Managing for Success in

Health Care Delivery What can we do?

Ruth A. Anderson RN, PhD, FAAN

Duke University School of Nursing

Purpose of Presentation

Demonstrate how we are applying the complexity science concepts to studies of management practices in health care

Show evidence base for complexity science derived hypotheses

Self Self OrganizationOrganization

Naturally occurring system property Arises through relationship patterns Works for or against goals

System ParametersSystem Parameters

Rate of new information Rate of new information flowflow

Nature of connections Nature of connections among peopleamong people

Cognitive diversityCognitive diversity

Ralph Stacey, 1996

Conceptual Model

Nursing Mgmt Practices

•Rate of information flow thru systemNumber & intensity of interconnections between agentsLevel of diversity within & between cognitive schema of system agents

Behaviors for

Quality Outcomes

Self-Organization

System Control Parameters

Process Outcomes

ManagementPractices Alter

Self

Organization

Management Practice

• Work Environment

• Participation in decision making

• Communication Openness

• Leadership behaviors

• Workforce diversity

System Parameters

• Rate of information flow

• Nature of interconnections

• Diversity within/between cognitive schema

Better & IMPROVED

Outcomes

Agents & information diversity:

|

Scope

Agents & information diversity:

|

Scope

Participation in Decision MakingParticipation in Decision Making

Agent connection & interaction:

|

Intensity

Agent connection & interaction:

|

Intensity

Depth|

Information “Richness”

Depth|

Information “Richness”

Breadth|

Information Diversity

Breadth|

Information Diversity

Decision Activities

Raising the IssueClarifying the IssueGenerating AlternativesEvaluating AlternativesChoosing Alternative

Decision Activities

Raising the IssueClarifying the IssueGenerating AlternativesEvaluating AlternativesChoosing Alternative

Decision Mechanisms

Established Com.Specially Created Com.Informal MeetingsChance EncountersOther

Decision Mechanisms

Established Com.Specially Created Com.Informal MeetingsChance EncountersOther

RN Participation & Improvement in Resident Outcomes

190 Nursing Homes Survey methods Administrators and Directors of Nursing Minimum Data Set

Improvement in Resident Outcomes

Anderson, R. A., & McDaniel, R. R., Jr. (1999). RN participation in organizational decision making and improvements in resident outcomes. Health Care Management Review., 24(1), 7-16.

What are the differences between most improved and least improved?

Size23%

Group 20%

Unexplained

57%

Controlling for:

• Size

• Change in Cost

• RN StaffingAnderson & McDaniel, 1999

Do Nurses Influence Final Choices Through Participation?

Participation in Decision MakingParticipation in Decision Making

Agent connection & interaction:

|

Intensity

Agent connection & interaction:

|

Intensity

Decision Activities

Raising the IssueClarifying the IssueGenerating AlternativesEvaluating AlternativesChoosing Alternative

Decision Activities

Raising the IssueClarifying the IssueGenerating AlternativesEvaluating AlternativesChoosing Alternative

Decision Mechanisms

Established Com.Specially Created Com.Informal MeetingsChance EncountersOther

Decision Mechanisms

Established Com.Specially Created Com.Informal MeetingsChance EncountersOther

Anderson, R. A., & McDaniel, R. R., Jr. (1998). Intensity of registered nurse participation in nursing home decision making. Gerontologist., 38(1), 90-100. Survey of 125 Nursing Homes

Participation in Decision MakingParticipation in Decision Making

Agent connection & interaction:

|

Intensity

Agent connection & interaction:

|

Intensity

Decision Activities

Raising the IssueClarifying the IssueGenerating AlternativesEvaluating AlternativesChoosing Alternative

Decision Activities

Raising the IssueClarifying the IssueGenerating AlternativesEvaluating AlternativesChoosing Alternative

Decision Mechanisms

Established Com.Specially Created Com.Informal MeetingsChance EncountersOther

Decision Mechanisms

Established Com.Specially Created Com.Informal MeetingsChance EncountersOther

Survey of 68 Public Health Agencies

Issel, L. M., & Anderson, R. A. (2001). Intensity of case managers' participation in organizational decision making. Research in Nursing & Health., 24(5), 361-372.

Error100%

Explained0%

Error87%

Explained13%

Participation of Clinical Professionals (MD and RN) =

Lower Cost/admission in Hospitals

Participation of MDs/RNs

Participation of Middle Managers

Ashmos, D. P., Huonker, J. W., & McDaniel, R. R. (1998). Participation as a complicating mechanism: The effect of clinical professional and middle manager participation on hospital performance. Health Care Management Review, 23(4), 7-20.

Complexity & Turnover Study

164 Nursing Homes Survey methods Administrator, Director of Nursing,

RNs, LPNs, CNAs (n~3500) Medicaid Cost Reports-Turnover

Anderson, R. A., Corazzini, K. N., & McDaniel, R. R. (2004). Complexity science and the dynamics of climate and communication: Reducing nursing home turnover. The Gerontologist, 44(3), 378-388.

Laissez-faire Climate Conflict prevents accomplishment Adm doesn’t care who gets hurt Little concern for employee

relations No room for new ideas It’s who you know Unclear goals Little effort to constantly improve

Reward Climate Adm does the right thing Adm looks out for worker Concern for relationships Learning encouraged What you do–not who you

know Clear goals & expectations Constructive feedback Always looking for a better

way

Accuracy Accuracy is the extent

to which one believes that the information conveyed by other parties is correct

Openness Openness is the

extent to which one can speak clearly and directly without fear of repercussions or misunderstanding

Climate, Communication & Turnover

Work Env X Open

Commun.27%

Unexplained73%

LPNs

Anderson, Corazzini & McDaniel, 2004

DON tenure Number of RNS LPN Workload Reward climate x

Communication openness

Climate, Communication & Turnover

Work Env X Open & Accurate Commun.

25%

Unexplained75%

Nurse Assistants

Anderson, Corazzini & McDaniel, 2004

CNA Workload Reward climate x

Communication openness

Reward climate x Communication accuracy

Laissez-faire Climate Conflict prevents accomplishment Adm doesn’t care who gets hurt Little concern for employee

relations No room for new ideas It’s who you know Unclear goals Little effort to constantly improve

Anderson, Corazzini & McDaniel, 2004

Communication Openness Openness is the extent

to which one can speak clearly and directly without fear of repercussions or misunderstanding

Complexity, Management Practices & Resident Outcomes

164 Nursing Homes Survey methods Directors of Nursing & RNs Minimum Data Set-Resident Outcomes Medicaid Cost Reports-Control Variables

Anderson, R. A., Issel, L. M., & McDaniel, R. R. J. (2003). Nursing homes as complex adaptive systems: Relationship between management practice and resident outcomes. Nursing Research, 52(1), 12-21.

Theoretical Model

Nursing Mgmt Practices

+

–

–

–Communication Openness

Participation in Decision Making

Relationship Leadership

Formalization

Control Variables

Contextual FactorsSizeOwnership Type

DON CharacteristicsTenure in positionDON Experience

Resident Outcomes

Prevalence of:Resident Behaviors ProblemsRestraint UseComplications of ImmobilityFractures

Anderson, Issel & McDaniel, 2003

System Parameters

• Rate of information flow

• Nature of interconnections

• Diversity within/between cognitive schema

Management Practice

• Communication Openness

People can say what they mean without fear of repercussion—during vertical and horizontal information exchanges.

Anderson, Issel & McDaniel, 2003

Error79%

Explained21%

Communication Openness & Restraint Use (N=164)

Context•Size ( – )

DON Characteristics•DON Tenure (–)•DON Experience (–)

Mgmt Practice• Communication

Openness (–)

Anderson, Issel & McDaniel, 2003

Anderson, Issel & McDaniel, 2003

Error85%

Explained15%

Problem Behaviors

Context•Size ( – )

Mgmt Practice•RN Participation in decision making (–)

Anderson, Issel & McDaniel, 2003

System Parameters

• Rate of information flow

• Nature of interconnections

• Diversity within/between cognitive schema

Management Practice

• Leadership behaviors

Relationship-oriented—product of human interaction and communication between manager and worker

Anderson, Issel & McDaniel, 2003

Error89%

Explained11%

Leadership & Fracture (N=164)

Mgmt Practice• Relationship-oriented

leadership (–)

Anderson, Issel & McDaniel, 2003

System Parameters

• Rate of information flow

• Nature of interconnections

• Diversity within/between cognitive schema

Management Practice

• Formalization

Centralized control using job descriptions, surveillance, and procedures and rules to ensure predictability

Error85%

Explained15%

Leadership, Formalization & Complications of Immobility

DON Characteristics• DON Experience (–)

Mgmt Practice• Relationship-oriented

leadership (–)• Formalization (+)

Anderson, Issel & McDaniel, 2003

N=164

Anderson, Issel & McDaniel, 2003

New Behaviors

Management Practices

• Work environment

• Communication

• Participation in decision making

• Leadership behaviors

• Workforce diversity

System Parameters

• Rate of information flow

• Nature of interconnections

• Diversity within/between cognitive schema

Self

Organization

Things to Think About for Effectiveness

Connection Diversity Information

exchange

MANAGE THE SYSTEM