4. Organizational Structure: The Decision-making Process

The internal organizational structure of the local school district should reflect and support the collaborative decision making of educators and health professionals at all levels of the organization. With the increasing complexity of health services required by students in school, both administrative and clinical judgments are critical in planning, implementing, and evaluating services for children with health impairments. Local school districts may need to review and revise organizational structures, policies and procedures to promote decision making that is truly collaborative in nature and to ensure that both administrative and clinical judgment are made by those who have the expertise and legal authority to make them.

It is important at the classroom level that team members (for example, the teacher, mental health professional, school nurse, physical therapist, occupational therapist and speech language pathologist) provide coordinated services with common, child-focused, and family centered goals. To do this, team members, including the family, must share information necessary to optimize the student's educational program and to ensure the student's health and safety. Similarly, it is essential that school administrators, school nurse supervisors, school medical advisers, pupil personnel coordinators and other appropriate supervisory and administrative personnel collaborate in planning programs, developing procedures, and resolving many of the difficult issues inherent in providing services for students with special needs. Finally, the local board of education should ensure that health-related issues are identified and considered in the process of developing and revising policy by consulting with the medical adviser, nursing supervisor, and community health experts. Consultation with attorneys who have expertise in education may also be beneficial in resolving legal issues regarding district policy or procedure.

Local school districts have the overall responsibility for providing a free and appropriate education in a safe environment for all of their students. In order to discharge administrative responsibilities as they relate to the health care of students in schools, local school districts should:

• hire qualified health professionals who are competent and appropriately licensed to provide consultation, training, supervision, and/or direct health care services for the specific population served;
• ensure interdisciplinary collaboration in the development of policies and procedures;
• establish clear lines of authority, responsibility, and accountability for clinical decision making;
• develop policies and procedures which ensure that clinical decisions related to the health status and health care of students are made by health professionals who are qualified and legally authorized to make such decisions;
• delegate the responsibility for developing clinical policies, procedures and protocols specific to the delivery of health care services in the district to appropriately qualified health and mental health clinicians;
• delegate the authority and responsibility for making clinical decisions to the health and mental health professionals who are qualified to make them;
• consult with community health experts or use health advisory committees that include such experts;
• develop policies that ensure appropriate privacy and maintenance of confidentiality around student health information, third-party medical/psychiatric records, and school health records, including a process for ongoing professional development on this topic;
• establish mechanisms for interdisciplinary planning, joint problem solving, and collaborative evaluation of student services; and
• provide time and funding for necessary continuing education, professional development and in-service training for health and mental health professionals.

Within a school district, school health professionals have primary responsibility for:

• safe clinical services;
• the development of sound clinical policies, procedures and protocols; and
• final decision-making authority in the clinical aspects of health care delivery.

School administrators, educators, medical advisers, school social workers, school nurses, speech language pathologists, school psychologists, school counselors, physical therapists, occupational therapists, food service supervisors, transportation supervisors, and other professionals within the school community need to collaborate in the development, review, and revision of related policies, procedures, and student services on a regular basis.

Most school decisions related to serving students with special health care needs require some combination of both administrative judgment and clinical judgment. It is sometimes difficult to identify the specific components of the decision-making process, but it is important to make a collaborative effort to do so. When the various components of a decision-making process can be identified, they can then be developed into a procedure, protocol, or decision rubric for the future management of similar issues.

Example of Collaborative Decision Making

It is essential for all personnel to recognize that there will be conflicts and problems that arise in the process of planning for, providing, and evaluating the special services that students with special health care needs may require in school. It is important, therefore, for school districts to:

• provide adequate orientation of personnel to interdisciplinary team functioning;
• promote regular team meetings for communication about issues and problem solving; and
• define for all personnel an administrative structure that establishes clear lines of responsibility and authority for administrative and clinical decisions, for joint decision-making and for recourse when the first line of problem resolution is ineffective.

The health, safety, and, in some cases, life of a student may depend on clear lines of decision-making among personnel. The following is an example of Collaborative Decision Making:

A new student is eligible to enter the preschool program located in a district's elementary school. Because of the student's health impairment, she will require a health care procedure daily while in school. In the process of planning for the student to enter school, the decision about who should perform the required procedure must be made. The steps of a collaborative process for making this decision, including both administrative and clinical components, as well as the primary responsibility for specific aspects of the decision, are outlined below. Although the primary responsibility for each decision is indicated by "CLINICAL" or "ADMINISTRATIVE", in most instances the decision maker will make better judgments when others have been consulted during the decision-making process.

1. Clinical

   The school nurse initiates a health assessment and, in consultation with the student's physician, family and other appropriate persons determines:

   • the level of care required for the student;
   • that (in this example) the procedure can be delegated to unlicensed assistive personnel; and
   • that the unlicensed assistive personnel should have professional level (non-nursing) judgment skills.

2. Administrative

   The administrator determines:

   • which professional staff members are available to perform the procedure; and
   • whether the job description of the personnel permit the performance of such assigned health procedures.

3. Administrative

   The administrator, after consultation with the potential candidates and the school nurse, chooses the individual professional (certifi ed staff member) who is most suitable to provide the care at the specified level.

4. Clinical

   The school nurse trains the individual designated by the administrator, determines when the individual is sufficiently competent to provide care, and provides regular supervision.

5. Clinical

   When the student's health status changes, the school nurse, in consultation with the student's physician, family and other appropriate persons, determines that the level of care required by the student can no longer be provided by an unlicensed individual.

6. Clinical

   The school nurse recommends that care be provided by a school nurse until the student's condition stabilizes.

7. Administrative

   The administrator immediately arranges to implement the recommendation; or if regular staff members are not immediately available, the administrator makes an alternative interim plan (which still meets the level of care recommended by the school nurse, such as reassigning a school nurse part-time from another building) while exploring the districts options and obtaining further consultation.

8. Collaborative

   The administrator, family, health professionals, teacher, pupil personnel specialists and outside consultants may all need to problem solve together to develop a viable plan to meet the student's needs at the new level of care required.