The Role of the Nurse Manager in Maintaining Quality and Managing Risk

Maintaining quality while eliminating risk is a major challenge facing everyone in the healthcare delivery system today. Patients in today's healthcare system expect the 'best care' possible. Administrators of healthcare organizations expect healthcare providers to deliver 'this best care' in the most efficient manner. Risk managers (including nurses) and regulatory agencies interpret 'the best care' as being 'the highest quality care' possible. Attainment of the goal of delivering the 'best care' or 'highest quality care' is not the challenge. The challenge comes when the modifiers to the delivery of the 'best care' are added (i.e., delivering the 'best care' in the 'most economical' way using the least resources possible).

Today's purchasers of healthcare are true consumers. Healthcare plans, businesses, industries, and individuals who are the ultimate purchasers of health services expect the most for the least. These consumers expect healthcare delivery organizations to present evidence of the quality, effectiveness, and economics of their services and to tailor the services to meet the individual's needs. Buyers of health care expect a 'report card' or 4consumer report' on the services provided, quality of the services, the cost, and the risks or absences of risk for each service or product line offered by the healthcare organization. Patient care teams under the leadership of professional nurses and nurse managers determine the grade on the 'report card' or the results for the 'consumer report'.

The nurse manager ultimately is responsible and accountable for inclusion of appropriate risk management strategies with strategies to enhance and maintain quality of care. The nurse manager leads the patient care team in providing the 'best care' in the most economical way while minimizing risk. Typically, individual nurse managers determine the achievement of the goals of specific units within a complex organization. Actualizing goals in today's healthcare arena requires nurse managers to be excellent change agents and role models. The priority changes are those that help the patient care staff in doing the same or more in terms of quality of care and services delivered with less in terms of resources used. "Doing more with less," raises several critical risk management issues. The critical risk management issues include the following:

• delegation
• staffing levels
• staff competencies
• documentation systems

Restructuring nursing units has affected nursing and nurse managers in a huge way. A major effect of restructuring of nursing units is a reduction in the ratio of the registered nurse (RN) to the non-registered nurse (non-RN) staff. Although the number of RNs on units has decreased, the acuity levels of the patients and the responsibilities of the RN staff have increased. To meet the care needs of the more acutely ill patient and the increased responsibilities, RNs must delegate aspects of patient care to non-RN team members. RNs educated in the last 15 years have been educated in an environment where total patient care, primary nursing, and all-RN staff comprises the care delivery systems and staffing patterns. These delivery systems and staffing patterns are no longer the usual, and the use of Unlicensed Assistive Personnel (UAPs) and delegation to such personnel become a necessity if quality care is going to be delivered while using fewer resources and managing risk.

Many nurses are not skilled in delegation. Principles of delegation are only recently being included in academic programs preparing professional nurses. Thus, many RNs must develop this management skill. RNs need to understand thoroughly the rationale for the new staffing mix and be supported in their new enhanced role (Hansten & Washburn, 1996). Probably the most important issue relevant to appropriate delegation is effective communication skills for all members of the healthcare team. Effective communication skills include the ability to listen, to understand, to question when unclear, and to convey information in an accurate and timely manner.

Delegation means transferring responsibility for performing a task to another person, while remaining the responsible and accountable person (Sullivan & Decker, 1997). The lack of knowledge about appropriate delegation and the legal burdens added by delegation diminish the RNs willingness to delegate. Thus, many RNs continue to do tasks that should or must be delegated to non-RN team members if quality care is going to be delivered in a more economical fashion. The inability to delegate results in RNs spending time carrying out tasks such as patient hygiene, therefore preventing RNs from completing assignments and tasks that cannot be delegated. An RNs time is better spent developing a plan of care, consulting with other healthcare providers, patient teaching, and performing tasks that require higher level skills and knowledge.

The appropriate use of delegation requires nurse managers to develop role descriptions that describe the scope of practice of every patient care team member. The RN staff must know what functions and activities can be delegated and what functions and activities cannot be delegated.

Another responsibility for nurse managers, in relation to delegation, is to ensure that RNs know how to:

• hold other RN team members accountable for appropriate delegation,

• hold team members accountable for the implementation of their delegated actions, provide the appropriate feedback to team members.

At times, nursing leadership may need to seek legal opinions regarding delegation of activities, including what can and cannot be delegated.

The nurse manager is also responsible for ensuring that the non-RN staff are competent in taking on the delegated tasks. That is, the nurse manager must ensure that staff are educated about the tasks to be delegated and have the opportunity to practice the skills with supervision. Practice with appropriate feedback is essential for learning and proficiency to occur. Then, the person to whom a task was delegated must periodically report back on tasks delegated and receive adequate supervision and oversight.

Staffing and maintaining appropriate staffing levels on nursing units remain the greatest challenge facing nurse managers and one of the most important challenges in risk management. Staffing must provide the appropriate mix and numbers of RN and non-RN staff for every shift every day. Although staffing and the challenges of staffing have been the focus of nursing studies, these studies have not been successful in elucidating the 'ideal' staff mix and the impact of changes in staffing on the performance of a healthcare organization or on a specific unit (Shindul-Rothschild & Duffy, 1996). Thus, there is no one 'perfect' formula for staffing a unit.

There are multiple proposed models to use as a framework to establish the staffing requirements on a particular unit. Regardless of the model used, there are several facts that can negatively affect any plan and create risks for the nurse manager. Steinwachs (1992) reported that, the most significant factor affecting RN staff productivity is the turnover rate. An increased turnover rate adds significant unplanned expenses for a unit and decreases productivity of the remaining RN and non-RN staff. The use of a greater number of UAPs and RNs from staffing agencies or RNs with temporary assignments are the results of increased RN staff turnover. These solutions can worsen, rather than enhance the productive use of RNs (Shindul-Rothschild & Duffy, 1996). A couple of significant effects of these solutions are that temporary and agency RNs spend more time performing tasks that should be delegated, and the regular RNs spend more time supervising the increasing number of non-RN staff members. RNs from outside the unit are also not as productive as the regular unit RNs, and RNs assigned permanently to the unit may spend significant time supervising temporary and agency RNs.

When a facility implements restructuring and redesign, nurse managers must be involved, especially if any changes directly involve the nursing unit. Restructuring and redesign usually mean more is going to be expected from everyone. During the actual restructuring and redesign process, nurse managers must be especially diligent to recognizing potential risk issues. As job descriptions expand to include new responsibilities for each member of the nursing care team, nurse managers must ensure that there are no violations of the Nurse Practice Act which guides the practice of professional nursing in that institution and that the RN and non-RN staff members receive the appropriate education to achieve competency in implementing the new responsibilities. Ongoing documentation of the specific competencies of each staff member must be maintained by the nurse manager.

A real challenge for nurse mangers in appropriately staffing a unit occurs when the census is 100%, and/or patient acuity is significantly higher than the 'average' level of acuity. Creative planning by the nurse manager is essential in meeting the staffing needs and having staff with the appropriate competency at these critical times because most units are staffed for an 'average' census, usually less than capacity, and an 'average' level of acuity. A unit based PRN pool, with a certain percentage of part-time staff who can increase to more hours as needed, or even full-time staff who can work 'overtime' are some solutions to staffing during these times. However, there may be times that 'extra' staff are used to the maximum and nurse managers will have to look beyond specific units. Units having nursing care hours exceeding patient acuity may be a source of nursing staff for units with higher census and acuity than usual. If all the nursing units experience 'hyper-average acuity' and/or 'hyper-average census' at the same time and it appears the situation is not going to change for some time, nurse managers may need to consider looking for appropriate staff coverage outside the facility. Using an outside agency for additional nursing staff is becoming a desirable way of providing cost effective staffing during 'hyper average' times (Shaffer & Kobs, 1997). Whenever nursing staff are reassigned to another unit or whenever agency nursing staff are used, nurse managers must ensure that these 'new' nursing personnel are competent in implementing the nursing care required by the patients on a specific nursing unit. Such personnel must know the policies of the institution, applicable procedures and guidelines unique to the facility including risk management practices. Temporary staff must have a thorough orientation to the work setting and ongoing oversight by the nurse manager. These practices are critical to managing risk, providing quality care, and meeting requirements of accrediting bodies such as the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO).

Ensuring clinical competency of staff is an ongoing activity and another key component of risk management. Nursing leaders must identify the universal staff competencies for all nursing personnel in an organization as well as unit-specific staff competencies. Staff must have knowledge of the competencies required for their jobs and successfully pass any clinical competency test(s) before being assigned responsibility for clinical activities on a unit. Time periods between competency checks must be determined, and appropriate documentation of the competencies must be maintained. As discussed in the preceding section, the use of UAPs, the implementation of appropriate delegation, the reassignment of staff across several units and the use of agency staff all require that nurse managers focus energy on implementing mechanisms for validating staff competency and implementing staff development activities that allow for reviewing, maintaining, and updating skills. New technologies being introduced into healthcare and on nursing units and the increasing complexity of patients also give impetus to the need for on-going mechanisms for development and documentation of clinical competencies. Nursing staff must have access to resources 24 hours a day to supplement any skill sets that they do not use on a routine basis. Nurse managers must ensure that staff have time to attend review classes and to demonstrate proficiency in newly-acquired or updated skills. If outside nursing agency personnel are used within a facility, the healthcare institution and the agency must have an agreement about what competencies the nursing personnel must bring to the assignment, who is responsible for evaluating the competencies, and who will make sure that personnel have the time and the opportunity to attend necessary review classes.

Maintaining a staff competency system is one of the major ways nurse managers minimize risk in today's healthcare delivery system. However, maintenance of and documentation for such a system while controlling costs is a challenge.

A system of documentation that communicates care provided and patient status is essential for the following:

• ensuring quality care,
• meeting state licensure requirements,
• achieving payment for care,
• obtaining and maintaining voluntary accreditation(s),
• managing risk

Quality of Care and State Licensure Requirements

Shea (1993) notes that audits of an institution's medical records determine whether the quality of care meets state licensing requirements. "If the documentation is inadequate, the implication is that the care was also inadequate" (p. 61).

Payment For Care

Payers look to medical records to determine whether or not care should be paid for. With the increasing emphasis on linking outcomes of care to payment, a thorough medical record that details the care given and outcomes of care is essential.

Voluntary Accreditation

Healthcare accreditation agencies, such as JCAHO, accredit health facilities such as acute care facilities and outpatient facilities and surgical centers. The Health Plan Employer Data and Information System (HEDIS 3.0), which has 71 performance measures to evaluate managed care plans, reports to the National Committee for Quality Assurance (NCQA) and releases a 'report card' for public review. The federal government evaluates skilled and long term facilities that receive Medicare moneys. Meeting the criteria set by these groups requires good documentation. In addition, agencies such as JCAHO set standards for documentation of care which must be followed if accreditation is to be achieved and maintained.

Managing Risk

Documentation of the who, what, where, why, when, and how of care is the best evidence of competent nursing practice. "The credibility of the information in a medical record is very difficult to refute. Because of this, the medical record is the nurse's best defense in the event of a law suit" (Shea, 1993, p. 62).

The paperless record.

A "paperless" patient record has special risk management issues that need to be considered. Many organizations are making the transition to a "paperless" patient record. Although the basic principles for documentation remain the same in a paperless system (i.e., accurate, concise, and succinct), maintaining the patient's right to privacy becomes a greater challenge. One needs only to peruse lay magazines to become aware of the security issues involved with computer systems. The first major guideline that must be established is the design of specific criteria for who can access patient information. Then, guidelines on the actual process of accessing patient information must be established. All staff must be knowledgeable about the policies governing access to patient information and the expected behaviors for those with access to the computer. Inservice classes are essential for those with computer access to ensure they have knowledge of how to use the system and also to ensure understanding of the importance of maintaining security and protecting patient privacy. All employees must be aware of the consequences of violating the policies and procedures related to the computerized patient record. Staff must be aware of strategies to minimize risk in the use of the paperless record. Such strategies include the following:

• not altering patient information previously entered,

• correctly identifying late patient information entries as late entries,

• logging-off the computer when not currently in use to prevent others from viewing patient information,

• positioning computer screens to minimize viewing by those who do not have the need to see or know the information,

• reporting any incidence of unauthorized entry into the record,

• accessing only the information that the healthcare personnel need to know. Computerized documentation systems are like any other new technologies introduced into the healthcare environment. Staff must be adequately educated on the appropriate use and related ethical and legal issues. Staff competencies must be reviewed on a regular basis, and competency checks must be maintained.

The paper record.

Shea ( 1993) provides the following guidance to nurses related to charting:

• write legibly,
• use ink,
• never erase an entry,
• provide the date and time for all entries,
• use a "late note" for matters charted out of sequence, and
• do not leave blank lines on the medical record (pp. 65-66).

Shea (1993) also offers good advice that is applicable to the paper and "paperless" record:

• never use a patient's chart to criticize another member of the healthcare team; that is, be truthful and tactful,
• document what is seen, heard, felt, and smelled, document thought processes, and document non compliant patient behavior (pp. 67-68).

The incident report.

Most facilities use an incident reporting system to document accidents and errors. Incident reports are an integral part of a risk management program and help risk managers track conditions that might need to be corrected. Incident reports can help those in staff development identify education and training needs. Incident reports assist nurse managers in tracking and maintaining staff competencies. Shea (1993) urges that nurses know what must be reported, (such knowledge is a must for an institution's nurse employees and any temporary staff an institution uses), complete the incident report in its entirety, be objective in reporting, include names of witnesses to the incident preserving the confidentiality of witness patients by using the patient's admission number, submit the incident report through proper channels, never refer to incident reports in a patient's record as the privilege of confidentiality can be waived, consult with nurse manager or the institution's risk manager when questions arise.

The role of the nurse manager in managing risk is a key one. However, it cannot be implemented successfully without the nurse manager being properly prepared for the position, assuming the appropriate responsibility inherent in the position, and receiving 100% support from senior nurse executives. A basic requirement for success for nurse managers is mastering effective communication skills. These skills are critical for communicating with everyone in the healthcare system: clients and their family members, nursing staff, support staff, physicians, staff from other departments, managers and administrative personnel throughout the organization, and staff in various community healthcare agencies.

As a role model, the nurse manager must be cognizant of the fact that staff will emulate the positive and adverse behaviors exhibited. Adverse behaviors of staff members will continue unless the nurse manager intervenes and clearly communicates the behavior that is acceptable and not acceptable. The nurse manager must identify and communicate the nursing staff performance and behavior expectations of the employing agency. In terms of risk management, the nurse manager must continuously communicate the expectations that the nursing staff will:

• perform at all times as a reasonable, pruden person would perform under the same or similar circumstances,
• strive to meet applicable standards of care,
• maintain competency in practice and currency in knowledge,
• communicate clearly, and
• ask for help when needed.

Summary

The nurse manager must ensure that quality care is delivered in a cost-effective manner. In addition, the nurse manager is a vital link to risk management in the practice setting. Appropriate delegation, competent staff, and

thorough, thoughtful documentation are key components in a risk management program and are factors that can influence the quality and cost of care.

References

Grimaldi, P.L. (1997). HEDIS is bigger and better. Nursing Management. 28 (1), 17, 21-22.

Hansten, R., & Washburn, M. (1996). Why don't nurses delegate ? Journal of Nursing Administration, 26 (12), 24-28.

Joint Commission on Accreditation of Healthcare Organizations (JCAHO). (1997). Comprehensive accreditation manual for hospitals: Oakbrook Terrace, IL: Author.

Standards for Accreditation of Managed care Organizations. (1997). Washington, DC: National Committee for Quality Assurance.

Shaffer, F., & Kobs, A. (1997). Measuring competencies of temporary staff. Nursing Management. 28 (5), 41-45.

Shea, M. A.(1993). Professional liability: A nurse's perspective. University City, MO: TVI, Inc.

Shindul-Rothschild, J., & Duffy, M. (1996). The impact of restructuring and work design on nursing practice and patient care. Best Practices and Benchmarking in Healthcare, 1 (6), 271-289.

Steinwachs, D.M. (1992). Redesign of delivery systems to enhance productivity. In S.M. Shortell & U.E. Teinhardt (eds.). Improving health policy and management: Nine critical research issues for the 1990s (pp. 275-310). Ann Arbor: Health Administration Press.

Sullivan, E.J., & Decker P.J., (eds.) (1997). Effective leadership and management in nursing. Menlo Park, CA: Addison-Wesley.

Helen A. Schaag, MSN, MA, RN is a healthcare consultant in Kansas City, Missouri.

Updated Selected References: 1999 through June 2001

Note: These references are not part of the independent study module, but are provided to you as suggestions for additional reading.

Alexander, L.N., Jarvis, W.R. (March 2000). Surveillance and control of surgical site infections in the era of managed care. Surgical Services Management, 6 (3), 15, 7-18, 20.

Ament, L. (Nov.-Dec. 1999). Quality management activities in the obstetric triage setting. Journal of Nurse-Midwifery, 44 (6), 592-9, 531-5.

Aufseerser-Wiess, M.R., Ondeck, D.A. (February 2000). Medication use risk management: hospital meets home care. Home Health Care Management & Practice 12 (2), 5-10.

Blouin, A.S., Brent, N.J. (December 2000). Legal insights. Above all, do no harm: patient and staff safety. Journal of Nursing Administration, 30 (12), 571-573.

Dombi, W. A. (January 2000). Agencies at risk: increased liability under prospective payment system (pps). Caring, 19 (1), 24-5.

Dombi, W.A. (St. Pierre, M. (June 1999). Interim payment system & risk management. Caring, 18 (6), 34-38.

Fiesta, J. (April 1999). Law for the nurse manager who is liable in equipment cases. Nurse Management, 30 (4), 12-13, 15.

George, J.E, Quattrone, M.S., Espinosa, J.A, Goldstone, M. (Spring 2000). Nurse administrators. What are the limits of clinical liability? Emergency Nurse Legal Bulletins, 26 (2), 2-4.

Hogue, E.E. (June 2000). Manager's corner: how to evaluate appropriateness for hospice services as an essential tool of sound risk management. Home Care and Hospice Update, 7 96), 1-2.

Kendra, M.A., George, V.D. (March-April 2001). Defining risk in home visiting. Public Health Nurse, 18 (2), 128-37.

LaDuke, S.D. (August 1999). When the blaming stops: lessons in risk management. Journal of Nursing Law, 6 (2), 23-32.

Marino, B.L., Reinhardt, K., Eichenberger, W.J., Steingard, R. (July-Sept. 2000). Prevalence of errors in a pediatric hospital medication system - implication for error proofing. Outcomes Management for Nursing Practice, 4 (3), 129-135.

Martin, G.A. (June 2000). To err is human: legal implications related to medication administration. Arkansas Nurse News, 17 (1), 16-18.

McKenzie, L. (Sept.-Oct. 2000). Reducing risks while improving care. Dimensions of Critical Care Nursing. 19 (5), 32-26.