This article in the series on management within the emergency department focuses on the importance of meetings and how to instigate change.
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Dr Ireland is not doing well. Evidence is mounting that he is having problems in coping with ill children. The amount of written evidence from within the department and from other departments along with discussion with the other members of senior staff has convinced Mr London that the issues need to be resolved. He has approached the Director of the SpR training programme and they both have decided to seek the advice of the postgraduate dean. Mr London has discussed the issue again with Dr Ireland who still thinks there is no problem with his management of paediatric patients. He is now saying he feels that he is being bullied and is considering talking to the personnel department. He is unhappy that the case is being discussed with the postgraduate dean. The annual training assessments are due. What actions should be taken now?
Patient with the advance directive
Dr York went into the department and assessed the patient, discussing the problem with her at length. The patient was clear that she wanted to die and agreed to have a talk with a psychiatrist before she went home. This confirmed the view that the patient was fully competent. Dr York phoned the GP, dictated a discharge letter outlining the episode and her actions, she also offered the patient follow up either at home or in St Jude's but this was declined.
To balance the budget either the department needs more income or to cut costs or both.
However, a first step is to make sure the budget is correct. Errors are particularly common in locum and nursing “bank” or agency costs. It is tedious to check all these details but often the A&E consultant is the only one with the detailed knowledge of staffing. Another major area to scrutinise is the cost for investigations and drugs. A list of the “top 20“ drugs by cost may reveal some surprises, thrombolytic agents for example may well be indicated for use in A&E but if you do not have the budget for this development you should be able to put a strong case for an increase in your budget to cover these costs. Increasingly patients destined for inpatient beds are spending longer in A&E and many of the tests ordered by the inpatient teams may appear on the A&E budget. This can be tedious work but some of it might be delegated to a trainee who wishes some management experience, just to show them how exciting management can be!
A case might be made to the Trust that they should seek extra funding. The number of patients attending has increased by 10% over the past two years but no extra funding has flowed to cover this extra work. Not only has the volume of cases increased but more patients are being admitted to hospital. The case mix is more complex and the drug budget shows that more patients are having their treatment started in A&E. A full business case has been prepared showing the extra costs of the work.
The major element in the costs is paying for locums and agency staff. Dr York has proposed that they employ another doctor to cover annual leave or study leave and create some slack in the rota to cover for sick leave. The figures suggest that this could be self financing. However, what type of post should be advertised? Can the department attract quality staff to non-training posts? The nursing problem is more difficult but Sister Oak has indicated that she might be able to employ some of the new recruits to the hospital to do the work.
The directorate minutes
Those who have read the minutes of the last directorate meeting (emjoline/SIMS8) will be disturbed by many of the issues. Mr London missed this meeting as he was at an APLS course. Dr York was going to deputise but was treating three patients brought into the department with serious injuries after a road traffic accident. This led to a number of controversial issues being discussed without A&E input. The threat from the orthopaedic team to stop admitting head injuries is going to pose a real problem in the management of patients. Equally the failure to progress the job description for the third A&E consultant is a blow. Mr London has had to do a lot of lobbying of the medical director to have some of these “decisions” re-examined. Management meetings are often boring but you can guarantee the one time you miss a significant meeting you will find that somehow you have lost ground. Committees and meetings are an important part of management. A time out will examine meetings and how to get the best out of them.
Presentation to the hospital trust board
This went well. The non-executive directors especially were impressed by the amount of work that the department was expected to perform. They were amazed when it was explained that long trolley times for patients waiting admission were nothing to do with the A&E department but were a symptom of capacity problems in the system. The ideas for improving waiting times were accepted and the plan to give £100 000 to the orthopaedic team for nurse practitioners was put on hold. A summary of the presentation is given in the internet section.
Box 1 lists the major functions of meetings. This is not exhaustive and will vary widely between different meetings
Information gathering Information giving Discussion of issues Decision making Task allocation Progress monitoring Strategic planning Team building Increasing personal profile Social Networking
The Green complaint
This was a complaint that concerned a young woman with meningitis who was sent home.1 The complaint has been investigated by the Ombudsman and the report has been released. No specific points have been found regarding the clinical decision but major problems in communication have been noted. The report has been picked up by a local newspaper and a highly inflammatory article has been written. This threatens not only the morale of staff but could disrupt the normal pathways of care within the department. How we react to this attack is critical and could have far reaching implications.
Meetings are a key part of management. They often give the structure to day to day management.
It is probably true that no real decisions are made at meetings but they are an essential part of the structure where strategy is formed, impressions made, and information gathered. Meetings may be informal or have the set structure of a committee with chairman, agenda, and minutes.
Box 2 shows some the meetings that a lead clinician or clinical director may be asked to attend, the list could be even greater. A manager has to learn to prioritise. Just as dealing with an “in tray” of correspondence you have to decide the relative importance of a meeting and how urgent it is for you to attend personally. This decision is not simple. A relatively minor meeting can be important in terms of networking, influencing, and gaining information. Some meetings will be seen as important “leadership” duties, the departmental staff meetings being a good example.
Box 2 lists the meetings that a lead clinician or clinical director may be asked to attend
Departmental staff meeting Department senior staff meeting Audit meeting Directorate meeting Hospital senior manager's meeting Regional A&E meeting SpR training meeting Clinical Governance Audit Meeting with Trust Board Hospital educational meeting Postgraduate trainers meeting Ambulance liaison meeting Meetings with patients Meetings with junior staff Meetings with other specialties Meetings with external agencies Meetings with management
Examine the list in box 2. What functions do these meetings serve? How would you prioritise? Which would you go to personally, which would you send a deputy to and which can be ignored?
This part of the article will concentrate on committee meetings. The amount and type of preparation will depend on your role in the meeting and its importance. If you are chairman/secretary of a committee, you will need to set aside time to prepare properly. The minutes of the last meeting should have been circulated shortly after that meeting and all your action points completed. However, it is good practice to ensure you have completed your own action points and if other members of the group are responsible for any key actions then talk to them to make sure that they have carried out the expected tasks. Do this at least a week ahead of the meeting to give yourself and others time to catch up with any outstanding work.
The agenda will need to be developed. This should indicate the person who will present the topic and if any supporting papers are needed. The tabling of long documents for discussion wastes committee time. This practice is very common, usually due to bad planning but sometimes used as a deliberate strategic device to “push through” a decision without full consideration of the issues, beware “tabled papers” at important meetings.
Adding times for agenda items can also be useful to try and keep the meeting running smoothly and to give people who need to attend only for specific items an indication of when they should arrive (box 3).
Box 3 Check list for agenda
Name of committee Date, time, place of meeting Agenda
Introduce those present/new members
Matters arising and action points from last meeting
– 3.1 Action point
– 3.2 Action point
– 3.3 Action point
Date and time next meeting
Contact details for agenda items/papers
If there are any very important or controversial issues that need to be resolved at the meeting then it is wise to try and discuss these in advance with key people within the organisation. You should have a clear view of how discussion of a topic is likely to develop. This means that there should be no major surprises at the meeting, or so you hope! In these discussions try to remain neutral and keep your own thoughts to yourself. If a very controversial topic is to be discussed then this information gathering may turn into “lobbying”, trying to win allies to your cause and to undermine any opposing arguments. If a topic is of vital import then you may need to prepare a written document to present to the committee.
The majority of meetings are straightforward and the management task is to ensure that the meeting keeps to time and gets through the whole agenda giving a reasonable amount of time to each item. The running order of the agenda is important. In general, key topics should be at the start of the meeting but at times those running meetings may try to “bury” an important topic at the end. Box 3 outlines the agenda for that meeting. It all might seem self evident but it suprpising how often details such as the time or place might be omitted (usually by accident but sometimes by design). Note item 3 is not just matters arising but is really a list of action points from the last meeting. This is a powerful device for performance management. It puts committee members on the spot and focuses the work of the committee.
If you are running a meeting then you will need a large number of skills. You should have the chairman's clear idea of strategy, the company worker's skills in keeping the team together, being able to subdue talkative members and encourage the shy members. You will need the monitor/evaluator skills to keep people focused on the subject under discussion and ensure that time is kept and you will need your resource investigator skills to draw on contacts and information that will inform debate. This may seem a huge challenge but fortunately many of the skills are transferable from other parts of the job such as teaching or managing a complex resuscitation (for team roles see Wardrope and McCormick2)
It is good practice to keep notes of a meeting, especially any action points that arise. If there are important points discussed then take careful notes of your own contributions. These can be checked against the minutes later as occasionally they appear to be from a very different meeting to the one you attended.
Post meeting actions
If you are responsible for the minutes do them immediately after the meeting. This is a task that gets harder and more difficult the longer you leave it. Minutes are not only a record of the meeting they should highlight the action points arising from the meeting. It is a good idea to do a separate list of the committee members and summarise their action points. Attach this list to the minutes.
Start the process of planning how you are going to meet your own action points. This may mean talking to other people, get your secretary to arrange a convenient time for the conversation. You may need to put a reminder in your diary to block out some time to do some research or a paper for the next meeting. You may have to delegate tasks to others. The sooner this is done after the meeting the more chance it will be complete by the next meeting.
If a meeting has made a decision that is unfavourable then you will have to judge your next actions carefully. It is often better to “sleep on it” and carefully consider your response. Try to discuss with a confidential, neutral party. Remember that democracy is sometimes right!
Meetings may be informal or formal. They are a major part of the management process. You must learn to prioritise the meetings that you wish to attend. Preparation for important meetings is essential. This entails not only preparing yourself but it may involve discussions with others to gauge their opinions and lobby for support. Post meeting work should be organised as soon as possible after a meeting. Good records of all meetings enable the manager to be sure of the discussions and outcomes of the meetings. Reflect on the functions of some meetings you have attended recently. Were they well run? Was the structure good? What makes a good chairman?
Box 4 Common “team roles” that you have to use at a meeting
Chairman Information resource (specialist) Advocate (both positive and negative) Secretary Social worker Monitor/evaluator Resource investigator
Were all the action points from the previous meeting carried out?
TIME OUT—MANAGING CHANGE
Never in the field of health care provision has the pace of change been greater. The changing demands and expectations, organisational restructuring and the redefining of the roles of both patients and professionals all combine to make our current environment seem very fluid. To the established certainties of death and taxes, NHS targets can now be added. Managers have to be able to implement change and ensure the continued provision of care with as little disruption as possible. Managers are meant to “thrive on chaos”3 and managing an A&E department provides many opportunities for managers to thrive!
Types of change
Change can take many forms
Incremental change, by a series of small steps, is the commonest change in most medical practice. This is perhaps the least challenging method of change and is the easiest to “sell” to staff. It has a significant problem, that if the pace of change is not maintained, then direction may be lost. To avoid incremental change “losing its way”, there needs to be a clear project plan and rigorous project management.
A step change is much more obvious. Examples of this would include merging A&E services, opening a new department, or opening a new observation ward. This type of change is often harder to sell and the costs are usually greater. Most of the planning and management is “up front”, well ahead of the time the change starts. The change then happens and the new project is born. In a step change, once the need for change and the funding is agreed, there is less chance that this type of project will be blown off course.
Transformational change is often a painful process that is required when organisations are in decline or very seriously underperforming. “Root and branch reform” or “process re-engineering” are the types of phrases associated with this type of radical change. Such a project is a major management challenge. It requires a clear vision of the objectives, high level leadership, and often a lot of resources, human if not financial, at least in the short-term.
All of these types of change will be used at some time by an A&E manager, the skill is knowing which change type would be most effective in any particular situation.
The first objective of any change is to define the objectives. Methods of strategic analysis have already been covered in earlier articles in this series. This analysis should help quantify the magnitude of change, the likely sources of resistance and the resources that will be required to make the change happen. We have discussed previously some of the tools that might help such as SWOT analysis or Force Field analysis.4 There are many others including “Sources and Potency Analysis”.5,6 These are all ways of answering the questions; “what do we want to change?”, “who is going to help us?”, and “what is going to block change?” As an “in tray” exercise apply these tools to the changes suggested in the box 5.
Box 5 How would you bring about these changes?
Initiating thrombolysis in your department Setting up a nurse practitioner minor injury service Rebuilding a part of the department Redesigning your admissions process
Complaint letter alleging assault by member of staff Cutting from local newspaper severely criticising the department Letter regarding Staff Nurse Holly and her grievance. St Jude's diary
Engineering the climate for change
Your analysis should indicate the major forces behind change and the major blocks that are anticipated. This is where the hard work starts. It seems that most of the work needs to be done in removing the blocks to change or neutralising these forces. However, this is not work that you can do on your own and you will need allies, probably recruited from those forces positive to the change. Working with a powerful ally, who initially might be ambivalent, can pay dividends but equally might be counter-productive. For example, enlisting the support of the director of finance might be crucial to your plan but if your lobbying is inept you might reveal too much about the possible costs and create a new powerful force against change. Seek out experienced colleagues, especially those who are neutral to the project and take as much advice as you can. This is the time to use the members of your team to fill the chairman and resource investigator roles.2 If you do not have anyone that fits these roles it is time to develop these traits in yourself.
During this process you will start to form a view as the best way to achieve the desired change. For example, you might have started the project with a view that a large step change might be the best way forward but your soundings indicate that this is not possible and you may have to adopt a more incremental approach.
Whatever the type of change you decide each needs some type of “change management plan”.
There are a number of different charts and methods to help the process (box 6). Milestones (perhaps millstones for some) need to be set down, listing the tasks that need to be done, who will carry out the tasks and when the task should be completed.7 All those in the project must have input into this process but be wary of extending the deadlines at this stage. Try to keep the schedule as tight as possible.
Box 6 Tools to help chart project management (for details see reference 6)
Work breakdown structure Milestone plan Gantt chart Responsibility chart Network diagram Risk matrix
Try to put these ideas into practice. Chose one of the examples in box 5 and set out plan on how you will achieve the change. Set down clear objectives, how success will be measured (preferably in terms of outcome for patients). Use at least one tool to analyse the forces for and against change, and develop a realistic project plan.
What action are you going to take over the SpR? What issues are being raised?
The media have got a hold of the Ombudsman report on the complaint about the case of meningitis who was sent home. Look at the newspaper article in the internet section. How are you going to react? The staff want you to do something?
Four forms have landed on your desk requesting release of medical records. What action will you take? (Release of notes to solicitors, Data Protection Act request for details, access to Medical Records Act request, and police request for statement of fact.)
The local radio station wants to do an interview about a local accident black spot where residents have been protesting. They want to do a live studio interview at five o'clock today.
How would you prioritise meetings that you have to attend? What traits do you need to develop as a person to make yourself an effective chairperson?
Write an answer to the most recent complaint alleging assault by the member of staff (details on internet section). How do you improve security for staff and patients? How would you support staff who have been victims of abuse?
A 12 year old child with a contaminated hand wound came to the department. He was not immunised against tetanus. His mother refused immunisation. Full details of the story in SIMS9 diary (emjonline/sims9). What issues does this case raise?
Some will remember Nurse Holly who made allegations of sexual harassment against one of the doctors in the department. She appears to be raising a grievance against you for not following Trust policy on harassment. How are you going to act?
We would like to thank Mr P Driscoll, Mr C Perez Avila, and Dr R Illingworth for their detailed comments and encouragement.
- SIMS ARTICLE 9: INTERNET PAGES
53, Redwood Close
I am writing to complain about a very serious matter, namely an assault on myself by a member of your staff. I was in the Casualty department on the night of 30th March with one of my friends who had suffered a head injury. Whilst we were waiting to be seen three men began hassling us and behaving in a threatening way. My friend and I were trying to defend ourselves from this attack when an extremely large male nurse appeared and began threatening us. He said that we would all get thrown out if we did not calm down. I tried to explain that it was not our fault and that we were innocent but at that point the nurse assaulted me and pinned me to the floor with my right arm behind my back. He then proceeded to roughly manhandle me out of the waiting room and told me not to return.
Since this incident I have had pain from my right shoulder everyday and it is making it difficult for me to find work.
I hope that you will investigate this incident fully as it is unacceptable for members of the so called caring profession to assault patients. Given that I could sue for assault I think the very least I can expect is a full written apology from the nurse involved.
Mr Wayne Chancer
Taken from the Jaemtown Echo:
Casualty Department Blunders Again
by David Devon
The recent trend in medical blunders and incompetence has reached our own Jaemtown hospital, St Jude�s. In a confidential document, the Health Service Watchdog criticises the care given to a young lady who presented to the casualty department last year with meningitis. Although we would not name the patient concerned we can say that she was in her early twenties and had learning difficulties. Her mother was concerned when she became unwell and took her immediately to the hospital for emergency care. Unfortunately, despite her mother�s protests, the lady was sent home and died a short time later of the killer bug meningitis. As if this was not bad enough, the blundering casualty medics have continued to deny they made any mistake and have forced the grieving mother to fight through the complaints procedures for a year. It seems clear that this young lady was not treated properly because of her handicap and her mother is now living with the fact that she trusted doctors who clearly were not up to their job.
This reporter is well aware of the good work done by many staff in the NHS and indeed the Health Service Watchdog finds no fault with the hard working nursing staff. Once again it is the arrogant medics who have gambled with someone else�s life, and lost. When will they learn the signs of meningitis? When will they listen to the concerns of relatives?
This is not the first time the local casualty department has come under the spotlight for the wrong reasons. Many of this paper�s readers will recall the appalling blunder of two years ago when a young girl was sent home following a head injury. The young girl had not even received a skull x-ray and later developed a potentially life threatening blood clot on the brain. Thanks to our campaign at the time all children with head injuries should now receive x-rays but this reporter has learnt that a new specialist in the casualty department is once again trying to deny our children the best care. Is she now going to take away all we fought so hard for?
Many of us rely on casualty for emergency care but few realise that it is staffed by junior doctors who have little experience, many are newly qualified. They care for us at our sickest with little or no supervision. The consequences of this are all too clear, must we have a third tragedy before we get the care we deserve. So, remember, if you are unfortunate enough to need emergency care insist on seeing a specialist, don�t let you or a member of your family become the next bad story out of St Jude�s.
Let us know what you think. Write to me or call the press office with your comments and experiences. Let�s get the care we deserve!
The Director Corporate Affairs, The Union St, Jude's Hospital, High Street, Jaemtown. London.
We are instructed to investigate a claim by one of our members that you did not correctly investigate an allegation of sexual misconduct. You should be aware that Ms. Holly was subjected to improper sexual advances by one of your staff. She made a formal complaint but feels that this was not properly investigated. Specifically we are instructed that you did not follow the procedures laid out in your Harassment Policy.
Ms Holly feels that her complaint was not taken seriously. She subsequently had to leave the department and feels that her career prospects and her reputation have been damaged.
We would like to give notice that we are lodging a formal grievance. We would like your response to this issue.
Click here to download/view the PowerPoint presentation: [REFORMING EMERGENCY CARE] - a presentation made by the Trust
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