You are a staff specialist preparing a business case to purchase an ultrasound scanner for the ED. A senior intensive care unit (ICU) colleague is pushing for the purchase of a different unit, mainly to assist with vascular access. This would be stored in the ICU and made available to the ED on request. The hospital executive will not provide funding for more than one unit.
Regarding conflict resolution, which ONE of the following statements is TRUE?
Answer: C: Successful negotiation has much in common with complaint management, and aggression management. Effective practices are based on seeking positive relationships with counterparts, rather than arguing, intimidating or losing your temper. These practices include:
Negotiation may be considered in four stages:
1- Preparation
2- Debate
3- Bargain
4- Agreement
Reference:
Regarding business planning for the ED, which ONE of the following statements is TRUE?
Answer: C: A business plan is a yearly framework agreed between the ED management team and the hospital management, setting out expected performance for the coming year, and the facilities available to support that performance. The four main components are finance, activity, quality and efficiency. It should be based on as much accurate information as possible about the past year’s activity, in order to set future projections. Once the plan is implemented, regular monitoring should continue to identify and remedy any variance.
The financial aspect, the budget plan, is used to project financial outcomes for the coming year. It is usually developed on the basis of the previous year’s financial activity, with every variance from that plan accounted for. Up to 85% of ED costs are fixed, with the largest single field related to staff wages. Purchases of new equipment over $5000 requires a business case including tenders to be prepared and submitted to hospital management. Capital expenditure refers to items with recurrent use over many years (e.g. infrastructure, buildings or monitoring equipment).
Activity may be expressed in terms of total attendances and triage mix, admissions by triage category, top diagnosis-related groups (DRGs) in any observation ward, and other relevant activity such as inter-hospital transfers. Quality and efficiency may be assessed by defined clinical indicators – such as waiting times per ATS triage category, access block, ambulance bypass – established internally or by external authorities such as ACEM or the Australian Council on Healthcare Standards (ACHS). Morbidity and mortality rates, written complaint rates and patient ‘Did Not Wait’ rates also constitute measures of quality.
Regarding continuous quality improvement (CQI), which ONE of the following statements is NOT TRUE?
Answer: B: CQI begins with the concept that things can be done better than they are being done now. Improving quality within an ED requires several elements, including defining clinically meaningful outcomes. Accepted elements of a CQI program for an ED may include ongoing improvements in clinical quality, cost efficiency and service quality. These three elements are not necessarily entirely compatible.
Improving quality in a specific setting requires setting standards, establishing weak points in processes, designing and implementing changes to address these weaknesses, and reviewing the process to ensure processes have improved. This should then be repeated to continue the process of advancing towards an ideal situation. The PDSA cycle is a cyclical tool to support ongoing developmental changes in a process in a stepwise fashion.
Clinical indicators from bodies such as ACHS are intended as clinically meaningful measures of healthcare. They address major areas of care, focusing on various aspects of that area such as the percentage of acute myocardial infarction patients receiving thrombolysis within 1 hour, or time to analgesia or antibiotics. However, their utility may be limited by being factors that are relatively easy to measure, rather than being actual indicators of quality. In addition, investigating an improvement in one aspect of care may miss consequent deterioration in other areas due to the same intervention.
Regarding the ED overcrowding, which ONE of the following statements is TRUE?
Answer: A: Overcrowding occurs when the ED function is impaired by the number of patients waiting or undergoing assessment, treatment or disposition exceeds either the physical or staffing capacity of the department. If this occurs, emergency clinicians have a responsibility to advise hospital management that patient care could be compromised. Hospital management then has a responsibility to restore a safe working environment.
If ambulances cannot safely offload patients and return to external activity, community emergency response capacity is reduced. Bed availability is a feature not only of physical bed numbers, but of how those beds are used. Improving GP services is advocated in the hope of diverting primary care-related problems away from the ED. However, there is little evidence that this is an effective strategy. Likewise health advice lines, while popular with the public, have not been shown to reduce ED attendance, and may in some circumstances make patients more likely to attend hospital.
References:
Regarding access block, which ONE of the following statements is TRUE?
Answer: B: Access block is defined as a total ED time from arrival to transfer, admission or death of over 8 hours.Studies have shown correlation with a number of adverse impacts on healthcare, including inpatient stay, mortality and time to clinical treatments such as analgesia or antibiotics.
Access block is mainly due to systemic lack of capacity throughout a health system (i.e. a symptom of whole-system hospital overload). While strategies aimed purely at improving ED function may show short-term benefits, these are unlikely to be maintained without addressing in-hospital bed management. Some strategies such as over census beds (transferring patients awaiting beds to inpatient wards) may be effective in spreading the clinical load but may encounter resistance difficult to reach acceptance. Hospital-wide measures are dependent on leadership from senior hospital management. Facility planning should aim for an access block of 10% or less.
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