Leading and Managing a Change in Clinical Practice: Patient on Ventilator and the Usage of Saline in Performing Suctioning Organizational direction depends on many factors. Most of them were an integral part of clinical practice for a while, but until the latter part of the 20th century has been so prominent in the organizational structure. This paper will explore the four factors that influence the management of clinic and are characterized by efficient designs. This paper will discuss about the leadership and management in relation to improving quality, change, care management, values and results. We will also present integration and possible implementation concepts, tools and strategies.

Discussion

Suctioning the patient on ventilator pose a unique challenge in following a clinical pathway or case management model of care. Our patient is on ventilator and we are performing suctioning by the usage of saline solution. Multiple decisions need to be made when our patient on ventilator reaches the point in his or her disease process where suctioning needs to be implemented.

Evidence-Based Practice

This is quite different than the healthcare environment that one is accustomed to managing. Although the environments are different, (Dougherty 2004, 150-896)there are applications that work for either situation. Leadership styles can be used in any area that people are managed by another person. The ability to work through the simulation provided an opportunity to use the three leadership styles and visualize the results from the team. The knowledge gained from the exercise will assist in managing the clinical and non-clinical staff. There will be opportunities that require utilization of the democratic leadership such as staff scheduling, uniform selection, and equipment selection. (Dougherty 2004, 150-896)While other projects will require that the autocratic leadership style is employed, such as policy development, corrective action, and regulatory compliance. The simulation assisted in understanding that leadership has to be flexible enough to know which style is the most excellent for current condition (Dougherty 2004, 150-896).

Planning

First of all effective planning which must be incorporated in all the steps of performing suctioning and should involve proper monitoring system (Levy 2005, 323- 368)?Due to the lack of any lookout event on planning our performance on ventilator would be affected. After you have identified the planning steps you need to decide regularity and frequency (Dougherty 2004, 150-896).

Division of Labour

Then comes division of labour is one of the basic concept of leadership and management for case management as given by Deming; workers hold jobs and managers improved with the improvement of system (Levy 2005, 323- 368). Deming developed the concept of overall management and change management model called the Shewhart cycle, or PDCA (Hamric 2005, 311-335). This model requires that for P-D-plan, do, C-check and A-law (Kelly, 2007, 17-89). Efforts to increase productivity clinical practice is, as pointed out by Deming, necessity and not an option.Deming emphasized that cooperation multidisciplinary teams improves communication channels. Solutions for potential and existing problems, thus more soluble and prevented. These advantages are provided for all areas of the Organization, including helping to contain costs (Dougherty 2004, 150-896).

Role Clarity

Role clarity is also a necessary component of a successful organization. This should be outlined by a clear job description and understanding of how the organizational structure functions (Levy 2005, 323- 368). When these tools are in place the organization will be more likely to successfully adapt to the internal and external factors brought on by the continually changing clinical practice environment (Yoder-Wise, 2003, 174-211). A particularly effective system of analyzing and redesigning clinical pathways was included in a study of suctioning our patient on ventilator, by Owen, et al., (2006). A multidisciplinary team was selected and assigned with the task of evaluating and redesigning the effectiveness of the clinical pathways process. They were known as the process improvement team (Dougherty 2004, 150-896).

Change Management

Encouraging people to willingly accept change and adapt new methods and procedures is a difficult undertaking. All change processes rely on a change agent. The change agent is given the authority to initiate, formally and informally, those processes that will assist in change (Levy 2005, 323- 368) Change agents can be members of the team working towards change by informal or formally appointed positions. Change is a continuous, dynamic process instead of a single occurrence. It is the process by which something becomes different than it was (Sullivan & Decker, 2005). Due to the rapid changes in clinical practice case management has had to recognize change and transform it to meet the demands of clinical practice and consumers. (Hamric 2005, 311-335).

Doctors, clinicians, dieticians and educators should have direct influence on care maps and clinical pathways (Dougherty 2004, 150-896). These positions need to be available to staff as resources for as well as for our patient on ventilator. An organization's structure can have profound effect on how change is perceived and implemented (Sullivan & Decker, 2005). The medical director and the chief medical officer would be at the apex of the organization with a shared executive function in policy (Dougherty 2004, 150-896).
Business management theory regards organizations as open systems. Several types of theories have been translated to the case management and clinical practice environment successfully. Case management uses theories of change that have been developed in the business fields of organizational development and organizational transformation. Normative models are necessary when there is more resistance to change present than in rational models (Dougherty 2004, 150-896). Lewin's model forms the cornerstone of normative models. Others have used his theory as bases for more expanded versions (Levy 2005, 323- 368). Open systems require the manager to have the experience and knowledge to anticipate changes in the working environment and manage them efficiently (Levy 2005, 323- 368).

Any attempt of movement by either force would cause a direct oppositional force of equal strength until equilibrium was regained. His theory opened the idea that to remove the restraining force would open up the path to change. Without resistance change would be a natural progression (Levy 2005, 323- 368). Lewin based his theory on social- psychological and cognitive views (Levy 2005, 323- 368). Lewin's theory proposed that driving forces, diametrically opposed, maintained the status quo (Hamric 2005, 311-335). This became known as the Force Field model. Analyzing and identifying the driving forces or facilitators and the restraining forces, barriers, is the first and most important part of the process. Barriers can occur at any step in the process and are factors that interfere with the movement of change in a positive direction; barriers can come from within the facility or from outside. Others incorporate change agents as catalysts and prime facilitators. Facilitators are factors that can be internal or external and cause movement toward positive change (Yoder-Wise, 2003). Theories differ on the part the change agent assumes. Some focus on the process of change itself and how the environment resists or accepts it. In the suctioning unit the official change agent would be the educator (Dougherty 2004, 150-896).

The implementation then takes place in accordance to the revised process; this is then evaluated. Managed Care End stage disease (ESRD) accounts for over 400,000 Americans (Levy 2005, 323- 368)?. Disease results in a total of 7% of Medicare's budget and a total of $23 billion dollars (Saxena & West, 2006, 380-389). Cost containment and consistent quality improvement are of paramount importance in the maintenance and care of ERSD for our patient who is on ventilator and suctioning treatment is being performed. Chronic kidney disease (CKD) is regulated by agencies and guidelines. These agencies recognize the benefit of structure and standardization of treatment and the quality and safety these measures bring (Kuchta, 2006, 4-8). In the absence of federal or state mandated changes, determining the need for change should need to be a group mandated (Levy 2005, 323- 368). After a target process is identified and acknowledged the process improvement team work to identify difficulties and adapt a change with measurable outcomes. The change should be based on best practice and evidence-based guidelines (Dougherty 2004, 150-896).

There had been a noticeable lack of pre-suctioning preparation despite the policies the facility followed according to the guidelines (Dougherty 2004, 150-896). A surgical clinical pathway should be in place to ensure the access, preferably the members of a multidiscipline team involved with initiating treatment should include the vascular surgeon, nephrologists, social worker, dietician and suctioning clinician. Owens described a model for pathway redesign for starting new suctioning our patient on ventilator (Owens, et al.2006).

Barriers are present in the complexity and comorbidity of end stage disease and the inherent individuality of each our patient on ventilator. Goals are set for each our patient on ventilator in each facility and a plan is drawn to correct variances. Suctioning facilities maintain standardization through medication standing orders and treatment procedures (Hamric 2005, 311-335). Sodium modelling and ultrafiltration conductivity values are all quantitative modes of tailoring suctioning to individual needs while acceptable treatment adequacies are mensurated within a standardized range. Suctioning access and the initial treatment course can be measured and managed through clinical pathways (Dougherty…