Administration Administration Part 2Part 2Sultana Qureshi, PGY-2Sultana Qureshi, PGY-2

OutlineOutline

Role of the Medical DirectorRole of the Medical Director Patient ComplaintsPatient Complaints Public RelationsPublic Relations Observation UnitsObservation Units

Executive Medical DirectorDr. Cam Waddell

Vice PresidentThelma Inkson

Regional Clinical Department Head

Dr. Gil Curry

Director, Emergency, Urgent Care and Health Link

Caroline Hatcher

Deputy RCDHDr. Wayne Sefcik

Undergraduate CoordinatorDr. L. Baker

Division Chief, Education

FRCP: Dr. B. YoungQI PhysicianDr. T. Rich

Site ChiefsFMC: Dr. G. Greenfield

PLC: Dr. P. DavidsRGH: Dr. C. Godfrey

Patient Care ManagersFMC: K. Howe

PLC: E. Shackleton RGH: T. Smith

Service Planning Coordinator

Judy Pedersen (interim for Maureen McNaul)

Research Coordinator

R. Vilneff

Data SpecialistD. Wang

Regional Clinical Nurse SpecialistA. Mageau

REDIS CoordinatorsK. JessenH. BattleD. Hone

AssistantPatient Care Managers

FMC: H. CrowePLC: B. JensenRGH: L. Walters

Division Chief, Research

Dr. M. Yarema

Associate ResearchDirectorVacant

Resident Research CoordinatorDr. C. Hall

Patient Care ManagerACH: T. Davidson

Regional Department of Emergency Medicine / Emergency Services Organizational ChartMay 2006

Director, Calgary Regional Sexual Assault Response Team

Dr. P. Head

Division Chief, EducationCCFP(EM):

Dr. N. Collins

Assistant Division Chief, Education

CCFP(EM): Dr. I. Walker

Assistant Resident Research CoordinatorDr. R. Morris

The Emergency The Emergency Department Department DirectorDirector

““80% of the job is 80% of the job is just showing up…”*just showing up…”*

*La Salle. Emerg Med Clin N Am. 2004;22:1-18.

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

Emergency Department Emergency Department DirectorDirectorPurpose of the PositionPurpose of the Position((ACEP Guidelines 1998)ACEP Guidelines 1998) Provide leadership & management for the EDProvide leadership & management for the ED

Work cooperatively with ED staff to provide emergency Work cooperatively with ED staff to provide emergency services to patientsservices to patients

To work cooperatively with diagnostic and therapeutic To work cooperatively with diagnostic and therapeutic services to ensure availability, quality, and effective use services to ensure availability, quality, and effective use of servicesof services

To provide input into preparation of departmental To provide input into preparation of departmental budgetbudget

Monitor community needs and provide input into EMS Monitor community needs and provide input into EMS and disaster planningand disaster planning

Aric Storck. Administration 2005

QualificationsQualifications Career EP with proven clinical and Career EP with proven clinical and

administrative skillsadministrative skills Board certified in EMBoard certified in EM Demonstrated knowledge and ability in Demonstrated knowledge and ability in

financial, managerial, and marketing financial, managerial, and marketing aspects of EMaspects of EM

Participates in CMEParticipates in CME Demonstrated ability to speak effectively Demonstrated ability to speak effectively

on administrative and clinical matters on administrative and clinical matters related to EMrelated to EM

ACEP Guidelines 1998

ResponsibilitiesResponsibilities

Leadership, organization, staffing, coordination, and Leadership, organization, staffing, coordination, and evaluation for ED activitiesevaluation for ED activities

Ensure ethical practice of EM within deptEnsure ethical practice of EM within dept Supervises and has responsibility for EP’s in clinical Supervises and has responsibility for EP’s in clinical

and administrative dutiesand administrative duties Acts as liaison between hospital administration and ED Acts as liaison between hospital administration and ED

staffstaff Should be member of hospital executive committee Should be member of hospital executive committee

and and represent interests of EMrepresent interests of EM Should be concerned with physician schedulingShould be concerned with physician scheduling

ACEP Guidelines 1998

Other responsibilitiesOther responsibilities

Department Department managementmanagement

EducationEducation LiaisonLiaison Public relationsPublic relations Recruitment and Recruitment and

orientationorientation Department meetingsDepartment meetings Committees – hospital Committees – hospital

and departmentaland departmental

Quality assuranceQuality assurance Peer reviewPeer review

Physician evaluationPhysician evaluation

PlanningPlanning LegalLegal

Risk managementRisk management

Contracts and Contracts and financesfinances

ACEP Guidelines 1998

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

What qualities What qualities makes a good ED makes a good ED Leader?Leader?

How does one become a How does one become a good ED leader?good ED leader?

1. Leadership must develop incrementally based on trust 1. Leadership must develop incrementally based on trust and credibility.and credibility.

2. Must develop a reputation for honesty, take selfless risk, 2. Must develop a reputation for honesty, take selfless risk, and seek to inspire by example. Shoulder a greater burden and seek to inspire by example. Shoulder a greater burden without complaint.without complaint.

3. Achieve “street smarts” by developing an accurate & 3. Achieve “street smarts” by developing an accurate & predictive intuition of what motivates action. Careful predictive intuition of what motivates action. Careful listening, keen observing, understanding their own listening, keen observing, understanding their own strengths and weaknesses.strengths and weaknesses.

4. Good leaders are not selfish & understand that 4. Good leaders are not selfish & understand that recognition & monetary reward are secondary to the goal recognition & monetary reward are secondary to the goal of providing excellent patient care. Take care of their of providing excellent patient care. Take care of their troops.troops.

La Salle. Leadership in Emergency Medicine. Emerg Clin N Am. 2004;22:1-18.

How does one become a How does one become a good ED leader?good ED leader?

5. Understand the ED is not an island, and 5. Understand the ED is not an island, and proactively collaborate with outside departments, proactively collaborate with outside departments, organizations..organizations..

6. Understand and accept conflict.6. Understand and accept conflict.

7. Perseverance to overcome resistance to 7. Perseverance to overcome resistance to change.change.

8. Understands the importance of perception and 8. Understands the importance of perception and works industriously to fashion fair perception and works industriously to fashion fair perception and promote vision that is realistic and attainable.promote vision that is realistic and attainable.

La Salle. Leadership in Emergency Medicine. Emerg Clin N Am. 2004;22:1-18.

Education:Education:

ACEP – Emergency Department ACEP – Emergency Department Director’s AcademyDirector’s Academy

Four phase courseFour phase course

Patient ComplaintsPatient Complaints

What do patients What do patients complain about?complain about?

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

Complaint Types

0

20

40

60

80

100

120

1

Types

Am

ou

nt

A1-1 A1-2 A1-3 A2 A3 A4 A5A6 A7 A8 B1 B2 B3 C1C2 C3 C4 C5 C6

Code Complaint Type

A1.1Access/Wait Times - Waiting

Room

A1.2 Access/Wait Times - Department

A1.3 Access/Wait Times - Other

A2 Financial

A3 Lost Belongings

A4 Physical Environment

A5 Communication Process

A6 Multiple Departments

A7 Triage

A8 Other

B1 Personal Interaction

B2 Care Provided

B3 Other

C1 Personal Interaction

C2 Physician Competence

C3 Discharge Issues

C4 Treatment Expectations

C5 Missed Diagnosis

C6 Other

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

1. Treatment expectations1. Treatment expectations 2. Personal interaction 2. Personal interaction 3. Length of waiting room stay3. Length of waiting room stay 4. Care provided4. Care provided 5. Triage5. Triage

Goals of a complaint Goals of a complaint systemsystem Facilitate positive interaction with patients, public Facilitate positive interaction with patients, public

and staffand staff

Identify systemic problems – integrate with QI Identify systemic problems – integrate with QI systemsystem

Identify personnel deficiencies (eg: poor Identify personnel deficiencies (eg: poor communication skills, staff demeanor,etc.)communication skills, staff demeanor,etc.)

Integrate with overall risk management strategies Integrate with overall risk management strategies and reduce litigious dispute resolution (ie: lawyers) and reduce litigious dispute resolution (ie: lawyers)

Aric Storck. Admin. 2005

Patient Representative Patient Representative ServiceService(CHR Website- Patient Concerns)(CHR Website- Patient Concerns)

is a point of entry into the regional health system for is a point of entry into the regional health system for patients or their advocates to patients or their advocates to express concerns, express concerns, complaints or messages of thankscomplaints or messages of thanks regarding patient regarding patient care care

takes a lead role in facilitating the internal review takes a lead role in facilitating the internal review process with a focus on client relations, information process with a focus on client relations, information sharing, and conflict resolutionsharing, and conflict resolution

resolutions based on mutual interests, with the goal resolutions based on mutual interests, with the goal that this leads to increased that this leads to increased consumer satisfactionconsumer satisfaction and and continuous quality improvement continuous quality improvement

Patient Representative Patient Representative ServiceService(CHR Website- Patient Concerns)(CHR Website- Patient Concerns)

Process:Process:

Issues may be brought forward in writing, by phone, or online Issues may be brought forward in writing, by phone, or online formform

The Patient Representative will assess the issue and The Patient Representative will assess the issue and determine whether a formal review is necessary or whether determine whether a formal review is necessary or whether other, more immediate measures are required (ie. inpatient vs. other, more immediate measures are required (ie. inpatient vs. remote outpatient complaint)remote outpatient complaint)

Concerns received once pt has left hospital- the issues are Concerns received once pt has left hospital- the issues are forwarded to the Regional Clinical Department Head if a forwarded to the Regional Clinical Department Head if a medical review is required, or the Director of the service if the medical review is required, or the Director of the service if the issues involve staff from the care areaissues involve staff from the care area

When messages of thanks are received regarding care, the When messages of thanks are received regarding care, the appropriate senior member of the service or hospital site writes appropriate senior member of the service or hospital site writes to the staff to commend them and provides a copy of the to the staff to commend them and provides a copy of the commendation received. commendation received.

Patient Representative Patient Representative ServiceService(CHR Website- Patient Concerns)(CHR Website- Patient Concerns) Time frame:Time frame:

Many issues can be addressed or resolved by the Patient Many issues can be addressed or resolved by the Patient Representative. This is particularly true when queries are about Representative. This is particularly true when queries are about regional programs or services, policies, processes, etc. regional programs or services, policies, processes, etc.

When a concern is received that requires a formal investigation, When a concern is received that requires a formal investigation, the goal is to respond back to the patient within a 4 week the goal is to respond back to the patient within a 4 week timeframe. (May be longer is multiple areas involved, or staff timeframe. (May be longer is multiple areas involved, or staff interview required.)interview required.)

Patient contacted in writing or by telephone. (new policies may Patient contacted in writing or by telephone. (new policies may require only writing. Is this a good idea?)require only writing. Is this a good idea?)

Patients must provide consent to review recordsPatients must provide consent to review records

Once lawyers involved, becomes CMPA issueOnce lawyers involved, becomes CMPA issue

Patient RightsPatient Rights(CHR Website- Patient Concerns)(CHR Website- Patient Concerns)

Be treated with respect and Be treated with respect and without discriminationwithout discrimination; ;

Expect that information about you is Expect that information about you is confidentialconfidential, and that you will , and that you will be informed when a medical doctor is legally required to disclose be informed when a medical doctor is legally required to disclose information for your safety or the safety of others; information for your safety or the safety of others;

Expect a medical doctor or health care worker Expect a medical doctor or health care worker not to take not to take physical, emotional, sexual or financial advantagephysical, emotional, sexual or financial advantage of you; of you;

Receive Receive reasonable explanationsreasonable explanations about your care, examinations about your care, examinations and treatment so that you may give or withhold informed consent; and treatment so that you may give or withhold informed consent;

Personal privacyPersonal privacy while disrobing, or when parts of your body are while disrobing, or when parts of your body are being examined; being examined;

RefuseRefuse a particular type of examination or treatment or a particular type of examination or treatment or withdraw withdraw consentconsent without obligation or harassment; without obligation or harassment;

Be informed of major delaysBe informed of major delays in consultations/treatments, if at all in consultations/treatments, if at all possible; possible;

Know if there are supervisors, consultants, students, interns or Know if there are supervisors, consultants, students, interns or others with whom your medical doctor will discuss your case;others with whom your medical doctor will discuss your case;

Receive a timely referralReceive a timely referral or consultation with another health or consultation with another health professional whenever you and the medical doctor believe it professional whenever you and the medical doctor believe it appropriate; appropriate;

Receive a second opinionReceive a second opinion regarding your treatment or the medical regarding your treatment or the medical doctor's methods; doctor's methods;

Be Be listened tolistened to carefully and to carefully and to receive supportreceive support throughout your throughout your health care experience; health care experience;

Have Have another person presentanother person present during examinations. during examinations.

Patient RightsPatient Rights(CHR Website- Patient Concerns)(CHR Website- Patient Concerns)

Respect the privacyRespect the privacy of other patients, medical doctors and staff; of other patients, medical doctors and staff;

Ask your medical doctor or health care workers for Ask your medical doctor or health care workers for further further information if you do not understand; information if you do not understand;

Let your medical doctor or health care worker Let your medical doctor or health care worker know if you feel know if you feel uncomfortable; uncomfortable;

CooperateCooperate and follow the care prescribed as recommended for and follow the care prescribed as recommended for you as long as you are in agreement; you as long as you are in agreement;

Inform the medical doctor or staff if you are unable to keep your Inform the medical doctor or staff if you are unable to keep your appointment; appointment;

Allow the medical doctor to have a Allow the medical doctor to have a staff member presentstaff member present during an during an examination examination

Patient ResponsibilitiesPatient Responsibilities(CHR Website- Patient Concerns)(CHR Website- Patient Concerns)

Key to Avoiding Key to Avoiding Complaints…Complaints…

CommunicationCommunication CommunicationCommunication CommunicationCommunication

Expressive qualityExpressive quality Verbal techniquesVerbal techniques Introduce oneself by nameIntroduce oneself by name Explain one’s role in the EDExplain one’s role in the ED Use reflective listeningUse reflective listening (i.e., (i.e.,

summarizing what the patient summarizing what the patient has said to demonstrate has said to demonstrate understanding)understanding)

Use Use empathetic commentsempathetic comments such as “I understand” or “Isuch as “I understand” or “I

see”see” Apologize for waits and Apologize for waits and

delaysdelays Apologize for interruptionsApologize for interruptions Nonverbal techniquesNonverbal techniques Have good eye contactHave good eye contact Smile (when appropriate)Smile (when appropriate) Adopt a “concerned” and Adopt a “concerned” and

“interested” look that shows “interested” look that shows you are listeningyou are listening

Allow the patient to describe Allow the patient to describe their problems their problems without without interruptionsinterruptions

Information deliveryInformation delivery Use Use anticipatory guidanceanticipatory guidance Provide information about Provide information about

diagnoses and potential diagnoses and potential causes of the problemcauses of the problem

Explain results of tests and Explain results of tests and their implicationstheir implications

Provide Provide discharge instructionsdischarge instructions (in writing if possible)(in writing if possible)

Explain the purpose of Explain the purpose of procedures and the potential procedures and the potential for pain for pain

Tailor the content to the Tailor the content to the intellectual level, medical intellectual level, medical sophistication, and language sophistication, and language mastery of the patientmastery of the patient

Foreign language Foreign language communicationcommunication

Acquire proficiency in Acquire proficiency in languages most common to languages most common to the regionthe region

Use professional interpretersUse professional interpreters

Public RelationsPublic Relations

Observation UnitsObservation Units

The primary objective of observation units is to The primary objective of observation units is to provide an alternative to hospitalization for provide an alternative to hospitalization for patients requiring extended diagnostic patients requiring extended diagnostic assessment or treatment for up to 24 hoursassessment or treatment for up to 24 hours

Advantages include:Advantages include: Improved resource use Improved resource use (50% less cost than admission)(50% less cost than admission)

Increased diagnostic accuracyIncreased diagnostic accuracy Higher patient satisfactionHigher patient satisfaction Increased educational and research opportunitiesIncreased educational and research opportunities

3 models of OUs3 models of OUs The scatter bed model The scatter bed model

any bed in the hospital can become an observation bedany bed in the hospital can become an observation bed generally does not work very well, because of inefficiencies due to the generally does not work very well, because of inefficiencies due to the

varying needs of patients on the floor varying needs of patients on the floor

The in-house defined unit modelThe in-house defined unit model usually run by hospitalists within the institutionusually run by hospitalists within the institution predominant problem tends to be reimbursement issues (mainly US predominant problem tends to be reimbursement issues (mainly US

problem with insurance companies)problem with insurance companies)

The linked emergency department modelThe linked emergency department model a “virtual unit,” where any bed in the ED can become an observation a “virtual unit,” where any bed in the ED can become an observation

bedbed typically does not work well since the staff is too busy with the sickest typically does not work well since the staff is too busy with the sickest

patientspatients

Defined UnitDefined Unit Technically the ideal model, with unit attached to ED.Technically the ideal model, with unit attached to ED. Most likely to manage care efficientlyMost likely to manage care efficiently

What type of What type of patients would you patients would you select?select?

Conditions Appropriate Conditions Appropriate for Observationfor Observation

Evaluation: Critical Diagnostic SyndromesEvaluation: Critical Diagnostic Syndromes Abdominal painAbdominal pain   Chest painChest pain     DVTDVT     Gastrointestinal bleedGastrointestinal bleed     SyncopeSyncope     Blunt abdominal traumaBlunt abdominal trauma     Blunt chest traumaBlunt chest trauma     Penetrating abdominal traumaPenetrating abdominal trauma     Penetrating chest traumaPenetrating chest trauma     Head injuryHead injury

Conditions Appropriate Conditions Appropriate for Observationfor Observation

Treatment: Emergency ConditionsTreatment: Emergency Conditions AsthmaAsthma Atrial fibrillationAtrial fibrillation Congestive heart failureCongestive heart failure     DehydrationDehydration     Infections Infections     PneumoniaPneumonia     PyelonephritisPyelonephritis