Administration Part 2

1. Administration Part 2 Sultana Qureshi, PGY-2

2. Outline • Role of the Medical Director • Patient Complaints • Public Relations • Observation Units

4. The Emergency Department Director

5. “80% of the job is just showing up…”* *La Salle. Emerg Med Clin N Am. 2004;22:1-18.

6. “…the ED administrative and clinical leader must learn how to acquire power of all types…”*

7. Emergency Department DirectorPurpose of the Position(ACEP Guidelines 1998) • Provide leadership & management for the ED • Work cooperatively with ED staff to provide emergency services to patients • To work cooperatively with diagnostic and therapeutic services to ensure availability, quality, and effective use of services • To provide input into preparation of departmental budget • Monitor community needs and provide input into EMS and disaster planning Aric Storck. Administration 2005

8. ACEP Guidelines 1998 Qualifications • Career EP with proven clinical and administrative skills • Board certified in EM • Demonstrated knowledge and ability in financial, managerial, and marketing aspects of EM • Participates in CME • Demonstrated ability to speak effectively on administrative and clinical matters related to EM

9. ACEP Guidelines 1998 Responsibilities • Leadership, organization, staffing, coordination, and evaluation for ED activities • Ensure ethical practice of EM within dept • Supervises and has responsibility for EP’s in clinical and administrative duties • Acts as liaison between hospital administration and ED staff • Should be member of hospital executive committee and represent interests of EM • Should be concerned with physician scheduling

10. Department management Education Liaison Public relations Recruitment and orientation Department meetings Committees – hospital and departmental Quality assurance Peer review Physician evaluation Planning Legal Risk management Contracts and finances ACEP Guidelines 1998 Other responsibilities

11. “The primary mission of the Emergency Department leader is to ensure excellence of professional performance at all levels so that safe patient care is delivered.”

12. What qualities makes a good ED Leader?

13. La Salle. Leadership in Emergency Medicine. Emerg Clin N Am. 2004;22:1-18. How does one become a good ED leader? • 1. Leadership must develop incrementally based on trust and credibility. • 2. Must develop a reputation for honesty, take selfless risk, and seek to inspire by example. Shoulder a greater burden without complaint. • 3. Achieve “street smarts” by developing an accurate & predictive intuition of what motivates action. Careful listening, keen observing, understanding their own strengths and weaknesses. • 4. Good leaders are not selfish & understand that recognition & monetary reward are secondary to the goal of providing excellent patient care. Take care of their troops.

14. La Salle. Leadership in Emergency Medicine. Emerg Clin N Am. 2004;22:1-18. How does one become a good ED leader? • 5. Understand the ED is not an island, and proactively collaborate with outside departments, organizations.. • 6. Understand and accept conflict. • 7. Perseverance to overcome resistance to change. • 8. Understands the importance of perception and works industriously to fashion fair perception and promote vision that is realistic and attainable.

15. Education: • ACEP – Emergency Department Director’s Academy • Four phase course

16. Patient Complaints

17. What do patients complain about?

18. Patient complaint types (CHR-EDs Apr-Oct 2005)

19. Patient complaint types (CHR-EDs Apr-Oct 2005) • 1. Treatment expectations • 2. Personal interaction • 3. Length of waiting room stay • 4. Care provided • 5. Triage

20. Goals of a complaint system • Facilitate positive interaction with patients, public and staff • Identify systemic problems – integrate with QI system • Identify personnel deficiencies (eg: poor communication skills, staff demeanor,etc.) • Integrate with overall risk management strategies and reduce litigious dispute resolution (ie: lawyers) Aric Storck. Admin. 2005

21. Patient Representative Service(CHR Website- Patient Concerns) • is a point of entry into the regional health system for patients or their advocates to express concerns, complaints or messages of thanks regarding patient care • takes a lead role in facilitating the internal review process with a focus on client relations, information sharing, and conflict resolution • resolutions based on mutual interests, with the goal that this leads to increased consumer satisfaction and continuous quality improvement

22. Patient Representative Service(CHR Website- Patient Concerns) • Process: • Issues may be brought forward in writing, by phone, or online form • The Patient Representative will assess the issue and determine whether a formal review is necessary or whether other, more immediate measures are required (ie. inpatient vs. remote outpatient complaint) • Concerns received once pt has left hospital- the issues are forwarded to the Regional Clinical Department Head if a medical review is required, or the Director of the service if the issues involve staff from the care area • When messages of thanks are received regarding care, the appropriate senior member of the service or hospital site writes to the staff to commend them and provides a copy of the commendation received.

23. Patient Representative Service(CHR Website- Patient Concerns) • Time frame: • Many issues can be addressed or resolved by the Patient Representative. This is particularly true when queries are about regional programs or services, policies, processes, etc. • When a concern is received that requires a formal investigation, the goal is to respond back to the patient within a 4 week timeframe. (May be longer is multiple areas involved, or staff interview required.) • Patient contacted in writing or by telephone. (new policies may require only writing. Is this a good idea?) • Patients must provide consent to review records • Once lawyers involved, becomes CMPA issue

24. Patient Rights(CHR Website- Patient Concerns) • Be treated with respect and without discrimination; • Expect that information about you is confidential, and that you will be informed when a medical doctor is legally required to disclose information for your safety or the safety of others; • Expect a medical doctor or health care worker not to take physical, emotional, sexual or financial advantage of you; • Receive reasonable explanations about your care, examinations and treatment so that you may give or withhold informed consent; • Personal privacy while disrobing, or when parts of your body are being examined; • Refuse a particular type of examination or treatment or withdraw consent without obligation or harassment;

25. Patient Rights(CHR Website- Patient Concerns) • Be informed of major delays in consultations/treatments, if at all possible; • Know if there are supervisors, consultants, students, interns or others with whom your medical doctor will discuss your case; • Receive a timely referral or consultation with another health professional whenever you and the medical doctor believe it appropriate; • Receive a second opinion regarding your treatment or the medical doctor's methods; • Be listened to carefully and to receive support throughout your health care experience; • Have another person present during examinations.

26. Patient Responsibilities(CHR Website- Patient Concerns) • Respect the privacy of other patients, medical doctors and staff; • Ask your medical doctor or health care workers for further information if you do not understand; • Let your medical doctor or health care worker know if you feel uncomfortable; • Cooperate and follow the care prescribed as recommended for you as long as you are in agreement; • Inform the medical doctor or staff if you are unable to keep your appointment; • Allow the medical doctor to have a staff member present during an examination

27. Key to Avoiding Complaints… • Communication • Communication • Communication

28. Expressive quality Verbal techniques Introduce oneself by name Explain one’s role in the ED Use reflective listening (i.e., summarizing what the patient has said to demonstrate understanding) Use empathetic comments such as “I understand” or “I see” Apologize for waits and delays Apologize for interruptions Nonverbal techniques Have good eye contact Smile (when appropriate) Adopt a “concerned” and “interested” look that shows you are listening Allow the patient to describe their problems without interruptions Information delivery Use anticipatory guidance Provide information about diagnoses and potential causes of the problem Explain results of tests and their implications Provide discharge instructions (in writing if possible) Explain the purpose of procedures and the potential for pain Tailor the content to the intellectual level, medical sophistication, and language mastery of the patient Foreign language communication Acquire proficiency in languages most common to the region Use professional interpreters

29. Public Relations

30. Observation Units

31. The primary objective of observation units is to provide an alternative to hospitalization for patients requiring extended diagnostic assessment or treatment for up to 24 hours • Advantages include: • Improved resource use (50% less cost than admission) • Increased diagnostic accuracy • Higher patient satisfaction • Increased educational and research opportunities

32. 3 models of OUs • The scatter bed model • any bed in the hospital can become an observation bed • generally does not work very well, because of inefficiencies due to the varying needs of patients on the floor • The in-house defined unit model • usually run by hospitalists within the institution • predominant problem tends to be reimbursement issues (mainly US problem with insurance companies) • The linked emergency department model • a “virtual unit,” where any bed in the ED can become an observation bed • typically does not work well since the staff is too busy with the sickest patients • Defined Unit • Technically the ideal model, with unit attached to ED. • Most likely to manage care efficiently

33. What type of patients would you select?

34. Conditions Appropriate for Observation • Evaluation: Critical Diagnostic Syndromes • Abdominal pain •  Chest pain •   DVT •   Gastrointestinal bleed •   Syncope •   Blunt abdominal trauma •   Blunt chest trauma •   Penetrating abdominal trauma •   Penetrating chest trauma •   Head injury

35. Conditions Appropriate for Observation • Treatment: Emergency Conditions • Asthma • Atrial fibrillation • Congestive heart failure •   Dehydration •   Infections •   Pneumonia •   Pyelonephritis