- Email: [email protected]
Accountability: Where to Start?
Lessons Learned Katherine Vestal, RN, PhD, FAAN, FACHE
Accountability: Where to Start? I t seems to me that the challenges of getting care delivered at the bedside are increasing exponentially as we try to balance the speed of clinical changes with technological changes to ensure that the hands-on care of the patient is flawless. Our increasing focus on safe and highquality care, especially for nurse-sensitive care, is renewing the pressure to be absolutely sure that nurses have the knowledge and skills to manage care and the ability to critically develop and manage care plans and execute them without error. We are now talking in almost every sentence about the need for nurses to be accountable for their practice and to own the outcomes that result. Nurse leaders would say that this trend is not new. Nurses are educated professionally to understand that they are accountable for their nursing practice and responsible for the care delivered by others to whom they have delegated. The concepts of accountability and responsibility are often used interchangeably in the daily care of patients. But is there a difference? And is it the leader who must make clear what the accountabilities and responsibilities of care team members are and ensure that providers are meeting the obligations? The reason these questions are arising more often is that we are all struggling to some extent to ensure that errors and omissions are avoided or eliminated. The increased focus on nurse-sensitive indicators as a part of quality care places the outcomes squarely on nursing practice. Interestingly, this shift has created a clearer picture for other providers about what nurses do as these practices now have a direct link to safety and quality measures and reimbursement. Nurse leaders in their own organizations have done a lot of work to design and implement care models that meet the unique needs of the patients. These models vary according to patient populations, human resource availability, and staff education and experience. Added to the design of models is the philosophy of care, strategic directions, and business imperatives. Once the model is designed and implemented, the leader has to ensure that care is safe, demonstrates high quality, and meets identified standards. Now the focus is centered on ensuring that every nurse, regardless of role or experi-
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ence or other circumstances, is both qualified and accountable for the practice standards required by his or her assigned patients. The nurses’ personal and professional obligation of being fully accountable for practice now comes with expectations and consequences. The expectations are that nurses will be knowledgeable and will practice to the standards. The consequences must also be clear. If a nurse does not have the knowledge for meeting the standards of practice, she or he must assume the responsibility to get that knowledge and skill. And once prepared, she or he must be held accountable to practice to those standards so as to not have untoward results. If he or she chooses not to practice to standards, then he or she must not be allowed to practice. Although this has clear implications for the individual nurse, it also has clear implications for the nurse leader. The nurse leader is both responsible for the direction of staff and accountable for the results. The concepts of responsibility and accountability are somewhat ambiguous and are the topics of uncountable lengthy scientific studies. From the most practical point of view, leaders can share responsibility for things that must be done, but, at the end of the day, they are accountable for the results. Nurses, for example, can share the care of a patient with other team members, but at the end of their shift, they are accountable to ensure that proper care was delivered and charted. The unit leader then is accountable for the care delivered and must be able to ensure that all standards are being met and that neither untoward events have occurred nor potential negative events have been avoided. What issues stand in the way of getting care right all the time? Here are a few things that need a lot of attention: • Nurses are spending less time at the bedside than is needed to provide care. The time they spend finding things, moving things, and writing things is time away from care. • Leaders themselves are often away from the unit, thus limiting the time they have to monitor and intervene in care. Continued on page 11
June 2010
Accountability: Where to Start? Continued from page 8
• The reduction in the use of practical care planning that is kept updated makes it hard to ensure continuity across staff schedules that change daily. • Although skills and knowledge acquisition is well prescribed during on-boarding, it is less structured for tenured staff, who often need to be evaluated for competencies on an ongoing basis. These competencies go far beyond the annual required updates. • Staff development models in organizations may no longer be adequate for the level of ongoing development needed and the ongoing review of nurses’ practice levels. • The consequences for poor performance, assuming the nurse has the knowledge, are sporadically applied, thus underperforming nurses are able to continue to practice without intervention. www.nurseleader.com
• Measurement of poor performance clinically is not specifically tied to the individual nurse and thus not remediated. Despite long lists of audits and reviews of clinical variables and errors, the data are not always used to pinpoint performance issues and correct them. This list could go on and on. The story it tells is that it is possible in organizations that everyone is accountable and no one is accountable. Accountability must be assigned by one person and measured for effectiveness. If the care model is to bring the intended results to care, it needs to be tied directly to an accountability model that clearly states what each role is accountable for so there is no ambiguity about who must produce the results. The accountability model then can support a logical cascading of rounds and reviews, starting at the top of leadership and progressing through each role that cares for the patient. Only
then will each provider be clear about what he or she is accountable for and what others are accountable for. And only then can the leader have the peace of mind that each nurse and each provider are crystal clear about their accountability in patient care. That is what it takes to get it right the first time. Katherine Vestal, RN, PhD, FAAN, FACHE, is president of Work Innovations, Inc., in Lake Leelanau, MI. She can be reached at [email protected]. 1541-4612/$ See front matter Copyright 2010 by Mosby Inc. All rights reserved. doi:10.1016/j.mnl/2010.03.011
Nurse Leader
11
Accountability: Where to Start? I t seems to me that the challenges of getting care delivered at the bedside are increasing exponentially as we try to balance the speed of clinical changes with technological changes to ensure that the hands-on care of the patient is flawless. Our increasing focus on safe and highquality care, especially for nurse-sensitive care, is renewing the pressure to be absolutely sure that nurses have the knowledge and skills to manage care and the ability to critically develop and manage care plans and execute them without error. We are now talking in almost every sentence about the need for nurses to be accountable for their practice and to own the outcomes that result. Nurse leaders would say that this trend is not new. Nurses are educated professionally to understand that they are accountable for their nursing practice and responsible for the care delivered by others to whom they have delegated. The concepts of accountability and responsibility are often used interchangeably in the daily care of patients. But is there a difference? And is it the leader who must make clear what the accountabilities and responsibilities of care team members are and ensure that providers are meeting the obligations? The reason these questions are arising more often is that we are all struggling to some extent to ensure that errors and omissions are avoided or eliminated. The increased focus on nurse-sensitive indicators as a part of quality care places the outcomes squarely on nursing practice. Interestingly, this shift has created a clearer picture for other providers about what nurses do as these practices now have a direct link to safety and quality measures and reimbursement. Nurse leaders in their own organizations have done a lot of work to design and implement care models that meet the unique needs of the patients. These models vary according to patient populations, human resource availability, and staff education and experience. Added to the design of models is the philosophy of care, strategic directions, and business imperatives. Once the model is designed and implemented, the leader has to ensure that care is safe, demonstrates high quality, and meets identified standards. Now the focus is centered on ensuring that every nurse, regardless of role or experi-
8
Nurse Leader
ence or other circumstances, is both qualified and accountable for the practice standards required by his or her assigned patients. The nurses’ personal and professional obligation of being fully accountable for practice now comes with expectations and consequences. The expectations are that nurses will be knowledgeable and will practice to the standards. The consequences must also be clear. If a nurse does not have the knowledge for meeting the standards of practice, she or he must assume the responsibility to get that knowledge and skill. And once prepared, she or he must be held accountable to practice to those standards so as to not have untoward results. If he or she chooses not to practice to standards, then he or she must not be allowed to practice. Although this has clear implications for the individual nurse, it also has clear implications for the nurse leader. The nurse leader is both responsible for the direction of staff and accountable for the results. The concepts of responsibility and accountability are somewhat ambiguous and are the topics of uncountable lengthy scientific studies. From the most practical point of view, leaders can share responsibility for things that must be done, but, at the end of the day, they are accountable for the results. Nurses, for example, can share the care of a patient with other team members, but at the end of their shift, they are accountable to ensure that proper care was delivered and charted. The unit leader then is accountable for the care delivered and must be able to ensure that all standards are being met and that neither untoward events have occurred nor potential negative events have been avoided. What issues stand in the way of getting care right all the time? Here are a few things that need a lot of attention: • Nurses are spending less time at the bedside than is needed to provide care. The time they spend finding things, moving things, and writing things is time away from care. • Leaders themselves are often away from the unit, thus limiting the time they have to monitor and intervene in care. Continued on page 11
June 2010
Accountability: Where to Start? Continued from page 8
• The reduction in the use of practical care planning that is kept updated makes it hard to ensure continuity across staff schedules that change daily. • Although skills and knowledge acquisition is well prescribed during on-boarding, it is less structured for tenured staff, who often need to be evaluated for competencies on an ongoing basis. These competencies go far beyond the annual required updates. • Staff development models in organizations may no longer be adequate for the level of ongoing development needed and the ongoing review of nurses’ practice levels. • The consequences for poor performance, assuming the nurse has the knowledge, are sporadically applied, thus underperforming nurses are able to continue to practice without intervention. www.nurseleader.com
• Measurement of poor performance clinically is not specifically tied to the individual nurse and thus not remediated. Despite long lists of audits and reviews of clinical variables and errors, the data are not always used to pinpoint performance issues and correct them. This list could go on and on. The story it tells is that it is possible in organizations that everyone is accountable and no one is accountable. Accountability must be assigned by one person and measured for effectiveness. If the care model is to bring the intended results to care, it needs to be tied directly to an accountability model that clearly states what each role is accountable for so there is no ambiguity about who must produce the results. The accountability model then can support a logical cascading of rounds and reviews, starting at the top of leadership and progressing through each role that cares for the patient. Only
then will each provider be clear about what he or she is accountable for and what others are accountable for. And only then can the leader have the peace of mind that each nurse and each provider are crystal clear about their accountability in patient care. That is what it takes to get it right the first time. Katherine Vestal, RN, PhD, FAAN, FACHE, is president of Work Innovations, Inc., in Lake Leelanau, MI. She can be reached at [email protected]. 1541-4612/$ See front matter Copyright 2010 by Mosby Inc. All rights reserved. doi:10.1016/j.mnl/2010.03.011
Nurse Leader
11