage meetings effectively

E. Demonstrate negotiation skills

F. Influence the practice through participation in professional organizations

G. Collaborate with other service lines

H. Shared decision‐making

I. Support a culture of innovation

1445‐1515

TEST TAKING SKILLS 1530‐1600

PRACTICE TEST 1600‐1620

COURSE EVALUATION 1620‐1630

6/3/2019

1

Certified Nurse Manager and Leader

Diane Smith DNP, RN, CCRN-K, ACNS-BC, CNML, PCCN-K

Assistant ProfessorNursing and Health Systems Leadership

University of Indianapolis

Exam PreparationPrevious Life

Diane Smith DNP, RN, CCRN-K, ACNS-BC, CNML, PCCN

Chief Nursing OfficerBaptist Health Extended Care Hospital

Eligibility Requirements• A valid and unrestricted license as RN

and• BSN degree or higher plus (2 years) 2080 hours

of experience in a nurse manager roleor

• BS degree not in Nursing plus (3 years) 3120 hours of experience in a nurse manager role

or• Diploma or Associate Degree plus (5 years)

5200 hours of experience in a nurse manager role

OVERVIEW

• Cost for AONE members is $300• Non member cost is $425• 115 Total Questions

– 100 questions count– 15 trial questions– 70 correct answers to pass

2 hours to take exam

Test Questions

• Most questions are scenario based

• Test divided into 4 sections– Financial Management

– Human Resource Management

– Performance Improvement

– Strategic Management and Technology

Certified Nurse Manager and Leader

Financial Management

Exam Preparation

6/3/2019

2

Introduction• Finance section is 18 questions – 18% of test

4 Recall

9 Application

5 Analysis

• This section deals with how to deal with costs.

• This is important, but probably not how you spend most of your time.

• Your situation will determine how responsible you are for this, but test expects you understand.

Exam Objectives

• Recognize the impact of reimbursement on revenue

• Anticipate the effects of changes on reimbursement programs for patient care

• Maximize the care efficiency and throughput

Exam Objectives continued

• Understand the relationship between value-based purchasing and quality outcomes with revenue reimbursement

• Create a budget

• Monitor a budget

• Analyze a budget and explain variance

• Conduct ongoing evaluation of productivity

Terms and

Definitions

Providers

• Doctors

• Nurses

• Technicians

Consumers

• Patients

• Families

6/3/2019

3

Suppliers

• Drug Companies

• Equipment vendors

• Supply vendors

• Technology vendors

Payers

• Insurance Companies

• Government Payers– Medicare

– Medicaid

Regulators

• The Joint Commission

• The Department of Health

Acuity

• Estimated severity of various disorders

• Usually measured by direct hours per patient day

Asset

• Something that you own

Average Daily Census (ADC)

• Average number of patients on a unit at a given time of day

• Usually measured at midnight

6/3/2019

4

Average Length of Stay(ALOS)

• Average length of time patients stay

Diagnostic Related Group(DRG)

• Categories of medical or surgical conditions specified in Medicare prospective payment systems

Equity

• The amount that an asset is owned completely, outside any balance due or outstanding loan

Full Time Equivalent (FTE)

• Work equivalent to 2080 hours / year– 40 hour / week employee = 1.0 FTE

– 36 hour / week employee = 0.9 FTE

– 24 hour / week employee = 0.6 FTE

Liability

• A debt owed

Long Term Investment

• An item with a life expectancy greater than 1 year

6/3/2019

5

Occupancy Rate

• Percent of occupied beds

Average Daily Census = Occupancy

Number of beds in Rate

Service

Patient Days

• Volume Measurement

Average Daily Census

X Number of Days in the Month / Year

Patient Days

Variable Costs

• Costs that change in direct relation to volume

Fixed Costs

• Costs that do not vary with changes in volume

Fixed versus Variable Staffing

• Fixed– Nurse Manager

– Clinical Nurse Specialist

– Clerical Staff

– Any staff that doesn’t change based on volume

• Variable– Nursing Staff

– Aides

– Techs

– Any staff levels that change based volume

Care HoursNursing Hours

6/3/2019

6

• Nursing Care hours– Hours of direct care provided to a patient

• Average NHPPD– Average number of hours required to

provide care to a group of patients with similar acuity

• Most organizations use all care staff– RN, LPN, NA, PCT

– Doesn’t count Nurse Manager, Clerical Staff

How to calculate NHPPD

Number of bodies giving care in a 24 hour

period x 8 hours

_________________________________

Number of patients

Example of NHPPD CalculationRN LPN

Days 4 2 24 PatientsEve 4 2Night 3 2Total 11 + 6 = 17 bodies

17 bodies x 8 hours = 136 hours /24 Pts=5.66 NHPPD

Medicare / Medicaid

• U. S. Government

• “CMS”

• “COP” = Conditions of Participation

Conditions of Participation

• Health care organizations must meet in orderto begin and continue participating in theMedicare and Medicaid programs.

• These minimum health and safety standardsare the foundation for improving quality andprotecting the health and safety ofbeneficiaries.

• Out of Compliance = Fines and threatenscontinued operation

Challenges to Financial Management

• Healthcare operates in a market of mismatchedsupply and demand

• Revenue does not match the cost of taking careof patients

• Reimbursement comes long after the servicesare rendered

• Reimbursement rules are different forphysicians than they are for hospitals

• Technology advancements make recentpurchases out of date

6/3/2019

7

Additional Challenges• Uninsured patients must be cared for without

discrimination toward ability to pay• People spend your money but have no

repercussions• Everyone wants the best that is available• Visits by Regulatory agencies drive up costs• Competition for short supply of qualified staff• Physicians offer services for insured patients in

their offices• “Mission driven” programs cost money

State / Federal Mandates• Mandated access

• Mandated reporting

• Mandated transparency

• “Never Events”

• HCAHPS –– Hospital Consumer Assessment of Healthcare

Providers and Systems

• Conditions of Participation

• OSHA

Value Based Purchasing

• Hospital Value-Based Purchasing (VBP) is part of the Centers for Medicare & Medicaid Services’ (CMS’) long-standing effort to link Medicare’s payment system to a value-based system to improve healthcare quality, including the quality of care provided in the inpatient hospital setting.

Value Based Purchasing

• Participating hospitals are paid for inpatient acute care services based on the quality of care, not just quantity of the services they provide.

• Congress authorized Inpatient Hospital VBP in Section 3001(a) of the Affordable Care Act. The program uses the hospital quality data reporting infrastructure developed for the Hospital Inpatient Quality Reporting (IQR) Program, which was authorized by Section 501(b) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.

• First, a percent reduction is made to participating hospitals’ base operating diagnosis-related group (DRG) payment amounts for the applicable fiscal year.

• For FY 2013: 1.0 percent;For FY 2014: 1.25 percent;For FY 2015: 1.5 percent;For FY 2016: 1.75 percent; and For FY 2017 and subsequent years: 2.0 percent.

• Second, payment adjustments are applied to participating hospitals on a claim-by-claim basis, and each hospital’s value-based incentive payment percentage that the hospital earns for the applicable fiscal year is determined based on that hospital’s Total Performance Score (TPS) on the Hospital VBP measures.

• The hospital’s TPS is converted to a value-based incentive payment adjustment factor, and that factor is then multiplied by the base operating DRG payment amount for each Medicare fee-for-service discharge in a fiscal year to calculate the adjusted payment amount that applies to the discharge for that fiscal year.

6/3/2019

8

HOW DOES THE VBP PROGRAM MEASURE HOSPITAL PERFORMANCE?

• CMS bases hospital performance on an approved set of measures and dimensions grouped into specific quality domains. Domains are assigned weights (percentages) which are then used to score each domain.

Table 1. Hospital VBP Domains and Relative Weights for Fiscal Year (FY) 2018 and

Subsequent Years

*Beginning FY 2019, “Patient and Caregiver-Centered Experience of Care/Care Coordination” to “Person and Community Engagement”

Domain Weight

Safety 25%

Clinical Care 25%

Efficiency and Cost Reduction 25%

Patient and Caregiver-Centered Experience of Care/Care Coordination*

25%

• Centers for Medicare and Medicaid Services. (2017, September). Hospital Value Based Purchasing.Retrieved from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdf

Financial Reports

Report Formats

CentralFinancialStatement

BalanceSheet

Changes inEquity

Statement ofCash Flows

OperatingStatement

Balance Sheet• Current Assets

– Can be quickly converted to cash

• Fixed Assets– Property, equipment

• Current Liabilities– Short term debt owed

• Long Term Liabilities– Long term debt owed

• Net Assets– Difference between Total Debt and Total Assets

6/3/2019

9

Reading the Balance Sheet Operating Statement• Compares Revenues to Expenses

• Many sources of each

• Detailed entries of both are included on the operating statement

Cash Flow Statement• Tells where you get your cash• Tells where you use your cash• Indicates how able you are to pay your

bills• “Cash on Hand”• “Days to receive collectables”• You are not responsible for collecting

cash…but you drive how it is spent!

Changes in Equity

• Identifies which assets have increased or

decreased

• Decrease can be do to devaluing of an item or Depreciation

BudgetingBudgeting

• Non-Salary– Cost of supplies, minor equipment, facilities

management, recruitment, etc

• Capital Budgets– Equipment

– Expansion• Facility

• Program

6/3/2019

10

Budgeting

• Written plan

• Projections for how money will be spent and earned

• Projections of money flow over time

• It is a PLAN….Not a Straight jacket!

• It provides a roadmap

• Your role in budgeting

• But no matter what your role… You still need to understand

Operating Budget

• Plan for the day to day operating revenues and expenses– Usually covers one year– Usually broken down to the unit level using “Cost

Centers”

• Individual department budgets drive the overallorganizational budget

• Includes– Labor– Supplies and other non-labor expenses– Revenue

Factors Effecting a Unit-Level Budget• External factors

– Inflation– Market competition– New services– Declining reimbursement

• Increase in self-pay• Change in Workload• Organization policies and objectives

– How you deal with the uninsured– Your “mission” work

Zero Balanced Budget• Expenses must be justified for each new

period

• Every budget period starts from “zero base” and every function is analyzed for needs and costs

• Budget is then built for what is needed for the upcoming period whether the budget is higher or lower than the last one

Advantages of Zero Based Budget

• Allows top level strategic goals to be implemented into budgeting process

• Find cost effective ways to improve operations

• Detects inflated budgets

• Useful for service departments where output is difficult to identify

• Increased in communication

Advantages of Zero Based Budgetcontinued

• Identifies and eliminates wasteful and obsolete operations

• Identifies opportunities for outsourcing

• Forces cost centers to identify their mission in relation to overall goals

6/3/2019

11

Disadvantages of Zero Based Budget

• Time consuming and exhausting

• Forced to justify every detail

• Managers need training

• Requires lots of information

• Honesty of managers must be reliable

Incremental budgeting• Manager only needs to justify increases

over the previous year’s projections

• Whatever you have already spent is automatically sanctioned and only increases need approval

Budget Forecasting

• Considers both fixed and variable costs looks at the past quarter instead of budgeting for the entire year.

• Can make changes in budget based on current events

Labor Budget• The single largest expense in the

Healthcare Budget

• Most labor costs occur in the Nursing Departments

• Labor is expensive

Steps to Figure Labor Budget

• Calculate the workload

• Calculate the necessary staff to match that workload

• Calculate the cost of that staff

Creating a Budget

Start by gathering information related to

historic trends and patterns

6/3/2019

12

Input needed• Average Daily Census• Average Acuity of Patients• Budgeted Paid Hours• Budgeted Worked Hours• Actual Worked Hours• Targeted Worked Hours• FTE’s needed• Salary and benefit information• Projected bonuses and cash awards• Supply requirements• Education and travel cost projections

Creating a Budget• Then comes the Negotiation…• Resources are finite• Some things won’t make the final cut• You need a plan for how you will make that

work…it can’t be to spend it anyway!• Prioritizations should drive allocation• You are in the best position to know what you

need to run your unit• You need to know when you have to “hold the

line” and “Die on the Mountain.”

PracticePractice

What is the occupancy rate for a unit that contains 12 beds and 8 of them have patients in them?

# patients = occupancy rate

total beds

8 / 12 = 66%

Practice

Calculate the ADC of a unit for

a week

# Patients for time period=ADC

# of days

70 / 7 = 10

Calculating Workload• Workload drives the number of staff that

you will need to care for patients

• You might be given this number…but for the test…you might have to figure it

6/3/2019

13

Calculating Workload

77,800 / 5200 = 14.96 NHPPD 77,800 / 2080 = 37.4 FTE

More Calculations

77,800 / 5200 = 14.96 NHPPD

77,800 / 2080 = 37.4 FTE You know this

Projected ADC for next year = 10 = 3650 Pt days

They tell you this

How many FTE’s will you need to staff?

3650 x 14.96 = 54,604 / 2080 = 26.25 FTE

If nobody takes a day off!

What happens when people take time off?

• Replacement factor

• Different ways to do it– Some take actual figures for time off

– Some use a “Replacement Factor”

– Ordinary to use 15-20%

• 1 FTE = 2080 hrs PAID in a year

• But they don’t WORK 2080 hours in a year

• Need to calculate the hours need to replace the

worker when they are on vacation

Some FTE calculations

A FTE works 5 shift in a weekworks 10 shifts in 2 weeks10 shifts in 2 weeks = 1.0 FTE

If you need 1 nurse every dayin 2 weeks you need 14 shifts14 shifts in 2 weeks = 1.4 FTE

If the replacement factor is 20%1.4 x .20 = .28 + 1.4 = 1.68

So, you need 1.68 FTEs of nurses for every shift ofcoverage desired

FTE’s continued

77,800 / 5200 = 14.96 NHPPD

77,800 / 2080 = 37.4 FTE

Projected ADC for next year = 10 = 3650 Pt days

How many FTE’s will you need to staff?

3650 x 14.96 = 54,604 / 2080 = 26.25 FTE

26.25 x .20 = 5.25 + 26.25 = 31.5 FTE with RF

More considerations• Staff who don’t need replacement

– Yourself– CNS– Anyone who doesn’t get replaced when they

take a day off • Only calculate 1.0 FTE for these positions

• How many “Bodies” do you need?– What is the weekend staffing pattern?– Multiply it times 2

6/3/2019

14

Weekend Coverage

18 shifts x 1.68 FTE = 30.24 FTE

If they were all Full Time you would only

have 30 bodies and you need at least 36!

FTE questions• Pay attention to shifts, whether they are 8

hour shifts or 12 hour shifts.

• You have to filter out distractions and focus on the question at hand.


Days 4 2 24 PatientsEve 4 2Night 4 2Total 12 + 6 = 18 bodies

18 bodies x 8 hours = 144 hours /24 Pts=6.0 NHPPD


Days 4 2 24 Patients

Night 4 2

Total 8 + 4 = 12 bodies

12 bodies x 12 hours = 144 hours /24 Pts =

6.0 NHPPD

Supply Budget• “Other Than Personnel Services” expenses

• Includes– Supplies

– Small Equipment

– Services

• Some are Variable costs– Volume Driven

• Some are Fixed Costs– Not driven by volume

Monitoring a budget

• Following monthly reports

• Access to necessary information

• For purposes of test, focus on needed

information and block out distracters

6/3/2019

15

Report on Budget VarianceComparing Budget to Actual

Analyze your budget• Getting down to the nitty gritty details

• Looking at how you can cut costs

• Playing the “What if?” scenarios

• Know your bottom line

• Know what you MUST have

Expense Forecasting• Predicting how much it is going to cost• Includes

– Start up costs - if any– Fixed costs– Variable costs

• Anticipated volumes• How much of your paid time will be OT?• How many LOAs will your employees take?• Who will leave the job?• How long will it take to recruit?• What new supplies with the CV surgeon require?• Will the new Cardiac CT decrease the # of Caths?

Ongoing Evaluation of Productivity

• NHPPD tracking

• Takes into account fluctuations of patient volume

• Shifts in Patient Acuity can impact projected

productivity– Flexing staffing

– Reassignment

– Cancellation

Capital Budget

• Acquisition of long term investments

• Expensive equipment

• Life time is greater than one year

• In any one year, only part of the cost is

accounted for

• If you put it into the year it was purchased, it would un-balance the expense

Justification• Building a sound, logical case for how the

purchase will benefit the organization– Partner with other departments

• Cash is limited

• What is the ROI? (Return on Investment)

6/3/2019

16

Cost Benefit Analysis

• Lease vs. Purchase

• Will the program bring in new business?

• Is it business you desire?– Not all business is good business!

– Will it decrease the use of something more costly? Would doing pacers in the Cath Lab free up needed OR time that could be filled with other cases…or would the OR sit empty with staff waiting around to do something?

References• American Organization of Nurse Executives Credentialing Center. (n.d.).

Certified Nurse Manager and Leader examination handbook. Author. Retrieved from http://www.aone.org/docs/certification/cnml-handbook.pdf

• Bylone, M. (2008). Certified Nurse Manager Leader Review. Powerpoint slides.

• Centers for Medicare and Medicaid Services. (2017, September). Hospital Value Based Purchasing.Retrieved from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdf

• Fike, G. C. & Smith-Stoner, M. (2016, April). Hours per patient day: Understanding this key measure of productivity. American Nurse Today. 11(4). Retrieved from https://www.americannursetoday.com/hours-per-patient-day-understanding-key-measure-productivity/

Questions?

You need to make wise decisions on how your money is spent.

1

Certified Nurse Manager and LeaderExam Preparation


Assistant ProfessorNursing and Health Systems Leadership


HUMAN RESOURCE MANAGEMENT

Introduction

• HR section is 37 questions = 37% of test– 8 Recall

– 18 Application

– 11 Analysis

• Section covers How to Deal with People

• This is what you do every day!

Terms and Definitions

Vacancy Rate

Number of Vacant Positions

Total number of positions available

Expressed as a percentage

Uses FTEs in calculation, not actual position numbersFor example

Open FTE 3 FTE

Total FTE 12 FTE

Vacancy Rate = 25%

Turnover Rate

Number of Employees who left for a defined period

Average Number of Employees during

that defined period

For Example

# RNs (bodies) who left 3

Avg # staff RNs for the year 12

Turnover Rate 25%

Types of Turnover

• Controllable : You have in your control the

ability to do something and the staff member

doesn’t leave

• Functional: Desirable – getting rid of bad

employees

• Internal: Staff move to other departments but

don’t leave organization

• Total: Staff leaves organization all together

2

HPPD = Hours / patient day

All staff assigned to a unit

NHPPD = Nurse hours /patient day

Clinical Staff assigned to a unit

Ratios compared to NHPPD

Nurse Patient Ratio

1:1 1:2 1:3 1:4 1:5

Nurse Hours / Patient Day

24 12 8 6 4.8

How to calculate NHPPD

Number of bodies giving care in a 24 hour

period x 8 hours (length of shifts)__________________________________________

Number of patients

Example of NHPPD Calculation

RN LPN

Days 4 2 24 Patients

Eve 4 2

Night 3 2

Total 11 + 6 = 17 bodies

17 bodies x 8 hours = 136 hours /24 Patients=

5.66 NHPPD

Evaluate Staffing Patterns

• How do you staff your unit?

• How do you know how many FTEs you need?

• How do you know how many bodies you

need to cover the weekends?

• How do you measure staffing patterns?

• What are options when you don’t have

enough staff?

Matching staff competencies with patient acuity

Synergy Model

3

Patient Characteristics

• Resiliency

• Vulnerability

• Stability

• Complexity

• Resource availability

• Participation in care

• Participation in decision-making

• Predictability

Nurse Competencies

• Clinical Judgment• Clinical Inquiry (Innovator/Evaluator)• Facilitation of Learning• Collaboration• Systems Thinking• Advocacy and Moral Agency• Caring Practices• Response to Diversity

Looking at variances

• Not enough help Add more staff

• Too much help Cancel or redistribute staff to other areas

• Census fluctuations create the need to

adjust staffing

• Some departments have fixed staffing patterns that do not adjust with census

• Base staffing targets on historical data and trends

The Nursing Shortage

Estimated to be

3.6 millionnurses short by 2030!

Registered Nursing.org (n.d.) The States with the Largest Nursing Shortages Retrieved from https://www.registerednursing.org/largest-nursing-shortages/

The Nursing Shortage

• Aging Workforce

• Lack of Nursing School Faculty

• Decreasing Nursing School enrollments

despite qualified applicants

• Increasing and broadening opportunities

for women and nurses

• Misunderstanding of Nursing’s position in

healthcare

Plan for Attrition

Identify potential nurses who will leave inthe next 12 months

– Retirement– Graduation– Promotion– Relocation– Returning to School– Family obligations

4

Strategies for anticipated attrition• Utilize over-hires

• Step up recruitment

• Look internally for suitable applicants

Hey..you would make a great nurse onmy unit…we have anopening.

Concerns related to Attrition

• Experienced nurses take their knowledge and expertise with them when they go

• Too many leaving at any given time can create gaps in skill mix, even when thenumbers still add up

• The deficit isn’t just in clinical skills, butin leadership as well

Recruitment Techniques

No longer a job of Human Resources

NursingSchools HRYour Unit

Strategies for Recruitment

• Job Fairs

• Student Rotations

• Summer Interns

• Develop a marketing approach for unit

• Partner with nursing schools to provide

resources for nursing clubs or speakers

for class projects

Recruitment: Role DifferencesHR Department

• Develop pool of

applicants

• Post positions

• Screen for suitability &

minimal requirements

• Process applicants for

hire

• Schedule for start date

• Offer letter

Nurse Manager• Attend job fairs to assist

in recruitment• Timely interviews• Involve staff in interview• Timely decisions• Prepare for new

employee• Select preceptor• Arrange for unit

orientation• Evaluate progress

Market you Unit

• Develop a brochure with information related to your unit

• Do you have a special patient population?– Peds? Ortho? Oncology? Cardiac?

• Does your unit boast any awards?– Beacon? Patient Satisfaction or Quality?

• Do you offer something others don’t?– No shift rotation?– Less Weekends?– No call?

5

Marketing your Unit

• Have staff attend job fairs

• Offer shadowing

• Post positive achievements in public

areas

• Do you have a unit newsletter? Provide

recent copies to prospective staff

Marketing Your Facility

• Know the demographics of the organization– Patient census– ED visits– Births per year– Total number of employees– Average tenure of a nurse– % RN as part of staffing patterns

Marketing Your Facility

• Awards– Patient Satisfaction scores

• Have you done a recent employee survey? If so, can you speak to the results?

• Patient outcome information, core measures

• Any regional specialties or Centers of Excellence?

Some Required Items before you start

• Job Analysis: Identify the specifics of the job– Reporting structure

– Does it supervise others

– Job Description: What are the key responsibilities of the job

– Scope of Practice

• Job Specification:– Special training or certification

– Working conditions

Staff Selection/Interviewing

• Job descriptions help to drive the

interview process

• Questions should draw out information

related to the candidate’s ability to

perform the job

• There are legal and illegal questions

Types of Interviews

6

Structured Interview• Individual

• Panel involves several interviewers

• Usually start with an “ice breaker”

– Careful about asking personal questions

• Interviewer may talk about the organization and the position

• Allow candidate to ask questions

– Education

– Experience

• Asks candidate questions

Unstructured Interview

• Interviewer wants to hear from the candidate, asks open ended questions

• Can put the candidate at ease, which may lead to them revealing something that they usually might not.

Information Interview

• Share information

• Get to know each other better

• Don’t really talk about the specifics of

the job or the applicant’s ability

• Can help to screen the applicant’s “fit”

• Can help applicant to get a feel for the

organization

• Not done very often

Directive Style

• Very structured

• Preset list of questions

• No deviation

• Somewhat formal

• Can turn off the applicant

• Is useful when doing a lot of interviews

for a position…gives comparative data

Meandering Style

• Interviewer does not use a list of

predetermined questions

• Used by inexperienced managers

• Is not usually impressive to the applicant

• Can yield very little useful information

Behavioral Interview

• Most used today

• Sets up situations for applicant and then

asks them to respond

• Can ask how an applicant has handled a

situation in the past

• Can provide very useful information

• Can give more information beyond the

actual words in the answer

7

Group/Team Interview

• Applicant meets with a group of people• Useful for holding staff interviews of

candidates• Saves time by grouping individuals together• Make sure staff know what questions they

are allowed to ask• Some organizations have a HR person

present to ensure appropriate questionsand discussion takes place

Mealtime Interviews

• Provides a casual setting which can

reveal other qualities of applicant

• Same rules apply even though it isn’t as

formal as meeting in an office

• Can help applicant to show off in a more

relaxed setting

• Be careful about the use of alcohol

Screening Interviews

• Quick and to the point

• Done often on the phone

• Helps to identify if applicant meets

requirements

• Helps applicant to get general details

about position to see if they should

move forward

Pitfalls and Legalities

EEOC

Equal Employment Opportunity Commission

No Discrimination

Do Not Ask

• Are you pregnant?

• Do you have a bad back?

• Do you have children?

• What is your nationality?

• What church do you attend?

• How old are you?

• Have you ever had a work related injury?

Specifically….

• Citizenship• Visual, speech or hearing disability• Plans for family or pregnancy• Past workman’s compensation claims• Past illness or absence from work• Off job activities• Number of children• Any question related to age, including

graduation from High School• Previous Union activities

8

Wrap it up

• Check the references

• Check for required licensure

• Criminal background checks

• Notify HR of intention to hire

The Job Offer

• Legal process

• Needs to be in writing

• Position / Title

• Rate of pay

• Start date

• Reporting supervisor

• Any pre-employment agreements

• Request for acceptance or rejection

Scope of Practice

• Variety of “nursing” positions• Need to delineate the role of each job title• Actions or procedures that are permitted by

law for a given job role• Each licensed position has a governing board

which determines the limits of authority• Based on required education and training• You must know your scope and the scope of

anyone you delegate to

Labor Laws

Fair Labor Standards Act of 1938

• Minimum standards for wages and overtime pay

• Defines exempt and non-exempt employees

• Provides for Equal Pay

Civil Rights Acts of 1964

Prohibits discrimination on the ground of race, color, sex, religion or national origin

9

Family Medical Leave Act of 1993

• Up to a total of 12 work weeks of unpaid leave during any 12 month period for:– Birth and care of the newborn child of employee– Placement with employee of a child for adoption or

foster care– To care for an immediate family member with a serious

health condition– To take medical leave when the employee is unable to

work due to a serious health condition

• Organizations with more than 50 employees• Eligible employees

– Employed for 12 months– Worked at least 1250 hours in past 12 months– Position cannot be filled for these 12 weeks

National Labor Relations (Wagner) Act 1935

• Right to organize

• Required employer to recognize unions selected by employees

• Prohibited interference with process

Labor-Management Relations (Taft-Hartley) Act 1947

• Amendment to Wagner Act

• Made closed shops illegal

• Gave some rights to management

• Right for management to express opinion about the union

American with Disabilities Act of 1990

• Prohibits discrimination due to disability

• Requires modification of workspace to make it accessible to a disabled worker

• Requires job restructuring, modification of schedule

• Acquire modified equipment, work station

Age Discrimination in Employment Act of 1967

• Protects workers over 40 years of age from discrimination related to age

• Permits favoritism to employees over 40

• Refers to all aspects of employment, including application process

Orientation

10

Assure Orientation

• Put your best foot forward

• Remember Maslow’s hierarchy of needs– Safety and Security

– Freedom from threatening events

• The first day on a new job can be pretty

threatening!

Adults as Learners

• Autonomous

• Self-directed

• Have a foundation of life experiences

• Previous knowledge base

• Goal directed

• Practical – not interested in learning for

learning’s sake

• Need to be shown respect

Develop an Orientation Program

• Identify learning needs of orientee

• Select Preceptor

• Set expectations

• Don’t forget to cover the non-clinical items

• Provide structured and detailed checklist

• New hire support group

• Welcome program

Nurse Manager’s Role

• Stay aware of progress– Weekly evaluation

– Discuss with preceptor

• “Check in” with orientee

• Follow up with areas of concern

• Check for paperwork at completion

Effective Orientation

• Get feedback from both orientee and preceptor– Did orientee reach milestones on time?

– Was the paperwork clear and did it help to keep the process focused?

• Check in frequently AFTER the orientation is officially over

Performance Management

A system that:– Monitors

– Measures

– Reports

– Improves

– Rewards

Employee performance

11

Performance Management• Not limited to Performance Evaluation• Includes

– Compensation– Competency Management– Succession Management

• Why do it?– Gives staff a chance to discuss expectations– Opportunity to review strengths and weaknesses– Identify strategies for improved performance– Provides data for

compensation/promotion/termination

Nurse Manager Role in Performance Management

• Provide staff the opportunity to discuss

job expectations and critical elements of

successful performance– Identify training needs

– Provide feedback, coaching, recognition

– Recognize employee’s Maslow needs• Belonging, socialization and love

• Provide annual performance evaluations

The Performance ManagementSystem

• Year round…not just at evaluation time– Main Facets:

• Planning

• Tracking

• Reviewing

• Gives staff continuous feedback

• Not just for new graduates/new hires

Performance Management Cycle

Complete annual

evaluation

ReviewingPlanning

Tracking

Identification and communication of

performance expectations

Ongoing tracking of performance

Shared responsibility with staff and manager

Planning

• Identify and communicate expectations

• Must be measurable

• Linked to goals of organization

• Specific to position they hold

• Can be specified in a written plan

Key Elements of PerformanceManagement

• Set Objectives

• Communicate Objectives

• Plan for ongoing education and development

• Monitor progress/performance

• Give ongoing feedback and coach toward successful achievement

12

Writing Great Goals

• Specific

• Measurable

• Attainable

• Realistic

• Timely

• Strategically linked

First steps…

Organizational Goals

Unit/Department Goals

Individual Goals

The Annual Appraisal

• Used to determine raises

• Identify unacceptable performance

• Determine training/education needs

• Review job expectations

• Identify talent

• Opportunities to provide challenges

Types of Evaluations

• Self Evaluations– Employee rates self

• Peer Evaluations– Fellow staff rate employee

• 360 Evaluations– Multi-layered evaluation– Should include peers, supervisor and

subordinates– Can include physicians and other department

personnel

Evaluation Pitfalls

• Allowing one bad situation cloud the entireyear’s performance

• Giving current credit for work done in the past• Allowing personal feelings to impact score• Confusing potential with performance• Giving a higher than deserved score because

you relate with the employee• Clumping all employees in the middle of the

scoring pack

Knowing when to discipline

• Continued poor performance

• Risky or intentional behavior

• Seriously disruptive behavior

13

Fitness for duty

• Can the employee perform the functions in their job description?

• Recognizing impaired employees

• Recognizing diversion

Job related risk factors for impaired employee

• Stress / Burnout• Sleep deprivation• Long work hours• Job demands / role strain• Easy access to controlled substances• Beliefs that knowledge about drugs prevents

addition• Personality factors (eg. Competiveness)• Specific jobs that may increase access to

drugs or increase level of stress

Signs and Symptoms(healthcare professionals are good at hiding these)

• Smell of alcohol on breath or clothing

• Poor hygiene

• Unkempt appearance

• Flushed face

• Slurred speech

• Tremors

• Dilated pupils, Red eyes

• Fatigue, mood swings

• Irritability, angry outbursts

• Interpersonal conflict

• Impaired memory, concentration, and/or coordination

• Wears long sleeves when inappropriate

Diversion

How do they do it?Among the most common opportunities for individuals to divert medications from in-hospital order origination to patient administration include:• Substitution of the diverted medication• Inaccurately chart medication administration at

the point of care, leading to a situation in which the chart reconciles with the automated dispensing cabinet record, even though the patient never received the medication.

• At the automated cabinet level, medications could be removed without detection.

How do they do it?• At the bedside, home medication reconciliation

provides an opportunity for a healthcare worker to pilfer the patient’s own medication right from the pill bottles.

• Leftover medications in sharps containers have proven a potentially deadly source for desperate individuals, and can promote the spread of life-threatening infectious disease by contaminated sharps injuries.

• Improper disposal of medication waste may allow one to document a medication was disposed of properly while in reality the excess was kept for personal use.

14

Continual Performance Development

• Address the unacceptable behavior• State the implications of the behavior• Share the facts you have uncovered• Be specific – Use current examples• Ask for explanations• Clarify remedy plan• Obtain agreement on next steps and expectations• Summarize by restating agreed expectations

and timeframe• Set up follow up meeting

Follow up Meeting

• Review concerns and goals from last meeting

• Discuss progress toward goals

• Did employee follow the outlined strategies?

If not…why not?

• If successful, have they achieved the goal or

is there still work to be done?

• If there is not substantial progress – need to

move to next step of discipline

Poor Performance

• Address it early• Not a favorite thing for NM to do• Consider all possible causes

– Knowledge deficit– Substance Abuse– Illness

• Little issues left unaddressed can turn into big issues

Corrective Actions• Know your organization policies• Usually in this order:

– Informal “chat”– Documented Verbal Warning– Written Warning I and II– Suspension

• Termination• Should include wording: “Failure to correct

this behavior will lead to further disciplinaryaction, up to and including termination.”

Termination

• Should be reserved for situations thatcannot be resolve in any other way

• Used for employees who refuse or arenot capable of meeting job expectations

• Can have legal ramifications – Use HR• If HR is resisting, ask why?• Do you have the proof required for

termination?• Know your organizational policies

Termination “Musts”

• Documentation that has been verified

• Don’t let employees reaction be a distracter

• Use a non-threatening tone

• Follow policy, do not do alone

• If you get last minute information that you

were unaware of, end session and investigate

• Regulations govern “final check” payouts

15

Staff Development

• Organizations have a responsibility to partner

• Provides job enrichment

• Designed to increase employee’s knowledge and attitude toward organization

• Employee must recognize the value

Staff Education Needs Assessment

• Helps to focus and set priorities

• Should be balanced with upcoming goals

Education Programming

• Should match up with identified needs

• Challenges all levels of expertise from novice to expert

• Creative scheduling to make available to all staff

Competency

• Not just knowledge – it is skill to do• Written tests do not prove competency in

many areas• Need hands on demonstrations• Should match procedures• Pick low volume and problem prone areas• Test new equipment and procedures• Competency Fairs vs. Expert Staff evaluators• Maintain paperwork

Promotion of ProfessionalDevelopment

• Certification• Ongoing education support

– Scheduling– Financial Support

• Career Paths– Opportunities for advancement and

promotion– Formal and informal leadership positions

Steps in Effective Education

• Motivation– Education is of value for job responsibilities– Tie it to improving patient outcomes

• Reinforcement– Needs to be frequent to change behavior

• Retention– Directly related to the amount of practice

• Transference– Ability to use information in a new setting

16

Staff Retention

• Three Key Attributes– Compensation

– Scheduling Options

– Intensity of Work

Healthy Work Environments

• Feeling valued

• Delivery of Care model that provides time to do “nursing”

• Shared Governance

Shared Governance

• The purpose of the Shared Governance Councils is to provide a structure in which clinical nurses can have autonomy in practice, decision making ability related to both clinical and professional practice decisions and collaborate to ensure a high level of professional performance by all nursing team members.

Are your Staff Satisfied?

• Staff Satisfaction Surveys• How is your turnover?• Can you recruit from within the organization?• Do you have a waiting list to work there?• Is the unit “buzz” a happy one?• Do staff socialize together outside of work?• Do staff celebrate at work?• Do others recruit your staff for promotions?• Are your patients happy?

Important to Retention…

• Quality of relationship with manager

• Ability to balance work and home life

• Amount of meaningful work…making a

difference

• Level of cooperation with co-workers

• Level of trust in workplace

Strategies for Staff Retention

• Praise Praise Praise!• Meaningful Recognition• Handwritten notes• Posting Certification Certificates• Clinical Ladders• Promotion of talented staff• Always ask employees for their side of the

story before jumping to conclusions• Don’t be afraid to admit if you make a mistake

17

Schedules

• Very important to employees

• Need to balance home and work

• Equitable

• Post in advance

• Make the “rules” known and follow them

• Self-scheduling

Promote Retention

• Get rid of dead wood

• Provide support to staff as they develop

• Encourage staff to reach potential

• Challenge staff

• Involve staff beyond unit walls

Conflict

Conflict Management• Comes out of frustration• Two individuals with two different patterns of

behavior = conflict• Stages of Conflict

– Differences– Discord– Dispute

• Types of Conflict– Relationship Conflict– Data Conflict– Interest Conflict– Value Conflict

Stages of Conflict – Stage 1

Differences– Escalation in an unproductive way

– More “telling” less “listening”

– Intolerance of others differences

– People are unwilling to let go of their own ideas and struggle to agree with others


Discord– Individual interests emerge– Loose sight of mutual goals– Situation is escalating– Decrease or absence of communication– Communication is less solution oriented– Defensive posturing– Using work arounds to get their way

18


Dispute– Conflict in full swing

– Verbal clashes

– “need to be heard” the priority

– Focused on getting people on their side

– Focused on achieving personal goals

– No regard for needs of group

Types of conflict

Relationship Conflict

• Occurs between individuals

• Presence of strong, negative emotions, poor communication, misperceptions

• Fix: Balance perceptions or emotions

Data Conflict

• Lack of information to make a wise decision

• Individuals interpret same data differently

• Fix: Get agreement on interpretation of data

Interest Conflict

• Competition over perceived needs

• Interests of one are satisfied over another

• Can be related to schedules, pay, promotions

• Fix: Get staff to state their own interests and work on achieving mutual interests

Value Conflict

• Perceived or actual incompatible belief systems

• Belief systems help us determine right/wrong,good/bad

• One person tries to impose beliefs on another• Fix: Have parties acknowledge differences

and agree that each has the right to own their own beliefs. It doesn’t make them right or wrong…just different!

19

Conflict Management

• Best handled at Unit Level

• Best if individuals can handle it themselves

• If not, consider mediating a meeting of the staff

• Seek assistance from HR professionals

Crisis Management

• Faced with REAL crisis– Identify the nature of the crisis– Intervene to minimize the damage– Recovery

• If you can, anticipate what crisis couldarise and PLAN your reaction

• Crisis can be organization wide, orconfined to one or two employees

• Your job as leader….LEAD!

Generations

Fourhooks. (2015, April 26). The Generation Guide - Millennials, Gen X, Y, Z and Baby Boomers. Retrieved from http://fourhooks.com/marketing/the-generation-guide-millennials-gen-x-y-z-and-baby-boomers-art5910718593/

Teams Teams

20

Teams• 4 Stages of development

– Forming• First come together• Excitement, anxiety and uncertainty• Your job = provide structure by setting goals, clarifying

tasks and deadlines, define roles

– Storming• Realize complicated work lies ahead• Panic, disparity between goals of team and reality of

work ahead• Conflict can arise as members vie for power & control• Your job = facilitate dialogue, build trust, guide to

decision making and problem solving

– Norming• People get used to working with each other

• Cooperation, acceptance, comfort

• Your job = Take a back seat

– Performing• Team performance is high

• People are focused on success

• Singing off the same page

• Your job = Monitor and help only if needed, suggesting new goals when ready

Team Development

FormingExcitement

Anxiety

Provide Structure

StormingPanic

Conflict & Power Struggles

Build Trust

NormingComfort

Acceptance

Allow Independence

PerformingTeam Performance

Focused on success

Monitor

Coaching• Someone who possesses knowledge works with

someone who needs the knowledge• It is teaching one on one• It can be done by anyone…it is not a formal

position• Can be used for clinical issues as well as

“people” issues• Not to be used when behavior or attitude issues

exist, serious infractions are involved such aschemical dependency, falsification of record orabuse

• Only works when BOTH parties buy in

Mentoring

• Useful with a “newbie”

• Useful for the “big picture”

• Requires mutual trust, respect and open

communication

21

Communication Principles

• A skill that involves constructing anddelivering a message…

• Then, listening and processing the responsefrom the other person

• Not difficult skills• Failure usually due to not taking the time

versus not having the skill• We focus on the tangible tasks…communication

gets left for last and gets left out

Skilled Communication - HWE

• Nurses must be as proficient in communication skills as they are in clinical skills

• Focuses on finding solutions• Invites and hears all perspectives• Holds self and others accountable• Establish and enforces zero-tolerance for

abuse and disrespect

The DifferencesCoaching

• Technical support

• Specific task focus

• Learning comes from

asking questions of

the coach

• Sometimes can be a

bit directive or

instructional

Mentoring• Big Picture• Whole person focus• Develop individual in

relationship to theirrole, not a task

• Can use coaching asa strategy

• Often employsstrategies to getindividual to thinkthrough an issue

Influence Others

• Encourage participation in professional acts:– Writing

– Speaking

– Mentoring

– Professional organization involvement

– Involvement in community and government

Role Model Professional Behavior

• Develop expertise

• Skilled communicator

• Ethics, standards and values

• Positive

• Dress appropriately

• Support ongoing education for self and others

• Value and respect others

• Respect yourself

Motivational Theory

• Sometimes called process theories -help us to understand behavior

• Four accepted Theories

22

• Reinforcement Theory– B. F. Skinner research

– Motivation = Learning

– People become conditioned to associate a behavior with a consequence

– Doesn’t account for why some reinforcements work for some people and not others

• Expectancy Theory– People’s expectations about a situation also help

determine their behavior– People don’t just respond passively to

reinforcement– Actively interact with environment– Relies on 3 motivation components:

• Expectancy: the perceived probability that a certain effort will lead to a desired action

• Instrumentality: the belief that a given performance level will lead to an outcome

• Valence: perceived of that outcome

• In nursing: Nurses expect to be taken for granted, being overworked and undervalued. May decide not to go the extra mile

• Equity Theory– Degree of perceived fairness in work

situation is key to job satisfaction and worker effort

– Equity doesn’t equal equality

– May make more money, but if felt to be proportionate to responsibility, they are okay

– If they perceive inequity, they will modify work

• Goal Setting Theory– People don’t expend effort for rewards but

to accomplish the goal

– More challenging goals lead to higher performance

Change Agent• See the need for change• Assess how it can be done• Deal effectively with the normal human

resistance• Change is the process of making something

different from what it was• Change agent is responsible for bringing

about change• Nurses are logical change agents

– impact many aspects of organization and patient lives

Promote Professional Development

• Promote Stress Management– Encourage staff to balance work and family– Give realistic timelines– Provide for personal recovery time– Promote activities at work that reduce stress

• Use Evidence Based Practice– Encourage research at unit level– Write policies that are supported by research– Encourage staff to utilize research to identify new

treatments, procedures and equipment

23

Self Awareness• Being aware of YOU• Facing the truth of who you really are• It is not who we want to be• What you believe in• It is our naked picture• Benefits

– Knowing yourself makes accepting or changing easier

– Helps you identify your strengths and weaknesses– Plots your roadmap to becoming who you want to

be

• Ask yourself: “Who am I?”

Who Am I?• Your values• Your strengths• Your weaknesses• Your dreams• How you handle yourself in stressful

situations• Your priorities

Do your actions match these answers?

Leadership Styles• Autocratic

– Leader makes decision and staff obey– Centralized decision making– Can cause hostility in workers

• Laissez-faire– Leader defers decision making to staff– Staff are frustrated because they are doing your

work and efficiency may suffer

• Democratic– Leader shares decision making– Staff like this

• Employee centered– Focus on human needs of staff

References• American Association of Critical Care Nurses. (2016). AACN Standards For Establishing

and Sustaining Healthy Work Environments: A Journey to Excellence (2nd ed.). Aliso Viejo, CA: Author

• American Organization of Nurse Executives Credentialing Center. (n.d.). Certified Nurse Manager and Leader examination handbook. Author. Retrieved from http://www.aone.org/docs/certification/cnml-handbook.pdf

• Bylone, M. (2008). Certified Nurse Manager Leader Review. Powerpoint slides.

• Fike, G. C. & Smith-Stoner, M. (2016, April). Hours per patient day: Understanding this key measure of productivity. American Nurse Today. 11(4). Retrieved from https://www.americannursetoday.com/hours-per-patient-day-understanding-key-measure-productivity/

• Fourhooks. (2015, April 26). The Generation Guide - Millennials, Gen X, Y, Z and Baby Boomers. Retrieved from http://fourhooks.com/marketing/the-generation-guide-millennials-gen-x-y-z-and-baby-boomers-art5910718593/

• Mind Tools (n.d.) Forming, Storming, Norming, and Performing

• Understanding the Stages of Team Formation. Retrieved from https://www.mindtools.com/pages/article/newLDR_86.htm

• Registered Nursing.org (n.d.) The States with the Largest Nursing Shortages Retrieved from https://www.registerednursing.org/largest-nursing-shortages/

• Smith, D. (2015). Synergy. Powerpoint slides.

• Smith, D. (2016). Recognizing an impaired coworker. Powerpoint slides.

• Steinbright Development Center. (n.d.). Type of interviews. Drexel University. Retrieved from https://drexel.edu/scdc/professional-pointers/interviewing/interview-types/

1

Performance ImprovementCNML Exam Preparation Program

Diane Smith

DNP, RN, CCRN-K, ACNS-BC, CNML, PCCN-K

Assistant Professor

Nursing and Health Systems Leadership


Introduction

Performance Improvement is 26 questions

– 26% of test

6 Recall

13 Application

7 Analysis

This section deals with safety and improving what you do every day.

Also concerned with customer and employee satisfaction.

Exam Objectives

Performance Improvement

Identify key performance indicators

Establish data collection methodology

Evaluate performance data

Respond to outcome measurement findings

Comply with documentation requirements

Customer and patient engagement

Assess customer and patient satisfaction

Develop strategies to address satisfaction issues

Patient safety

Monitor and report sentinel events

Participate in root cause analysis

Promote evidence-based practices

Manage incident reporting

2

Maintain survey and regulatory readiness

Monitor and promote workplace safely requirements

Promote intra/interdepartmental communication

Terms and Definitions

Adverse Events

Any unfavorable and unintended sign associated with the use of a medical treatment or procedure, regardless of whether it is considered related to the medical treatment or procedure

Disclosure

Providing information to a patient or family about an incident

Error

Failure of a planned action to be completed as intended or the use of the wrong plan

Fall

Unintentional coming to rest on the ground, floor, or other lower level, but not as a result of syncope or overwhelming external force

3

Just Culture

Frontline personnel feel comfortable disclosing errors, including their own, while maintaining accountability

Recognizing that individuals should not be held accountable for system failings over which they have no control

Zero tolerance for reckless behavior

Medical Error

An adverse event or near miss that is preventable with the current state of medical knowledge

PDSA/ PDCA

Plan Do Study Act

Plan Do Check Act

Root Cause Analysis (RCA)

A process that helps clinicians identify the underlying causes of an adverse event

Goal is to design prevention strategies and solution

Sentinel Event

Unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof

Systems Errors

Errors not attributable to individual negligence or misconduct

4

Transparency

Implies being open about what the organization does and how well it does it

The Need for Quality Management

Initial Programs

– Fragmented

– Focused on Quality in the silos of individual departments

– Centered on data collection not on finding solutions

Complete and detailed analysis of systems and interactions is needed for sustained gains

Role of Nurse Manager

Drill down to the single contributing factor

Eliminate it, modify it, improve upon it

Get staff focused on Patient Safety

Educate yourself

Educate your staff

Ensure effective training of staff for new procedures

Ensuring Adequate Staffing

More than the numbers

Focusing on matching patient needs with nurse competency = Synergy

Taking into consideration experience of nursing staff

Staff can be expert at handling one situation and novice at another

Geographic Assignments do not necessarily accomplish these goals

Ensuring Information Dissemination

Select appropriate method of communication when giving information

– E‐mail

– Voice mail

– Newsletter

– Posting signs

– Staff Meetings

Access to information in a timely manner

What’s the best way?

Information about the business of the organization

– Usually doesn’t impact patient outcomes

– Announcements abut the picnic

– Can be read at staff ’s convenience

– Posted or e‐mail

Information about new policies or procedures

– Same as above

– Allow time for discussion at staff meeting to ensure they are understood

5

Information about Educational Offerings

– Posted flyers

– Distributed through e‐mail

Information about Quality Monitoring

– Post in Conference Room

– Use graphs for trending

– Discuss at staff meeting to uncover new solutions

E‐mail might be a favorite tool for you….it might not be the same with your staff!

Ensuring Procedural Compliance

Involve staff in the creation of written guidelines

Utilize best practice and research

Policy changes should precede Practice changes!

Communicate the content

Can be more than one right way to do something…but doing it differently each time can yield disastrous results!

Ensuring Safe Patient Environments

Equipment selection

Bed Utilization – appropriate patient placement

Stay informed of new procedures

Environment upkeep

Involve staff in reporting issues with environment

Fostering a Culture of Safety

Just Culture

Focus on improving patient outcomes, not financial gains

Focusing on doing the right thing for patients will yield improvements in the bottom line

You have a choice….– Chase the numbers?

– Focus on Patient Outcomes?

Total Quality Management (TQM)

Originated in 1950’s in manufacturing

Deals with culture, attitude and organization

How does it meet the needs of the customer?

“Do the right things, right the first time, every time.”

Designing systems to produce consistent and optimal outcomes

You will be part of teams focused on Quality or you may lead teams in your own area

Principles of TQM

Management commitment

Employee empowerment

Fact‐based decision making

Continuous Improvement

Customer focused

6

Continuous Quality Improvement Founded by Edward Deming, PhD

Statistician in WWII

Traveled to Japan where he embrace country’s changes in production methods

Requires the development of the best possible process

Focused on reaching milestones and then striving for next gain

Reducing waste by 50% and then by 50% again

LEAN or Toyota Production System

Don’t say “If it ain’t broke don’t fix it”

Say “Make it better yet!”

Steps in CQI Process Assemble team

Define scope

Set goals

Understand the process as it currently works

Plan the project with timelines

Determine information needs

Choose tools

Identify the root cause

Develop solutions

Implement solutions

Review Results

Standardize work

Key Performance Indicators

Some examples– Medication Errors

– Pressure Ulcer Prevalence

– Core Measures

– Falls with injury

– VAP

– CLABSI

– CAUTI

– Surgical Site Infections

Relevant Charting Techniques

PDCA

– Developed by Walter Shewhart in 1930’s

– “Deming Wheel”

Plan Do

CheckAct

Run Chart

Used to discover patterns that occur over time

Pareto ChartIdentify factors that have the greatest cumulative effect on the system

7

Flow Chart

Used to

breakdown steps

in a process

Cause and Effect “Fishbone”

People Place

Equipment Policy

Event

Pictorial display of issues identified that yielded a particular event

Root Cause Analysis

Gantt ChartTasks and progress

in relation to time

Scatter Diagram

Identify relationships

between 2 variables

Control ChartCompare results with upper and lower limits and targets

HistogramUsed to determine the

distribution of data

8

Measures of Patient Satisfaction

Surveys given to patients

HCAHPS = Hospital Consumer Assessments of Healthcare Providers and Systems

CMS partnered with AHRQ to publicly report patient satisfaction

27 standard questions

Sample of Public Reporting

Patient Safety

Medication Errors

According to the CDC in 2013:– 611,105 people died of heart disease,

– 584,881 died of cancer,

– 149,205 died of chronic respiratory disease—the top three causes of death in the U.S

Medication Errors

According to the CDC in 2013:– 611,105 people died of heart disease,

– 584,881 died of cancer,

– 251,454 deaths stemmed from a medical error,

– 149,205 died of chronic respiratory disease—the top three causes of death in the U.S

Medication Errors

At least 1.5 million Americans are sickened, injured or killed each year by errors in prescribing, dispensing and taking medications

Mistakes in giving drugs are so prevalent in hospitals that, on average, a patient will be subjected to a medication error each day he or she occupies a hospital bed

The extra expense of treating drug‐related injuries occurring in hospitals alone was estimatedconservatively to be $3.5 billion a year (IOM 2006)

9

What do we know about why mistakes occur?

Cause of Mistakes

Bad Systems…not bad people

Series of eventsNot just one wrong happening

Human Factors Engineering

The study of the interrelationships between:

– Humans

– The tools they use

– The environment in which they live and work

Why Do Errors Occur – Some Obstacles

Workload fluctuations

Interruptions

Fatigue

Multi‐tasking

Failure to follow‐up

Poor handoffs

Ineffective

communication

Not following protocol

Excessive professional

courtesy

Complacency

High‐risk phase

Task (target) fixation

Many errors are caused by activities that rely on weak aspects of cognition:– short‐term memory

– attention span

– reliance on vigilance

– non‐standard processes

10

Why: Confirmation BiasThe paomnnehil pweor of the hmuan mnid !

Acorccdmig to a rscheearch at Cmabirgde Uienrvtisy,

it deosn’t mttaer in wuht oerdr th ltteers in a wrd

are, the olny imprmoent tigng is taht the frsit and

lsat ltteer be at the rghit pclae.

The rset can be a taotl mses and you can still raed it

wthouit a pobrelm.

Tihs is bcuseae the huamn mnid deos not raed ervey

lteter by istlef, but the word as a wlohe.

Amzanig huh!?

The “Look-alike” HazardWhy: We have a bias to see what we expect

The “Look-alike” HazardWhy: We have a bias to see what we expect

Error Reduction Strategies –Ranked by effectiveness Forcing functions and constraints

Automation and computerization

Standardization and protocols

Checklists and double‐check systems

Rules and policies

Education and information

“Be more careful. Be vigilant.”

If an error is possible, someone will make it. The designer must

assume that all possible errors will occur….

-Donald Norman

Cognitive Scientist

Most effective

Least effective

Prevention: Forcing Functions

OR gas hoses are color coded and have unique connectors

Prevention: Natural Mappings

11

Prevention: Natural MappingsPrevention: DefensesThings we put in place to prevent errors

Transforming DifficultTasks into Simple Ones

Simplify the structure of tasks

Make things visible

Create good mappings

Use constraints

Plan for error

When all else fails….Standardize

Work-Arounds A workaround is a bypass of a recognized

problem in a system. A workaround is typically

a temporary fix that implies that a genuine

solution to the problem is needed.

In implementing a workaround it is important

to flag the change so as to later implement a

proper solution.

If you are looking for a way to get arounda problem – you need to let someone know

immediately so the problem can be fixed

Poor Communication

Illegible Handwriting

Phone Communication

Abbreviations

Information received by untrained person

Incomplete report

National Patient Safety Goals

Healthy Work EnvironmentStudy By AACN Serious communication issues

People unwilling to call on others for inappropriate behavior

Fear blocks communication and increases poor outcomes for patients

12

A decade later…

Why are we afraid to tell some one they are acting inappropriately?

Sentinel EventMonitoring/ReportingCommunication is the leading cause of all reported sentinel events since 1995

Patient assessment is #2

Compliance is #3

– Policies are developed to ensure consistence and safety

– Policies are not followed

Incident Reporting

Useful to identify trends and patterns

Should be used to identify “near misses”

Timely follow up

Discoverable

13

Workplace Safety Requirements

Regulations

OSHA Occupational Safety & Health Administration

Out of Department of Labor at Federal level

OSHA's mission is to prevent work‐related injuries, illnesses, and deaths

Since the agency was created in 1971, occupational deaths have been cut by 62% and injuries have declined by 42%

In 2017, there were 5,147 deaths on the job.

Approximately 2.8 of every 100 employees experienced a job related injury or illness.

Intra/interdepartmentalCommunication SBAR

– Situation

– Background

– Assessment

– Recommendation

“Ticket to Ride” “Passport to Transport”

Handoffs are linked to dropped information

Medication Reconciliation

References American Association of Critical Care Nurses. (2016). AACN Standards for

Establishing and Sustaining Healthy Work Environments: A Journey to excellence, (2nd

ed.). Aliso Viejo, CA: Author.

American Organization of Nurse Executives (n.d.). Certified Nurse Manager Leader handbook. Retrived from http://www.aone.org/docs/certification/cnml-handbook.pdf

Bylone, M. (2008). Certified Nurse Manager Leader Review. Powerpoint slides.

Eastman, P. (2006). IOM Report: Medication Errors Injure Millions. Emergency Medicine News 28 (9), p 44–46 doi: 10.1097/01.EEM.0000316941.60357.a2

McLaughlin, D. B. & Olson, J. R. (2017). Healthcare Operations Management. (3rd ed.). Chicago, IL: Health Administration Press

McMains, V. (2016, May 3). Johns Hopkins study suggests medical errors are third-leading cause of death in U.S. Retrieved from https://hub.jhu.edu/2016/05/03/medical-errors-third-leading-cause-of-death/

The Joint Commission. (2018, November 18). Facts about the National Patient Safety Goals. Retrieved from https://www.jointcommission.org/facts_about_the_national_patient_safety_goals/

Questions?

6/3/2019

1

STRATEGIC MANAGEMENT AND TECHNOLOGYCNML Certification Preparation Program

Diane Smith, DNP, RN, CCRN-K, ACNS-BC, CNML, PCCN-K

Assistant Professor



Introduction

HR section is 19 questions = 19% of test 4 Recall

9 Application

6 Analysis

Section covers how to be a Change Agent

Negotiating and acquiring new technology

Exam ObjectivesFacilitate Change

Assess readiness for change

Involve the staff in the Change Process

Communicate changes

Evaluate the outcomes

Project Management Identify roles

Establish timelines and milestones

Allocate resources

Manage project plans

Exam Objectives

Contingency Plans (Disaster planning)

Demonstrate written and oral presentation skills

Manage meeting effectively

Demonstrate Negotiation skills

Influence practice through participation in professional organizations

Collaborate with other service lines

Exam Objectives

Shared Decision MakingEstablish a vision statement

Facilitate a structure of shared governance

Implement structures and processes

Support a Just Culture

Support a culture of innovation

ACT AS A CHANGE AGENT RELATED TO TECHNOLOGY

Change agents…not meant for everyone!

Educate yourself

Prepare for the nay-sayers

Identify the advantages of technologies

Be realistic about the disadvantages…it doesn’t make everything better

6/3/2019

2

CHANGE MODEL Can be used as a framework for any changes

Will require modification to match change

Your role Design an environment where people can learn

Where change is embraced

Were creativity and innovation are fostered

Look inward… reflect on your own beliefs about change

CHANGE MODELSix distinct functions

Creating Dissatisfaction

Forming a change team

Developing and communicating a change vision

Determining Change strategies

Taking Action

Evaluating Outcomes

CREATING DISSATISFACTION You are likely to have the most information

about the need for change First step is to create urgency for change /

rationale for change Change does not happen unless people are

dissatisfied Your job is to help people become

dissatisfied! Then…explain reason for change Create a vision that things will be better Start taking action to improve outcomes

FORMING A CHANGE TEAM You cannot demand and implement change by

yourself Ultimate change will be better and more sustained if

others are involved Final outcome will be greater than if only one person

is involved Include key staff members Include appropriate disciplines Represent all shifts, all jobs, and informal leaders Include diverse expertise…must be seen as

trustworthy Once the team meets, ask “Who is missing?”

DEVELOPING & COMMUNICATING CHANGE VISION

Need to have a vision specific to change initiative

Vision willProvide direction

Clarify general direction to be taken

Simplify more detailed decision

Align actions of the team

DETERMINING CHANGE STRATEGIES

Assess for facilitating and restricting factors

Need written goals and plans

Make assignments clear

Determine timelines

Weeks…not months

Follow through to completion

Don’t sacrifice “good” while you wait for “perfect”

6/3/2019

3

STEPS TO TAKE Assess the environment for readiness Identify facilitators and barriers Assess strategies to deal with both Barriers can be people, technology, values and

structures Design a climate for change where risk taking is the

norm and failures are acceptable Take small steps and multiple steps at the same time Opt for a broad sense of action…involve many

people Measure your success

Use data of numbers and written surveys Don’t miss the opportunity to include How Staff Feel about it

also

EVALUATION EMERGING INFORMATION TECHNOLOGY

Stay abreast of changes in technology Go to vendor exhibits Read to stay current Attend conferences

Obtain the “consumer report” equivalent for products

Consult with Biomedical Engineer Perform clinical trial Trust the input of the bedside clinician Look for items that enhance practice

PRESENTATION SKILLSWritten

Know when it is okay to be informal E-mail is informal but becoming accepted as

“preferred” Do not use “on-line speak” in the business setting Pitfalls of e-mail Computers templates

Oral Know your audience Be aware of your posture/gestures Can be intimidating “Death by Power Point” Practice Use notes

MANAGE MEETINGS EFFECTIVELY Know the goal and purpose of the meeting

Informational Problem solving Follow up

Different strategies for different purposes Use an Agenda

Decide whether to let non-agenda items get air time

PAT Purpose Agenda Timeline Start and stop on time Keep minutes and distribute in a timely

manner Follow up open items in next agenda

DEMONSTRATE NEGOTIATION SKILLS

An extension of the “compromise” Usually involves higher stakes Bargaining for each side’s give and take Advantages

Useful for high stake issues Solution usually seen as more formal and

permanent than compromise Does not require consensus Usually puts conflict to rest

DEMONSTRATE NEGOTIATION SKILLS

Disadvantages Getting to agreement can be time consuming

Often seen as permanent and if one side doesn’t like the result, or they feel they had to give up something…unhappy campers

Flush out issues at beginning and work toward solution

Know what is negotiable before you start

6/3/2019

4

INFLUENCE PRACTICE

Professional organizations should exist to represent issues important to members

Useful for pushing issues to a higher level Should be Standard Setters Practice Protocols Educational Offerings Opportunity for your involvement all the way

to the National level Organizations partner with others

STRATEGIC PLANS: COLLABORATING WITH OTHER SERVICE LINES

Very few strategic initiatives involve only your unit

Need to partner with others to get cooperation Also, they have information and perspective you

do not possessMake face to face contact with non-nursing

peers Identify the other’s agenda…how can you both

win? Projects that address multiple areas are

appealing to senior management

SHARED DECISION-MAKING Collaboration between Nurse Manager and

staffWork together toward unit and organizational

goalsManagement and Staff are PARTNERS An Accountability approach to relationships Helps to build a Healthy Work Environment 4 Principles

Equity Ownership Partnership Accountability

EquityWillingness to equally participate in

achieving common goalsTreats all members of the team with

respectEvery team member sees their value

OwnershipTeam members recognize the unit’s

success depends on how well they do their job

Each team member sees how their job fits into achieving the goal

PartnershipDefining joint outcomes and working

together to achieve the goals

It is the only way to permanently change a culture

AccountabilityCommitment of all to participate in decision

making

Owning decisions and willing to be evaluated against them

CHALLENGES TO SHARED GOVERNANCE

Nurse Manager feels threatened by giving control to staff

Staff have not developed skills to lead groups

Staff get the “I make the decisions part”…lag behind on the “I take accountability for the consequences…”

6/3/2019

5

CONTINGENCY PLANNING Disaster Planning

Internal External

What’s your role? Make sure your department knows it’s role Read your organization’s plan BEFORE there is a

disaster Encourage participation in drills Participate in debriefing

Get feedback from staff involved

References American Organization of Nurse Executives. (n.d.). Certified

Nurse Manager Leader handbook. Retrieved from http://www.aone.org/docs/certification/cnml-handbook.pdf

Bylone, M. (2008). Certified Nurse Manager Leader Review. Powerpoint slides.

McLaughlin, D. B. & Olson, J. R. (2017). Healthcare Operations Management (3rd ed.). Chicago, IL: Health Administration Press

Questions?

6/3/2019

1

Test Taking Skills for Certification


Assistant Professor



CNML by state April 2019

91

209

84

81

13

75

161

49

121 CT

17 DE

123

1431

215

27

37 MD

44

26

12

9

45

2 RI24

7

19

69

54

9

26

3

32 MA95

9

25

19 NH

13

40

28

12

39

27

3

5

2

15

15

3

4

8 VT

66 NJ

Objectives

Review eligibility requirements for exam

Discuss strategies for exam preparation

Advantages of Certification Certification is the formal recognition of

specialized knowledge, skills and experience.

The Certification credentials after your name demonstrates to the profession a high level of commitment to your field of practice and a high level of knowledge and skill unique to your role.

Specialty certification enhances professional reputation of nurses.

Eligibility Requirements A valid and unrestricted license a RN;

and

A baccalaureate in nursing degree or higher plus 2080 hours of experience in a nurse manager role or

A non-nursing baccalaureate degree plus 3120 hours of experience in a nurse manager role or

A diploma or associate degree in nursing plus 5200 hours of experience in a nurse manager role.

Application Fees CNML Exam

AONE Member $300

Non Member $425

Rescheduling fee $100

6/3/2019

2

OVERVIEW

115 Total Questions 100 questions count 15 trial questions 70 correct answers to pass

2 hours to take exam

Test Questions

Most questions are scenario based

Test divided into 4 sections Finance Management

Human Resource Management

Performance Improvement

Strategic Management and Technology

Preparation Reference List AONE has created a reference list for you

to study from

http://www.aone.org/initiatives/cnml-prepare.shtml

Study Groups

Consider forming a small exam study group to share ideas. Candidates who pool their resources and study together may be more confident in their knowledge and more likely to succeed at passing the exam. Consider scheduling to test at the same time and traveling to the testing site together and support one another every step of the way.

E Learning Essential of Nurse Manager Orientation

40 CNE

6/3/2019

3

Test Taking Skills Testing site Visit the location

Where is it?

Parking?

What can I bring with me?

What does it smell like?

What does it sound like?

What does it feel like?

Day before exam DO NOT STUDY

Relax

Get a good

night’s sleep

Day of exam Eat a good breakfast

Arrive at testing site early

Use rest room before going into exam

Memory Dump

Second Memory Dump

Exam Expect the exam to be difficult

Questions based on perfect, text book scenarios, do not read into the question

What is question asking you?

What is the question asking you? Remove distracters

Consider the answers

Eliminate incorrect answers

Answer all the questions, Mark the ones you unsure of

Come back to those questions if you have time

6/3/2019

4

References American Hospital Association. (2019). Current CNML Certificants

by State as of Monday, April 29, 2019. Retrieved from https://ams.aha.org/eWeb/Temp/AHACertProgramsbyState__nfaha_c0519b8b-ec81-4a25-97fe-4b42107bb8444292019.PDF

American Organization of Nurse Executives. (n.d. a). Certified Nurse Manager Leader handbook. Retrieved from http://www.aone.org/docs/certification/cnml-handbook.pdf

American Organization of Nurse Executives. (n.d. b). Certified Nurse Manager Leader references. Retrieved from http://www.aone.org/initiatives/cnml-prepare.shtml

Smith, D. (2018). Test Taking Skills CCRN & PCCN. Powerpoint slides

6/3/2019

1

CNML Practice Questions

Diane Smith, DNP, RN, CCRN-K, ACNS-BC, CNML, PCCN-K

Assistant Professor



1. Which of the following is an appropriate reason to request FMLA?

A. Birth of a grandchild

B. Uncle’s heart surgery

C. Adoption of a child

D. Sister’s out patient procedure

2. Which of the following information is required to build a zero balanced budget?

A. Projected census based on new procedure

B. Last year’s Capital Budget

C. Turnover rate

D. Patient Satisfaction Scores

3. Shared Governance is an example of a

A. Centralized organizational model

B. Laissez-faire leadership style

C. Decentralized organizational model

D. Horizontal centralization

4. The following is an appropriate question to ask in an interview

A. When did you graduate from High school?

B. Where you involved in the union at your last position?

C. How would you handle an irate physician complaining about an order not being completed?

D. Are you planning a family?

5.You have received a few complaints about two staff members who have been arguing on the unit .What would your next action be?

A. Terminate the two nurses experiencing the conflict

B. Prepare to transfer one nurse to a different department

C. Visit with both nurses individually

D. Talk to the rest of the staff

6/3/2019

2

6. Which of the following is depicted on a run chart?A. Used to break down steps in a process

B. Used to determine relationships over time

C. Compare results with upper and lower limits and targets

D. Used to determine the distribution of data

7. A Nurse Manager is requesting a new position of a nurse educator for the upcoming fiscal year. The Chief Nursing Officer has requested a business plan. The Nurse Manager should:

A. Develop market strategies for the position

B. Survey nursing staff to assess institutional need

C. Consult college/university faculty

D. Quantify long term objectives

8. Several Nurses have come to the Nurse Manager to complain about the the length of time it takes for the lab to be on the unit to draw labs which increase the length of time to obtain results. What action should the Nurse Manager take?

A. Call the Manager of the lab to relay the information

B. Develop a unit based team to fix the problem

C. Develop a policy specifying turn around times for lab tests

D. Develop a team including nurses from your unit and staff from the lab to address the issue

9. After the Nurse Manager announced the decision to start a new program suggested by The Joint Commission. One of the nurses came to the office and stated, we tried that at the previous hospital I worked at and it does not work. What would the most appropriate response from the Nurse manger be?

A. We could really use your expertise on the committee, our first meeting is on Tuesday.

B. The Joint Commission said we have to do it, so we have to make it work.

C. We will make sure every one makes it to the education

D. We will make a policy so everyone will have to do it.

10. Based on the above information, what is the average daily census on a 36 bed unit?

Patient Classification

Patient Days

Ave Care hours

Total Unit Workload

1 1250 2.5 3125

2 3000 4.2 12,600

3 2500 6.8 17,000

4 1500 10.0 15,000

5 800 12.5 10,000

Total 9050 36.0 57,725

A. 22.5

B. 24.7

C. 25.9

D. 32.8

11. Based on the above information, how many FTE’s are required to staff this 36 bed unit?

Patient Classification

Patient Days

Ave Care hours

Total Unit Workload

1 1250 2.5 3125

2 3000 4.2 12,600

3 2500 6.8 17,000

4 1500 10.0 15,000

5 800 12.5 10,000

Total 9050 36.0 57,725

A. 22.8

B. 24.7

C. 27.7

D. 32.8

6/3/2019

3

CENP Practice Questions

1. Which of the following is the best example of a leader effectively controlling group

discussion?A. Focusing on the person monopolizing the

discussion

B. Calling attention to a person who won’t talk

C. Emphasizing the idea of difference rather than conflict

D. Confronting angry or painful feelings whenever they surface

2. Which of the following is required before a nurse executive gives permission for a

researcher to access staff nurses?

A. Verbal approval from the medical director

B. Written approval from the governing board

C. Verbal approval from the impacted nurse manager

D. Written approval from the institutional review board

3. The newly-hired nurse executive desires to instill trustworthiness as an ethical principle in all patient care operations. Which of the following is the best way of

inspiring trust in a staff?

A. React differently to similar situations

B. Set a maximum time to listen to staff concerns

C. Respond in a timely manner to requests

D. Send requests to committees for considerations

4. A nurse executive decided to use a Pareto analysis to design feedback mechanisms for

adopting practice based on outcomes. The use of such a tool is effective because it

A. Identifies the few causes responsible for the most problems.

B. Selects one solution from among several available options.

C. Develops the thinking process.

D. Generates several solutions.

5. Which of the following is essential planning information for any piece of capital equipment?

A. Return on investment analysis

B. Staff training

C. Location of nearest field service office

D. Cost of replacement parts

6/3/2019

4

NE-BC Practice Questions

1. Which statement is an outcome indicator?

A. “The nurse working in a coronary care unit has successfully completed an advanced coronary care course.”

B. “The nursing care plan outlines a strategy for each patient problem.”

C. “The patient names all medications to be taken after discharge.”

D. “The patient newly diagnosed with diabetes mellitus receives 10 hours of instruction.”

2. When scheduling staff in a nursing department, a

staffing coordinator first takes into account the:

A. complexity of the nursing care required for the department.

B. number and type of nursing care providers that are available.

C. number of patient days and the number of hours of nursing care required by each patient per day.

D. severity of the illnesses and cost of nursing care per patient.

3. Which is an accurate statement about the shared governance professional practice

model?

A. Nursing management at the unit level maintains accountability for registered nurse practice.

B. Nursing management delegates decision-making authority to the lowest possible level of the nursing staff.

C. Professional nurses participate in clinical decision making, but all final authority rests with the chief nursing executive.

D. Staff members selected by their peers participate on committees or decision-making councils

4. In order to meet the continuous quality improvement requirements of an accreditation

agency, a hospital is required to implement:

A. intensive in-service education.

B. interdepartmental staff meetings.

C. patient satisfaction surveys.

D. the use of midlevel practitioners.

5. A Gantt chart helps a process improvement team to:

A. calculate a time estimate for each activity.

B. determine outcomes, risks, and needed information.

C. plan and control for uncertain conditions.

D. visualize tracking of multiple tasks.

6/3/2019

5

6. Policies for the proper handling of biohazardous waste are formulated to follow

the guideline that waste:

A. can be effectively disposed of by incineration.

B. can be rendered harmless by chemical disinfection, incineration, or autoclaving.

C. requires no special treatment if buried in a dump site regulated by the US Environmental Protection Agency.

D. should only be handled by maintenance workers.

7. A nurse executive wants to expand services and offer a birthing center which is not available in the community. To

justify the need for the center, the nurse executive first:

A. conducts a market research study.

B. determines the availability of qualified nurses.

C. networks with the community.

D. prepares goals and objectives.

8. A newly appointed assistant director of nursing for a clinical service notices that staff appear to deliver care in a

disorganized, fragmented, superficial, and task-oriented manner. The assistant director's first action is to:

A. gather data about the nature of the problem and ask the director of nursing for advice.

B. review the philosophy statement and meet with the staff to distribute and discuss it.

C. schedule conferences with staff members to discuss basic values and beliefs about nursing and begin to establish goals together.

D. schedule meetings with the staff to share these observations and tell them what changes are desirable.

9. A nurse refuses an assignment to care for a patient who is in cervical traction because the nurse does not know how to provide care for this kind of patient. The nurse manager's

best course of action is to:

A. float the nurse to a non orthopedic unit.B. give the nurse a brief in-service instruction on how to

care for the patient.C. reassign the patient to another nurse.

D. reassure the nurse that he or she is capable of providing this care.

10. The federal organization responsible for monitoring the Diagnosis-Related Group program is the:

A. Center for Medicare and Medicaid Services.

B. General Accounting Office.

C. National Institutes of Health.

D. Office of Inspector General.

11. A 14-year-old girl, who is a Jehovah's Witness, is admitted for anemia. The physician determines that blood transfusions are

necessary, but the girl's parents refuse consent. The girl states that she wishes to be treated. It is appropriate for the nurse manager to:

A. contact local clergy for assistance in crisis intervention.

B. inform the girl that her parents must consent before treatment can be given.

C. inform the girl that she is a minor and incapable of such decisions under state law.

D. request that the administration contact the hospital attorney for legal counsel.

6/3/2019

6

12. A patient has a terminal illness. Against the family's wishes, the patient requests a “do not resuscitate” order. Which ethical principle supports the patient's decision?

A. Autonomy

B. Beneficence

C. Justice

D. Non-maleficence

13. A nurse manager overhears a conversation that a staff nurse is having in a patient's room with a family member. The manager

recognizes that the nurse is discussing the patient's condition as if the patient were not present. The manager is concerned because the nurse

seems to have violated the ethical principle of:

A. Autonomy.

B. Beneficence.

C. Justice.

D. Non-maleficence.

14. Which budget assumes that no existing programs are entitled to automatic approval?

A. Forecast

B. Static

C. Variable

D. Zero-based

15. To identify the nursing staff needed for a new inpatient unit, the manager's first action is to:

A. determine the patient care needs and time required to meet those needs.

B. solicit internal staff who are challenged by new endeavors.

C. determine which staffing model will be utilized.

D. hire unlicensed assistive personnel to work with each registered nurse.

16. The major goal of group brainstorming is to:

A. collect ideas through a survey process and then prioritize the ideas.

B. generate ideas through facilitation without criticism or evaluation.

C. generate ideas through group discussion without following procedural rules.

D. stimulate discussion of ideas until a consensus is reached.

17. Unfreezing, moving, and refreezing are the primary components of the theory of:

A. goal setting.

B. motivation.

C. organizational development.

D. planned change.

6/3/2019

7

18. In decentralized systems, authority is delegated to the staff member who:

A. has been chosen by the supervisor.

B. has completed the competency requirements.

C. is at the level of the action.

D. is in the first-line management position.

19. The failure or refusal to hire an individual on the basis of the individual's race, color, religion, sex, or national origin is

specifically prohibited by:

A. the Fair Labor Standards Act.

B. the Hill-Burton Act.

C. the National Labor Relations Act.

D. Title VII of the Civil Rights Act of 1964.

20. A nurse manager is aware that union-organizing activities are being conducted at the institution. According to National

Labor Relations Board regulations, it is permissible for management to:

A. distribute information to workers about the union's record on dues, strikes, and other aspects of the union's performance.

B. offer additional insurance coverage while the organizing activities are taking place.

C. provide an unscheduled wage increase while the organizing activities are taking place.

D. restrain the union-organizing committee from soliciting authorization cards.

21. A nurse manager wants to promote greater autonomy in the practice of nursing. The manager's

initial step is to:

A. designate the nursing practice standards that will be expected of the nurses.

B. formulate a pilot unit where greater autonomy can be trialed.

C. seek the support of the board of directors before encouraging specific actions.

D. use a standardized instrument to measure individual nurse performance.

22. In a performance appraisal, the beneficial influence that positive ratings in some areas can have on the overall appraisal is known as the:

A. halo effect.

B. Hawthorne effect.

C. leniency effect.

D. recency effect.

23. A nursing department with openings in key management positions is undergoing a reorganization. The department

has a large number of self-directed, highly motivated nurses. Which organizational structure would be most appropriate?

A. A structure that includes line and staff positions

B. Ad hoc

C. Functional

D. Matrix

6/3/2019

8

24. The successful implementation of change requires:

A. a focus on a specific timeline.

B. a project manager specifically assigned to manage the change.

C. the elimination of constraints on resources.

D. the involvement of those affected

NEA-BC Practice Questions

1. An educational institution contracts with a hospital to offer clinical experience for nursing students. The nurse

executive ensures that each contract includes a:

A. clause that all nursing faculty members be licensed.

B. copy of the nursing program's curriculum.

C. mandate that each student carry individual malpractice insurance.

D. provision that the hospital's nursing department retains responsibility for nursing care provided by the students.

2. A home health agency applies the principle of justice to patient care when:

A. admitting patients who are medically complex.

B. providing 24-hour coverage as required.

C. referring patients to community agencies.

D. scheduling sufficient time for each patient's care.

3. The American Nurses Association's Code of Ethics for Nurses with Interpretive Statements

serves:

A. as a guide for the highest standards of ethical nursing practice.

B. as a legally binding document.

C. to mandate ethical behavior as a prerequisite for nursing licensure.

D. to outline the minimum level of ethical behavior for nurses.

4. Regarding professional ethics, a nurse executive is responsible for ensuring that:

A. a nursing committee is established and meets regularly.

B. each nurse receives a copy of the American Nurses Association's Code of Ethics for Nurses with Interpretive Statements.

C. educational offerings on ethics are held for the nursing staff every two years.

D. nursing is represented in the formal mechanism for addressing ethical dilemmas.

6/3/2019

9

5. When evaluating a nursing department's philosophy statement, a nurse executive's most

important action is to:

A. assess whether consistency exists between the statement and nursing practice.

B. create a task force of registered nurses to regularly review the statement.

C. determine whether the statement is flexible.

D. solicit input from peers about the statement's relevance.

6. In which study is sampling bias a factor?

A. Nursing administration students are studied to examine trends in graduate nursing education.

B. Patients are studied to determine how medication teaching affects compliance.

C. Physicians are studied to investigate the medical profession's acceptance of nurses as members of the treatment team.

D. Psychiatric nurses are studied to assess their attitudes toward clients whose cultural backgrounds differ from their own.

7. What is the key consideration in selecting a nurse to be a preceptor?

A. The duration of the preceptor program

B. The nurse's completion of a preceptor course

C. The nurse's level of experience

D. The nurse's seniority in the organization

8. During union-organizing efforts, an unfair labor practice occurs if management:

A. informs employees that the nurse executive would rather deal directly with them than with the union when differences arise.

B. refuses to allow employees to attend a meeting convened by labor organizers during work hours.

C. removes outside organizers from the organization's premises.

D. supplies the union with requested information about specific employees of the organization.

9. Which is an accurate statement about an employer's liability for sexual harassment?

A. If an employee who has been sexually harassed subsequently resigns, the employer is no longer liable.

B. Lack of knowledge of a sexual harassment incident does not eliminate liability.

C. Liability is limited to employee behavior that violates an agency's sexual harassment policy.

D. Liability is limited to sexual harassment by employees, whether occurring between coworkers or supervisors and subordinates.

10. To comply with the Americans with Disabilities Act of 1990, a health care facility must:

A. employ readers for job applicants who are visually impaired.

B. equip computer systems with voice recognition software.

C. install elevators in service areas.

D. remove physical barriers in patient care areas.

6/3/2019

10

11. A nurse executive has staff authority, rather than line authority, if the nurse executive:

A. does not appear on an organizational chart.

B. has subordinates over whom authority is exercised.

C. is responsible for achieving accomplishing organizational objectives.

D. serves in an advisory capacity.

12. A conflict arises between a hospital's operating room nurses and surgical unit nurses over patient arrival times at the operating room. The

nurse executive appoints a performance improvement team to examine the conflict. Which statement by a team member best indicates progress toward

conflict resolution?

A. “I did not realize how much time is involved in preparing patients for surgery.”

B. “I think it is pretty clear that some people are more responsible than others for this problem.”

C. “I think we should keep exact records of the time factors for one month, then we will know where the discrepancy lies.”

D. “It is always good to be able to vent your feelings. It helps when you can tell people what you think.”

13. Health care professionals form a coalition to propose amendments to the state's nurse practice act. Controversies surface regarding role

definitions. To communicate information about the proposed changes, the coalition's most effective action is to:

A. form a network of all categories of nurses in the state.

B. mail the minutes from coalition meetings to all constituencies.

C. request that coalition members put the proposed changes on the meeting agendas of other groups to which they belong.

D. work with groups that have lobbied in the past for changes in the state's nurse practice act.

References

• American Nurses Credentialing Center (n.d.). Sample Test questions: Nurse Executive Sample questions. Retrieved from https://www.nursingworld.org/certification/our-certifications/study-aids-ce/sample-test-questions/stq-nurseexec/

• American Organization of Nurse Executives Credentialing Center. (n.d.). Certified Nurse Manager and Leader examination handbook. Author. Retrieved from http://www.aone.org/docs/certification/cnml-handbook.pdf

• American Organization of Nurse Executives Credentialing Center. (n.d.). Certified Executive in Nursing Practice examination handbook. Author. Retrieved from http://www.aone.org/docs/certification/cenp-handbook.pdf

Answers to Practice Questions

Number CNML CENP NE‐BC NEA‐BC

1 C C C D

2 A D C D

3 C C D A

4 C B C D

5 C A D A

6 B B A

7 D A C

8 D C D

9 A C B

10 B A D

11 C D D

12 A A

13 A A

14 D

15 A

16 B

17 D

18 C

19 D

20 A

21 A

22 A

23 D

24 D

Preparation for the CNML exam is a combination of knowledge and application of knowledge. The following sources are just a few of the possible references available to give an overview of nursing management. We also suggest you refer to current journal articles to see how that knowledge is applied. We do not list journal articles since new and updated information is regularly available. Leadership Textbooks Grohar‐Murray, M., Langan, J. (2011) Leadership and Management in Nursing, 4th ed. Upper Saddle River, NJ: Pearson Education, Inc. Huber, D. (2009). Leadership and nursing care management 4th ed. Philadelphia: W.B. Saunders Company. Marrelli, , T.M (2004). The Nurse Manager’s Survival Guide: Practical answers to everyday problems, 3rd ed. St. Louis: Mosby Marquis, B.L., Huston, C. (2009) Leadership Roles and Management Functions in Nursing, 6th ed. Philadelphia: Wolters Kluwer Health/Lippincott, Williams & Wilkins. Melynk, B. & Fineout‐Overholt, E. Evidence‐Based Practice in Nursing & Healthcare: A Guide to Best Practice Lippincott Williams & Wilkins; Second edition (June 2, 2010) Sullivan, E.J. & Decker, P.J. (2009) Effective leadership and management in nursing. 7th ed., Upper Saddle River, N.J. Pearson Prentice Hall A Swansburg, R.C. & Swansburg, R.J. (2002) Introduction to Management and Leadership for Nurse Managers (3rd). Jones and Bartlett Publishers, Inc. Yoder‐Wise, P.S. (2010) Leading and Managing in Nursing, 5th ed. St. Louis: Mosby Foundational Documents AONE Guiding Principles http://www.aone.org/resources/principles.shtml Principles and Elements of a Healthful Practice/Work Environment http://www.aone.org/resources/leadership%20tools/library.shtml ANA Scope & Standards of Practice: Nursing Administration. (2009) Center for Medicare and Medicaid Services. cms.gov The Future of Nursing: Leading Change, Advancing Health, Institute of Medicine, 2010. The Joint Commission Standards and Measurements http://www.jointcommission.org/ Becoming a High Reliability Organization http://www.ahrq.gov/qual/hroadvice/

References for Specific Content Areas

Finance Finkler, S. and Kovener, C. (2012) Financial Management for Nurse Managers and Executives, 4th ed. Philadelphia; Saunders Finkler, S. & McHugh, M. (2007). Budgeting Concepts for Nurse Managers (4th ed). St. Louis, Missouri: Saunders/Elsevier

Business Skills Lloyd, R. (2004) Quality Health Care: A Guide to Developing and Using Indicators. Sudbury, MA: Jones and Bartlett Publishing. Mathis, R. & Jackson, J. (2010) Human Resource Management, 13th ed. South‐Western College Pub

Human Resources Benner, P; From Novice to Expert: Excellence and Power in Clinical Nursing Practice; commemorative edition; Upper Saddle River, NJ; Prentice Hall, 2006 Patterson, K. Grenny, J., McMillian, R. Switzler, A. (2012) Crucial Conversations: Tools for talking when stakes are high, 2nd ed., New York: McGraw. ACQ 11/2/2011 Gibson, J.L., Ivancevich, J.M., Donnelly, J.H., Konopaske, R. (2009). Organizations Behavior, Structure, Processes. McGraw‐Hill: New York: New York. Mathis, R. & Jackson, J. (2010) Human Resource Management, 13th ed. South‐Western College Pub

Performance Improvement Hughes, R. (2008) Tools and strategies for quality improvement and patient safety. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK2682/ Leape, L. (2002) Reporting adverse events. New England Journal of Medicine, 147(20), 1633 Agency for Healthcare Research and Quality http://www.ahrq.gov/ Committee on Quality Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Center. Washington, DC: National Academy Press; 2001. Schmidt, N. & Brown, J. (2009) Evidence‐based practice for nurses: Appraisal and application. Sudsbury. Jones and Bartlett ACQ 11/2/2011 Committee on Quality of Health Care in America, Institute of Medicine, 2000; To Err is Human: Building a Safer Health System, Linda T. Kohn, Janet Corrigan, and Molla S. Donaldson, Editors Quint‐Studer (2004) Hardwiring Excellence: Purpose, Worthwhile Work, Making a Difference. Gulf Breeze, FL: Fire Starter Publishing.

Strategic Management and Technology Borkowski, N. (2009) Organizational behavior, theory, and design in healthcare. Sudbury, MA: Jones and Bartlett Publishers. Harris, J., Roussel, L., Walters, S., and Dearman, C. (2011) Project Planning and Management, Jones and Bartlett Learning, Sudbury, MA. Lombardo, M. and Eichinger, R. (2009) For Your Improvement: A development and coaching guide, Lominger, Minneapolis. Porter‐O’Grady, T and Malloch, K. (2010) Quantum Leadership: Advancing Information, Transforming Health Care, Third Edition, Jones and Bartlett Learning, Sudbury, MA. Swihart, Diane. Shared Governance: A Practical Approach to Reshaping Professional Nursing Practice. (2006)

Rev 5.12