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he role and responsibility of the director of nursing (DON) have changed dramatically in long-term care facilities over the past 10 years. Directors of nursing are held accountable for many processes that are under much more scrutiny in 2004 than ever before. With litigations on the rise, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), stricter regulatory standards, and quality improvement activities, DONs cannot attempt to meet the challenges without successful systems in place to aid them in managing and monitoring facility processes.
       Recently, I had the opportunity/challenge to assist a 132-bed skilled facility by serving as its interim DON. Even though I had the knowledge and expertise plus 28+ years of long-term care experience, I felt the challenge first hand of the day-to-day operation of a nursing department. I had served as a DON for several years in the past, and quickly realized there were many more challenges in 2004 than there were in the past. What I discovered in this position was that initially I was forced to spend most of my time “putting out fires” due to a lack of consistent systems being in place for many of the important and routine processes that are performed by the nursing department. In my consulting practice, I usually assist in development of systems as a result of negative outcome surveys or identification of a problem area. However, proactively, facilities should examine the current systems prior to the identification of problems.
       Lack of systems (process management) can lead to negative surveys, staff turnover, and DON burnout. I realized early on that without systems in place, there was no way I could get a handle on the nursing department and I would continue to “put out fires” rather than move forward. Initially, you do what you have to do to survive. Then you evaluate each area in your department and decide what system will allow you to get and maintain control of the process to assure best outcomes.
       Whereas consultants are able to normally focus on specific areas within a facility at any given time, DONs are challenged with focusing on all clinical areas every day. This is virtually impossible without working systems that enable the DON to “direct” more and “do” less. If systems are not in place, this will not happen quickly, as it requires planning, education, and consistent monitoring to assure employees are following the process (system).
       You may have the most knowledgeable DON when it comes to clinical skills, but leading a nursing department in 2004 takes much more than clinical knowledge. Directors of nursing must also possess or acquire:
• Organizational skills
• Team building skills
• Supervisory/management skills
• Time management skills
• Delegation skills
• Recruitment/retention skills
• Training skills
• Interpersonal skills.
       Even with all the above, a DON cannot be successful without systems in place to assist him or her in monitoring and managing the many areas in his or her department. This is the component (systems) that many facilities lack. While all facilities have policies and procedures, what systems are in place to assure the policies and procedures are being followed consistently? For example, what is your system for assuring that your policies and procedures regarding restraint usage are being followed? Do you have forms, meetings, consents, monitoring tools, and lastly a person delegated to assure all is being done? If you don’t, you probably have a policy and procedure but not a system. Do not confuse a system with a procedure. While a procedure may explain what or how something is to be done, it does not explain the system in place the DON may utilize to assure that policy and procedure are being followed. With the example of restraints, the DON may hold or assign a meeting once a week or month to discuss all restraints in the facility. The discussion may include restraints that have been reduced to a lesser restrictive level, those that have been removed, falls occurring with residents with restraints, etc. In addition, he or she may delegate a quality assurance (QA) audit to be done checking for release of restraints and free time, update to the care plan, etc. The DON may delegate a team leader that is responsible for monitoring restraint usage and reporting to the DON. While the DON is ultimately responsible for appropriate restraint use, he or she cannot possibly do all this himself or herself and thus must have a system to assure ongoing monitoring and management.
       Restraints are an example of just one area; think of the many areas that require ongoing monitoring and need systems for which the DON is ultimately responsible. Some examples of these areas are weight loss, tube feedings, wounds, infections, physician orders, psychotropic drugs, labs, care plans, documentation, incidents, orientation, staff development, residents with behavior problems, scheduling, hiring/firing, physician visits, QA, assessments, falls, Prospective Payment System (PPS), restorative nursing, medication administration, admissions, discharges, surveys, and more.
       Do you and your staff know what systems are in place to assure ongoing monitoring and management of nursing department processes? If you do not, what would happen if you had to fill the shoes of the DON today? There are many resources available to assist the DON to develop systems to allow him or her to truly “direct” the nursing department. In future issues, we will be discussing how to help DONs acquire or improve needed skills as well as how to put systems in place to assist them in running their departments.
       Once a year, New Day Professional Services sponsors a Director of Nursing Boot Camp where topics covered include, at a minimum, leadership skills, survey survival skills, and topics relevant to DONs to help them “recharge” and learn from and with their peers. The boot camp this year is May 5–7 in Charleston, South Carolina. For more information or to request a copy of the brochure, call New Day Professional Services at (803) 796-7835 or visit http://www.newdayprofessionals.com.