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ED Accreditation Update
Proposed leadership standard revisions emphasize resolution of conflicts among leaders
The Joint Commission has proposed revisions to its leadership standard that reinforce its emphasis on effective communication and conflict resolution between and among what it calls the "key leadership components" of a hospital: The ED manager and other department managers, ED physicians, and other organized medical staff, and the governing body.
The new proposed standard, 2.50, includes the following Elements of Performance: Criteria are used to assign primary accountability for the decisions that are the collective responsibility of the leadership components. There is a process for making decisions when a leadership component fails to fulfill its accountability. The process is implemented when required by the situation.
In addition, the revised Element of Performance for L.D. 2.40 reads as follows: Leadership components implement a process to resolve conflicts in decision making.
Conflict resolution, both between ED management and other department managers, as well as within the ED itself, is a leadership skill of growing importance, experts agree.
"It sounds like the new concept they are trying to get at is to add muscle in terms of leadership to make things happen in the area of solving problems," says Bruce Janiak, MD, FACEP, FAAP, professor of emergency medicine at the Medical College of Georgia, Augusta, and former president of the American College of Emergency Physicians (ACEP).
Nurses, doctors, administrators collaborate
The whole gist of solving problems in the ED is you have to solve them collaboratively, says Donna L. Mason, RN, MS, CEN, nurse manager at Vanderbilt University Medical Center Adult Emergency Services in Nashville, TN, and current president of the Emergency Nurses Association. "No ED has or ever will in the future be able to make unilateral decisions," Mason says. "Nursing, physicians, and hospital administration have to be collaborative and make decisions together."
The issue of overcrowding helps illustrate the need for conflict resolution skills, Janiak says. "For example, you have patients who need to go to the ICU but can't because there are no beds," he says. "The ICU physicians have a 'solution,' which is that the ED staff can manage the patients until a bed is available."
That solution, however, is not acceptable to the ED, says Janiak. "ED physicians will complain they are not trained for long-term management of ICU-type patients, and that the real solution is somewhere else in the hospital," he says.
Sometimes, Janiak says, the solution comes from some person or entity who sits above the ED director, such as the chief of staff or a senior physician executive vice president.
The problem is that such individuals often are weak decision makers, Janiak says. Because they often are not emergency physicians, they may not be sympathetic to the ED's cause, he says. "They may not side with anyone or make any decision," he says.
In the real world, he continues, the ED manager "has to be quite a politician." The clever ED manager will contact a combination of the executive committee and risk management, Janiak suggests. "They should pose the issue at hand in the following manner: 'What would be safer — to put the patient in the ICU when it is overcrowded, expand the size of the ICU, or keep them there in our ED where they take up a bed and where the doctors who manage them not are trained to handle their long-term care?'" he says.
The risk manager will quickly figure out theses patients do not have to be in the ED, Janiak maintains. "Hopefully, they will get the ball rolling to expand services, and to convince the ICU staff they should come down to the ED to manage the patients — that is, round in two places, as this would be better for the patient," he suggests.
Finding a solution
Mason agrees that overcrowding is an excellent example of interdepartmental conflict. "But I, my physician colleagues, my administrative support, and the people who can best affect crowding throughput in hospital got together in collaborative effort and found some solutions," she shares.
The interdisciplinary team outlined by Mason worked with the informatics staff to develop a computer board with color-coded markers for each patient. "Once the patient has been here for six hours, the color of their name changes and they need to go [out of the ED]," says Mason. "If we have an order for them to go to an inpatient area, there is one color; for observation, another."
With this system, ED nurses take care of only short-term admissions, while long-term admissions are sent upstairs. "The inpatients are happier because they have a bed, and we turn patients over quicker," says Mason.
There several other areas of potential conflict, such as the issue of whether nursing or CT staff perform oral contrasts, Mason says. "You have to realize that people get frustrated with the processes, not with other people," she advises.
In these collaborations, says Mason, the different parties discuss what it is about that process that is not working. "You pull groups together that are affected and make the situation better; you always look for both parties to win," she observes.
These issues are not always quickly resolved, Mason confesses. For example, the conflict with oral contrasts is ongoing. "The CT folks, instead of giving the contrast themselves, expect [ED] nurses to give it and spend an hour looking for a nurse," she notes. "We think they should give it." Discussions are taking place between the ED and CT. "We're working collaboratively to try to do what's best for the patient; we are going to win in the long run," Mason predicts.
Engender sense of teamwork
Within the ED itself, says Janiak, "the ability handle these conflicts is directly related to teamwork, which comes down from the leadership of the physician director."
"If the unit is compartmentalized, that is, 'We are doctors, you are nurses, and we don't talk to each other,' these conflicts are hard to resolve," says Janiak. "But they can be resolved if they are made to feel they are all one team, all on the same mission to improve health care."
This type of team behavior eliminates the fear of hierarchical structures, Janiak continues. "For example, doctors are taught not to yell at nurses when they ask questions," he says. This simple team approach eliminates most interdepartmental conflicts, Janiak asserts. "Show me an ED that has a number of documents about conflict resolution, and I will show you one that does not have many conflicts — because they have thought things through," he says. What would these documents contain? "They would have some reference to collaborative work, to sharing of information, and specific recommendations on how nurses and doctors are obligated to address each other when questions arise," Janiak says.
Masons says this type of approach "helps people socialize together and develop mutual respect. You must have this in the ED because you have to depend on each other to make things work in a life-and-death crisis."
For more information on conflict resolution in the ED, contact:
To download a free copy of the revised standards, go to www.jointcommission.org/Standards/FieldReviews, then scroll down to "Revised Leadership Standards Field Review."