4/11/2018

1

WHAT IS THE MAGIC NUMBER?

LEADERSHIP INFRASTRUCTURE PANEL

FACILITATOR & PANELISTS

Facilitator:Paula J. Webb, DNP, RN, NEA-BC

Panelist:Sheralyn Hartline, MSN, RNC-NICMarlee Crankshaw, DNP, RN, CNMLRegina Reynolds, MSN, RNC-NIC, NEA-BC

DISCLOSUREContracted Program Coordinator for Synova Associates, LLC

4/11/2018

2

OBJECTIVES

Understand the literature surrounding Span of Control

Identify various approaches to addressing Span of Control

SPAN OF CONTROL KEY ELEMENTS

1950’s – defined as number of FTEs reporting to one manager

1993 – added manager’s planning, organizing and leadership functions

1998 – consider scope of responsibility

a) Size & number of units

b) Number of sites

c) Managerial support personnel

d) Budgetary responsibility

( Modash, Brintnell & Rodger, 2005)

POSITIVE IMPACTS OF LARGE SPAN OF CONTROL

Improved communication

Greater flexibility

Improved employee morale

Effective delegation of responsibilities and authority makes job more fulfilling and rewarding

Reduced financial impact to the organization

( Modash, Brintnell & Rodger, 2005)

4/11/2018

3

NEGATIVE IMPACTS OF LARGE SPAN OF CONTROL

Changes in communication patterns with increases in the number of interactions

Micromanaging leads to decreased employee satisfaction

Increased turnover rates

Lack of time for overseeing quality initiatives

( Modash, Brintnell & Rodger, 2005)

NEGATIVE IMPACTS OF LARGE SPAN OF CONTROL

Lack of visibility to staff

Lack of time to create a vision/goals for area

Lack of coordination

Lack of follow-up

Being out of touch with staff concerns/needs

(Holm-Petersen, Ostergaard & Andersen, 2017)

EFFECTS OF HIGH SPAN OF CONTROL

Job Strain – symptoms of mental strain, emotional exhaustion and physical/mental issues

Burnout – emotional exhaustion, decreased person fulfillment, role conflict, scope creep

Organizational commitment – decrease of commitment found to be a greater indicator of turnover than other factors

Turnover intention – voluntary turnover due to all of the above

(Wong & Laschinger, 2015; Nelson, 2017)

4/11/2018

4

STEPS TO REDUCE THE WORKLOAD

Make the work meaningful – job with a purpose, meaning and making a difference

Address the appropriateness and breadth of the work – outside of the normal scope of work, ie: housekeeping, food service, etc

Self-care: relaxation techniques, vacations, leaving work at work

(Nelson, 2017)

SPAN OF CONTROL MITIGATION STRATEGIES

Decrease span of control based on complexity of areas

Administrative assistant support to decrease workload tasks. (Ie: payroll functions, scheduling appointments.)

Transformational leadership development

(Simpson, Dearmon & Graves, 2017)

NURSE MANAGER ESSENTIAL METRICS

Tool developed to identify need for clinical/operational support & administrative/secretarial support

5 essential metrics identified:

Number of cost centers

Headcount

Department workload

Hours of operation

Controllable expense

Calculations provided

(Jones, McLaughlin, Gebbens & Terhorst, 2015)

University of Pittsburgh Medical Center

4/11/2018

5

SPAN OF CONTROL TOOL

The Ottawa Hospital Clinical Management Span of Control Decision-Making Indicator Tool (2005):

3 Decision Making Categories

Unit-focused: complexity of unit & material management

Staff-focused: # of staff reporting to manager, skill/autonomy of staff, staffing stability & diversity of staff

Program-focused: diversity of the units, budgetary & statistical responsibilities

( Modash, Brintnell & Rodger, 2005)

REFERENCES

• Baird Simpson, B., Dearmon, V., & Graves, R. (2017). Mitigating the Impact of Nurse Manager Large Spans of Control...reprinted with permission from Nurs Admin Q, 2017;41 (2): 178-186. Journal Of Nursing Administration, S11-S19. doi:10.1097/NAQ.0000000000000214

• Holm-Petersen, C., Østergaard, S., & Andersen, P. N. (2017). Size does matter - span of control in hospitals. Journal Of Health Organization & Management, 31(2), 192-206. doi:10.1108/JHOM-04-2016-0073

• Jones, D., McLaughlin, M., Gebbens, C., & Terhorst, L. (2015). Utilizing a Scope and Span of Control Tool to Measure Workload and Determine Supporting Resources for Nurse Managers. Journal Of Nursing Administration, 45(5), 243-249. doi:10.1097/NNA.0000000000000193

• Merrill, K. C., Pepper, G., & Blegen, M. (2013). Managerial span of control: a pilot study comparing departmental complexity and number of direct reports. Nursing Leadership (1910-622X), 26(3), 53-67.

• Morash, R., Brintnell, J., & Rodger, G.L. (2005). A span of control tool for clinical managers. Nursing Leadership 18(3), 83-93.

REFERENCES

• Nelson, K. E. (2017). Nurse Manager Perceptions of Work Overload and Strategies to Address It. Nurse Leader, 15(6), 406-408. doi:10.1016/j.mnl.2017.09.009

• Simpson, B. B., Dearmon, V., & Graves, R. (2017). Mitigating the Impact of Nurse Manager Large Spans of Control. Nursing Administration Quarterly, 41(2), 178-186. doi:10.1097/NAQ.0000000000000214

• Wong, C. A., Elliott-Miller, P., Laschinger, H., Cuddihy, M., Meyer, R. M., Keatings, M., & ... Szudy, N. (2015). Examining the relationships between span of control and manager job and unit performance outcomes. Journal Of Nursing Management, 23(2), 156-168. doi:10.1111/jonm.12107

• Wong, C. A., & Spence Laschinger, H. K. (2015). The influence of frontline manager job strain on burnout, commitment and turnover intention: A cross-sectional study. International Journal Of Nursing Studies, 52(12), 1824-1833. doi:10.1016/j.ijnurstu.2015.09.006

• Wong, C. A., Elliott-Miller, P., Laschinger, H., Cuddihy, M., Meyer, R. M., Keatings, M., & ... Szudy, N. (2014). Exploring Managers' Views on Span of Control: More Than a Headcount. Nursing Leadership (1910-622X), 27(1), 45-61.

4/11/2018

6

COOK CHILDREN’S MEDICAL CENTER NICU

SHERALYN HARTLINE, MSN, RNC-NIC

DISCLOSURE

I have no actual or potential conflict of interest in relation to this program/presentation

COOK CHILDREN’S MEDICAL CENTER

• 99 single patient rooms, 106 beds

• Level IV tertiary care center

• ADC 64

• 1050 admits per year

4/11/2018

7

NICU LEADERSHIP TEAM

• 300 employees

• 7 managers- responsible for operations and all evaluations of staff

• Increase in demands for quality projects, collaboratives, audits, etc

NICU/ECMO Director

7 Clinical Managers

DELEGATION OF DUTIES

• What can be delegated?

• Staff engagement

• How to get staff to complete tasks

• Follow up on audits completed

RESPONSIBILITIES

• Charge nurse duties- Kevin/handwashing audits, and mentoring program/clabsiaudits, zero harm coaches

• Safety coaches- K card audits

• QI auditors

• VON quality improvement project taken over by staff

• Outreach coordinator- auditing responsibilities

• PICC team

4/11/2018

8

BENEFITS TO STAFF AND UNIT

• More engaged

• Ownership

• Professional Development Program

• Must follow up each month to make sure audits were done!

INNOVATIVE LEADERSHIP MODEL

Marlee Crankshaw, DNP, RN, CNML

April 2018

Disclosure

I have no actual or potential

conflict of interest in relation to

this program/presentation

4/11/2018

9

BACKGROUND

At The Monroe Carell Jr Childrens Hospital at Vanderbilt (

MCJCHV ) in Nashville TN

98 bed NICU Level IV

20 beds in separate unit within adult hospital , adjacent to L & D –

admits new deliveries

Open Bay Lay out

78 beds in Childrens Hospital –

44 private rooms, no rooming in accommodations

34 private rooms, with overnight accommodations

LEADERSHIP STRUCTURE

Chief Nursing Officer

Administrative

Director

Day

CSL

ManagerBusiness

ManagerManager

Day

CSL

Day

CSL

Day

CSL

Day

CSLNight

CSL

Night

CSL

Night

CSL

Night

CSL

Night

CSL

20-

30

Staff

20-

30

Staff

20-

30

Staff

20-

30

Staff

20-

30

Staff

20-

30

Staff

20-

30

Staff

20-

30

Staff

20-

30

Staff

20-

30

Staff

CSL MODEL

Two 12 hour shifts at bedside or charge role

Two 8 hour shifts in administrative role

Scheduled one weekend per 6 weeks

Holidays are covered by on call ( rotation list )

All CSLs are assigned specific tasks & projects

All CSLs conduct mid year & annual evals

4/11/2018

10

EXPECTATIONS

Admin Director ( AD ) & Managers ( Mgrs ) meet 2 X month with

entire CSL group

AD & Mgrs meet each week for team meeting

Mgrs meet with their CSLs 1 X month

Review their projects & discuss staff concerns

Performance, attendance, problems, etc

CSLs round on their staff members regularly

THE MATCH GAME

We strive to find the best ‘fit’ for CSL / staff member

We do consider ages, personality types

More often than not, its simply a matter of ‘numbers’ – desire to keep

span of control evenly distributed

CSL RETENTION

This model began Oct 2012 as new model for Vanderbilt as of

Sept 2016

Retirement ( 1 )

Promotions/Graduations ( 6 )

Family Obligations/Personal Loss ( 6 )

Dissatisfaction/Stress of Job ( 2 )

Termination ( 1 )

4/11/2018

11

REFLECTIONS

Changing from hourly to exempt is major struggle

Matching skills to passion is difficult & timely

Competition within group is real

‘Rising rivalry’ is real

Orientation to the role cannot be tasks & classes—so much more is

needed for success

Making Your Case for

Additional Manager(s)

Regina Reynolds, MSN, RNC-NIC, NEA-BC

Director Of Nursing-NICU

Parkland Health & Hospital System

Disclosure

I have no actual or potential conflict of

interest in relation to this

program/presentation

4/11/2018

12

Background

• Parkland Health & Hospital System

– Dallas County Hospital

– 13,000 deliveries per year (average)

– 96 bed level III NICU

– All private rooms

– Mixed acuity

– Current Leadership structure was based on ADC of 68:

Nursing Org Chart

NICU Org Chart

Director of Nursing NICU

4 Direct Reports

Strategic Planning

Unit Manager NICU

15 Direct Reports

OperationsAssociate Unit Manager

NICU48 Direct Reports

Associate Unit ManagerNICU

29 Direct Reports

Associate Unit ManagerNICU

48 Direct Reports

Associate Unit ManagerNICU

48 Direct ReportsAssociate Unit Manager

NICU46 Direct Reports

4/11/2018

13

Utilizing a Span of

Control ToolThe Ottawa Hospital Clinical Management Span

of Control Decision-Making Indicator Tool

(2005):3 Decision Making Categories

• Unit-focused: Score 32

• Staff-focused: 53

• Program-focused: 24

• Total Score 109 (excessive span of control)

( Modash, Brintnell & Rodger, 2005)

Impacting Factors

• Complexity of the unit/variation in equipment and

supply acquisition

• Total staff175 FTE

• Higher number of novice nurses and non-

professional staff

• 20% turnover rate and high usage of FMLA and

intermittent leave

• Expectations of Director, VP, Medical Director X

2 and Chief

• Operating budget in excess of $12,000,000

Decisions

What Type role to addAssociate Unit Manager –vs- Unit Manager –vs-

Supervisor

• Determine what other responsibilities the role will

take on

• Do you have an internal candidate prepared to

move into entry level position?

• Other things to consider?

4/11/2018

14

Considerations for

Smaller Units

Making the case may be more difficult in

smaller units• Turnover rate >10%

• Staff satisfaction

• Staff engagement

• Risk management issues

• What is the education span of coverage?

QUESTIONS????

OTTAWA HOSPITAL CLINICAL MANAGEMENT SPAN OF CONTROL DECISION-MAKING INDICATOR TOOL

4/11/2018

15

CONTACT INFORMATION

Facilitator:Paula J. Webb, DNP, RN, NEA-BC (pwebb@synovaassociates.com)

Panelist:Sheralyn Hartline, MSN, RNC-NIC (Sheralyn.Hartline@cookchildrens.org)

Marlee Crankshaw, DNP, RN, CNML (marlee.crankshaw@vumc.org)

Regina Reynolds, MSN, RNC-NIC, NEA-BC (REGINA.REYNOLDS@phhs.org)