Administration Rounds Session 1

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Administration RoundsSession 1

• Yael Moussadji, PGY3
• Emergency Medicine
• Preceptor Dr. Roger Galbraith

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Why is Administration Important?

• Historically, Emergency Medicine had no
  legitimacy, no specialized field of knowledge and
  expertise, no organization, and no identity
• It had no specialty status, no training programs,
  no board certification process, and no respect
• Today, EDs face multiple contemporary issues
  including staff shortages, overcrowding and
  ambulance diversions, increased workplace stress,
  and environmental concerns
• Administration, and administrators, in a variety
  of capacities have worked to bring our specialty
  out of the past, and continue to enrich it
  through the current challenges that we face

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The Role of Adminstration in Emergency Medicine

• Advocacy
• Professional Education
• Clinical standards of practice and policies
• Research
• Practice Management
• Leadership and leadership development
• Interest groups and networking, and identity
• Wellness and well-being
• Service to the public

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Roles

• Advocacy
• Despite being a young specialty, EM needs an
  active and aggressive public relations and
  lobbying effort in order to ensure public
  knowledge of its existence and public support and
  endorsement of its goals and agendas
• Professional Education
• This involves both Residency training programs
  and conferences in order to educate ED care
  providers with the unique body of knowledge that
  is emerging

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Roles

• Clinical Practice Guidelines/Standards
• EM must establish a set of its own clinical
  guidelines that have not only ethical
  considerations, but reflect the unique realities
  of the ED population and environment
• Research
• We need a network of information and
  information-sharers that allows researchers to
  communicate and that provides research results to
  the ED community
• We need to support EM research financially, and
  provide a vehicle for training researchers and
  publishing their work
• The research of EM must answer the questions
  posed by the practitioners of EM

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Roles

• Leadership
• If we are to develop credibility as a
  full-fledged specialty, we must develop our own
  leaders to become spokespersons and advocates,
  who will then become involved in other areas of
  influence such as hospital adminstration,
  governmental agencies, private industry, and
  larger professional societies
• Practice Management
• ED managers must acquire a specialized skill set
  that allows them to manage a highly developed,
  multiple tasking, technology driven complex
  environment where patients with a huge variety of
  problems are encountered by a large degree of
  highly specialized personnel, all in a cost
  effective and efficient manner

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Roles

• Wellness and well-being
• Ways of enhancing wellness and limiting stress
  have to be found in order to promote longevity
  and long term survival of the specialty
• Service
• This is the most intangible, but most
  significant it is why we do what we do and is
  what maintains the ultimate success of our
  specialty
• Medical ethics, QI, medical error,
  communications skills are all contributors

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Communication Skills

• Breaking Bad News
• Telephone Advice
• Conflict Resolution

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Breaking Bad News

• Bad news is defined as any news that negatively
  alters the patients or family members view of
  his or her future
• Hippocrates advised concealing most things from
  the patient while you are attending to him. Give
  necessary orders with cheerfulness and serenity
  reveal nothing of the patients future or present
  condition.
• Now, with an emphasis on patient autonomy and
  empowerment, we know that the majority of
  patients desire and deserve full disclosure

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Literature

• What patients and families experience
• Use of technical language (eg. relative risk)
• Breaking of bad news in a hallway or location
  lacking privacy
• Neglecting to offer social or clergy supports
• Perceived lack of sympathy, lack of information,
  and being unable to answer questions
• Neglecting to prepare family members of the
  possibility of an autopsy

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Literature

• What patients and families want
• A clear, direct statement of the news
• Time to talk together in private
• Openness to emotion
• Ongoing involvement in decision making
• Diversity among patients and families
• In a study of 54 surviving family members of
  patients who died from trauma, 9 desired a hug,
  handholding, or a pat on the shoulder when
  receiving bad news 16 did not want any type of
  physical touching

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Physicians and Bad News

• Most of us struggle with giving bad news because
  we dont have adequate training in giving it,
  have a fear of being blamed and not knowing all
  the answers, and fear our own emotional reactions
• Consensus guidelines have been created to help us
• Following traumatic deaths, the most important
  features judged by families were the attitude of
  the person giving it, the clarity of the message,
  privacy, and the newsgivers ability to answer
  questions
• Therefore, it is not an isolated skill, but a
  particular form of communication with which we
  need to be comfortable
• Our own humanity may at times be the most
  powerful healing instrument

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The ABCDEs of Giving Bad News

• A Advanced preparation
• B Build a therapeutic environment/relationship
• C Communicate well
• D Deal with patient and family reactions
• E Encourage and validate emotions

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Advance Preparation

• Know the relevant clinical data, review the
  medical record and talk with consultants
• Arrange for adequate time in a comfortable quiet
  room with seating for all involved and determine
  who should attend
• Consider the goals of the meeting
• Mentally rehearse how you will give the news
• Prepare emotionally
• Take a step back

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Build a Therapeutic Relationship

• This stage is where you build rapport and trust
• Introduce yourself to everyone and ask for names
  and relationship to the patient
• Determine what the patient and family want to
  know and already know
• Use pacing and reflective listening to quickly
  demonstrate empathy and compassion
• Provide a brief summary of the patients illness

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Communicate Bad News

• Speak slowly, deliberately, clearly, presenting
  information in small chunks
• Foreshadow the bad news Im sorry, but I have
  bad news or I have difficult news pause for a
  moment
• Speak frankly and compassionately, avoiding
  medical jargon and euphemisms
• Use the words cancer or death
• Once the news is delivered allow for silence and
  a chance to absorb the information and respond
  this pause allows the anticipatory grief of all
  the implications of this news, and the way they
  are responded to can determine the future course
  of the acceptance process

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Deal with Reactions

• Assess and respond to emotional reactions
• Allow the patient time to talk early and often
  encourage questions and provide information at
  their pace
• Check their understanding to make sure they are
  receiving the information we are giving
• Communicate compassion, kindness, caring, and
  empathy by acknowledging, validating, and
  relfecting emotion
• It is appropriate to say I dont know

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Encourage, Validate, Provide Support

• Offer realistic hope and explore what the news
  means to the receiver ask if there is something
  we can do to help
• Use interdisciplinary services to enhance care
  and facilitate their access to support
• Bring closure to the interview, and outline the
  potential next steps for the family
• Remain available to the family while they remain
  in the ED
• Notify the GP and enlist their help in follow-up
• Self-reflect

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Conflict Management in the ED

• All human interactions have the potential to
  develop conflict
• Defined as a disagreement within oneself or
  between people that has the potential to cause
  harm
• Usually involves differences in ideas,
  perspectives, priorities, beliefs, values, and
  goals
• The organizational structure of the ED can also
  contribute

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The Natural History of Conflict

• Phase 1
• One or more parties with experience frustration,
  a strong imperative undirected emotion that
  almost always demands rapid attention
• Phase 2
• Conceptualization and rationalization of the
  cause in order to crystallize thoughts and
  feelings into action
• Phase 3
• Expression on conflict a series of behaviours
  directed toward our constructed cause
• Phase 4
• Formalizes the conflict situation as behaviours
  result in destructive outcomes

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The 7 Habits of Highly Effective People, by
Steven Covey

• While stressors responsible for conflict may be
  unavoidable or inappropriately conceptualized,
  the behaviours and outcomes can be modified by
  prolonging the time between phases 2 and 3
• Group exercise Identify a conflict situation you
  experienced recently at work. What was the
  stimulus?
• Make a note of the differences that caused the
  disagreement
• Describe the phases of conflict and whether it
  involved differences of values, skills,
  priorities, or organizational structures?

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Accelerators of Conflict

• Role and identity issues
• Performance, function, and process factors (as
  determinants of role conflict)
• Differing goals and individual differences
• Problems with communication and feedback
• Power and rivalry, lack of support and
  collegiality
• Absence of role modeling and expertise

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Four Ways of Handling Conflict

• Avoidance - denying existence of conflict
• Accomodation - letting the other party decide
• Competition aggressively pursuing ways to
  achieve your goal
• Collaboration actively looking after your own
  interests but not losing sight of the interests
  of others

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Conflict Management Styles

• Avoid
• Usually involves no declaration from one of the
  parties and therefore no cooperation is sought
• Useful as a short term strategy when there is a
  lot of heat rarely useful for long term change
• Accommodate
• Places the emphasis on achieving the others
  desired outcome
• Expedient, but unlikely to result in a long term
  solution
• Compete
• Entails little cooperation
• Works when outcomes are most important and
  resources are limited works against attempts to
  forge cohesiveness
• Collaborate
• Most time consuming and draining best suited for
  sustainable change

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Comparing Ways of Handling Conflict
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Group Exercise cont

• Each management style entails a different level
  of assertion and cooperation
• Describe the way in which you handled your
  conflict

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Outcomes of Conflict

• Constructive
• Growth occurs
• Problems are resolved
• Groups are unified
• Productivity is increased
• Commitment is increased

• Destructive
• Negativism results
• Resolutions diminish
• Groups divide
• Productivity decreases
• Satisfaction is decreased

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Conflict in Emergency Medicine

• Diversity in training, experience, and
  perspectives between colleagues
• Differences in professional opinion and value
  systems
• Effects of sleep deprivation and stress on
  interpersonal communication
• Lack of understanding of triage and role of ED,
  excessive patient demands
• Telephone conversations and lack of face to face
  contact with consultants

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Communication and Conflict with Patients

• Physician-patient relationship is sudden and
  occurs with little choice
• Frequent mismatch between the patients
  perspective of his/her illness and ours, which
  are impacted by social, cultural, and language
  barriers as well as differences in response to
  illness
• Patients are often under the influence of
  substances or disease states which can impair
  their judgment, or may refuse to consent for or
  comply with medical treatment

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Strategies for Effective Patient Communication

• Instead of viewing the disease as the central
  issue and the patient in the background, start to
  view the patient as the central figure in the
  context of the illness or injury (shifts the
  motivation from treating the disease to treating
  the patient with the disease)
• Strategies to do this include conducting a more
  patient centred interview by sitting at the
  bedside, being eye to eye level, asking
  open-ended questions, and being as non-directed
  as possible (time permitting)
• Avoid an authoritarian approach, which can
  escalate during stress and fails to recognize
  patient fears and concerns
• Use a collaborative or participatory approach
• Patients will respond more positively to a
  physician who is perceived to be genuinely
  interested in their well being

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Dos and Donts of Patient Communication

• Do
• Sit
• Make eye contact
• Use the patients name
• Touch the patients arm or shoulder while
  examining them
• Ask open-ended questions
• Involve the patient in treatment options
• Find out the patients concerns

• Dont
• Stand over the patient
• Chart while talking
• Refer to the patient by their presenting
  complaint
• Touch the patient using only tools
• Use only yes or no questions
• Ignore the patients fears

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Communication with Nursing

• Good nursing is crucial to emergency medicine
• Nursing is defined as the diagnosis and
  treatment of human responses to actual and
  potential health problems
• Borders between emergency nursing and emergency
  medicine are more indistinct than they are in
  other specialties, which contributes toward
  collaborative practice
• Therefore, failure to develop shared values can
  breed conflict

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Collaboration with Nursing

• Nursing often provides the humanistic components
  of communication time, patient education, and
  direct care
• Recognize their value and expertise in order to
  achieve our common purposes
• Other opportunities for collaboration include MM
  rounds, involvement in academic research
  projects, and social events (team building
  exercise)

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Communication Between Medical Colleagues

• The strongest perceived predictor of positive
  communication is the physicians perceived
  autonomy
• Negative communication experiences are associated
  with perceived environmental stress
• Differing value systems can result in
  unreasonable demands or lack of availability of
  consult services, diagnostic, or therapeutic
  modalities
• Telephone consultation provides little feedback,
  limited time for discussion, and is impacted by
  excessive background noise, incomplete data, and
  inopportune timing

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Approach to Conflict Resolution in the ED
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Take Home Points

• Establishing consensus and reaffirming common
  goals is the first step toward conflict
  resolution (providing the best care possible to
  patients and families)
• Avoid accusations of laziness, not answering
  pages, or unresponsiveness
• Listen actively, have respect and display
  empathy, maintain a professional demeanor
• Compromise, but not on care
• Be specific in your expectations, communicate
  clearly