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The question about weekend waiting times will be discussed in the next edition. However, there are some things that will not wait, complaints for example should be dealt with promptly. The full replies are listed on the internet pages for this month. In summary Dr York felt that the accident and emergency (A&E) staff acted appropriately (see internet pages for answer from the consultant and from the chief executive).
You have to ensure the advertisements for the next set of junior doctors (SHOs) are ready as this will not wait. The draft person specification for the SHO and the advertisement are in the internet pages.Emerg Med J 2001;18:222–224
We have asked to meet the chief executive
The first article introduced the concepts of the series, gave some baseline information and set initial problems to be answered. However, the series will also call “time outs” from day to day management to discuss important points of management theory or to take a longer term strategic view. This will be done under the headings of strategy, people management, specialist topics, A&E topics and, perhaps most importantly, attitudes.
From the start of your management life it is important to develop a proactive approach rather than a reactive one. This will enable you to take control of your own (and departments) destiny. We will therefore begin by looking at Strategy, this is the process by which we define our objectives, examine the department's current strengths and weaknesses and state where we want to be in five years time.
In the first article we defined management as the organisation and motivation of groups to achieve planned objectives. In A&E management there are many people who will hand down objectives, for example the chief executive has already given you a clear objective about the waiting time. In any management position (even if it is concerning our own career), there should be clearly defined objectives. There are a number of well established tools that can greatly assist strategic planning to analyse the current position and try to look to the future.
Specialist management topics
Specialist emergency medicine topics
External environment analysis
SWOT, OBJECTIVE SETTING, GAP ANALYIS, STAKEHOLDER ANALYSIS
This is classic management approach to analysis and objective setting.
The pneumonic FESSG1 has been used to help list the tools of strategic analysis. It is basically a way of saying
“where are we now?”
“where do we want to be?”
“what is the gap between present reality and future vision?”
“what financial and human resources do we need to achieve the future vision?”
“who else do we need to convince to get there?”
“Where are we now?”
SWOT analysis is a management tool that has been used for decades2 because it is practical, easy to understand and simple to use. The department's strengths, weaknesses, opportunities and threats may be listed. This process will have two dimensions, internal—those operating within the department—and external. In any business it is essential to consider the external influences on the work of the department, as the main problems in providing a service might lie elsewhere. An obvious example of this is the lack of beds causing long trolley waits and the consequent catastrophic effects on patient care and the workload of A&E staff.3
The objective is to give clear understanding of the present position. The work of an emergency medicine manager can be divided into different areas of activity under the headings of “clinical service”, “teaching”, “management” and “audit/clinical governance/research”. Each can be subjected to a SWOT list.
“Where do we want to be?”
With a clear and honest picture of the present position you can state where you want the department (career, business) to be in five years time. This is the process of “long term objective setting”. At this stage, aspire to great things as the process of putting dreams into operational plans will always bring any hopes down to earth.
“What is the gap between present reality and future vision?”
This is gap analysis, examining the differences between the two positions. It is at this stage where the amount of work to be done to achieve the vision starts to become obvious. The analysis may reveal several yawning chasms. However, there are methods that will help bridge these obstacles and in future articles we will take some of these objectives through the next steps of planning by discussing change management and project management techniques.
“What financial and human resources do we need to achieve the future vision?”
This step is where reality really starts to gnaw at the heels of vision. This work often needs much greater thought, research and detail. At this point senior managers will ask for a “business case” that sets out the objectives, resources required, plan for implementation and measures of success. Setting out a business case will be one task in a future edition.
“Who else do we need to convince to get there?”
Stakeholder analysis is probably one of the first key steps in turning aspiration into definite plans. In major changes, for example in amalgamating two A&E departments the list will be huge. The analysis will also highlight those whose help is critical to success, these are likely to be senior management figures in the Trust, the district health authority or even the regional outpost of the NHS Executive. List the internal and external stakeholders who have an interest in such a change. Highlight those who are the key people to involve in your plans.
Time out—People management
RECRUITMENT AND SELECTION
A&E departments spend 90% of their budget on staff. The recruitment, selection, continuing training and development of staff is one of the key roles of A&E managers. Staff selection should begin with job analysis.4 This step is often neglected and we tend to “replace like with like”. However from time to time managers are forced, often by external factors to perform a major review of staffing (skills mix review). We will revisit this subject in later issues but it is wise to keep an open mind about how a vacancy might be used.
The immediate task is the SHO recruitment programme. It is essential to attract good quality staff. Sound staff selection procedures have to meet both legal and NHS requirements. Applicants are increasingly aware of employment law and the process of selection has to be demonstrably fair. Nevertheless it is clear that you as an employer have to ensure that the best people are appointed. The job analysis should lead to the production of the job description (example on the web). This must contain certain information, the place of duty, type of duty, hours of duty, reference to pay scales and conditions of service.4 However, if you are trying to attract applicants it is worthwhile investing some time in trying to “sell” the post.
The person specification is the most important document in the whole selection process. If properly constructed it should make short listing and interview process much more straight forward and importantly lead to a clear and fair selection of candidates. The traditional model would specify essential attributes and desirable attributes against four or five criteria.4 Guly advises the addition of a “bonus” column for attributes.5 One model of a person specification is given on the internet.
Letter of reply to complaint.
Letter from complainant.
Person specification and advertisement for SHO.
Complaint from orthopaedic surgeon.
St Judes diary.
Complaint letters about the unfortunate case, the complainant is not satisfied.
Complaint from fracture clinic re check radiographs after plaster of Paris application.
Write a short strategic report for the medium/long term for an A&E department, you may use St Judes' or your own department.
Use the tools of SWOT analysis, OBJECTIVE setting, GAP and STAKEHOLDER analysis.
List the first three action points that you think you should take as the first steps in any strategic change.
The SHO teaching programme for the next month needs to be done.
We would like to thank I Sammy, Carlos Perez Avilla and Peter Driscoll for detailed comments.
The characters and incidents in this series are mostly fictional and resemblance to any department, individual or event are coincidental. Some problems are based on real situations but details have been altered and in no case are any details used that might identify an individual or department.
- SIMS ARTICLE 2: INTERNET IN TRAY
The Internet pages are divided into "feedback" and "in tray". Feedback gives some of the actions taken over the previous management problems.
Article 2- Internet FEEDBACK
Dr. York was very concerned about the complaint and asked Dr. London�s advice. He said to contact the trust�s solicitors.
Dr. York�s reply to the letter of complaint.
Dear Mrs. Penny,
Thank you for your letter regarding Janice Green. The facts of the case are as follows. Ms. Green was booked in at 16.50 on 4th January 00. She was assessed and placed in triage category 3 in view of her learning problems. She was seen by the doctor at 18.15 who obtained a full history of a fever and feeling generally unwell. Examination revealed no specific problems but the case was discussed with a senior. It was thought that meningitis was a possible diagnosis among others such as a Urinary tract infection or a viral infection. Various tests were sent. Antibiotics were given and the patient referred to the Medical Registrar. I suggest you write to the medical consultant of that day to obtain his views. The nursing staff did receive a phone call from Mrs. Green and queried the diagnosis but were told that Janice could go home.
All the staff of the A&E department were concerned and saddened by the news that Janice had died. However I think we can assure Mrs. Green that the A&E staff did all they could to reach the correct diagnosis. The signs were not typical of meningitis and there were other possible causes for the fever. However the A&E staff did start the appropriate treatment and did refer Janice to the appropriate specialty. The A&E department cannot be responsible for the decisions made by other staff.
If Mrs. Green would like to discuss the case I would be happy to make an appointment to see her.
Chief executive reply to complainant.
Dear Mrs. Green,
Thank you for your letter and I am sorry to hear of your concerns and these have been investigated with Dr. York the A&E consultant, Dr. White the Consultant Physician and Sister Oak the senior sister in the department.
I understand that you daughter did come to the A&E department feeling unwell with a fever. The A&E staff performed a full examination and one doctor did think that meningitis was a possibility. However the signs were not typical and this has been confirmed by both Dr. York and Dr. White. Dr. York thinks that the A&E staff acted entirely appropriately.
Dr. White confirms that Janice was fully examined by the medical registrar. He found no signs of meningitis nor any suggestion in the notes that this was suspected. Meningitis can be a difficult diagnosis. The staff involved very sorry to hear of Janice�s death.
If you have any further concerns please do not hesitate to contact Mrs. Penny, Director of Quality on extension 2345.
Recruitment and selection
PERSON SPECIFICATION. SHO A&E.
MEDICAL EDUCATION UNIVERSITY RECOGNISED BY GMC
ATLS/ALS EVIDENCE OF CONTINUING PROFESSIONAL DEVELOPMENT
ENGAGED IN STUDY FOR HIGHER QUAL.
FIRST PART HIGHER EXAM
6MONTHS MEDICINE AND SURGERY. AT LEAST SIX MONTHS IN RECOGNISED TRAINING POST
6 MONTHS POST REG EXPERIENCE
PREVIOUS A&E WORK
EXCELLENT COMMUNICATION SKILLS. GOOD TEAMWORKING SKILLS
EVIDENCE TEAM WORK (GAMES/ HOBBIES)
CV (WRITTEN) INTERVIEW
ABLE TO WORK FULL SHIFT PATTERN
SHO ACCIDENT AND EMERGENCY- 9 POSTS
ST. JUDE�S HOSPITAL.
We invite applications for our SHO posts in this forward looking department seeing 65,000 new patients per year. Excellent rota and very good training program with elements of ALS/ ATLS teaching. Further information from Dr. York A&E consultant (0194 271 4870). Application forms from personnel department.ARTICLE 2 - INTRAY
TASK- Do SWOT/GAP/STAKEHOLDER ANALYSES
INFORMATION- Reply from complainant to chief executives letter
Dear Ms. Butcher,
In reply to your letter you seem to be saying that it is acceptable for your staff to send out a young woman with meningitis I do not agree.
I was told that meningitis was a possible diagnosis. Why did the medical doctor not do anything to check this? I am still convinced that staff did not take this seriously due to Janice�s learning problems.
INFORMATION- Letter from Mrs. Penny to Dr. York,
Please could you give your further views on the issues raised by Mrs. Green.
TASK- Investigate further, list actions, formulate letter of reply.
INFORMATION- Letter from Mr. Glasgow, Orthopaedic consultant
Dear Dr. York,
I saw yet another patient in the fracture clinic today who had a plaster of paris applied for an undisplaced distal radial fracture. This commonly happens and I am sure you are aware that even for undisplaced fractures it is essential to have a check x-ray after the plaster has been applied.
Please tell your staff this is essential.
TASK- List action taken/formulate reply.
TASK- What action are you going to take over the training committee report?
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