Article Text

Article 4. Team structure, waiting time and a psychotic patient is banging on your door
  1. J Wardrope,
  2. S McCormick
  1. Department 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)

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Feedback

The SWOT analysis has set a large agenda and the direction of the department. The internet feedback contains a project plan along with an example of a delegated operational plan (weekend waiting time). This is a critical part of strategic planning and a step that is often neglected. However, this process reveals the priorities, the resources required and helps plan delegation to other members of the team. It is not possible to do everything on your own. The operational plan sets out in some detail the process that will achieve the objective and sets out the targets for the manager.

This process of Management by objective1 is a powerful tool that gives clarity, form and performance targets for both the manager and the person who is being given the “lead” in delivering the results. SpRs should all be familiar with this process as they should have an educational plan made at the start of their training (strategic plan), yearly objective setting (operational plans) with three to six monthly reviews of progress.

Replies to the complaint letters about waiting time are given along with a letter to the deputy chief executive. One of the complaints was about Dr York. This is always a significant event. Dr York has acted correctly in asking a colleague's advice. This achieves a number of different results. Firstly, and most importantly, it gives the opportunity to talk about the matter. Internalisation of feelings of anger/guilt/ frustration/fear is unhealthy. Sharing these is an important part of staying sane! Secondly, it will bring some objectivity to bear on the response. Denial and self justification are natural reactions but also a sense of guilt might lead to errors in answering the complaint appropriately. Lastly, there may an underlying problem that needs further attention. This complaint was about attitude …

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Supplementary materials

  • SIMS ARTICLE 4: 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 4 - FEEDBACK

     

    STRATEGIC PLAN SUMMARY (SUMMARY)

    objective

    import dept

    import external

    urgency

    internal solution

    external help?

    Lead person

    help

    waiting time

    very

    very

    very

    part

    part

    DrYork

    Sis Oak

    SpR training

    very

    mod.

    very

    yes

    part

    Mr Lon

    Spr

    trolley times

    very

    very

    very

    no

    yes

    Mr Lon

    Bus Ma

    SHO training

    very

    mod

    mod

    yes

    no

    SpR.

    Dr York

    Nurse education

    very

    not

    mod

    yes

    no

    Sis Oak

    Sis Ash

    ATLS

    very/mod/not

    not

    mod/none

    yes

    some

    Dr York

    SpR/SisAsh

     

    This summary starts to show the problems that are important to everyone, the urgency of the problem, whether the solution lies within the department or external help or resource is needed. It also lists responsibility for the task along with a deputy. There are some issues over which there is some disagreement within the team. For example, some think that trying to run an ATLS course is important for the long term viability and reputation of the department and important is attracting staff. Others think that staff can easily be sent on such a course and that the drain on time and resources is not worthwhile.

    If we look at one of these in detail we can develop an operational plan for the short to medium term. Let us use waiting time as an example. Everyone agrees that this is important to the department and externally.

     

    OPERATIONAL PLAN - WAITING TIME.

    Objective -  to cut waiting time for minor injuries at weekends.

    Present position - 11-15% pats wait more than four hours on Sat/Sun.

    Aim - to reduce this to less than 5% patients waiting more than four hours.

    Time scale - within six months.

    Project plan -

    • Examine SHO rota and make changes ahead of August intake. (complete by 1.7.01)
    • Convene small group with all grades and types of staff to examine working practice. (by 1.8.01)
    • Bid for a small increase in nursing to allow some nurse practitioner sessions at main site at weekends. (bid to be agreed with Sister Oak by mid July)
    • Train at least three more senior nurses to NP standard. (by 01.01.02)

     

    COMPLAINT LETTERS

    Dear Mrs Penny,

    Thank you for your letter regarding the waiting time complaints the facts of the cases are as follows:

    Case 1.

    This gentleman booked into the department at 11.13 with a knee problem that had been present for 3 months. The Triage nurse assessed the patient and as there appeared to be no acute problem he was given a triage category 5. The nurse has clearly recorded her advice that it was likely that he would have to wait and that the waiting time was at least 2 hours and that this was likely to get worse. She also recorded that the patient was given the choice of consulting his general practitioner.

    I saw the patient personally at 15.30. I had been working for four hours to try and reduce the long waiting time that had developed. I fully assessed the patient and the history and examination led me to the conclusion that the problem was due to long standing degenerative arthritis and there was no need for any urgent treatment or referral. I told the patient that he needed to consult his general practitioner for advice and that in the meantime he should continue with exercises he had been shown and to take simple painkillers such as paracetamol. At this point the patient became very angry and started shouting. Unfortunately but this time I was very tired and very hungry and I may well have appeared rude.

    I would like to say that I apologise for any rudeness to the patient. However I would like to day that I was provoked at a time when I was tired. However I would like to emphasise the following points. Firstly the patient was seen a 4 hours and 15 minutes. Our aim is to see patients in this triage category with 4 hours. However there were many other patients with much more serious problems who took priority over this patient. The day was very busy. Secondly the patient was told the he would have to wait and that he would have low priority. Thirdly if he had taken the advice of the triage nurse then he could have chosen to see his general practitioner.

    Regarding the other complaint the facts of the case are as follows. The patient booked in at 12.20 with a cut to the finger. He was assessed as triage category 4, the wound was dressed. I saw this patient at 15.20. He had cut himself on glass. After assessment he was sent for an x-ray. There was a long queue in x-ray and the x-ray was not carried out until 16.25. Unfortunately I was unable see the patient personally but his treatment was continued by the other staff. Left the department at 17.40.

    I apologise that the patient had to wait 3 hours to be seen. We are aware that this is along time to wait. I thank the patient for the suggestions and will use them in our current review of the waiting time problem at the weekend. However I would like to point out that the main cause of waiting is the imbalance between the demand on our service and the number of staff that we have. The patient is right that there are ways to improve the service but these are going to require extra staff.

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

    Dear Deputy Chief executive,

    Thank you for the letter about the waiting time problem. I enclose copies of my replies. The staff in the A&E Dept fully agree that this is a major problem and we are exploring ways to improve the situation. However I would like to add that the heavy clinical load does sometimes make it difficult to give as much time to management as I would like. I have found it difficult to gain access to Board members to discuss these issues. Perhaps senior management should also be working on Saturday afternoons.

    I will soon have a paper on the problem and will make an appointment with your secretary to discuss these matters personally in the near future.

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

     

    Letter re request for ECG machine

    Dear Dr. York,

    I have considered your request for a new ECG machine but the equipment budget for this year is heavily overspent. I suggest that you re-submit this request in the next financial year when I will try to give it some priority.

     

    Reply to request for independent review

    Dear Mrs. Green,

    The Trust Independent Review Convenor has agreed that in this case there should be an Independent Review. Two doctors from another region have been asked to examine the case and a date has been set for a visit by the Doctors. We expect that you will wish to be present at the visit and to talk to these doctors so that you can express your continuing concerns. If you wish to discuss this matter then please contact me. You may wish to send this letter to the Community Health Council and I have enclosed an extra copy.

    Yours sincerely

    Mrs. Penny.

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

     

    Short listing control form.

    This type of documentation is increasingly used to ensure decisions on short listing are seen to be fair. The final decision must always be a judgement but the use of the essential/desirable/bonus criteria and how many of these an individual has means that it can be shown that due process has been followed.. In a normal short list control form one would normally just indicate those to be short listed and those to be rejected but this table has been completed to try and indicate the use of person specification to measure the number of criteria fulfilled by each individual. No doubt that many will disagree with the final short listing. Feedback is welcomed.

    E - meets essential criteria

    D - meets one of desirable criteria

    B - meets one of the bonus criteria.

     

     

    CANDIDATE

    SHORTLIST

    REJECT

    REASON

    KY

    D,D

    X

    NO WORK IN RECOGNISED POST

    AP

    E,B

    X

    NO A&E, BETTER APPLICANTS

    SM

    E,B

    X.

    NO A&E BETTER APPLICANTS

    OP

    E,D,D,D,B

     

    COURSES: PAEDS GP PSYCH

    DF

    E,D,D,D,D

     

    PART 1, COURSES INST

    SJ

    E,D,D,D,B

     

    MRCP/ALS

    RF

    E,D,B

     

    MEDICINE NO COURSES

    EY

    E,D,B

     

    MEDICINE NO COURSES

    RR

    E,D,B

     

    FRCS 1, ATLS, ORTHO

    TR

    E,D,D,D

     

    MRCS ALS/ALTS/ORTHO-PAEDS EXP

    CB

    E,D,D,D,B

     

    MRCP/ATLS/ALS/A&E EXP

    WL

    E, D

    X

     

      


     

    Article 3 - IN TRAY

     

    letter from medicrep to dr york re j smith accident

    MedicRep Inc.
    Medico-legal House
    Milton Keynes
    United Kingdom

     

    Dear Dr. York,

    RE- J. Smith,

    Date of Accident 1.4.2001

    We are instructed G.&S solicitors acting on behalf of Mr Smith commission a report dealing with personal injury resulting from a road traffic accident. The main injury has been to the neck.

    We would be grateful if you would examine our client and give an opinion regarding the causation of the injury and the condition and prognosis of the patient.

    We would be grateful if you could examine any medical records that you think necessary and we enclose our client signed consent form for release of records.

    We confirm that we will be responsible for your reasonable fees.

    We look forward to receiving your report within 2 months.

    Yours faithfully

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

     

    Memo

    The PC Smithers at from the police at Emtown station is investigating a burglary. They found blood on a widow oops sorry window! and he is asking if we would examine the register and give them the names of any one with cuts to the hands who came in between 20.00 last night and 06.00 this morning.

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

     

    As you are reading this you are aware of a great deal of shouting in the department. There is a well built young man who is obviously mentally disturbed, who staff want to examine and refer. However he wants to go and pick up the Ferrari that he has just ordered. A friend and a cousin say that he has been acting increasingly odd for two weeks with increasing delusions about being a millionaire but that morning he has gone to work, resigned and then went an tried to order two very expensive cars. (He is worker at the local factory and part time night club doorman). What do you do?

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