Article Text

PDF

Article 1. Introduction—St Jude's, the “virtual” A&E department
  1. J Wardrope,
  2. S McCormick
  1. Departement of Accident and Emergency Medicine, Northern General Hospital, Herries Road, Sheffield S5 7AU, UK
  1. Correspondence to: Mr Wardrope (Jim.Wardrope{at}northngh-tr.trent.nhs.uk)

Statistics from Altmetric.com

What is management and what is SIMS?

There are a range of definitions of “management”.13 A useful concise definition is “management is the organisation and motivation of groups of people to achieve planned objectives”. Management is part of every day accident and emergency (A&E) consultant practice. Many readers in a recent survey requested more articles on management topics. The journal has for some time been running a series on such issues424 and this will serve as a good grounding for this new venture where we hope to apply the theory to “real” situations. Management in A&E is a dynamic process with many inputs and outputs, conflicting demands and objectives, the conflicting priority of clinical work and managerial work. The aim of this series is to try and make management problems to come alive by creating a “virtual A&E department”. This will be part of a large district general hospital, St Jude's. The hospital will have characters, the hard but fair chief executive, a less than helpful medical director and “unfocused” colleagues. There will be everyday problems such as dealing with complaints, long waiting times and staff recruitment.

The series, how will this work?

Each article will have five different sections (see box 1). Three of these will be in the journal and two will be on the internet. Space is at a premium in the journal but to make this creation real, we need to communicate budgets, rotas, waiting time profiles and other documents. Therefore we will use the web to provide this information. The internet also gives an opportunity for you to provide feedback (see below). This article is different to the rest in the series as we are trying to establish concepts, but subsequent articles will contain the following key elements (box 1).

The journal “in tray tasks” contains, in shorthand, the management tasks that are being set for that issue. There will be references to the internet where the full text of documents will be lodged (see below).

Journal feedback gives feedback on the previous problems and how the issues are developing. Again this will be a brief summary with fuller responses the internet.

Time out will examine in greater detail some of the management theory behind the processes of everyday management, using practical examples from the series. It will include issues such as strategic analysis and planning, team structure and function, project management.

Box 1 The structure of simulated interactive management

HOW THE SERIES WILL WORK

  • In the journal

    • “In tray tasks”

    • Feedback on previous months tasks

    • “Time out”

  • On the internet

    • “In tray”—detailed documents

    • Detailed feedback

  • Your response

    • E-mail replies to the exercises—CPD credits (UK)

Internet “in tray” will provide detailed information such as budgets, rotas and gossip!

Internet feedback will provide more detailed response and documentation to that in the journal “feedback” section.

Internet responses allows you to respond to the series and gain Continuing Professional Development (CPD) credits.

If you want to give feedback the address is www.emjonline.com

How should you use this series?

The whole aim is to be interactive therefore you will need internet access. If you do not, then this should be your first management objective and learning experience. You can e-mail your responses to the editorial team, This can be done as an individual but we feel that it might be more successful if this was a group activity, perhaps centred around SpR training. You can form “virtual directorates”. The web documents can be downloaded and discussed at “directorate meetings”. If you e-mail responses to most of the “in tray” problems then this would be counted as one hour of CPD time. We cannot incorporate all the replies into the model but you will find that good ideas will be used in future articles and risky strategies may be given a trial, some will succeed but others will fail. This series may be read as an interesting “soap” or taken as an interactive educational tool, the choice is yours.

Box 2 Summary of information on the internet site

INTERNET INFORMATION (www.emjonline.com)

  • Details of the department

  • Details of main characters

  • Department budget

  • SHO rota

  • Letter from the chief executive

  • Radiograph results

  • Letter of complaint and factual context

  • Letter from personnel

  • Report on SpR training from training committee

Why bother with management?

Some might think that “management” is always changing and thus theories about management structures are a waste of time or that change to important day to day problems is not possible within the NHS. However, many of the principles of management are almost timeless. Often they deal with the very basic drives of human behaviour. While the cultural, legal and organisational context may change human nature seems to be much more constant. Some very old texts may give great insight to handling strategy such as Machiavelli's The Prince25 or Handy favours Churchill's Biography of the Duke of Marlborough.26 Part of management is coping with change and while many of us may be sceptical of the vision of leaders “learning to love change”27 we must be able to handle change to our patient's and department's advantage.

British legal frameworks and NHS structures will not apply in other countries. Nevertheless we believe that global pressures and constraints in health care impose very similar demands on emergency medicine. Staff recruitment, waiting times, inpatient bed availability and risk management are all part of the management of any emergency care facility. Our international readers will be able to change the management exercises in this series to meet their needs and we welcome feedback on the similarities and differences in your challenges.

In tray

BACKGROUND

St Jude's is a large A&E department seeing 65 000 new patients per year. The hospital has all the main specialties “on site” and has aspirations to be a leading part of the sub-regional health system. The department has a core of experienced nursing staff but has trouble in recruiting SHOs. It has two specialist registrars but recently was only given qualified educational approval. It has three consultant posts, one vacant, one occupied by a consultant nearing retirement and one newly appointed consultant. Dr York has recently taken up post having completed her SpR training. The story will be seen from Dr York's perspective but you can take any part you wish! Full details of the department and some key characters are to be found on the “internet in tray”.

“IN TRAY”—SUMMARY OF INFORMATION AND TASKS

  • As a recently appointed consultant you find that the computer you were promised has not arrived.

  • A letter from the chief executive welcoming you and asking your advice on some problems in the A&E department.

  • A complaint letter, needs to be investigated and a reply formulated.

  • A pile of results from the previous day.

  • A letter from personnel asking you to draft an advert and person specification.

  • Report from the registrar training committee.

What do you do now?

Log on to the internet site (www.emjonline.com) and look at the material. If you wish to take part you will need to set up folders for the various documents (easily done on disk). What action are you going to take? You might wish to investigate the complaint and formulate a reply. If so e-mail it to us. How are you going to respond to the chief executive? What other actions need to be carried out?

One last task is to write down the organisational structure of your own hospital. List the positions of key managers and also the names of the individuals currently in post.

Who is the “boss” of the hospital? What is the name of the nurse who sits on the management board? What is the difference between executive and non-executive directors? Management is about people and knowing the “movers and shakers” in your organisation is one of the first steps in departmental leadership.

Time out

At the start of the series we will take some time to reflect on some important questions:

  • What do I need to learn?

  • How can I learn?

  • What business are we in anyway?

What do I need to learn?

The learning areas fall very neatly into some easily recognised categories; Knowledge, Skills and Attitudes.28 Examples of some of the areas of learning are summarised in table 1. This list is far from exhaustive.

Table 1

Areas of learning and some examples of subjects

How can I learn?

As with the clinical aspects of emergency medicine, it is the day to day handling of management issues with help and supervision of an experienced colleague that will provide the best learning. This management series tries to provide some “issues” to highlight certain facets of the skills and knowledge base. However, attitudes are hard to instil from afar. Thus this series can only be a start to learning, a focus for discussion and reflective thinking but is up to you to seek out those in your own workplace who can provide teaching and discussion of these issues.The reference list is a rich source of material as is the reading list given at the end of the article.

What business are we in?

The main and most important role of the A&E department is the provision of immediately available health care. We are not the only providers of this service, more urgent health care is provided by primary care and even more by patients themselves. The great success of A&E as a specialty has been the organisation and delivery of high quality emergency care.

However, there are other areas that are integral to our service, areas that are often not recognised by hospital management as taking resource and time. These are areas where high levels of effort are needed if we are to achieve the most from our organisation.

What are the core activities of emergency medicine

  • Provision of a high quality clinical service for the evaluation and treatment of patients with urgent health care needs.

  • Contingency planning for the rare emergency events

  • “Total quality” approach to clinical assessment and risk management

  • Teaching, training and staff development

Planning for the unpredictable seems illogical but is part of modern management theory. Emergency medicine is about being one step ahead of the problem, be that a difficult clinical case, the single contaminated victim or a major disaster. A proper response to rare events needs planning, training and flexibility. Emergency medicine must take the lead in this, no one else will.

Teaching and the development of people are perhaps the most vital roles for a departmental manager. We are highly dependent on a highly skilled and motivated work force. A department that does not value and develop staff will not flourish. There are often other teaching commitments to other staff groups, undergraduates, postgraduates and the general public.

Provision of “Quality” is one of the hallmarks of the management movements of the 1980s and 1990s. This has been one of the keystones of emergency medicine. The high volume of cases, often with difficult clinical problems requires that each person tries to deliver “total quality care”, backed up with quality control systems such as the routine reporting of radiographs. Audit is another quality control tool.

Accident prevention and research are areas that may not be part of all departments' strategy. In the UK there is not enough funding or trained manpower in every department to carry out these functions. However, these activities are an important part of the national response to emergency care.

Similarly other departments will have roles in prehospital care or have special interests in one facet of emergency medicine. Such diversity is healthy and often lead to development of the specialty but they are not “core” to every department.

Summary

Management is part of everyday life in emergency care. This project will hopefully bring alive management issues, give a “real” framework to assist the discussion of management theory and hopefully to entertain. We look forward to your feedback on the tasks and welcome ideas on how the St Jude's should go forward.

Reading list

  • Cole GA. Management theory and practice. 5th ed. London: Letts Educational, 1999. (good “all round” text with many references)

  • Flanagan H, Spurgeon P. Public sector managerial effectiveness. Buckingham: Open University Press, 1996.

  • Handy C. Understanding organisations, 3rd ed. London: Penguin Business, 1985.

  • Martin M, Jackson T. People and organisations. Personnel practice. London: Institute of Personnel and Development,1998.

  • Pugh DS, Hickson DJ. Writers on organisations. 4th ed. London: Penguin Business, 1989.

  • Walton MW. Management and managing: leadership in the NHS. Cheltenham: Stanley Thornes, 1997.

  • Rosen RA. Managing to get it right. Dallas: American College of emergency Physicians, 1998.

Acknowledgments

We would like to thank Peter Driscoll and Ian Sammy for their detailed comments. The characters, the hospital and most managerial situations in this series are fictitious and any resemblance to an individual or department is coincidental. Some management situations are based on real episodes but details have been changed. We acknowledge the work of G A Cole in his book Management theory and practice that is extensively referenced in this series.

References

View Abstract
  • SIMS ARTICLE 1: INTERNET IN TRAY
     

    Complaint

    Information Letter from Quality Co-ordinator re complaint

    Dear Dr. York,

    Please find enclosed a letter of complaint regarding the management of a patient under your care. I would be grateful if you could investigate this matter and reply to me within two weeks. A copy has been sent Sister Oak to answer the nursing issues.

    Yours sincerely,

    Mrs. Penny . Quality co-ordinator.

    -------------------------------------------------------
     

    Information letter from complainant

    Dear Sir,

    I wish to complain about the treatment of  my daughter by your casualty department. She was  35 years old and suffered from learning problems. She was taken to your hospital after becoming unconscious and very unwell. She had to wait 2 hours. She was seen by a doctor who said he was not sure what was wrong but there was a possibility that the problem was an infection and meningitis was a possibility.

    He said that he had discussed the case with his seniors and that he had given her antibiotics and that a brain scan was being arranged. I was told that she would be kept in hospital and so I went home to collect some clothes. I was stunned when I received a phone call to say that she would be coming home and that the problem was only a water infection. I asked  if there had been a mix up as the doctor had told me that this was a possible meningitis case. However the nurse said she had been seen by the medical experts and it was all right for her to come home.

    When she came home she was slightly better but still very hot and not herself. I  looked after her that night. She was in a great deal of pain and shock. The next morning  at home I could not wake her up. I phoned for my doctor who came straight away. He arranged an ambulance and  she was admitted to hospital but died later that day. The death certificate gave a diagnosis of  meningitis.

    I cannot understand why she was sent home. Why did one doctor say the problem was meningitis but the expert said that it was a water infection. Did the fact that she had learning problems mean that she was not taken seriously? Why did the nurse insist on her coming home when I asked about the meningitis?

    Yours

    Jane Green (mother of  Janice Green.).
     

    ------------------------------------------------
     

    Information: Facts from AED record

    35 year old female booked in at 16.15 brought by 999 ambulance. History of  increasing drowsiness and feeling unwell. Fever. Triage assessment:  unwell, drowsy but answers questions. Temp 38.5 C. Pulse 110. BP 120/70. Triage Category  3 in view of learning disability.

    Seen by Senior House Officer (SHO) at 17.00. History from mother patient has learning problems. Unwell since this morning. Feels hot. Not eating, vomited once. Been drowsy. No previous similar problems.  No specific complaints on pain. ? going to toilet more often than usual. Down�s syndrome otherwise well. Lives with mother. Recently returned from holiday with local charity group.

    Examination.   Unwell, Hot. No nodes/clubbing/jaundice. ENT NAD Good colour. CVS. P 100 regular, BP 120/70, HS. Normal. Resp. Chest clear. Abdo - slightly tender lower abdo. No rebound/guarding. CNS. Drowsy but opens eyes to command. Obeys commands. Difficulty in understanding questions ?normal. Cranial nerves intact fundoscopy difficult. ? pain in neck on movement. PNS. Normal power/tone reflexes.

    Impression 35 year old with pyrexia ?cause, drowsy, some lower abdominal pain.

    Discussed with senior. Plan -  I.V. access, bloods, antibiotics. Check urine. Refer to medicine for admission and ?CT scan.

    Medical registrar. Hx as above.  No focal complaints/signs. Well. Temp now 38 C. P100. Blood in urine. WBC 15. Probable UTI. Home. GP follow up.

    Nursing notes.   Phone call from mother. Says she was told this was meningitis so why is she coming home? Checked with medical registrar. Confirms UTI. Home, see GP if problems.
     
    ------------------------------------------------

    Information: staff interview

    SHO: Remembers case very well. Discussed with senior who examined. Thought she had neck stiffness so refer to medics. Set up I.V., took bloods and referred to medical registrar. No further contact.

    Staff nurse: Remembers incident well, checked with medical registrar who was quite clear the lady could go home.

    --------------------------------------------------------------------------------------------------------------------

    Chief Executive

    Information: Letter from chief executive

    Dear Dr. York,

    Welcome to the Trust. I hope that you are settling into your new post. I am sorry that I missed our appointment that had been arranged for your induction. I will ask my secretary to try and re-arrange this. You know that the Trust view  the Casualty department as a very important part of the hospital and we look forward to your new ideas and enthusiasm in helping us solve some long standing problems.  You may be aware that we have had a number of complaints about the waiting time, especially at weekends. One of these was from a prominent local figure. I would be grateful for a short paper on how this problem might be solved. The matter is urgent and if you could let me have your thoughts within 1 month I would be grateful.

    Chief exec.

    --------------------------------------------------------------------------------------------------------------------

    Recruitment /selection

    Information: Letter from personnel re Senior House Officer (SHO)  recruitment/selection

    Dear Dr. York,

    Mr. London has told me that you are now responsible for SHO recruitment. I enclose a copy of the job advert we used last time. We have never received a formal person specification from Mr. London. Could you please draft one for us?

    --------------------------------------------------------------------------------------------------------------------

    Information: Existing advert for SHO

    SHO � A&E St. Judes� hospital.  9-posts

    Required for busy department seeing 65,000 patients per year. Apply to personnel dept on ���..

    --------------------------------------------------------------------------------------------------------------------

    Training: Specialist Registrar (SpR)

    Information: Report of training committee

    Dear Mr. London,

    As you know the training committee visited the region recently and a copy of the report is enclosed. As you can see the visitors were concerned about some aspects the training in your department. I would be grateful if you could let me have a plan on how you are going to meet these concerns before the next visit.

    Strengths � A busy DGH with good case mix. Very good nursing staff but too few at times, especially at weekends. Reasonable medical staffing but again  very busy at weekends and the SpR is a �pair of hands�. Good support from paediatrics and ITU.  Good training is paediatrics from the consultant.

    Weaknesses � Single handed consultant (two vacancies). Little supervision for general medical cases. No management training, audit or research activity. No computer for SpR. No office for SpR.

    Recommendations

    Provisional educational approval for 1 year. Re-visit by the training committee to ensure that weaknesses have been addressed. Chair of the regional committee to make contingency plans to place the trainees in other units if weaknesses not addressed.

    --------------------------------------------------------------------------------------------------------------------

    Miscellaneous

    Information: Pile of x-ray results (the A&E opinion on these had been �NAD�)
     

    • Ankle � small avulsion fracture talus
    • Wrist � soft tissue swelling dorsum wrist
    • Abdomen � small radio-opaque density left pelvis, probably phlebolith but could be ureteric stone
    • Ankle � soft tissue swelling lateral malleolus
    • Wrist � small torus fracure distal radius
    • Elbow � anterior fat pad. No fracture seen
    • Cervical spine � C7 /T1 not visualised. Abnormality spinous process. Soft tissue swelling
    • Shoulder � calcification in the rotator cuff area
    • Knee � probable bifid patella but could be a fracture
    • Skull �  hyperostosis frontalis intera
    • Facial bones �  bony swelling antrum, probable oteoid osteoma

     

     
     

Footnotes

  • Conflicts of interest: JW is editor of EMJ but this series was conceived and approved before commencing this post.

Request permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.