ACTEP2014 ED director

EMERGENCY DEPARTMENT
DIRECTOR
ROLE, RESPONSIBILITY AND IMPORTANCE
Piyaporn Thipayarat,MD
Bangkok Hospital Pattaya
Wednesday, November 26, 14 1

EMERGENCY PHYSICIAN!!

New Emergency Physician
in Old Emergency Department!!
Introduce yourself
Learn your new ED

Our Emergency Room

Life Saving Equipments

New Emergency Physician
in Old Emergency Department!!
Introduce yourself
Learn your new ED
Learn your new staff members
Build a trust
Set up your own Emergency Department

Developing Leadership and Communication Skills
Implementing Effective Peer Review and Physician Profiling
The Problem Physicians
Interaction That Create/Prevent Malpractice
Customer Relations and Patient Satisfaction
Physician Contracts
Hospital Contracts
Emergency Department Director

New Physician Recruiting and orientation
Productivity and compensation: Measurement and feedback
Effective conflict management
Billing and coding
Reimbursement issues
Staffing and scheduling methodologies

Conduction effective meetings
Risk management
Legally interviewing, hiring and terminating
Containing cost while providing prudent care
Driving hospital quality

Negotiating Skill
Preventing error in emergency medicine
Patient complaint management
Engineering patient flowI: theory, metrics and application,
directing change

Physician Contracts
Hospital Contracts

Leadership
It’s as easy at 1,2,3...
But what is 1,2,3??

Leadership
1. There is some one Myth for every man, which, if we but
knew it, would make us understand all that he did and
thought”.

The Details of the One Myth
• It’s different for each person
• There are some similarities within specialties (trauma surgeons,
orthopedists, pediatricians, internists
• “What excites you most about this?”
• “What concerns you most?”
• “What would success look like to you and your patients?”
• “What role would you like to play as we move forward?”

Leadership
2. All meaningful and lasting change is driven by
INTRINSIC motivation

1/27/2011
Extrinsic Vs. Natural Change
Forced Change-
Extrinsic
Natural
Diffusion
Time
Extrinsic Vs. Intrinsic Change
Extrinsic
Intrinsic
12
Extrinsic Vs. Natural Change
Forced Change-
Extrinsic
Natural
Diffusion
Time
Extrinsic Vs. Intrinsic Change
Extrinsic
Intrinsic
Time
Intrinsic Motivation

Leadership
3. What is in this person or group’s
self-interest?

Leadership Skills
1,2and 3
1. What is their intrinsic motivation ?
2. What is the One Myth for this person?
3. What is in this person or group’s self- interest?

What are the differences between
Leadership and Management?
Do the differences REALLY make
any difference?

Leadership VS Management
Leadership
Envisioning
Strategies
Alignment
Empowerment
Direction setting
Execution
Management
Planning
Budgeting
Organizing
Staffing
Controlling
Problem Solving

The fundamental purpose of
management is to keep the current
system functioning.
The fundamental purpose of leadership is
to produce change, especially non-incremental
change.
The Wisdom of John Kotter

Managers do things right
Leaders do the right thing
The Wisdom of Warren Bennis

So Which Would You Rather Be...
• A LEADER ?
• A MANAGER ?

HINT!!!!!
Most of the time-it’s
BOTH!!!!!
If managers do things right and
leaders do the right •
things,
ED medical directors must do
both-every day of their lives
Homework Assignment
• What are the 3
biggest problems
currently facing
your emergency
department?
Wednesday, November 26, 14 51 28

TeamWork
• Two words which combine to make a far more
powerful single concept
• The single best measure of the health and success
of your emergency department is the relationship
between the doctors and nurses
• Unique in all of healthcare

TeamWork
MD-RN Leaders
• Proactive, positive relationship
• MD as the strongest advocate for nurses
• Frequent meetings
• Supportive relationship
• Team goals, team results
• Empowerment, not autonomy
• Seek and celebrate small victories
• Celebrate publicly

MD Leader
• Autonomous
• Authoritarian
• Hierarchical
• Intense, focused time
• Outcomes-driven
• Technical expertise
• Problem Solver
• Linear perspective
RN Leader
TeamWork
• Dependent
• Collaborative
• Communications
• Expanded time
• Process-driven
• Interactive-service
• Critical thinking skills
• Circular perspective

Leadership and Administration
• Align strategic incentives.
• Meet frequently-use time judiciously
• The power of the carbon copy, email, voice mail
• Make them a part of the ED team
• If you ask for advice, be sure you’re prepared to take it
• Understand the language, philosophy, strategies
• Inform them of problems prospectively
• Public praise, private problems
• Be responsive
• If it’s an ED problem, it’s your problem

Leadership and the Medical Staffs
• Meet with the leaders regularly
• Make them a part of the ED team
• Offer concrete, succinct solutions to problems
• Meet on their turf
• Protect your flank-use the cc
• Focus, focus, focus...
• Surprise them
• Adversaries often become the best allies

Physician Contracts
Hospital Contracts

Why Do Peer Review/MD Profiling?
1 Assure that quality is delivered
2 Make JCAHO happy
3 The contract requires us to
4 Make sure we don’t have any “bad” doc
5 Assure the group practices as a group
6 Aligning strategic incentives
7 Protect Your Patient(Patient Safety)
8 Protect Your Practice(Risk Reduction)

C o nt r asting Peer Review and Profiling
Peer Review Physician Profiling
1 Usually set by clinical
parameters
2 Done by or on behalf of
clinicians
3 Increasingly Evidence-
Based
4 Who is going to guide
your fate?
5 Done by us
1.Usually set by hospital
2.Very often done by non-clinicians
3. IT your friend?
4. Often done in the dark
5. Fate is guided by others
6. Done to us

The Sharp End of the Stick
70-80% of errors blamed on the last person to touch the situation.
After investigation, less than 20% of errors can be
attributed to the last person to touch the situation.

Peer Review Process

The 1st Tier of Peer Review
1. Returns within 48, 72 hours
Change in Diagnosis
Admission
Change in therapy
2. Radiology over-reads
3. ECG over-reads
4. Condition on discharge
5. ASA in AMI
6. Beta blocker in AMI?

The 2nd Tier of Peer Review
1. Time Indicators : door to doc, doc-to decision,
decision-to-discharge
- Admission
-Discharge
-Fast Track
2. Quality Indicators
- Door to needle
-Door to Cath lab
-Sepsis bundle

The 3rd Tier of Peer Review
1 Discharge Summaries on all admitted patients
2 Copy of ED medical record to personal
physicians
3 Downcoding/incomplete chart reports
4 Complaints/compliments
5 Team time indicators
6 Boarder Hours(Reasons?)
7 Meaningful data trending

Physician Profiling
Clinician Performance
Evaluation Summary
Case Review Summary

Physician Profiling
Patient Satisfaction

The 1st Tier of Peer Review
1. Returns within 48, 72 hours
Change in Diagnosis
Admission
Change in therapy
2. Radiology over-reads
3. ECG over-reads
4. Condition on discharge
5. ASA in AMI
6. Beta blocker in AMI?

Physician Contracts
Hospital Contracts

The Physician With a problem are our
“special” colleagues
Goal: Discourage Disruptive Behavior
4-6% give us 90% of the problems

Most Common Behavior Problems
# Degrading Comments and Insults
# Yelling
# Cursing
# Inappropriate Joking
# Refusing to Work Together

When does “their” problem
becomes “your” problem?

Your Problem
When the behavior creates stressful environment
and interferes with other’s effective functioning

Problem Management
* Identify
* Understand
* Investigate(Facts vs Perception)
* Make a Decision
* Intervention
* Disposition
* Communication
* Follow-up

Type of Problems
*Clinically poor
*Insubordination
*Low productivity
*Anger Management
*Sexual Harassment
*Complainers
*Emotional Problems
*Tardiness Dropping shifts
*Personal Hygiene Issues

Do Not let the Problem Physician
become the
Problem Director!!

Physician Contracts
Hospital Contracts

"Top box" patient satisfaction scores for Poudre Valley Hospital

Patient Satisfaction and HCAHPS Survey Responses of Patients' Hospital
Experiences: Davis Hospital and Medical Center

Understanding Expectations is the Key

The First Reason to Get
Customer Service is.....
It Makes Your Job Easier!

Do You Offer Good Customer Service?
It Depends!

A-Team Members
Positive
Proactive
Confident
Competent
Compassionate
Communication
Teamwork
Trust
Teacher
Does whatever it takes
Sense of humor
Moves the meat

B-Team Members
Late
Constant
Complainer
Can’t do
Always surprised
Negative
Reactive
Confused
Poor communication
Lazy

How many B-Team members
does it take to destroy
an entire shift?

What’s a good doctor?
Doctor’s courtesy
Doctor Took Time to Listen
Doctor Informative
Doctor’s concern for Comfort

What’s an “A” team nurse?
1. Nurse’s courtesy
2. Nurse took time to listen
3. Nurse’s attention your needs
4. Nurse informative regarding treatment
5. Nurse’s concern your privacy

What’s a good patient?
Intubated
Paralyzed
On a ventilator
Orphan (No Family)
Speaks our language
Doesn’t come back
In and Out Fast
Wants Only One Thing
Compliant (Wants it OUR Way)

What’s the point??

Billing and coding

Recruitment
Retention
Orientation

Orientation
essential components
Corporate structure
Hospital
Departmental/Clinical
Critical Components
Charting
Policies
Patient flow
Outsiders
Essential Provider scope

Billing and coding

Conflict

Risk management
Legally interviewing, hiring and terminating
Containing cost while providing prudent care
Driving hospital quality

Characteristics of meetings
Well Conducted
Time Efficient
Meaningful
Focused

Objective of meetings
To have or not to have a meeting
How to prepare in advance
How to conduct a meeting
Avoiding traps and terrorists
What to do after the meeting ends

To have or not have....
Is it necessary?
or
Can it be avoided?
Two Reasons for Meetings
- Problem solving
- Information Exchange
Reasons to avoid meetings
- Nothing of significance to discuss
- No decisions to be made
- The leadership doesn’t want/need
permission

Setting the Seating

Conduct the Meeting

Concluding the Meeting

Negotiating Skill
Engineering patient flowI: theory, metrics and application,
directing change

Patient Complaint Management
People complaint because:
Perceived Injury
Perceived Mistreatment
Expectations went Unmet

What does your administrator
want from you?
Problem solvers
Documented evidence
Satisfied customers

What does your ED staff want
from you?
Collaboration and Problem
Solvers
We must satisfy more than
just the patients’ concerns

What does your EMS provider
want from you?
They want to be treated like they
are worth > $2,000 each time
they come....

Satisfaction defined:
Pre-purchase expectation are
met or surpassed
....so...
Creating satisfaction requires
meeting, surpassing or
lowering expectation

Create DISSATISFACTION by
Rising Expectations
SATISFACTION Requires Meeting, and perhaps
Lowering Expectation

Create DISSATISFACTION by
Rising Expectations
Nurse “ The doctor will be in a minute.”
You “ I’ll be right back.”
Third party “ Just go to the ER and get X-ray.”

P atient Complaint Management

Negotiating Skill
Engineering patient flow: theory, metrics and
application, directing change

Engineering patient flow

ED patient flow

Re-engineering patient flow

Let’s build our ED!!

ACTEP2014 ED director

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ACTEP2014 ED director