The Department of Urology in a National Health Service (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. anaesthesia, medical records, pharmacy et cetera).
The immediate trigger for change was the combined impact of a financial crisis and new EC regulations limiting the number of hours medical staff are allowed to work.
Factors contributing to the financial crisis. In 1997 the UK government introduced new regulations which required all NHS hospitals to treat non-emergency patients within eighteen weeks. Financial penalties were introduced for failing to comply with the 18-week referral-to-treatment target. The Urology Department was unable to meet this target with its in-house resources and responded by sub-contracting 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 Department 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, realised that there was a problem. Managers were criticised for not sharing this information earlier.
Factors contributing to the shortage of medical staff. In October 1998, the European Working Time Directive (EWTD) was incorporated into UK law but full implementation was delayed. An interim target was that all junior doctors would work a maximum 56-hour week by 2007. Full implementation was set for August 2009 when a 48-hour week was introduced. The 48 hour week has led to staffing problems that have significantly compromised the department’s 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 threatened 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 middle-grade medical staff that does not compromise patient care or training. They have also agreed that this will 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 bed, 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 staff to ignore messages with the result that important information is not always disseminated effectively.
The slow response of 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 theatres, but the results of a survey of six month’s activity are still not available despite this being crucial to determining the potential throughput of patients.
The poor quality of the data collected 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 department’s financial problem.
Finally, plans to increase the numbers 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 department’s financial position and the need to stop sub-contracting 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 that there is a more pressing problem that has to be addressed first. They argue that middle and junior grade 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 to ensure that 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.