which the concepts of caring are taking hold in practice, employing three separate measures, including an assessment of how job satisfaction is being impacted by its implementation. Having a rigorous method of measurement specified for a framework of care helps advance and sustain the framework of care in several ways. It identifies (a) what specific components of the framework can be shown to relate to improved outcomes, (b) what components of the framework are critical for staff members to embrace in order to enact the framework of care, and (c) where the important components of the framework are working well within the organization and where they need additional support. The measurement process for CBAS accomplished all of these things. Implementation of CBAS in 18 hospitals in Scotland is reviewed in detail in Chapter 18.
There are several frameworks of care that are not included in this book but are reported in the literature. Sometimes frameworks are adopted in name only or amended dramatically for specific contexts. For example, the term patient‐centered care is a general term proposed by the Institute of Medicine (IOM), which it defines as “providing care that is respectful of, and responsive to, individual preference, needs, and values, and ensuring that patient values guide all clinical decisions” (IOM, 2001, p. 5). This term is applied to a wide variety of models developed for specific organizations. Examples include the Cleveland Clinic's use of the IOM definition to create its own organization‐specific patient‐centered framework of care (Smith, 2018). Some companies have helped implement specific frameworks also termed patient‐centered care. For example, Planetree has a number of methods to help organizations implement and become certified in a framework of patient‐centered care (Planetree, 2020). Livestrong, a nonprofit organization which provides support for people with cancer, worked with the consulting firm Upstream to develop yet another framework of patient‐centered care (Upstream, 2020). And finally, the Health Education of England (HEE), an agency within the National Health Service (NHS) of England, provides support to implement what it also calls patient‐centered care (HEE, 2020).
Some theorists assert that Watson's Theory of Transpersonal Caring (2008a) is a framework of care when the processes of caring behaviors are taught with the intention that they be carried out within operations of care. While the implementation of any processes of caring in the absence of structures, processes, and policies to support the sustaining of the behaviors cannot be called a framework of care, the implementation of Watson's caring behaviors is an integral part of several frameworks of care delivery.
RBC's Four Decades of Wisdom
Later in this book, as case studies are presented in which people working in Relationship‐Based Care cultures have had success in using predictive analytics to improve outcomes, they often credit the success of the project—or even the very existence of the project—to what they have learned while implementing RBC. Often, what they credit, however, is some of the long‐honed wisdom baked into the process of implementing RBC that is not readily apparent in the dimensions of the model itself. You will see references to responsibility + authority +accountability (R+A+A), Primary Nursing, the importance of clarity, and more. In order to help you better understand those concepts when you meet them in your reading, here is a summary of each concept.
The Three Key Relationships in Relationship‐Based Care
The most central tenet in Relationship‐Based Care is that every relationship matters. Therefore, it is essential that all people in the organization tend to the quality of their relationships with themselves (self‐awareness), with their colleagues, and with patients and families. Many discussions of these three relationships also focus on “care of” self, colleagues, and patients and families.
Relationship with Self/Care of Self
To stay healthy and be emotionally available for others, clinicians must pay attention to their own energy levels, be self‐aware and mindful as they interact, and practice self‐care for body, mind, and spirit.
Relationship with Colleagues/Care of Colleagues
Healthy interpersonal relationships between colleagues positively impact the patient experience. All team members must model mutual respect, trust, open and honest communication, and consistent, visible support of one another.
Relationship with Patients and Families/Care of Patients and Families
In RBC cultures, patients are seen, heard, and cared for as distinct individuals. Care and service are designed to prevent unnecessary suffering due to delays, physical or emotional discomfort, and lack of information about what is happening. The care delivery system of Primary Nursing, which is explained later in this chapter, is used because it is the system most supportive of the nurse–patient relationship (Manthey, 1980; Wessel & Manthey, 2015).
Several chapters in this book document studies seeking to understand the relationship between care of self and/or the care of the unit manager and nurse job satisfaction.
Responsibility + Authority + Accountability (R+A+A)
The theoretical framework known as R+A+A has appeared in nearly every book Creative Health Care Management (CHCM), the originators or RBC, has published (Felgen, 2007; Guanci & Medeiros, 2018; Koloroutis, 2004; Koloroutis & Abelson, 2017; Koloroutis, Felgen, Person, & Wessel, 2007; Manthey, 1980, 2007).
Any individual or group, whether council, task force, or committee, needs a clear scope of responsibility and a defined level of authority for decision making. R+A+A can also provide a mutually agreed upon system to assure reflection and review of the impact of everyone's efforts. Clarity around all three elements is necessary for success. They are defined as follows:
Responsibility
Must include the clear articulation of expectations
Always a two‐way process: responsibility must be both allocated and accepted
Authority
The right to act in areas in which one has been given and has accepted responsibility
The level of authority must be appropriate for the responsibility
Creative Health Care Management uses four levels of authority to establish clear expectations for decision making:
Level 1: Authority to collect information
Level 2: Authority to collect information, assess, then make recommendations
Level 3: Authority to collect information, assess, determine actions, pause to communicate and enhance, then act
Level 4: Authority to assess and act, informing others after taking action
Accountability
Ownership for the consequences of one's decision and actions
Sets the stage for learning and directing future actions
When responsibility is understood
