Transcript Document 7399279

Administration Rounds
Session 1
Yael Moussadji, PGY3
Emergency Medicine
Preceptor: Dr. Roger Galbraith
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
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
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
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 informationsharers 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
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
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
Communication Skills
Breaking Bad News
Telephone Advice
Conflict Resolution
Breaking Bad News
Bad news is defined as “any news that negatively
alters the patient’s [or family member’s] 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 patient’s 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
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
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
Physicians and Bad News
Most of us struggle with giving bad news because we
don’t 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
The ABCDE’s 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
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
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 patient’s illness
Communicate Bad News
Speak slowly, deliberately, clearly, presenting information
in small chunks
Foreshadow the bad news “I’m 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
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 don’t know”
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
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
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
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?
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
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
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 other’s 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
Comparing Ways of Handling Conflict
Group Exercise con’t
Each management style entails a different
level of assertion and cooperation
Describe the way in which you handled
your conflict
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
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
Communication and Conflict with Patients
Physician-patient relationship is sudden and
occurs with little choice
Frequent mismatch between the patient’s
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
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 openended 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
Do’s and Don’ts of Patient
Communication
Do…
Sit
Make eye contact
Use the patient’s name
Touch the patient’s arm or
shoulder while examining
them
Ask open-ended questions
Involve the patient in
treatment options
Find out the patient’s
concerns
Don’t
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
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
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
M&M rounds, involvement in academic research
projects, and social events (team building
exercise)
Communication Between Medical Colleagues
The strongest perceived predictor of positive
communication is the physician’s 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
Approach to Conflict Resolution in the ED
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