Boundary setting and prevention in healthcare intervention strategy

Healthcare Management

Section A. 1)a) In the fable, the boundary was set with a definition that people getting hurt by the cliff was a problem. The boundary that was set for the solution to the problem was therefore set at dealing with the people who were hurt by the falls. The problem with this is that people were still getting hurt. But maybe in some cases they were not dying as much. So the boundary was set at a place where people got hurt, but were not killed as frequently. If the boundary was set in a different place -- the fable advocates for the fence -- then the outcomes would be different. The fence as a boundary is set at a place where the falls are reduced significantly in the first place. Think about other places to set the boundary -- say people are falling because they are trying to take selfies, and the boundary is set at a ban on selfie sticks. This again might reduce falls, but ultimately will not eliminate them. So setting the boundary at the fence provides the best opportunity to reduce injury because the fence serves as a literal barrier to the critical incident, which is falling off the cliff, whatever the cause.

b) The establishment of the boundary establishes that the preferred intervention is to help people once they have hurt themselves. Governing the behavior that leads to the injury in the first place is not set as the appropriate boundary in this instance. By setting a boundary that allows people to do whatever they wish, no matter the consequences, has certain effects. First, it allows some people to get their selfies (or whatever) without barrier, but it also has the effect of more people falling. So there is a trade-off here between freedom of movement and injury prevention.

c) Given the choice, the intervention was viewed by many to be a success. They were able to reduce the death maybe, because the ambulance in the valley was able to help people who had fallen more quickly, which should perhaps reduce deaths, but not injuries. So by the measure chosen, the intervention was a success. The problem was the framing of the issue, which led to the wrong measure of success. It should have been to reduce injuries, which in turn would have led to an entirely different intervention -- the fence. By that measure, the strategy of putting an ambulance in the valley was a failure, because just as many people fell and were injured.

What this fable tells us is that it is important to frame questions, and define boundaries, effectively. The fable is clearly a parallel of a lot of issues that we face in public health today. President Obama made preventative care part of his platform with the ACA, and since then there has been more attention paid to preventative care. Companies have been doing this for a long time -- providing health and wellness resources to encourage their employees to eat better, exercise more, and to undertake the habits that result in lower rates of disease and illness. The health care community has recognized this, but still rests on a break-fix model, where most people only enter the health care system when something is wrong. Further, the health care system is set up mainly to deal with people when something is wrong -- the resources for preventative medicine are not that well-developed yet.

Yet, as the fable illustrates, there is a lot of logic in focusing on preventative medicine, because when there are fewer people in the system, and they enter the system with fewer problems, or less serious ones, the health care system is better able to take care of them. Plus, on the aggregate level, the population is healthier. People might complain about the fence, but everybody who gets injured or dies falling off that cliff is someone who either needs care or otherwise cannot contribute to the betterment of society. Healthy preventative care is important for societal outcomes, not just individual ones, and the fable does a good job of illustrating that.

2. I am committed to continuing to learn and improve, and as such I have several skills that I believe will help me in my role as a health care manager. The first is leadership. The task of management is essentially functional -- deploying resources to meet organizational objectives, but leadership is what encapsulates the human side. Leadership can be a tough thing to define -- mostly you know it when you see it -- but it involves bringing people together around a vision, and ensuring that everybody has the tools that they need to excel at bringing together that vision. There are a number of different leadership styles, and one of the things that I want to do is to start to identify my leadership style, and what the best ones are for healthcare managers, so that I can start to fill in the gaps between where I am today and where I need to be in the future (Mindtools, 2016).

Communication is another skill that I wish to improve. I believe my written communication is pretty good already, but there are gaps where it comes to interpersonal communication, and I feel that listening, and being able to understand what other people are trying to say is an important part of the human side of leadership and management. Ultimately, you are dealing with people in the health care context and it is important to build the communications skills that will help me to convey my vision, how I want things done, to deal with people\'s problems, to build trust and other important elements of the job.

Another skill that I believe is critical to my success going forward is to develop conflict resolution. This flows from communication -- particularly listening -- but it goes beyond that. We like to think that as leaders we can focus on moving forward and implementing our plans, but the day-to-day reality is that there are disagreements and interpersonal conflicts in the workplace. Jordan and Troth (2004) have examined the role that emotional intelligence plays in conflict resolution. This is an area that I would like to explore further, because I believe that building this skill is essential. Workplace conflict does a lot of damage, and one of the things a manager can do to improve performance is to minimize conflict, and when conflict does arise to deal with it quickly. That can really only be accomplished by understanding different interests, listening to positions, and by working towards a resolution. It is understood that in any organization there are resource constraints that will arise, and sometimes there is no one magic solution; interests must be weighed, and not every resolution will make everybody happy. Being able to manage that process so that there is at the very least procedural fairness is something that is important. I believe that this is a critical managerial skill.

I also look to finance as a skill that I would like to improve upon. In general, it seems that healthcare management is focused on a lot of things, but at the end of the day it is still a management job. And that means understanding things like finance, performance metrics, and how those metrics contribute to the bottom line. The reality is that even if I don\'t work with my subordinates on a financial basis, my bosses are going to evaluate my performance, and the performance of my supervisor, on measures that include financial measures. So it would be a good idea for me to boost my skills in that area, so that I am better equipped to really understand the higher-level context of my work, where it fits within the organization as a whole, and how I can meet the needs that my bosses have set out for me.

There are a lot of other things that I look forward to learning, of course. Being fresh out of school, I have a lot to learn, and the learning curve will be quite steep at times. But the reality is that I will target the above because I think that each will make a big contribution to my future performance, and these are all areas where I feel that I can gain significant improvement. I look forward to taking the needed steps to learning and upgrading my skills in these areas, because that will help me become the best manager that I can possibly be, with a wide-ranging skill set.

3. There are several challenges facing the health care industry going forward. The first is rising costs. This has been an issue in health care for some time. There are several reasons for it -- lack of competition in markets, rapidly rising drug costs (Tuttle, 2016), and a rapid pace of technological innovation that delivers better care, but sometimes costs quite a bit more. Because the rising cost of health care has a number of different underlying causes, there is really no one magic bullet solution. In fact, people want better drugs and better treatments, so you don\'t want to reduce the level of innovation just to keep costs in line. There are some fantastic technologies in development, and if they cost more, so be it. But I guess there is a need for some flexibility where people receive older treatments if they can\'t afford the latest innovations.

Another challenge going forward is the issue of rural health care. While health care capacity in the big cities is more or less acceptable (there are exceptions), people in rural areas often struggle to find doctors -- especially specialists -- and travel longer distances when they do (Magilvy & Congdon, 2000). Furthermore, they often have to travel to big cities for specialized care as rural hospitals are underfunded and therefore have less technology than the big urban hospitals. The rural population skews older than the urban, which creates an even bigger need for health care capacity in rural areas, but there are no major plans to govern the distribution of health care providers to meet this need. Hence, a crisis.

A third major issue over the course of the next five years is the uncertainty surrounding the Affordable Care Act. This act brought about many changes to health care, especially on the insurance side. Now, there is tremendous political risk that steps can be undertaken to unwind the ACA and its key provisions. The problem of course is that the people who would repeal the Act or unwind its provisions do not have a meaningful plan to replace the ACA. The health care industry has just become used to the ACA, and its destruction would throw the industry back into a state of chaos, would remove millions of people from the health care system at great risk to their health, and would generally create a health care crisis in this country. The fact that the health care community has no idea what is going to happen only makes it worse because nobody can plan -- uncertainty is not a good thing when running an organization and the current political state of the ACA is one of extreme uncertainty.

\' The fourth major issue in health care right now is what the aging of America means for health care. Baby boomers are in early retirement, or are entering retirement. They very much at an age where their health care needs begin to escalate. This means changes in demand for health care. Not only is their greater demand, but what kinds of things are demanded will also change. Today, we need to start planning for when this large cohort of people enters elder care -- do we have enough capacity in our care homes? How much capacity should be build, knowing that the Gen X is coming behind them with far fewer people? To what degree is home care an option for the boomers? This isn\'t just a matter of making sure there\'s enough capacity in hospitals, because care needs change as people age, and ultimately figuring out what the aging of the baby boomers means to health care and how the health care community should respond are all critical issues relating to the aging of America.

A final issue that we have to look at in health care going forward for the next five years is the staffing crisis. This is in addition to the rural crisis, which obviously has a staffing element. But there has been a shortage of nurses for a long time in this country, and it is necessary to look at how as health care managers we can attract and retain talent. I cannot solve the nation-wide nursing shortage, but I can ensure that my team has all the nursing talent that we need. This isn\'t easy, however, because there is intense competition for quality nurses. But that\'s part of my job -- to ensure that the nursing shortage does not hinder my own organization.

Section B.

Executive Summary

The case focuses around a supervisor, Lawson, who is new to the job. One of her nurses, Wilson, is a problem. There are many areas where Wilson\'s performance is unsatisfactory and her continue employment not only creates discord among the staff but it also lowers the performance of the entire team. At present, Lawson has done some research into the issue, but she ultimately does not have a lot of facts at her disposal and she does not necessarily know anything about the underlying issues either.

Essential Elements

The major players here are Lawson, who is the supervisor, and Wilson, who is the nurse with whom everybody has a problem. Lawson is new, and Wilson has been around long enough to establish some seniority. They both work at a municipal health care facility, and Lawson does not technically have the ability to fire Wilson. The issues with Wilson have seemingly been going on for years, but Lawson cannot worry about the past, or deal with past issues based on anecdotal evidence.

Prioritizing the Problems

The most important problem is dealing with Wilson. This is not a matter necessarily of firing Wilson, but it is a matter of eliminating the downsides to having Wilson on staff. That means learning more. Lawson cannot fire Wilson without building a strong case, which would include documented verbal and written warnings, empirical evidence of performance below expected standards for the job, and other fact-based evidence to make the case that Wilson should be removed. This material is important from a legal perspective. So there are two major priorities here initially, and the first is to build the body of evidence against Wilson -- start gathering the facts in preparation of removing Wilson.

The second is to actually sit down and talk to Wilson. Now, Wilson is not helping herself with her excuses -- she does appear to be hiding something, and honestly Lawson needs to understand what that is. It may be that addressing the issues Wilson has in her personal life will help to ameliorate her performance deficiencies. This is part of fact-based management, to get the facts from all sides.

The one major sub-problem that needs immediate attention is Wilson\'s tendency to disappear during rush times when nobody can reasonably cover for her. That puts patients at risk and as such it also puts the entire organization at risk. Dealing with this problem cannot wait until the rest of the investigation is completed. So Lawson needs to make sure that she tackles this issue first and foremost, and not wait until she has an opportunity to either talk to Wilson or start the process of building the case. After all, since Lawson cannot fire Wilson herself, that process could end up taking months. And where malpractice is concerned, the organization does not have months.

Causal Factors

We actually do not know the causal factors. The conventional wisdom is that Wilson is just plain terrible, but nobody has really pried the truth out of Wilson as to the underlying issues. It may be that she simply has a terrible attitude and will always be a lousy worker. Or, there might be other reasons. It is critical for Lawson to take the time to properly understand the causal factors, and not jump to conclusions based on the circumstantial and anecdotal evidence presented in the case. Lawson can sit down to talk to Wilson and find out what\'s going on. But Wilson clearly doesn\'t want to talk about it, so that is something that Lawson has to bear in mind, and she may have to work harder to pry that information about of Wilson.

If the causal factor is just that Wilson is lousy, then that makes it a lot easier. It will not take much effort to document the steps needed to remove Wilson. And those appear to be the two major alternatives here. They are not mutually exclusive -- one could start the process of removing Wilson but also talk to Wilson to see if there isn\'t some underlying causal factor we don\'t know about. The first alternative of talking to her has the benefit of not needing to go through the hassle of firing her, but might open a can of worms. In other words, if she has some underlying reason (like caring for a mentally disabled child, or something) that is taking her time and attention away from her duties, the organization could find ways to be more accommodating, but sometimes such accommodations are almost more costly than just removing the person. But, of course, talking to Wilson is the right thing to do. It is the human-centric approach.

To not talk to Wilson but instead initiate the process of a verbal warning, written warning, dismissal is time-consuming, does not address the malpractice factor, and to do it without talking to her first would certainly engender defensiveness, and would also align the other workers against her. So there are a lot of drawbacks to that option without the first one as well. But immediate remedial action does need to take place with the malpractice issue -- she simply has to be alerted to the fact that it is a violation of her terms of employment to either go walkabout or to perform non-essential tasks when there is an emergency crisis where all staff are required to contribute. In any case, doing nothing does not resolve the problem, and the problem is creating negativity in the workplace.

Consequences

The first alternative, because it is not mutually exclusive to the second, has no downside. At worst, you find out that Wilson is lousy, that her performance cannot be saved, and that she needs to go. She might get defensive about it, but any incidence of sabotage would be grounds for immediate dismissal. The upside of the first option is that whatever she\'s not talking about could be quite material to her track record and to her current performance. Finding out what this is may prove a turning point in Wilson\'s performance.

While there are negative consequences to initiating the verbal and written warnings without talking to Wilson first, there are fewer if they are done in conjunction with the first alternative. Doing them now means it will take longer to get rid of her if she is irredeemable. But if she is not, being put on probation creates incentive for her to get better, while at the same time the organization can maybe find ways to work with her to accommodate whatever that underlying issue is. The organization also has to cover itself where the malpractice issue is concerned -- to not initiate proceedings against Wilson leaves the organization exposed should a patient die while she is failing to perform her duties.

Recommendation

It is recommended that both A and B. are undertaken. If Lawson does not have a job description and performance standards for Wilson, she needs to develop those and have Wilson sign off on them. This is the first step to dismissal, assuming that Wilson lives in a state with legal protections (a right to work state, she might be able to have Wilson dismissed immediately but otherwise she\'ll need to document the transgressions). It is recommended that Lawson sits down and talks to Wilson. This has to happen as soon as possible. It will not be a verbal warning at this point, but Lawson has to make clear that Wilson needs to be forthcoming about the issues affecting her performance. If it is just her not being a good employee, that helps Lawson set a course for removing Wilson, but at this point Lawson needs to acquire this knowledge. It is recommended that the two steps be undertaken simultaneously.

Further, it is recommended that Lawson makes clear, in writing if necessary, that in situations of emergency where all staff are required, that in no uncertain terms should Wilson either leave or perform non-essential tasks. That has to be done immediately, so that Wilson understands whatever else happens that this cannot happen. Documenting this step is important for the organization to reduce its legal risk.

Performance Measurement

The talk with Wilson should be illuminating, but if it is not, and Wilson refuses to be more forthcoming, then Lawson can only assume that Wilson is not a capable employee. The time for speculation will have passed. Then, the measures will be related to Wilson\'s performance and when she fails to live up to those standards, she will be removed, in accordance with the multiple-stage process that protects the organization from wrongful dismissal action. Lawson\'s performance has to be measured overall on patient outcomes and organizational metrics such as operating, financial and employee satisfaction metrics. The status of any given employee is not part of the metrics on which Lawson will be evaluated, but how she handles Wilson will probably move the needle on a few of these, so it matters for Lawson to handle this situation effectively and either get Wilson up to standard or to remove her from the team.

Quantitatively, this ends up being based on errors that occur in the team (operating measures) and the satisfaction measures for the team, which can be derived from formal surveys of staff satisfaction. So there are ways to measure Lawson\'s performance. They will not specifically relate to Wilson -- only measures of Wilson\'s performance can be used to evaluate whatever interventions Lawson takes -- but they will be the outcomes against which Lawson herself is measured.