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, such as anaesthesia, medical records and pharmacy. The immediate trigger for change was the combined impact of a financial crisis and the full implementation of the European Working Time Directive (EWTD), the new European Commission regulations limiting the number of hours that medical staff are allowed to work. Factors contributing to the financial crisis The UK Government introduced new regulations requiring 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-treatment target. The urology department was unable to meet this target with its in-house resources and responded by 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 Fullimplementation of the EWTD was delayed for several years, and the urology department was only required to comply with an interim target that restricted junior doctors to working a maximum 56-hour week. When, eventually, the EWTD was fully implemented and a maximum 48-hour week was imposed, this 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 practise 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: Bring the work currently being performed in the private hospital back into the urology department Provide an EWTD-compliant roster for junior and middile level 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 (the number of beds and operating theatres) and to 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: Tension hetween 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 patients' needs. 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. ailure to_agree about the extra beds, opera will_be required to treat all patients in-house Some members of the executive team believe that better utilisation 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 toimprove the efficiency of the operating theatres and make better use of staff time. Information overioad Emails are regularly cascaded from the senior executive team toall staff about a wide range of matters. This has led some staff to ignore messages, with the resuit that important information is not always disseminated effectively. The slow response of those who have been asked to investigate problems and For example, a departmental theatre efficiency group was formed to improve the efficiency of operating theatres, but the results of a six-month survey of activity are still not available, despite this being crucial to determining the potential throughput of patients. Ppart of their normal work For example, medical procedures are often coded incorrectly. This makes it difficult to forecast future income. It also has resulted in loss of income in the past, thereby contributing to the department's financial problems. ment t thenumber an i There are two conflicting views. Managers concerned about the department's 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 staff who believe that there is a more pressing problem that must be addressed immediately. These staff 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 will ensure that the work rosters 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. Question : As the nursing director you must now position staff in the urology department for the changes that will take place in the future. Each of the situational issues outlined in the case study (in italics) are examples of ineffective communication. Utilising information from the 'communications' lecture material, how would you ensure the situational issues are addressed? (500 words)