Complexities in Health Care Management: Who Holds the Rubik's Cube?

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Managing organizations to achieve business strategies has been common in business literature since the start of the industrial revolution, long before health care costs and management were being discussed.

Nursing has been fortunate to have many superb leaders, both clinically and organizationally; however, organizational management has had a lower priority in the past than its importance warranted. In the past several decades, health care organizations and consumers have recognized that strong leadership in management systems and processes is critical for optimal clinical outcomes for our patients.

The nursing process is a useful framework for understanding and achieving an organization's mission, vision, and strategic direction in a way that is similar to how it is applied in clinical management. Obviously, organizational needs and outcomes as related to diagnosis, planning, intervention, and evaluation have different content material and outcome expectations than in clinical management. What we do know is that management of both is essential to ensure excellent outcomes for individuals and populations.

What has changed recently in the processes of clinical and organizational management is the understanding and acceptance that individual accountability is not enough. The complexity involved in the clinical care of a patient has increased exponentially with the aging population. Multiple diagnoses have become common, especially among the chronically ill. Increased advancements in medical science, along with the number and sophistication of technologies, have increased interventions.

The result of this trend is the necessity for multiple accountability; no one individual can successfully manage comprehensive patient care with its magnitude of ramifications. A team of knowledgeable, skilled people is required to provide expert clinical management. This development requires an expanded set of skills for our clinical nursing colleagues, including interdisciplinary communications and the ability to access knowledge and build positive interpersonal relationships with team members, patients, and families. This does not negate the control over nursing practice that belongs to the profession; rather, it improves the control process by identifying the expertise, role, and responsibility inherent in each team member.

Building teams and identifying accountabi-lity in roles and functions are not simple tasks; sometimes specific tasks overlap, such as case management. There are definitive roles played by social workers and different roles played by nurses, yet the title is often used interchangeably. When professional practice for nurses is well defined by the organization, it becomes clear that clinical planning, intervention, evaluation, and modification of the health care regimen are within the role of the professional nurse case manager. Professional nursing frequently should and does have the responsibility of deciding who holds the Rubik's cube; that is, defining who is responsible for the coordination of care in specific situations regardless of the multiple accountabilities. Defining these roles with our physician colleagues is also a necessity in today's environment, as functions among nurses and physicians often converge.

This same paradigm can be applied to organizational management. It is no longer enough to be knowledgeable about nursing practice and the organization of nursing service. The successful leader/manager also has to build skills in a variety of other disciplines. The most obvious one that comes to mind is finance. At the same time, alliance building, consistent communication, analytical skills, and strong interpersonal relationships are also necessities.

Recognizing nursing's uniqueness and importance is critical; however, recognizing and supporting the total organization's achievement of its mission is good for everyone. The process of accepting multiple accountability as essential to meeting organizational goals requires the same type of preparation for nurse leaders/managers as required for clinical management, including an ability to meet new cultural requirements, systems, technology, and societal demands. Similar to clinical management, nursing management must also identify who holds the Rubik's cube. Coordination to achieve management goals and objectives is essential. Anyone who remembers the quality circle concept will recall that it failed because no one was charged with responsibility, coordination, and follow up.

We must be prepared to identify and accept new roles and functions without regard to territorial issues. After all is said and done, the complexities involved in managing collective and individual accountability, as well as coordination, take well-prepared and seasoned leadership. The outcomes are well worth the effort.