NR 446 WEEK 5 EDAPT NOTES LEADING IN AN ORGANISATION
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NR 446
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NR 446 WEEK 5 EDAPT NOTES LEADING IN AN
ORGANISATION
WEEK 5 EDAPT NOTES NR 446
LEADING IN AN ORGANISATION:
In healthcare delivery settings, formal or informal leadership processes are used. Formal
leadership uses hierarchical means, where power provides a structure for defining
authority, responsibility, and accountability. Informal leadership focuses on employee
relationships and the characteristics within those relationships to lead the organization.
Both types of leadership have unique communication channels.
Which top-level healthcare managers are responsible for the overall performance of
the organization?
The board of directors, chief executive officer, and chief nursing officer are top-level
healthcare managers responsible for the overall performance of healthcare organizations.
The nursing supervisor and department head are middle-level managers. Middle-level
managers report to top-level managers and oversee lower-level managers.
In healthcare delivery systems, Medicare provides health insurance coverage under
Part A, Part B, Part C, and Part D supplemental plans. Match each type of insurance
coverage with its description:
Medicare is a federal government funded program, providing health insurance for
individuals over the age of 65 and for other individuals with certain chronic illnesses.
• Part A: hospital insurance—covers inpatient hospital services, skilled nursing
facilities (SNFs), and home health benefits.
• Part B: medical insurance—covers physician services, durable medical equipment,
and outpatient hospital services.
• Part C: medical advantage insurance—combines parts A & B and may include vision,
dental, or hearing services.
• Part D: prescription insurance—provides a prescription medication benefit.
With shared governance, nurses at every level of an organization play a key role in
the decision-making process. The nurses and nurse managers are interconnected
and become representatives of the healthcare service process.
Healthcare systems are multifaceted and consist of different care delivery settings and sub-
settings including, but not limited to:
• Preventative care: public community-based health programs
• Primary care: specialist clinics
• Acute care: hospitals
• Sub-acute care: outpatient surgical centers
• Long-term care: long-term care facilities and home healthcare agencies
, NR 446 WEEK 5 EDAPT NOTES LEADING IN AN
ORGANISATION
• Chronic care: home healthcare agencies, long-term care facilities, managed group
homes, alternative medicine centers
• Rehabilitative care: hospital, home health, or outpatient care centers
• End-of-life care: hospice centers
In healthcare delivery systems, private insurance companies provide healthcare coverage
and account for a percentage of revenue.
• The cost of health insurance for employees is passed by the employer to the
consumer.
• Everyone pays part of the country’s healthcare costs with every purchase made.
• Individuals pay a portion of healthcare costs directly through payments for
insurance premiums, deductibles, and copayments.
Medicaid (state) and Medicare (federal) government programs also provide funding
revenue for healthcare delivery systems in the United States. Medicare and Medicaid are
paid for by taxes from citizens.
• Medicaid provides state-funded health insurance coverage for individuals with
economic hardship, and long-term care coverage for individuals with disabilities and
low income.
• Medicare provides federal-funded health insurance coverage for individuals over
the age of 65 and for other individuals with certain chronic illnesses. Medicare is
divided into four supplemental plans (Parts A-D).
• Part A: hospital insurance—covers inpatient hospital services, skilled nursing
facilities (SNFs), and home health benefits
• Part B: medical insurance—covers physician services, durable medical
equipment, and outpatient hospital services
• Part C: medical advantage insurance—combines parts A & B and may include
vision, dental, or hearing services
• Part D: prescription insurance—provides a prescription medication benefit
Delivery System Subsystem
Preventative Care - Public health programs
Long-Term Care - Home healthcare agencies
Sub-Acute Care - Outpatient surgical centers
Acute Care - Hospitals
End-of-Life Care - Hospice centers
Primary Care- Specialist clinics
, NR 446 WEEK 5 EDAPT NOTES LEADING IN AN
ORGANISATION
Managed Care Models
In the order of fee for service, preferred provider organization, point of service, and health
maintenance organization, the cost of care becomes less expensive but the options for
types of care become more restrictive.
Fee for Service
• A fixed percent of covered expenses is paid by the member.
• The member pays copays and deductibles.
• Preventive care may or may not be covered.
Preferred Provider Organization (PPO)
• A primary care physician is not required.
• There is flexibility in the choice of healthcare provider.
• A referral to a specialist or other healthcare professional is not needed.
• The amount paid in copays depends on whether the provider is inside or outside of
the PPO network.
• The types of services covered depend on whether it is inside or outside the PPO
network.
Point of Service (POS)
• This combines the characteristics of an HMO and a PPO.
• The use of network providers is encouraged but not required.
• There is generally no deductible when using network providers.
• A referral from the primary care provider is not required to receive out-of-network
care but out-of-pocket charges may be higher.
• A referral by the primary care provider is required for in-network specialist visits.
Health Maintenance Organization (HMO)
• The client chooses one primary care physician.
• A referral to any other healthcare provider is required, except in emergencies.
• Visits outside of the network are not typically covered by insurance even if referred
by a primary care physician.
• Women do not need a referral from a primary care physician to see an ob-gyn in
their network for routine services and obstetrical care.
, NR 446 WEEK 5 EDAPT NOTES LEADING IN AN
ORGANISATION
Who leads an organization?
Three levels of management lead an organization: top-level managers, who are responsible
for overall performance; middle-level managers, who report to top managers and oversee
lower-level managers; and first-level managers, who oversee frontline employees
and ensure that work is performed correctly and timely.
Starting with the top of the organization (i.e., highest leadership position), let’s review
common titles based on management level.
Top-Level Managers
• Nursing supervisor
• Nursing director
• Department heads
• Nurse manager
First-Level Managers
• Team leaders
• Charge nurses
• Primary care nurses
• Case managers
There are two types of decision-making in organizational structures:
Centralized decision making:
• Decisions are made by a few managers at the top of the hierarchy. For example, the
Chief Nursing Officer (CNO) makes the final decision on all nursing policies for the
organization.
• This occurs within a more formal organizational structure.
Decentralized decision making:
• Decision-making is distributed throughout the organization and problems are
solved at the lowest managerial level. For example, nursing policies may be unit-
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