Administration Heather Patterson PGY-2 March 15, 2007 Preceptor: Dr. Gavin Greenfield

Administration

Heather Patterson

PGY-2

March 15, 2007

Preceptor: Dr. Gavin Greenfield

Objectives

1. Role of the Administrator-Heirarchy in the CHR ED

2. Public Relations 3. Patient complaints and satisfaction4. Physician-physician complaints5. Staff- physician complaints6. Observation Units7. Determining schedules

Name that future administrator…

• Likes to wear pink shirts and/or tight shirts

• Will still respond to “chief”

• Likes to make sure we all feel part of the team….

Emergency Department Director

Qualifications

• Board certified emergency physician• Proven clinical and administrative skills• CME participation• Demonstrated knowledge and ability in

financial, managerial, and marketing aspects of EM

• Demonstrated ability to speak effectively on administrative and clinical matters related to EM

Emergency Department Director

Purpose of the Position (ACEP)

• Leadership & management in the ED• Work cooperatively with ED staff to provide

emergency services for patients. • Work cooperatively with diagnostic and

therapeutic services to ensure availability, quality, and effective use of services

• Provide input into preparation of departmental budget

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

Emergency Department DirectorResponsibilities

• ED activities: leadership, organization, staffing, coordination, scheduling, and evaluation

• Ethical practice of EM within dept• Supervision of clinical and

administrative duties for EP’s • Hospital executive committee:

represent interests of EM– Liaison between hospital administration

and ED staff

Emergency Department DirectorSummary

• Department management

• Recruitment and orientation

• Education• Public relations • Liaison• Department meetings• Committees – hospital

and departmental

• Quality assurance• Peer review

– Physician evaluation

• Planning• Legal

– Risk management• Contracts and

finances

The Bottom Line:

The role of the administrator is to make the emergency

department a better place for patients and staff

Name that future administrator…..

• Likes to wear women’s clothes for special occasions

• Adults tend to be afraid of him so he works with kids now

• Owns a car but doesn’t use it often– runs, bikes, or swims instead….

Heirarchy ….

Executive Medical DirectorDr. Cam Waddell

Vice PresidentThelma Inkson

Regional Clinical Department HeadDr. Gil Curry

Director, Emergency, Urgent Care and Health Link

Caroline Hatcher

Acting DeputyRCDH

Dr. Lester Mercuur

Undergraduate CoordinatorL. Campfens

Division Chief, Education

FRCP: C. Hall

QI PhysicianT. Rich

Site ChiefsFMC: W. SefcikPLC: P. Davids

RGH: C. Godfrey

Patient Care ManagersFMC: B. KatholPLC: D. KellyRGH: T. Smith

Service Planning Coordinator

Maureen McNaul

Research CoordinatorR. Iwanow

Data SpecialistD. Wang

Regional Clinical Nurse Specialist

Vacant

REDIS CoordinatorsK. JessenS. LuznyH. BattleD. Hone

AssistantPatient Care Managers

FMC: T. DavidsonPLC: D. DooleyRGH: L. Walters

Division Chief, ResearchM. Yarema

Associate ResearchDirectorVacant

Resident Research Coordinator

C. Hall

Patient Care ManagerACH: K. Howe

Regional Department of Emergency Medicine / Emergency Services Organizational ChartJuly 2005

Director, Calgary Regional Sexual Assault Response Team

P. Head

Division Chief, Education

CCFP(EM): N. Collins

Assistant Division Chief, Education

CCFP(EM): I. Walker

Assistant Resident Research Coordinator’s

N. Collins & I. Walker

Bad publicity

• Recent cases:– July 2006

• “repeatedly asked for help for 3 hours, but were told they had to wait for a bed”. Miscarriage in waiting room.

– September 2006• “began miscarrying in the packed waiting room

and was denied a place to go despite asking for help. She had waited for 6 hours”.

– September 2006• “miscarried in waiting room after waiting more

than 6 hours”

Public Relations

• Gavin….

Patient Complaints:

• Why do we have a complaint system?• Identify systemic problems and create solutions (QI)• Identify personal deficiencies ie information delivery,

communication skills, bedside manner• Promote positive interactions with patients, public, and

staff• Reduce litigious dispute resolution • Create risk management strategies

Patient Complaints:

• Waiting time related– Waiting room time– Wait time for physician once in bed– Overall health care system and wait times

• Patient expectations– Meds not given ie: Narcotics refused for chronic pain

patient– Did not get tests they want ie: MRI, CT, Xray– Did not get admitted

• Personal interactions– MD, nurse, radiology

Patient Complaints:

Patient Complaints:

• Patients are encouraged to speak directly to those involved OR if uncomfortable, to speak with a supervisor, patient care manager or clinic manager

• Patient Care Representative Service:– “Point of entry into the regional health system for

patients or their advocates to express concerns, complaints or commendations regarding patient care”

– Can access this resource in person, by phone, fax, or email

Patient Complaints:

• Complaints are sent to the relevant department

• Non-MD related patient care managers• MD related site chiefs

• Chart reviewed• MD contacted for clarification and written comments• Patient is contacted in writing or by phone UNLESS

lawyer is involved. Then CMPA takes over.

Program/UnitAccess to Service

Clinical Support

Diagnostic Imaging

Financial

Medical Care (Physician)

Nursing Care

Other

Support Services

Grand Total

Emergency Services 13 1 1 4 19 36 2 3 79

PADIS 1 1

Urgent Care (8th & 8th Health Centre) 1 2 2 5

Grand Total 14 1 1 4 21 39 2 3 85


Care Del. (Multi Disciplinary)

Clinical Support

Financial


Nursing Care

Other

Support Services

Grand Total

Emergency Services 7 10 1 6 34 42 2 1 103

Security (8th & 8th Health Centre) 1 1

South Calgary Health Centre 2 1 2 2 7

Urgent Care (8th & 8th Health Centre) 2 1 2 5

Grand Total 11 10 1 7 37 46 2 2 116


Care Del. (Multi Disciplinary)

Financial


Nursing Care

Other

System

Grand Total

Emergency Services 71 23 7 37 37 4 1 180

Mental Health (8th & 8th Health Centre) 1 1

South Calgary Health Centre 1 2 5 2 10

Urgent Care (8th & 8th Health Centre) 1 1 2 2 6

Grand Total 72 24 8 42 44 6 1 197

Physician Complaints:

What do you do if you have a conflict with another physician?

Patient Satisfaction

• What factors influence patient satisfaction in emerg?


• Interpersonal skills:– Nursing and

physician– “expressive

quality”• Friendliness,

courtesy, respectfulness, compassion

• Mannerisms and perceived humanitarian concern


• Interpersonal skills:– Information delivery

• Amount, quality and understandability of information given

• Communication skills


• Wait times:– Perceived vs actual

• Actual wait time does not impact satisfaction rankings

• If patient feels that they have waited too long for their particular complaint, dissatisfaction is likely to arise!

– Studies show that neither patients nor providers are good at estimating times• Patients and physicians tend to overestimate


• Statistically not significant:• MD factors:

– Gender– Marital status– Technical skills

• ED factors:– Time/day– Busy dept/volume

• Patient factors – Acuity (1995) – debatable, nonreproducible results – Pain, chronic illness, medical vs surgical, insurance,

diagnosis– Tests done– Number of prior visits

Patient Satisfaction – how can we improve?

• Interpersonal interactions:– Things you learned in medical school

• Verbal and nonverbal communication is very important

• Be empathetic

– Information delivery• Explain everything that you do in an accessible

manner appropriate for the patient. • Use professional interpreters

Patient Satisfaction – how can we improve?

• Interventions:– Customer training. Improved pt impression

of nurse and MD skills and overall satisfaction (Mayer et al 1998)

– MD business cards given to pts. Improvement (schiermeyer et al 1994)

– Observation units in asthma and cardiac patients. Improvement. (Mowen et al 1993, Ryeman et al 1997, 1999)

– TV in rooms, standardized verbal estimates of wait time, and feedback forms available made no difference.

– Video in waiting room about ED. No impact (Krishal et al 1993, Corbet et al 2000 – poorly designed)

Observation Units

• The good, the bad, the ugly…..– What?– Why?– Who?– How?

Observation Units –What?

• Observation Units:– Area where patients can be observed or

have early investigation/management in ED

• Assessment Unit:– ED patients are assessed and initial

management is undertaken by inpatient hospital teams

• Admission Ward:– Admitted patient holding area

Observation Units – Older Stats

• US (1989)– 27% have obs units– 16% are in process of getting units

• UK (1998)– 57% have obs units

• AUS (1989)– 50%

Observation Units – Why?

• Patient Satisfaction:– Several non randomized trials say

increased pt satisfaction– 1999 Rydman et al (AEM) found increased

patient satisfaction with use of obs unit• Randomized 163 asthma pts to obs unit or usual

inpatient care• Patients reported fewer problems with care

received, communication, emotional support, physical comfort

• Fewer investigations in obs unit

Observation Units – Why?

• Emerg Impact:– Studies have suggested (1990s):

• Reduce ED workload• Improvement in ED flow• Faster referral to specialists

• LOS (1997)

– Decreased overall length of stay– Potential financial benefit for region

• If used appropriately for predetermined disease entities

Observation Units – Why not?

• Hospital impact– Study in the UK (1997) suggested if the ED

and hospital is functioning well and good clinical skills, no significant improvement is seen.

• Emerg Impact:– Staffing – “Dumping area”/ improper use

• Social vs medical pts

– Time limits exceeded– Inadequate/inefficient transfers to inpatient

units

Observation Units - Who?

• High risk discharge• Short term treatment• Short term observation


• Diagnostic evaluation• Abdominal pain • Chest pain (low probability of myocardial

infarction) • Flank pain (rule out renal colic) • Gastrointestinal bleeding with initial evaluation • Chest trauma (normal initial evaluation and chest

radiograph) • Abdominal trauma (normal initial evaluation and

lavage) • Drug overdose (clinically stable) • Syncope (negative initial evaluation) • Vaginal bleeding, threatened abortion

Management of observation units. Ann Emerg Med June 1995;25:823-830


• Short-term therapy • Allergic reactions • Asthma • Acute exacerbation of chronic congestive heart

failure • Dehydration • Hyperglycemia (mild to moderate)• Hypertensive urgencies • Selected infections (eg, pyelonephritis) • Seizure disorder requiring anticonvulsant

loading • Sickle cell pain crisis • Blood transfusion



• Psychosocial needs • Alcohol intoxication • Adjustment reaction • Depression • Psychosis • Social disposition problems • Wrist laceration – psych related


Observation Units – Admission Crit.

• Clearly identified patient care goals – Evaluation of high-risk chief complaints – Short-term therapy of an emergency condition – Meeting psychosocial needs

• Limited need for intense medical services

• Limited severity of illness; anticipation of discharge home within time limits

• Clinical condition appropriate for observation



• How do we do?– 2 MDs retrospectively reviewed 1606 charts

of ED patients in the ED >4hrs – Asked to determine if they were

appropriate for Obs Unit, admission, or discharge.

– Compared to actual outcomes– We didn’t do a great job.

• 363 selected for OU. 181/363 discharged. • 1253 not appropriate for OU. 799/1253

admitted. 232/799 were appropriate for OU.

Observation Units - How?

• Clear admission criteria• Well planned policies and procedures• Know who’s the boss!• Proper staffing, location and

equipement• Quality assurance

Observation Units – Quality Assurance

• Utilization data:– Volume: %admit from ED and to inpatient

unit, timing, duration of stay, % exceeding time limit

– Care: morbidity, mortality, critical incidents, appropriateness of treatment, RTED

– Patient complaints

• Financial benefit?– Studies need to be done to assess actual

benefit vs theorized.– Strict inclusion criteria would be required

Observation Units – Benefit?

New Fellowship….. ACH - Career Opportunity in Emergency Medicine . . .

Waiting Room Medicine Fellowship

• Rotations include:– Unmonitored Cardiology — Make decisions about which of the 6 patients with

crushing chest pain should get the next available bed when it opens up in the morning.

– WR Surgery — You'd be surprised how many things you can sew, lance, drain and wrap in a simple WR chair.

– Communication Skills — Key objectives for the communication skills module include learning how to ask embarrassing questions in front of a crowd, learning to say "I'm sorry for the care you're receiving" in a manner that doesn't lead to your being assaulted by angry family members, and learning to say "these curtains are soundproof" with a straight face.

– EMS — Deal with ambulance diversion, critical care bypass; provide catering and nutritional requirements for waiting ambulance crews. Gain valuable skills in diverting ambulances with seriously ill patients from your ED to another equally overcrowded ED.

New Fellowship….. ACH - Career Opportunity in Emergency Medicine . . . Waiting

Room Medicine Fellowship

• Rotations include:– Lab & Radiology — Learn to make judicious use of investigations based on a

triage note and/or EMS report; no need to bother yourself with talking to or examining the patient until all the labs are back.

– Triage in the Real World — Practise reverse triage, where CTAS IVs and Vs are seen expeditiously, because they are "quick and easy," and CTAS IIs and IIIs are left to languish for hours.

– WR Ethics — Triage the conflicting values of good patient care and maintaining the flow.

– WR Admin Interactions — Dealing with disappointment; how to carry on after seeking help from the administrators on call.

– WR Patients as Monitors — Learning to use other WR patients for the reassessment of critically ill patients (with a focus on teaching lay people about the recognition of seizures, initial management of cardiac arrest, and guidelines for involving the triage nurse in WR care).

New Fellowship….. ACH - Career Opportunity in Emergency Medicine . . . Waiting

Room Medicine Fellowship

• Advanced Electives– Parking Lot Medicine – WR Intensive Care — Pocket Pressors are our friends

• Learning Materials– Standard EM texts, PLUS – All seasons of MASH on DVD

• Special Opportunity for ED Chiefs!

ACH - Career Opportunity in Emergency Medicine . . . Waiting Room Medicine Fellowship

• Applicants must have 1 yr of EM experience or be a final year resident.• CMPA coverage is essential – you are going to need it!• Pls send a letter detailing why you would like to specialize in WR medicine.

New Fellowship…..

Documents

Administration Heather Patterson PGY-2 March 15, 2007 Preceptor: Dr. Gavin Greenfield