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Case Study 34.1 Managing change in the urology department of a hospital in England
The Department of Urology in an NHS hospital in England is struggling to respond to external pressures for change. The manager responsible for the department has approached you for advice about how to manage the situation.
For many years the department has operated with five consultant surgeons, a number of middle-grade and junior doctors and a complement of nurses and other clinical staff. In terms of infrastructure, it has two 18-bed wards (co-located shared rooms with beds for patients who require a similar kind of care) and two operating theatres. Several departments within the hospital provide support services for diagnostic investigations and other essential supporting functions (e.g. anesthesia, medical records, pharmacy, etc.)
The immediate trigger for change was the combined impact of a financial crisis and the full implantation of new European Commission regulations limiting the number of hours medical staff are allowed to work.
Factors contributing to the financial crisis
The UK government introduced new regulations which required all NHS hospitals to treat non-emergency patients within 18 weeks, and financial penalties were introduced for failing to comply with the 18-week-referral-to-treatmnet target. The urology department was unable to meet this target with its in-house resources and responded by subcontracting some treatments to a private hospital. Initially, this was a cost-effective solution but, over a period of time, costs increased to the point where the urology was losing money on every patient it sent to the private hospital. Most members of staff were unaware of this. It was not until managers called an emergency meeting that staff including the five consultant surgeons, realized there was a problem. Managers were criticized for not sharing this information earlier.
Factors contributing to the shortage of medical staff
Full implementation of the European Working Time Directive (EWTD) was delayed for several years, and the urology department was only required to comply with an interim target that restricted junior doctors o working a maximum 56-hour week. When, eventually, the regulations were fully implemented and a maximum 48-hour week was imposed, this led to staffing problems that have significantly compromised the departments ability to provide quality and continuity of patient care. It has also undermined the quality of the training given to junior doctors. For example, junior doctors working night shifts do not have the opportunity to assist surgeons undertaking complex operations or to practice operating procedures under their supervision. The situation has deteriorated to the point where the external body responsible for validating the training has threaten to withdraw its validation.
Managing the crisis: the story so far
Members of the executive team (which includes the five consultant surgeons, senior nurses and senior managers) have agreed that there is an urgent need to (a) bring the work currently being performed in the private hospital back into the urology department, and (b) provide an EWTD-compliant rota for junior and mid-grade medical staff that does not compromise patient care or training. They have also agreed that this will that require the department to expand its physical resources (number of beds and operating theatres) and recruit more staff. However, they have failed to produce an agreed plan to meet these challenges.
Members of staff who are not part of the executive team do not appear to appreciate the seriousness of the problem.
Some of the reasons why the situation is proving difficult to manage are:
A tension between managers and clinicians. Some doctors and nurses perceive managers as being motivated by financial and other concerns not directly related to patient care. They believe that managers also lack specialist knowledge about the needs of patients. Managers, on the other hand, believe that many clinicians fail to appreciate that efficiency-improving and cost cutting measures can be achieved without undermining the quality and safety of patient care, and that often more efficient ways of working can deliver improved clinical outcomes.
A failure to agree about the extra beds, operating theatre and staff capacity that will be required to treat all patients in-house. Some members of the executive team believe that better utilization of existing beds could reduce the number of extra beds required. There is also a view (again not shared by everyone) that steps could be taken to improve the efficiency of the operating theatres and make better use of staff time.
Information overload. Emails are regularly cascaded from the senior executive team to all staff about a wide range of matters. This has led some of the staff to ignore messages with the result that important information is not always disseminated effectively.
The slow response pf those who have been asked to investigate problems and provide the executive team with data for decision making. For, example, a departmental theatre efficiency group was formed to improve the efficiency of the operating theaters, but the results of a survey of six months activity are still not available, despite this being crucial to determining the potential throughput of patients.
The poor quality of the data cted by members of the department on a regular basis as part of their normal work. For example medical procedures are often wrongly coded. This makes it difficult to forecast future income. It has also resulted in the loss of income in the past, thereby contributing to the departments financial problem.
Finally, plans to increase the number of medical and nursing staff have been frustrated by disagreements about the number and grades required. There are two conflicting views. Managers concerned about the departments financial position and the need to stop subcontracting work out to the private hospital are leading the argument in favour of recruiting more consultant surgeons. This argument is being resisted by others who believe there is a more pressing problem that has to be addressed first. They argue that middle-grade and junior doctors are unable to support the current level of activity generated by the existing five consultant surgeons. Consequently, the first priority should be to recruit three or four new junior doctors. This way forward, they argue, will also help ensure the work rotas for sub-consultant grade doctors will be EWTD-compliant, will provide more time for training, and could improve the productivity of the existing consultants by enabling them to run larger outpatient clinics.
Directions
Case
Chapter 34, Case Study 34.1 Pulling it all together: a concluding case study.
Read the case.
Identify the three concepts or theories you feel are most relevant to this case.
Formulate the advice that you would give to the Urology Department manager.
Explain how this advice is informed by theory; i.e., relate your advice back to the workings of the theory (theories) you believe to be the most relevant to this case.
Directions
Create a two-page briefing note that addresses
The three concepts or theories you feel are most relevant to this case.
The advice, recommendations, or conclusions that you would give to the Urology Department manager. Explain how this advice is informed by theory; i.e., relate your advice back to the workings of the theory (theories) you believe to be the most relevant to this case.
Create a PowerPoint or Prezi slide presentation that addresses the requirements stated above.
Create a video presentation
Resource: How to Write a Briefing Note
Written briefings are usually done in the form of briefing notes. A briefing note is a short paper that quickly and effectively informs a decision-maker about an issue.
A well-prepared briefing note quickly and efficiently fills a person in on an issue. Some characteristics of a briefing note should be:
concise: a short document isnt necessarily concise; concise means every word is used as efficiently as possible
clear: keep it simple and to the point; always keep your reader firmly in mind and include only what matters to that reader
reliable: the information in a briefing note must be accurate, sound and dependable
structured: use headings, subheadings, lists, font, etc
The most important point to remember about the structure of briefing notes is that they have three main parts: the purpose (usually stated as the issue, topic or purpose), a summary of the facts (what this section contains and the headings used will be determined by the purpose of the briefing note); and the conclusion (this may be a conclusion, a recommendation or other advice, or both)
These three main parts could be presented under the following headings.
Issue: (also Topic, Purpose): A concise statement of the issue, proposal or problem. This section should explain in one or two lines the topic, purpose or problem statement.
Background: The details the reader needs in order to understand what follows (how a situation arose, previous decisions/problems, actions leading up to the current situation). Typically this section gives a brief summary of the history of the topic and other background information. What led up to this problem or issue? How has it evolved?
Key Concepts/Theories: A summary of the key concepts or theories (3) you feel are most relevant to this case. Remember to substantiate any statements with evidence. Explain how this advice is informed by theory; i.e., relate your advice back to the workings of the theory (theories) you believe to be the most relevant to this case.
Recommendations and/or Conclusions: Conclusions summarize what you want your reader to infer. Do not introduce anything new in the Conclusion. If you are including a recommendations section, it should offer the best and most sound advice you can offer. Make sure the recommendation is clear, direct and substantiated by the facts you have put forward.
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