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Thank you for the replies to last month's in tray. Further feedback is given in emjonline (www.emjonline/contents/SIMS3).
The strategic reports were very interesting and many had similar ideas to Dr York's own analysis (detailed feedback on internet). Some of you suggested that the report should be shared with the chief executive. This is a high risk strategy but with a possibility of gaining influence in high places. Most of you identified the accident and emergency (A&E) staff as key stakeholders and suggested a “time out” with the staff. This was successful and a brief report of this meeting is appended. Unfortunately Sister Oak was on annual leave and Mr London did not come as it was his half day (file note of this meeting on the internet). The next stage is to formulate a project plan for the major objectives. Aspiration is easy, realisation is difficult.Emerg Med J 2001;18:283–284
The complainant is still very unhappy and is asking for an independent review. Her letter and the response are on the internet. This complaint is not going well and we will take a “time out” to examine the reasons and see if lessons can be learned.
Some of you acted on the results that were in the first “in tray” but many did not. A letter from a solicitor has arrived and likely to result in a claim for damages.
Letter has arrived from Sister Oak who has seen a copy of your strategy and is not happy with some aspects of it and is also unhappy she was not consulted.
Your report has also ruffled more feathers. The medical director is not happy that the chief executive has been sent a report without his input.
A letter of response to Mr Glasgow shows you are willing to discuss such issues in a constructive manner but need some evidence to base this practice.
The complaint by Mrs Green is not going well. Let us examine the response so far and look at some of the attitudinal problems that are developing.
Everyone would agree that this is a serious complaint. Dr York has done all the right things so far.1, 2 She asked a senior colleague for advice but was given a very pragmatic, if terse and unhelpful response. We need to examine Mr London's attitude in some detail in a later issue. She then sought evidence on the complaint, first from the medical notes and then by interviewing the doctor involved and confirming the nursing view. Her reply showed appropriate empathy for the complainant and at the same time support for her staff who she judged had acted appropriately. She gave a clear invitation to the complainant to meet and discuss the issues.
However, this is obviously a complex complaint involving more than one department. It seems that she did not discuss the issue with the physician. The letter of reply did not address one of the complainant's key worries that her daughter's learning problems had resulted in poor treatment. The final letter of reply from the trust also omitted the offer to meet and discuss this issue and on the whole was rather defensive.
Let us examine the attitudes of the main players in this complaint.
The complainant is obviously angry. She has lost a daughter, probably she has put a great deal of effort into her care over 35 years. However, she may also be feeling guilty (although she has no real reason) as she left her daughter to go home when she thought she was being admitted to hospital. It is inevitable that she will be thinking “what if I had stayed and been able to challenge the doctors at that time”. She will also feel afraid that she is taking on a huge organisation and criticising doctors.3 These negative feelings may be sublimated and repressed by the complainant or are manifest by increased hostility.
Dr York is obviously concerned about this serious setback so early in her post. She will feel rebuffed by her senior colleague. She obviously empathises with the complainant yet equally wants to support her staff. A complaint can certainly have major effects on staff4 who may well need support. However, support can easily turn into hostility and denial and these emotions may intrude on a balanced reply. There will probably be some hostility to the medical team who might be viewed as the villains by the A&E staff. The medical team will have corresponding feelings towards A&E. Often there is hostility towards the complaints department of the hospital.
The key problem in this complaint at this stage looks like poor communication at the time of the clinical incident. Poor communication in the handling of the complaint is compounding the problems.
If all the complainant's concerns had been addressed, if A&E and the physicians had discussed the response, if the reply had offered a meeting to discuss the complaint then it might have been settled.
There is no right and wrong in many of these matters but judgement is often helped by self knowledge and appreciation of these powerful human feelings, the feelings both of ourselves and others.
Time out—Strategic decision making
WAITING TIME PROBLEM
It might be appropriate to examine our feelings about waiting time complaints and waiting time problems but perhaps we have had enough self analysis for one issue. We will use the waiting time problem to look at the steps in planning and effecting change, using decision management5 and change management tools.6, 7
Decision management is commonplace in all types of management. The design of a new car, new timetables for the BBC, and even waiting time problems in A&E can be tackled using this approach. This is usually one of the first lessons on any management course where teams are given a project to complete and then reflect on the processes (for example, in five minutes build the tallest tower possible using plain paper and paper clips).
Test leading options
Try to apply this structure to the waiting time problem. One common response to waiting problems is “we need more staff”. In real life this is often the case but within the resources available it should be possible to make some impact. Therefore at the beginning of the exercise take it as one of the objectives that any plans must be within current resources.
Waiting time figures are on the internet as are SHO rotas (emjonline/contents/SIMS3 and emjoline/eduction/).
Complainant response requesting an independent review.
Hospital response to request.
Two letters of complaint about waiting time at the weekend.
Letter from Sister Oak about your strategy.
Letter from medical director about the strategy.
Note from Sister Ash—ECG machine broke last night. The back up machine is so obsolete they cannot find any recording paper for it! She wants urgent action as she says it is unsafe to care for patients with chest pain.
Letter from deputy chief executive regarding legal claim.
CVs and request to shortlist.
Waiting time figures.
Outline the project plan that might deliver some of the aspirations revealed by the SWOT analysis. Take each of the major objectives and decide how urgent each is, how much effort is going to be needed, who might be the best person to “lead” the initiative and which ones you are going to “champion” (see Cole).8
What is the procedure for an independent review? What preparation is needed? Should you consult the Trust's solicitors? (For those who have not already done so).
Write a short paper on how you are going to approach the waiting time problem.
This is the start of the business planning season. Outline the main headings of a business plan for St Jude's (or patient services plan as they are sometimes called).
How are you going to deal with the medical director and Sister Oak?
What are you going to do about the ECG machine?
What actions are needed over the legal claim?
Shortlist the candidates (four posts).
Dr York's SWOT analysis on St Judes.
SHO teaching programme.
File note of “time out” with department staff.
Replies to letters of complaint from article 2.
Waiting time figures.
Junior doctor rota.
Internet in tray
More on letter of complaint requesting external review.
Letters about waiting time problem.
Letter about broken ECG machine.
Applications for SHO job.
The characters and incidents in this series are mostly fictional and any resemblance to persons or departments is coincidental. Some situations are based on real problems but in no case have names or details been used that might identify a department or person.
We would like to thank Peter Driscoll, Robin Illingworth and Carlos Perez-Avilla for their detailed comments and advice.
- SIMS ARTICLE 3: INTERNET PAGES
The Internet pages are divided into "feedback" and "in tray". Feedback gives some of the actions taken over the previous management problems.
Article 3 - FEEDBACK
SWOT ANALYSIS. CONFIDENTIAL FOR DR YORK ONLY.
Good workload and in good geographic position.
Reasonable SHO numbers
Staff grade posts
Good nursing staff
Good speciality mix in inpatient teams.
Long waits at weekends
Poor physical space.
Equipment poor (old ECG machines, no blood gas machine)
Nursing a bit "traditional"
Improve waiting times
? A&E Modernisation money
Improve teaching program
Some specialities not helpful
Withdrawal of training recognition.
3 key actions:
Discuss with Mr London
Time out with A&E staff
Discuss with management - probably at CEO meeting
PROPOSED SHO TEACHING PROGRAMME
Dr York, Dr Ireland & Miss Devon
Mr London, Dr York & Mr Bathi
The Sick Child I
Mr London, Dr Ireland & Dr Wales
Emergency Radiology I
Dr Xavier Ray
Ophthalmology in A&E
Mr U V Itis
Dealing with Relatives
Sister Lisa Ash
The Major Incident Plan
Dr H Hamley
How to Teach
Emergency Radiology II
Dr Xavier Ray
The Sick Child II
Spinal Cord Injuries
Funny Dos in the Elderly
ATLS, ALS & APLS Revision
Dr York, Dr Ireland & Mr Bathi
Mr T Nutcracker
Dr H Hamley
Drugs & Alcohol
Obs & Gynae In A&E
Medico Legal Problems
Audit & Research
Burns and Scalds
Mr AO Screw
Dermatology in A&E
Stress in Medicine
Job Review, Feedback and Quiz
Dr York & Mr London
FILE NOTE OF TIME OUT WITH A&E STAFF (DR YORK)
Did SWOT analysis and the staff mostly agreed with my own thoughts.
Main problems identified were long waits especially at weekends, very poor equipment and accommodation and problems with finding beds. Nurses were a bit frustrated about restriction of extended roles. Doctors felt that the nurses could do more such as ECG�s , bloods and simple suturing.
Nurses thought that some doctors did not work efficiently and this meant long waiting times. SHOs spend a lot of time in writing notes. Nurses felt a bit unsupported by senior medical staff.
Very clear vision that we want to be an excellent DGH A&E.
Service objectives - Cut waits for minors. Improve trolley times. ENP. Extended roles. More senior doctors.
Teaching objectives - No nurse teaching at present: start nurse education program. Improve SpR teaching/training.. Improve SHO teaching. ? Start ATLS course.
Management objectives - Improve influence on the directorate. ? Move to general medicine. ? Own directorate. Regular staff meetings with reps from all staff groups and grades. Start planning for new building. GET MORE EQUIPMENT!!
Audit/research - Start some regular sessions with all staff on audit- start with waiting times. Examine reasons for Trolley waits. SpR projects in audit. Nurse audit of patients that could be seen by nurse practitioner. ? Consider participation in multicenter trial.
LETTER FROM DR YORK RE REQUEST FOR MORE INFORMATION
Dear Mrs. Penny,
Thank you for your letter and the request for more information. I can add little to the facts. I have talked to the staff again and both are clear that meningitis was in the differential diagnosis. The SHO says that he said this when he referred the case to the medical registrar.
I can assure Mrs. Green that Janice�s learning problems did not mean that she had less care. On the contrary we try to be extra careful in patients where the communication may not be easy.
As I have said previously I would welcome and the chance to discuss this directly with Mrs. Green.
LETTER FROM THE TRUST TO MRS GREEN
Dear Mrs. Green,
Thank you for your letter. We have asked for further information. The A&E department and the medical department would like to re-assure you that Janice�s learning problems would not in any way affect the level of care. Indeed the doctors are aware that they need to be extra careful when there might be communication problems. The main problem seems to be that the symptoms and signs were not typical of meningitis and the doctor thought a water infection a much more likely cause of the fever.
Dr. York the A&E consultant would be happy to meet you and to discuss these problems. If you would like to do this please contact Mrs. Penny our Quality Co-ordinator on the telephone number given above.
Again the staff and myself wish to convey our condolences and are willing to answer any further questions .
Article 3 - IN TRAY
Letters of complaint about waiting time and letter from Dep. Chief Exec.
Dear Dr. York,
I believe that you were on duty last weekend. I was the duty manager and I took two separate complaints about waiting times is the A&E department. I have passed these onto the Patient Partnership department and no doubt you will be asked to comment through the normal complaints procedure. However I believe that Ms. Butcher has already asked for your advice on this problem. The Trust Board wishes some action on this issue. The improvement in waiting times in A&E departments is one of the main targets listed in the National Plan for the NHS and I would be grateful for your plans on how to improve the situation.
Dear Dr. York,
Please find enclosed two complaints that were received by telephone last weekend. I believe you were on call. I would be grateful if you could investigate the issues raised and reply within two weeks.
- I waited 5 hours to see a doctor. I saw Dr York. She was very rude and said that I should have gone to my GP with my painful knee. I did this and my GP has sent off an immediate request for an urgent appointment with a specialist. Obviously there is something seriously wrong and I hope you will take action against the uncaring Casualty doctor.
- I realise that Accident and Emergency doctors are very busy especially at weekends but I had to wait 6 hours with a cut to the finger that needed two stitches and a tetanus injection. Could this not have been done by a nurse and so freeing the doctor for more urgent cases. I do not usually complain but I feel that with some thought it should be possible to improve the service for such minor problems.
NEED REQUEST FOR INDEPENDENT REVIEW.
Note from Sister Ash
- Last night the ECG broke down. The "back up" is so ancient that we could not find any paper for it. I had to go personally to Ward 6 to borrow their machine AND TAKE IT BACK!!!!. We have been asking for a new machine for ages. All other wards seem to have "pagewriters" that make it so much better to put in the notes. Can you do something about this? The nurses are fed up and frustrated. Ta.
Letter from Deputy Chief Exec about legal claim.
(for those that acted on the "results" then this does not apply).
Dear Dr. York.,
As you may know, one of my responsibilities (with the Medical Director) is that of Clinical Governance. The enclosed letter from solicitors seems to highlight a problem with your risk management procedures. I wonder if you could send me the departmental policy on the review of tests and recall of patients.
Re- Karen Sims
We would like to apply for full disclosure of the medical records for the above patient to investigate a possible claim for negligence. Our client instructs us that she attended your department after a road traffic accident when she injured her neck. She was told the X-ray was normal. She consulted her GP as she continued to have symptoms. Her GP was informed that the X-ray was not normal and our client has been referred urgently as a private patient to a neurosurgeon. The prognosis is not certain but our client is severely disabled at the present time.
We seek voluntary disclosure under the pre-action protocol. Please reply within 14 days or we will commence formal proceedings.
Waiting time statistics
% seen within 1hr
% seen 2 hours
% waiting > 4hrs.
Conflicts of interest: JW is an editor of the EMJ but this series was conceived and approved before he took up that post.
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