Clinical Organization and Process Integration

Overview of Transitions in Structures and Processes

• Internal structures and processes are often influenced by external forces

• Contemporary nursing homes are transitioning from hospital-inspired clinical designs to residential models

• Emphasis on client-centered care that integrates layout and design with empowering residents, families, and staff

The NHA’s Role

• Understand clinical and adjunct operations

• Take a “hands on” approach in coordinating clinical and adjunct processes

• Develop an organizational culture of interdepartmental communication and cooperation

Objectives of Process Integration• Build a multidisciplinary team that

interfaces in all aspects of holistic care delivery

• Address all aspects of a patient’s needs without duplicating or disregarding any needed services

• Achieve the highest practicable level of well-being for each patient

Main Components of Integrated Processes

• Overarching human factors

• Socio-residential component

- Room and board

- Amenities

• Clinical component

Outcomes of Integrated Processes

• A total living environment is created

• A patient’s physical, mental, social, and spiritual needs are met

Parson’s Sick-Role Model and Its Implications

• Relinquish individual control

• Comply with directives

• Rigid daily routines and “blocking routines”

• Social distance between staff and patients

• The model is inappropriate for care delivery in nursing homes (compare with the integrated model on p. 175)

Socio-Residential Orientation• Control is shared between patients and

caregivers• Medical and nursing care needs are

addressed in homelike setting• Residents’ quality of life is maximized• Structures and processes are designed to

support the needs of both residents and their families

Total Living Environment of Holistic Care

• Each resident’s physical, mental, social, and spiritual needs are addressed

• Efficient delivery of clinical care is achieved while emphasizing individual pursuits and social interaction

• Overarching human factors govern clinical and socio-residential services

• Residential structures are designed to support clinical and social services in a homelike environment

Objectives That Guide the Creation of a Total Living Environment

• Holistic health

• Maximized quality of life

• The environment itself must promote healing of the body, mind, and spirit

The Realistic Context - 1• Nursing facilities must function as efficient

organizations• Seeking efficiency will dilute social and

residential aspects to some extent• Neither the individual patient nor the society can

afford the cost of private-duty care for everyone• Small-scale conflicts are likely to occur in group

living environments

The Realistic Context - 2• Patient autonomy must be pursued, but this

pursuit can also be vexatious• Some level of dependency in a patient is

unavoidable• Adaptation to change does not follow any

standard formula• Different patients’ needs and desires often

conflict

Self-Contained Nursing Units

• Nursing stations

• Bathing rooms

• Dining rooms

• Lounges

• Clean linen closets

• Soiled-utility areas

Nursing Units: Organization

• To the extent possible, designate units according to clinical criteria, specialization, or complexity

• Match staff skills to patient care needs

• To the extent possible, segregate patients with cognitive impairments or behavioral problems

Advantages of a Distinct Non-certified Unit

• Upgraded amenities can be offered without concern for discrimination

• The unit is sheltered from certification surveys

Odor Control

• Enclosed soiled-utility areas

• Removal of heavy wastes from linens

• Linen is deposited in containers with tight closing lids

• Proper ventilation of utility rooms

• Proper sanitation

Nursing Station

• Hub of clinical care

• Centrally located to serve a nursing unit

• Located to provide adequate supervision

Staffing

• Minimum staff-to-patient ratios are specified by state licensing regulations

• Regulations do not suggest adequate staffing

• Regulatory staffing levels are arbitrary because they are not based on case-mix

Staffing Considerations

• Case-mix

• Skill-mix

• Training

• Matching skill-mix to case-mix

• Distribution of staff hours between the three shifts

Nursing Station Furnishings

• Call signals

• Medical records

• Pharmaceuticals

Controlled Substances

• Governed by the Controlled Substances Act

• Possession and use is illegal except when medically prescribed by a physician

• Doubled-locked storage

• Recordkeeping and verification

• Destroyed when no longer prescribed

Social Aspects

• Personal domain

• Public domain

Personal Domain

• Security

• Autonomy

• Privacy

Security

• Physical safety

• Freedom from risk, danger, and anxiety

• Safekeeping of personal property

Autonomy

• Balancing dependency against self-determination

• Promoting patient rights

• Protecting each patient from infringement of rights

• Personalizing individual spaces

• Allowing informed choices

Privacy

• Privacy of space, time, and person

• Intimacy

• Accommodation of individual preferences

• Freedom from unwanted intrusion

• Dignity

Public Domain

• Compatibility

• Dining

• Socializing

Compatibility

• Room sharing

• Dining

• Other social activities

• Bonding with other residents, volunteers, and staff

Dining

• Making it a social event

• Seating arrangements

• Clinical and social dining areas

• Dining environment

Socializing

• Personal interests

• Social events

• Interior and exterior spaces

• Seating arrangements

Residential Features

• Homelike

• Design, furnishings, décor

• Emphasis on social structures

• Safety and accessibility

Modern Architectural Features

• Small private rooms

• Elimination of long corridors

• Neighborhood living arrangements

• Connection of indoor and outdoor spaces

• Cluster design

• Nested single-room design

Cluster Design• Replaces the traditional corridors• Clusters are small residential units

(households, neighborhoods)• 8 to 12 private rooms per cluster• 2 to 4 clusters per nursing unit• Each cluster is self-contained for the

delivery of services which increases efficiency

Nested Single-Room Design

• A special design that enables small private rooms to be “nested” to conserve space and construction costs

• Nested rooms can be part of clusters which offer the efficiencies of cluster design

Safety

• Federal, state, and local building codes

• Life Safety Code

• Safety practices to prevent falls

• Elimination of hazards

• Monitoring and supervision

• Security of person and property

Americans with Disabilities Act (ADA) of 1990

• Public accommodations include nursing homes

• Requires adaptations be made to provide access to the disabled

• Requires that auxiliary aids for communication be provided for public use

Other Residential Features• Wayfinding• Enhanced environments• Positive stimulation and distraction• Minimizing negative distractions• Aesthetics and comfort: the two must be

integrated- Lighting- Color- Furnishings