What is management and what is SIMS?

There are a range of definitions of “management”.^1–3 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 issues^4–24 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.

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.

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.

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.

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.