Administration Part 2 Sultana Qureshi, PGY-2

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

The Emergency Department Director

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

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

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

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

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

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

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. 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.

What qualities makes a good ED Leader?

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

Education: ACEP – Emergency Department Directors Academy ACEP – Emergency Department Directors Academy Four phase course Four phase course

Patient Complaints

What do patients complain about?

Patient complaint types (CHR-EDs Apr-Oct 2005) Code Complaint Type A1.1Access/Wait Times - Waiting Room A1.2Access/Wait Times - Department A1.3Access/Wait Times - Other A2Financial A3Lost Belongings A4Physical Environment A5Communication Process A6Multiple Departments A7Triage A8Other B1Personal Interaction B2Care Provided B3Other C1Personal Interaction C2Physician Competence C3Discharge Issues C4Treatment Expectations C5Missed Diagnosis C6Other

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

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

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

Patient Representative Service (CHR Website- Patient Concerns) Process: Process: Issues may be brought forward in writing, by phone, or online form 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) 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 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. 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.

Patient Representative Service (CHR Website- Patient Concerns) Time frame: 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. 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.) 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?) 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 Patients must provide consent to review records Once lawyers involved, becomes CMPA issue Once lawyers involved, becomes CMPA issue

Patient Rights (CHR Website- Patient Concerns) Be treated with respect and without discrimination; 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 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; 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; 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; 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; Refuse a particular type of examination or treatment or withdraw consent without obligation or harassment;

Be informed of major delays in consultations/treatments, if at all possible; 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; 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 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; 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; Be listened to carefully and to receive support throughout your health care experience; Have another person present during examinations. Have another person present during examinations. Patient Rights (CHR Website- Patient Concerns)

Respect the privacy of other patients, medical doctors and staff; 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; 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; 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; 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; 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 Allow the medical doctor to have a staff member present during an examination Patient Responsibilities (CHR Website- Patient Concerns)

Key to Avoiding Complaints… Communication Communication

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

Public Relations

Observation Units

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 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: Advantages include: Improved resource use (50% less cost than admission) Improved resource use (50% less cost than admission) Increased diagnostic accuracy Increased diagnostic accuracy Higher patient satisfaction Higher patient satisfaction Increased educational and research opportunities Increased educational and research opportunities

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

What type of patients would you select?

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

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