Organisation and management - PACT - ESICM

AN ESICM MULTIDISCIPLINARY DISTANCE LEARNING PROGRAMMEFOR INTENSIVE CARE TRAININGOrganisation and managementProfessionalismUpdate 2012Module Authors (Update 2012)Pascale GRUBERAndrew JACQUESCritical Care Medicine, The Royal Marsden NHSFoundation Trust, London, UKIntensive Care Medicine, Royal Berkshire NHS Trust,UKModule Authors (first edition)William Sibbald, Department of Medicine, Sunnybrook & Women’s HealthSciences Centre, University of Toronto, Toronto, CanadaAndrew Webb, Medical Directors’ Offices, UCL Hospitals, London, UnitedKingdomModule ReviewersSection EditorTimothy Evans, Andrew Webb, Janice ZimmermanCarl Waldmann

Organisation and managementUpdate 2012Editor-in-ChiefDeputy Editor-in-ChiefDermot Phelan, Dept of Critical CareMedicine, Mater Hospital/University CollegeDublin, IrelandAnne Berit Guttormsen, Bergen, NorwayMedical Copy-editorSelf-assessment AuthorEditorial ManagerBusiness ManagerChair of Education and TrainingCommitteeCharles Hinds, Barts and The London Schoolof Medicine and DentistryHans Flaatten, Bergen, NorwayKathleen Brown, Triwords Limited, Tayport,UKEstelle Flament, ESICM, Brussels, BelgiumMarco Maggiorini, Zurich, SwitzerlandPACT Editorial BoardEditor-in-ChiefDeputy Editor-in-ChiefRespiratory failureCardiovascular critical careNeuro-critical careCritical Care informatics,management and outcomeTrauma and Emergency MedicineInfection/inflammation and SepsisKidney Injury and Metabolism.Abdomen and nutritionPeri-operative ICM/surgery andimagingProfessional development andEthicsEducation and assessmentConsultant to the PACT BoardDermot PhelanAnne Berit GuttormsenAnders LarssonJan Poelaert/Marco MaggioriniMauro OddoCarl WaldmannJanice ZimmermanJohan GroeneveldCharles HindsTorsten SchröderGavin LaveryLia FluitGraham RamsayCopyright© 2012. European Society of Intensive Care Medicine. All rights reserved.

LEARNING OBJECTIVESAfter studying this module on Organisation and management, you should be able to:1. Understand organisational factors that are associated with improved ICUperformance, patient safety and outcome2. Understand the importance of managing and leading in intensive care3. Describe key functions of a physician-manager and physician-leader4. Use leadership and team building to solve problems and improve ICU performanceFACULTY DISCLOSURESThe authors of this module have not reported any disclosures.DURATION 7 hoursCopyright©2012. European Society of Intensive Care Medicine. All rights reserved.

ContentsIntroduction ..................................................................................................................... 11/ The ICU clinical service .............................................................................................. 3Levels of ICU care ....................................................................................................... 3Structural or organisational requirements of ICUs ................................................ 3Size of the ICU ......................................................................................................... 4Regionalisation of ICU services .............................................................................. 4Sub-speciality ICUs ................................................................................................. 5Open versus closed ICUs ......................................................................................... 6Staffing .................................................................................................................... 6Organisational factors contributing to an improved ICU clinical service ............... 102/ Planning, budgeting and financial management .................................................... 12Planning .................................................................................................................... 12‘Strategic’ vs annual ‘budget’ planning ..................................................................... 13Strategic planning ................................................................................................. 13Annual budget planning ......................................................................................... 15Budgeting ................................................................................................................... 17Managing the ICU budget ...................................................................................... 17Types of ICU budgets ............................................................................................. 17Budget monitoring ................................................................................................ 18Financial management ............................................................................................. 19For-profit ............................................................................................................... 19Not-for-profit ........................................................................................................ 19Government-funded .............................................................................................. 203/ Control, audit and quality improvement ................................................................. 22Output (outcome) control ..................................................................................... 22Process control ...................................................................................................... 22Input (structure) control ....................................................................................... 234/ Policies, guidelines and procedures ........................................................................ 325/ Human resource management ................................................................................ 35Hiring ........................................................................................................................ 35Orientation ................................................................................................................ 35Retention ................................................................................................................... 35Performance reviews ................................................................................................. 35Employee assistance programmes............................................................................ 396/ The role of the physician-manager .......................................................................... 40The job description of an ICU physician-manager .................................................. 40

Roles and functions of an ICU physician-manager .................................................. 42Roles ...................................................................................................................... 42Functions ............................................................................................................... 42Relationships of an ICU manager ......................................................................... 46Hierarchy of hospital management .......................................................................... 477/ Leadership in the ICU .............................................................................................. 48Leadership in context ............................................................................................... 49Approaches to leadership ......................................................................................... 50Trait ....................................................................................................................... 50Situational ............................................................................................................. 50Transformational and transactional leadership .................................................... 51Leadership attributes that contribute to success .................................................. 53Using power... effectively and judiciously ................................................................ 548/ Managing teams and teamwork in the ICU............................................................. 55Why is teamwork important in intensive care?........................................................ 55Types of teams........................................................................................................... 56Motivation ................................................................................................................. 57Cohesion .................................................................................................................... 57Characteristics of effective teams ............................................................................. 58Communication strategies to improve teamwork ................................................ 59Use of effective leadership to improve teamwork ................................................ 60Coordination strategies used to improve teamwork ............................................ 60Effective decision-making strategies to improve teamwork ................................ 61Using teams to solve problems ............................................................................. 61Managing conflicts in ICU ........................................................................................ 63Conclusion .................................................................................................................... 66Appendix ....................................................................................................................... 67Additional resources ................................................................................................. 67Textbooks .............................................................................................................. 67Patient challenges ......................................................................................................... 68

INTRODUCTIONTraditionally much of the focus in intensive care has been on the clinical aspects,such as novel drugs therapies and technology improvements to facilitate organsupport. Yet the goal of delivering high-quality care requires intensive care physiciansto engage more broadly in aspects of patient care that go beyond the bedside. Thisrequires a comprehensive understanding of the key principles underlying effectiveintensive care unit (ICU) organisation and management.Intensive care is an expensive resource with up to 0.5–1% of gross domestic productand 20% of hospital budgets allocated to intensive care in Western countries. Its highcost means that it is often under scrutiny by governmental and private fundingagencies that look to ensure that ICUs are providing best ‘value for money’. Forexample, in the United States key stakeholders involved in intensive care deliveryagreed on reform priorities regarding organisation and management of ICUsincluding:Standardising performance by creating practice management guidelinesfor staffing, training, and work with centralised supervision of compliance.Development of incentive-based, performance-related methods ofreimbursement.Increasing public awareness and understanding of intensive care.Regionalisation of the adult intensive care system based on local needs,capabilities, and professional competencies.Training of non-intensive care physicians to relieve manpower shortages.Nguyen YL, Wunsch H, Angus D. Critical care: the impact of organization andmanagement on outcomes. Curr Opin Crit Care 2010; 16(5): 487–492. PMID20689418Barnato AE, Kahn JM, Rubenfeld GD, McCauley K, Fontaine D, Frassica JJ, et al.Prioritizing the organization and management of intensive care services in theUnited States: the PrOMIS Conference. Crit Care Med 2007; 35(4): 1003–1011.PMID 17334242The demand for intensive care services continues to rise as lifeexpectancy, healthcare technology and patient expectations increase.At a time when nearly every country is facing a period in which thefunding for healthcare is coming under pressure, this poses a uniquechallenge. ICU physician-managers are increasingly being asked todevelop process improvements that result in enhanced resourceutilisation and better patient outcomes. These ‘challenges’ aremanaged more effectively when the workforce has been trained inhealthcare management. Healthcare management and leadershiptraining are increasingly being considered as an essential part ofunder- and postgraduate medical education.The need forintensive caretrainees to bothstudy and practisethe principles ofhealthcaremanagement andleadership is greaternow than in anyprevious generationof ICU physicians.1

Gillam S. Teaching doctors in training about management and leadership. BMJ 2011;343: d5672. PMID 21914758NHS Institute for Innovation and Improvement and Academy of Medical RoyalColleges. Medical Leadership Competency Framework. 2nd ed. Coventry: NHSInstitute for Innovation and Improvement; 2009. ISBN-978-1-906535-91-9http://www.fmlm.ac.uk/resources/articleshttp://www.futurehealth.ucsf.eduThis module provides an introduction to ICU organisation and management. Itacquaints the reader with generic management and leadership concepts essential tothe understanding of the organisational environment within which the ICUphysician-managers or leaders function, provide tools that can used on a day-to-daybasis (e.g. planning, organising, decision-making, staffing, controlling, motivating,leading, directing) and establishes a basis for further study in the field of healthcaremanagement. Many of the principles outlined in this module relate to genericorganisational and leadership practices, with citations from classic healthcareliterature. The authors fully acknowledge that cultural differences do exist but thesedifferences should not override universal standards of good healthcare practiceswhich are to deliver safe, effective, efficient, and patient-centred care. Wherepossible, research studies relating to contemporary healthcare management onpragmatic issues of concern to intensive care physicians have been included. Asresearch into some of these topics still remains ‘novel’, this module also uses nonhealthcareliterature to include lessons from industry which we believe are applicableto intensive care.This module is divided into key sections.1. The ICU clinical service2. Planning, budgeting and financial management3. Control, audit and quality improvement4. Policies, guidelines and procedures5. Human resource management6. Role of the physician-manager7. Leadership in the ICU8. Managing teams and teamwork in the ICUEach section is intended to stand alone; sections are not sequential and may beaddressed in any order.2

1/ THE ICU CLINICAL SERVICEThe ICU service cannot be considered in isolation. The ICU service must take intoaccount the needs of other clinical service groupings (i.e. medicine and surgery) itsupports within the hospital, regional healthcare services and the local population.This is important for planning and operational purposes. For example, an ICU in ahospital that is a regional trauma centre will have different requirements for staffexpertise, technology and clinical support (i.e. vascular surgery, interventionalradiology, pathology) compared to a general ICU. Not all hospitals develop their ICUfacilities in the same way and ICU must be able to adapt to the needs of the hospitaland the population they serve in terms of size, staffing and technology.Patients who benefit from ICU admission can be divided into those who are:At risk of deterioration of one or more vital organ functions requiringintense monitoring and treatment that cannot be provided on the regularward.Patients who require treatment for established failure of one or more vitalorgan functions such as cardiovascular, respiratory, renal, metabolic orcerebral function.Levels of ICU careTraditionally adult ICUs are classified into three levels of care:Level I: patients at risk or recovering from vital organ dysfunctionnecessitating intense monitoring and treatment whose condition is toounstable to be managed on the regular ward. These patients are at risk ofdeveloping one or multiple organ failures.Level II: patients requiring monitoring and pharmacological and/ordevice-related support (e.g., haemodynamic support, renal replacementtherapy) of one vital organ system with a life-threatening character.Level III: patients with multiple (>2) life-threatening vital organ failure.These patients depend on pharmacological as well as device-related organsupport (e.g. haemodynamic support, respiratory assistance or renalreplacement therapy).Several levels of care can be integrated into the same ICU in a flexible organisationalmodel providing that the ICU is capable of providing level III care.Structural or organisational requirements of ICUsRecommendations on basic structural and organisational requirements of ICUs areoutlined in the reference below.3

with resources and expertise to deliver high-quality care. It may have the additionalbenefit of cost savings by taking advantage of the economies of scale, as higher casevolumes are associated with lower per-patient costs. A successful regionalisedhealthcare system requires a number of key components:Identification of regional centres by location and resources.A robust system to reliably identify high-risk patients.Timely and safe transfer to regional centres.Support for post-acute care, such as access to step-down units or amechanism to transfer patients back to their hospitals of origin.Disadvantages include the potential to worsen clinical outcomes duringtransportation of critically ill patients to regional centres particularly if transfer timesare long or difficult, the possibility that resources at regional centres may becomeoverwhelmed and finally, regionalisation within sub-specialty ICUs may lead to lossof skills and experience, limiting flexibility of staff.Kahn JM, Goss CH, Heagerty PJ, Kramer AA, O’Brien CR, Rubenfeld GD. Hospitalvolume and the outcomes of mechanical ventilation. N Engl J Med 2006;355(1): 41–50. PMID 16822995Peelen L, de Keizer NF, Peek N, Scheffer GJ, van der Voort PH, de Jonge E. Theinfluence of volume and intensive care unit organization on hospital mortalityin patients admitted with severe sepsis: a retrospective multicentre cohortstudy. Crit Care 2007; 11(2): R40. PMID 17378934Lecuyer L, Chevret S, Guidet B, Aegerter P, Martel P, Schlemmer B, et al. Case volumeand mortality in haematological patients with acute respiratory failure. EurRespir J 2008; 32(3): 748–754. PMID 18448491Glance LG, Li Y, Osler TM, Dick A, Mukamel DB. Impact of patient volume on themortality rate of adult intensive care unit patients. Crit Care Med 2006; 34(7):1925–1934. PMID 16715030Sub-speciality ICUsICU beds in hospitals may be organised into separate sub-specialty ICUs such asmedical, surgical, burns, neurosurgical and cardiac or a single general ICU. MostICUs in Europe (74%) are mixed medical and surgical. Sub-specialty ICUs mayimprove outcomes by reduction of practice variability and use of specialist skillshowever, there is evidence to suggest that risk adjusted mortality and length of stay issimilar for patients treated in general and sub-specialty ICUs.Lott JP, Iwashyna TJ, Christie JD, Asch DA, Kramer AA, Khan JM. Critical illnessoutcomes in speciality versus general intensive care units. Am J Respir Crit CareMed 2009; 179(8): 676–683. PMID 192019235

Open versus closed ICUsIn the open ICU model, primary admitting physicians direct care of patients withinput from intensive care physicians via consultation. In contrast, in the closed ICUmodel, intensive care physicians are primarily responsible for patient care.Admission, discharge and referral decisions are managed by intensive care physiciansin the closed ICU model. Data has demonstrated that a closed ICU is associated withbetter patient outcomes, shorter lengths of ICU and in-hospital stay, improvedefficiency and lower costs.Carson SS, Stocking C, Podsadecki T, Christenson J, Pohlman A, MacRae S, et al.Effects of organizational change in the medical intensive care unit of a teachinghospital: a comparison of ‘open’ and ‘closed’ formats. JAMA 1996; 276(4): 322–328. PMID 8656546Multz AS, Chalfin DB, Samson IM, Dantzker DR, Fein AM, Steinberg HN, et al. A“closed” medical intensive care unit (MICU) improves resource utilization whencompared with an “open” MICU. Am J Respir Crit Care Med 1998; 157(5 Pt 1):1468–1473. PMID 9603125Hanson CW 3rd, Deutschman CS, Anderson HL 3rd, Reilly PM, Behringer EC, SchwabCW, et al. Effects of an organized critical care service on outcomes and resourceutilization: a cohort study. Crit Care Med 1999; 27(2): 270–274. PMID10075049Ghorra S, Reinert SE, Cioffi W, Buczko G, Simms HH. Analysis of the effect ofconversion from open to closed surgical intensive care unit. Ann Surg 1999;229(2): 163–171. PMID 10024095StaffingConsider the advantages and disadvantages of a closed versus open ICU model.The optimal level of staffing will depend on the type and size of the ICU. There isgood evidence that quality of ICU care is strongly influenced by the organisation ofmedical and nursing staff on the ICU. The ICU team should be led by the ICUDirector, a physician-manager, who has the responsibility for the administrative andmedical management of the unit and the Head Nurse who is responsible for thefunctioning and quality of the nursing care.Medical staffPhysician staffing patterns in ICUs vary markedly between different countries. MostICUs in Europe have 24-hour intensivist coverage but 25–30% of ICUs still do not. InEurope, Italy and Spain have the highest number of ICUs with full-time intensivistcoverage. Only 67% of ICUs have a dedicated full-time ICU physician-manager. In theUnited States intensivist coverage is provided in only half of ICUs during weekdaydaylight hours and less outside this period (20% during weekend days, 12% duringweeknights, and 10% during weekend nights).See Figure 1 in the Vincent et al. reference, below.6

Vincent JL, Suter P, Bihari D, Bruining H. Organization of intensive care units inEurope: lessons from the EPIC study. Intensive Care Med 1997; 23(11): 1181–1184. PMID 9434928. Full text.Angus DC, Shorr AF, White A, Dremsizov TT, Schmitz RJ, Kelley MA; Committee onManpower for Pulmonary and Critical Care Societies (COMPACCS). Criticalcare delivery in the United States: distribution of services and compliance withLeapfrog recommendations. Crit Care Med 2006; 34(4): 1016–1024. PMID16505703Studies have shown that ICUs with daytime high-intensity physician staffing(mandatory intensivist consultation or closed ICU model) have lower in-hospitalmortality, iatrogenic complications, lengths of hospital stay, hospital costs and postoperativecomplications compared to low-intensity physician staffing (no intensivistor elective intensivist consultation). Patients receiving care under intensivists are alsomore likely to receive evidence-based standard care (e.g. deep vein thrombosis andstress ulcer prophylaxis).The Leapfrog Group, a business consortium of more than 150 private and publichealthcare sector purchasers in the United States, recommended that board-certifiedcritical care specialists should be available during daytime hours and be able toreturn pager calls within five minutes and arrange an ICU physician extender toreach the patient within five minutes. The group estimated that applying ICUphysician safety staffing standards could save more than 54,000 lives in the UnitedStates each year.Dimick JB, Pronovost PJ, Heitmiller RF, Lipsett PA. Intensive care unit physicianstaffing is associated with decreased length of stay, hospital cost, andcomplications after esophageal resection. Crit Care Med 2001, 29(4): 753–758.PMID 11373463Pronovost PJ, Jenckes MW, Dorman T, Garrett E, Breslow MJ, Rosenfeld BA, et al.Organizational characteristics of intensive care units related to outcomes ofabdominal aortic surgery. JAMA 1999; 281(14): 1310–1317. PMID 10208147Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Physicianstaffing patterns and clinical outcomes in critically ill patients: a systematicreview. JAMA 2002; 288(17): 2151–2162. PMID 12413375Kahn JM, Brake H, Steinberg KP. Intensivist physician staffing and the process of carein academic medical centres. Qual Saf Health Care 2007; 16(5): 329–333. PMID17913772Levy MM, Rapoport J, Lemeshow S, Chalfin DB, Phillips G, Danis M. Associationbetween critical care physician management and patient mortality in theintensive care unit. Ann Intern Med 2008; 148(11): 801–809. PMID 185199267

Q. Review the references cited above and identify at least three outcomesof an intensivist-led ICU model of clinical care delivery that areimproved.A. An intensivist-led model of ICU care has been reported to be associated with:Lower risk of cardiac arrest, acute renal failure, septicaemia and reintubationReduced hospital length of stayLower hospital and ICU mortalityReduction in resource usePatients more likely to receive evidence-based careWith daytime high-intensity physician staffing consistently associated with improvedoutcomes there has been a call for expansion to be able to offer this service 24/7.Studies have shown improvements in processes of care, staff satisfaction and adecrease in ICU complication rate and hospital length of stay following introductionof 24/7 intensivist coverage. Proponents of 24/7 hour intensivist staffing suggest thatnight-time intensivist staffing may result in earlier establishment of treatment plans,more timely resuscitation of unstable patients and more consistent bedside medicaldecision-making at all hours of the day. However, this still remains controversial.Wallace et al. demonstrated that addition of night-time intensivist staffing in ICUswith high-intensity daytime staff did not lead to a reduction in in-hospital mortality,only in those ICUs with low-intensity staffing during the day.Gajic O, Afessa B. Physician staffing models and patient safety in the ICU. Chest 2009;135(4): 1038–1044. PMID 19349399Arabi Y. Pro/Con debate: should 24/7 in-house intensivist coverage be implemented?Crit Care 2008; 12(3): 216. PMID 18557996Blunt MC, Burchett KR. Out-of-hours consultant cover and case-mix-adjustedmortality in intensive care. Lancet 2000; 356(9231): 735–736. PMID 11085695Wallace DJ, Angus DC, Barnato AE, Kramer AA, Kahn JM. Nighttime intensiviststaffing and mortality among critically ill patients. N Engl J Med 2012; 366(22):2093–2101. PMID 22612639TelemedicineThe shortage of intensivists has also led to the increasing use of telemedicinetechnology. Telemedicine uses a combination of video-conferencing technology,telemetry and an electronic medical record to allow off-site intensivists to assist inthe management of critically ill patients. The most comprehensive systems use a teamof physicians and critical care nurses who continuously monitor patients’physiological parameters, order laboratory and radiographic studies, initiatepreventive treatments (e.g., stress ulcer prophylaxis), and aid in diagnosis andtreatment plans. The effectiveness of telemedicine is closely dependent on:How the telemedicine is used by the remote physicians and critical carenurses to alter care in the monitored units.Acceptance.Telemedicine technology.8

The impact of telemedicine is unclear with some studies demonstrating reductions inin-hospital mortality and lengths of stay.Thomas EJ, Lucke JF, Wueste L, Weavind L, Patel B. Association of telemedicine forremote monitoring of intensive care patients with mortality, complications, andlength of stay. JAMA 2009; 302(24): 2671–2678. PMID 20040555Young LB, Chan PS, Lu X, Nallamothu BK, Sasson C, Cram PM. Impact of telemedicineintensive care unit coverage on patient outcomes: a systematic review and metaanalysis.Arch Intern Med 2011; 171(6): 498–506.PMID 21444842Nursing staffNursing staff account for the majority of the ICU workforce. There is large variabilityacross ICUs in nurse-to-patient ratios, ranging from 1:1 in some ICUs to as high as 1:4in other units. The number of intensive care nurses necessary to provide appropriatecare and observation should be calculated according to the levels of care and WorkUtilisation Ratio (or similar instrument). Studies on the impact of nurse-to-patientratios in the hospitals have suggested that lower nurse-to-patient ratios areassociated with higher rates of complications.Moreno R, Reis Miranda D. Nursing staff in intensive care in Europe: the mismatchbetween planning and practice. Chest 1998; 113(3): 752–758. PMID 9515853Amaravadi RK, Dimick JB, Pronovost PJ, Lipsett PA. ICU nurse-to-patient ratio isassociated with complications and resource use after esophagectomy. IntensiveCare Med 2000; 26(12): 1857–1862. PMID 11271096Kovner C, Jones C, Zhan C, Gergen PJ, Basu J. Nurse staffing and postsurgical adverseevents: an analysis of administrative data from a sample of U.S. hospitals,1990–1996. Health Serv Res 2002; 37(3): 611–629. PMID 12132597Allied health professionalsICU staffing needs must also take account of the widermultidisciplinary team including dietitians, physiotherapists,pharmacists and occupational therapists who are all an integral partof the ICU service. The optimal levels of staffing of allied healthprofessionals in an ICU are variable and closely dependent on theneeds of the service. For example, the staffing of an academic ICUwith a lot of teaching, research and a regional retrieval service maynot be the same in a non-academic ICU, even if the number and levelof ICU beds is similar.The presence of apharmacist on ICUrounds andcomputerised physicianorder entry have beenshown to be associatedwith a substantiallylower rate of adversedrug errors.9

Leape LL, Cullen DJ, Clapp MD, Burdick E, Demonaco HJ, Erickson JI, et al.Pharmacist participation on physician rounds and adverse drug events in theintensive care unit. JAMA 1999; 282(3): 267–270. PMID 10422996Bates DW, Leape LL, Cullen DJ, Laird N, Petersen LA, Teich JM, et al. Effect ofcomputerized physician order entry and a team intervention on prevention ofserious medication errors. JAMA 1998; 280(15): 1311–1316. PMID 9794308Organisational factors contributing to an improved ICUclinical serviceStudies exploring the effects of organisation on effectiveness and efficiency of ICUs inEurope have demonstrated marked variability in practice often resulting in wastedresources and performance inefficiencies.Reis Miranda D, Ryan DW, Schaufeli WB, Fidler V (eds). Organization andManagement of Intensive Care. A Prospective Study in 12 European Countries.Berlin and Heidelberg: Springer-Verlag; 1997A number of ICU structural and organisational factors have been associated withbetter ICU performance, patient safety and outcome:Effective multidisciplinary teamwork.Higher volume of patients coming through the ICU.A closed unit model.High-intensity ICU physician coverage.Presence of a full-time ICU Director.Higher nurse-to-patient ratios.Having a pharmacist participate in daily rounds in the ICU.Reduction in investigations that do not change clinical management.Implementation of evidence-based protocols and guidelines.Use of computer-based alerting and reminding systems.Randolph AG, Pronovost P. Reorganizing the delivery of intensive care could improveefficiency and save lives. J Eval Clin Pract 2002; 8(1): 1–8. PMID 11882096Zimmerman JE, Shortell SM, Rousseau DM, Duffy J, Gillies RR, Knaus WA, et al.Improving intensive care: observations based on organizational case studies innine intensive care units: a prospective, multicenter study. Crit Care Med 1993;21(10): 1443–1451. PMID 8403951Based on data collected on almost 18,000 patients in 42 ICUs, Shortell andcolleagues found that superior organisational practices among ICUs were related tofour characteristics:10

A patient-centred culture.Strong medical and nursing leadership.Effective communication and coordination.Open, collaborative approaches to problem-solving and conflictmanagement.From a more traditional outcomes-based assessment of an ICU’s performance,Shortell’s research also found that promoting good interdisciplinary teamwork, teamcoordination and conflict management by an ICU’s leadership team, was associatedwith:Lower nurse turnover.A lower risk-adjusted length of stay.A greater ability to meet needs of family members.Shortell SM, Zimmerman JE, Rousseau DM, Gillies RR, Wagner DP, Draper EA, et al.The performance of intensive care units: does good management make adifference? Med Care 1994; 32(5): 508–525. PMID 818297811

2/ PLANNING, BUDGETING AND FINANCIALMANAGEMENTPlanningPlanning is an important activity that an ICU physician-manager undertakes. To besuccessful, an ICU physician-manager must have a clear vision of the short-and longtermplans for the ICU. Planning for the ICU involves determining its direction by:a/ creating objectivesb/ designing and implementing strategies to achieve the objectives.Planning for the ICU is important because it:Makes the physician-manager focus on outputs. This means that all ICUactivity should be directed to achieving predefined objectives (or outputs).Enables the ICU physician-manager to develop priorities and make betterdecisions about allocating available resources.It enables the ICU physician-manager to both measure progress anddetermine whether expected results are being achieved.The ICU physician-manager should not decide what the ICU needs (e.g. staff,consumables) until decisions have been made about what the ICU’s objectives are.Planning cycleGood planning requires focus onwhat the ICU wants to do (alsoreferred to as ‘outputs’). Forexample, outputs could refer toefficient patient care, leadership inteaching, and/or creating a ‘worldclass’ programme in healthservices research. Once a plan hasbeen developed to describe whatthe ICU team wants to achieve,inputs and processes are linkedwith goals. Importantly, constantevaluation (the feedback loop) ismaintained to ensure that prespecifiedgoals are beingaccomplished.Planning is never complete. Once created, ongoing surveillance is maintained by thephysician-manager to identify factors that might be considered as necessitating achange in the plan. Stated differently, a successful physician-leader understands thatadaptive change is critical to his/her success and to the success of the ICU team.12

Q. Describe examples of inputs and processes controlled by the ICUphysician-manager to achieve desired outputs.A. Inputs include resources such as device technology (monitoring, mechanical ventilators,dialysis machines), number of beds, staff, support services (blood gas laboratory, statlaboratory), organisational characteristics, (nursing skills, ‘open’ versus ‘closed’ ICU status,composition and experience of the ICU team).Processes include how communication occurs in the ICU, how the team is formulated, howdecision-making is formulated and conflict is managed.‘Strategic’ vs annual ‘budget’ planningThere are two types of planning which are differentiated by their time frames. TheICU’s strategic plan, typically known as the 5-year plan, are long-term goals andobjectives. The ICU’s budget plan is short-term, usually developed on an annualbasis. To create an annual budget, the ICU physician-manager should take his staffand colleagues through a process of determining goals and objectives for that year,after which the budget is developed to support the short-term goals.Strategic planningStrategic planning is both externally and internally focused. Outcomes of strategicplanning include development of a vision, a mission statement, objectives andpolicies and procedures. Strategic planning involves three steps, which areundertaken in sequence:A strategic assessmentFormulating objectivesMaking strategic choicesA strategic assessmentA strategic assessment involves gathering information from several sources,compiling and evaluating this information and making assumptions about the future.Also referred to as an ‘environmental analysis’, this first step forces the physicianmanagerto analyse and understand trends, both internal and external to the ICU. Forexample, an environmental analysis ten years ago would have considered the impactof information technology on ICU care.‘Threats’ identified in the environmental analysis are events that could adverselyimpact on the ICU’s future, for example, changes in reimbursement, staffing and/orin the introduction of new technologies.THINK Consider your strategy – how would you plan for the changes in working hours asa result of the European Working Time Directive. How do you ensure that the ICUremains adequately staffed, patient safety is maintained and training of future intensivecare physicians is supported?In the strategic assessment, the ICU physician-manager also tries to identify future‘opportunities’. For example, changes in research funding opportunities throughindustry might cause you to consider a strategy that emphasises recruitment of new13

ICU staff physicians with expertise in clinical trials. New technologies may beintroduced into intensive care that require special skill sets for clinicians using thesetechnologies. An example would be echocardiography. Should your strategic planconsider recruiting an ICU physician who has been trained in the use ofechocardiography?When undertaking the environmental analysis, the ICU physician-manager mustmake an candid examination of the ICU’s strengths (for example, national level ofaccreditation as a training centre, the qualifications of its professional and clinicalstaff, its capacity to do research, and the range of life-support programmes itprovides) and weaknesses (for example, does the ICU have outdated equipment, apoor reputation for doing industry-related research, or excessive physicianattrition?).ICU.Identify the S.W.O.T. (strengths, weaknesses, opportunities and threats) for yourFormulating objectivesAfter completing a S.W.O.T. analysis, the planning process shouldinclude the creation of a mission and vision statement. Followingthis, goals and objectives for the ICU are formulated.Goals are simply aclearer statement ofthe vision,specifying theaccomplishments tobe achieved if thevision is to becomereal.A mission statement describes the purposes for which the ICU exists. It summariseswhat the ICU team aspires to achieve – and the vision of what their future should be.A compelling mission statement mobilises and motivates the ICU team in focusingtheir activities, collectively, in support of the mission. It helps translate energies intoa team-based approach where the team’s futures are considered more important thanthe individuals. Essential elements that a mission statement needs to capture include:What is the ICU?Why does the ICU exist?Who is the ICU’s constituency?An example of a mission statement from an oncological ICU might be:‘Our primary goal is to provide safe, effective, patient-centred, high-quality care to allcancer patients suffering from critical illness.’Objectives are statements of the results that an ICU seeks to achieve. They describehow the mission will be accomplished and give direction to the ICU’s activities.Objectives must be ‘S.M.A.R.T.’: specific, measureable, achievable, relevant andtimely. They should also:Enable the physician-manager to work toward specific endpoints.Provide prioritising criteria for decision-making around the ICU’s clinicaland academic programmes.14

Give ICU colleagues and co-workers a sense of direction as this creates asense of stability which is particularly important in the turbulence of thecurrent economic climate.Stakeholders should be included by the physician-leader when developing both longtermand annual ICU objectives. Broadly speaking, the typical ICU has three types ofstakeholders:Internal (e.g. the ICU staff).Interface (e.g. patients’ families, other clinical departments in thehospital).External (e.g. agencies funding the ICU’s activities, such as governmentand private insurers).Making strategic choicesAfter creating the ICU’s mission statement and objectives, the planning process thenneeds to identify strategies that will lead to achieving the unit’s objectives. Strategiesare broad general programmes designed by the ICU to meet its objectives, andgenerally require a commitment of resources. Examples include:Changing the scope of ICU services. For example, this could includeadding echocardiography services to the ICU teams’ skills (contrasted withobtaining echocardiography through consultation with Cardiology).Diversifying services the ICU provides. For example, the ICUplanning process might identify opportunities in providing pre-operativeevaluation of patients projected for admission to the ICU.Integrating ICU activities within other programmes. For example,the ICU planning process might identify opportunities for sharing staff instrategies with other special care units in the hospital, such as step-downunits and operating theatre recovery areas.Annual budget planningThe ICU annual operating budget describes, for example, expenses relating tostaffing, equipment and operating technology. To be successful, ICU physicianmanagersneed to participate in the planning and managing of the ICU’s operatingbudget, even if they are not directly accountable for the budget.How does an annual operating budget relate to the ‘planning’ functions of an ICUphysician-manager? It translates objectives identified in a strategic plan tooperational implementation, thereby creating a financial roadmap of its activities.For example, the ICU’s strategic plan might have identified the addition of noninvasiveventilation services to its patient care activities. The annual operating budgetwould then ‘translate’ this objective into the expenditure required to train staff orpurchase equipment.When developing the operating budget, the ICU physician-manager needs to make anumber of assumptions. For example, the number of cases likely to be referred to theICU for care should be considered, using consultation with other services andmonitoring from historical trends. The hospital’s senior management team is a goodplace to begin, asking them to project the anticipated ICU activity levels for the15

udgetary year under consideration. Consultation with other services, for example,the Department of Respiratory Medicine, should identify the number of cases theyanticipate might be referred to the ICU for non-invasive ventilation.One way to do this is to create a survey document for circulation to stakeholdersbefore the budget building process begins. The document should ask groups such as:Senior Management if the hospital is planning the addition of newprogrammes or services that might impact on the ICU (e.g. regional centrefor trauma, neurosurgery).Clinical departments whose patients are admitted to the ICU, if they haveadded any new staff whose skills include the provision of procedures thatmight require ICU care (e.g. new appointment of vascular surgeon,interventional radiologist).The ICU budget development process is also the time when cost pressures need to beidentified and assumptions made with regard to the total impact. For example,contract negotiations with the hospital’s nursing service might raise staff wages.Other sources of cost pressures that need to be identified in the budget buildingprocess include:a/ anticipated changes in drug pricesb/ anticipated changes in reimbursement from insurers (government and/or private)c/ anticipated changes in physician remuneration levelsd/ the cost of investing in new technologiese/ repairs and renewal of service contracts for existing equipmentTHINK Consider that you are asked to develop an annual budget for your ICU. Think ofassumptions you would make if the hospital’s management team said they would provideresources to add two more beds to the total ICU bed complement.It is also good practice during the annual budget planning to think about costefficiency. ICU costs may be reduced by providing more activity for the same budgetor providing the same amount of activity for less costs. Cost improvementprogrammes encourage physician-managers to develop new ways and techniquesto provide care. This may involve looking at ways to streamline processes, decreaseinefficiencies and improve pathways of care for critically ill patients. In somehospitals, an incentive programme is employed to encourage innovative thinking inthis area. For example, strategies to reduce unit costs, if successful, might lead tosenior management returning to the ICU some of the savings for activities such aspurchase of new technologies and educational programmes for the staff.THINK Consider approaches to providing care in your ICU that would allow you toreduce costs, while keeping the same patient throughput as in the previous year andmaintaining high-quality care.Q. Describe examples of ICU cost improvement initiativesA.1. Flexible working and facilitating personal development to increase permanent staffretention thus reducing the dependence on temporary staff (who may be more expensive).2. Flexible staff rotas dependent on ICU activity.3. Re-negotiation of service contracts for medical equipment.16

4. Review of stock and equipment.5. Bulk or shared contracts with other service areas e.g. Department of Surgery.6. Change in skill mix of staff (e.g. use of health care assistants).7. Increase cost awareness (e.g. price labelling of stock).BudgetingManaging the ICU budgetBudgets serve a dual purpose. They are numericalexpressions of plans and they are control standardsagainst which results can be compared.The ICU operating budget describes ICU expensesrequired to achieve annual objectives, such as a givencase volume. This means an ICU budget is a statement ofexpected revenues and expected expenses over a definedtime period.Budgeting is part ofmanaging: it involvesallocating resourcesdeliberately andprudently to achieveprogrammeobjectives. Thisincludesprogrammingapproved goals intospecific projects andactivities, staffing,and procurement ofresources.Q. Describe the objectives of an ICU annual operating budgetA. Objectives of an ICU budget are to:Numerically describe its annual plan.Create a basis for evaluating its financial performance.Create control standards against which results can be compared.Create cost awareness by the ICU staff.Types of ICU budgetsRevenueA revenue budget describes revenue generation from patient care (revenue frompatient billings and government funding), education (revenue for teaching students)and research (revenue from research agencies and industry).Operating expenseAn operating expense budget includes costs of day-to-day ICU operations, forexample wages, equipment and supplies.Expenses in ICU operating budgets can be divided into direct (i.e. directly related toindividual patient care and running of the ICU) or indirect (i.e. ‘central expense’shared by all departments in the hospital). An alternative way of analysing expensesis to consider fixed and variable costs. Fixed costs exist no matter how many patientsare treated and thus are unrelated to ICU activity (e.g. staff wages, contracts,equipment maintenance) whereas variable costs are influenced by the activity of the17

ICU (e.g. disposable equipment, drugs). Staff wages account for 60–70% of directcosts in the ICU.For more information on costs, see the PACT module on Quality assurance and costeffectiveness.Budget monitoringMonitoring the budget is an important activity for the physician-manager. Thehospital usually establishes a process by which necessary data are collected,distributed and evaluated by patient care unit managers. The hospital generallyidentifies what it considers to be performance indicators and measures variance(actual performance versus what was planned).Financial, e.g. cost per unit of service.Staffing, e.g. cost per unit of service or staff paid hours as a percentage oftotal paid hours.Workload.Productivity, e.g. staff productivity index.Utilisation, e.g. workload per patient or activity.The physician-manager will then be required, following review of the data, to identifyreasons for variance and the type of activities that will be instituted to bring thebudget back in line with what was predicted in its initial development.An example of the types of data and the processes used for this type of analysis isshown below.18

Q. Describe some of the causes of variance that might be found whenmonitoring the ICU budget.A.New or discontinued technology or procedure.Change in number of cases referred from the operating or emergency room.Unexpected repairs to equipment.Unexpected change in service providers, for example leading to increased orientationcosts. Changing physician practice patterns, for example use new/differentantimicrobial agents.An increase in the number of patients admitted with high illness severity.Unexpected increase in number of vacancies because of illness or maternity.Q. The variable budget concept may be extended to an internal tradingaccount such that referrers hold a budget to buy the ICU service theyneed. What are the advantages of such a system?A. Shifting the financial responsibility for referral to the referrer allows:The financial risk of longer stay patients or increased activity following, for instance, anew consultant appointment, is moved to the source of such activity rather than theICU.Financial management is focused on balancing income and expenditure rather thansimply containing expenditure.In larger hospitals where close liaison between cost centres may be difficult,interaction is made more explicit. Developments in all interacting cost centres areforced to take account of the implications for the ICU.Clearly the overall financial risk to the hospital does not disappear but it makesexplicit the requirement to think through at a proper strategic level the impact andcost of ICU services.Financial managementFor the ICU, its financing and funding has many possible sources, mostly determinedby the hospital’s reimbursement mechanisms. The different examples of how thehospital and its ICU can be financed include for-profit, not-for-profit andgovernment-funded.For-profitIn this example, the payer is usually the commercial insurance industry whoseprimary responsibility is to their shareholders. Like business, a for-profit hospitalcannot survive unless costs are less than charges. In this model, the ICU physicianmanagerfocuses his/her efforts on maximising the unit’s revenue and minimising itscosts.Not-for-profitIn a not-for-profit ICU, revenue which exceeds costs is reinvested to support growthand development. Not-for-profit hospitals receive operating funds from two sources,consumers and philanthropy; they usually have tax-exempt status. In this situation,19

the ICU physician-manager needs to ensure that costs are less than revenue income(which is approved by the hospital’s senior management team during the annualbudget building process).Government-fundedIn hospitals funded by government, the ICU physician-manager needs to ensureproviding care is accomplished within a predefined budget. In some (enlightened)government-funded systems, maintaining efficiency (ensuring costs are belowrevenue) leads to reinvestment for growth and development.THINK Reflect on the various financing/revenue sources of your hospital. What is themajor source of revenue for patient care activities? Does the financing source for thehospital determine patient demographics in the ICU?All systems for financial management within intensive care need to operate withinthe resource constraints. In the future, the global demand for ICU services willcontinue to increase. The reasons for this are multi-factorial and include:Ageing populationDisease co-morbiditiesGreater public expectationsTechnological advancementsNovel drug therapiesChanges in disease demographicsThis demand is unlikely to be matched by a commensurate increase in healthcareresources. Strategies for dealing with the imbalance between resource and demandinclude:Reduction in demandLimitation of supply (rationing)Improved efficiencyFor most ICUs reducing demand is unlikely to be achievable. ICUs have thereforefocused on various ways of increasing efficiency and identifying ways to reduce costs.Such approaches have involved the use of formularies for drug choice, stock lists fordisposables and technology that is cheaper but with equivalent benefit, eliminatingunnecessary diagnostic tests, the development of agreed ICU polices and proceduresand more efficient patient pathways focused on reducing lengths of stay.Although efficiency in care may decrease the cost-per-admission tosome extent, more definitive cost reductions require some degree of‘rationing of ICU services’. In such an approach, intensive carephysicians must be able to identify those patients who would notbenefit from intensive care before or early in their admission.However, there are several caveats to this approach: (a) most hospitalcosts are fixed and minimally affected by reductions in ICU length ofstay mainly as the costs of the first few days on ICU are highest (b)current prognostic systems lack specificity in the prediction of death,limiting their usefulness in decision-making; (c) limiting interventivecare even to those patients with dismal prognosis only accounts for a20Rationing isdefined as ‘theallocation ofhealthcareresources in theface of limitedavailability,whichnecessarilymeans thatbeneficialinterventions arewithheld fromsomeindividuals’.

minority of ICU admissions; and finally it involves (d) complexethical considerations.See the PACT module on Quality assurance and cost-effectiveness.See the PACT module on Ethics.THINK Having a 24-hour discharge capability may facilitate ICU efficiency and reducecosts by decreasing ICU length of stay but what are the potential disadvantages ofdischarging patients late at night?For more information on cost containment and rationing:See ESICM Flash Conferences: Michael Pinsky. The natural history of costcontainment. Berlin 2011.Andreas Valentin. Rationing in the intensive care. Berlin 2011.Truog RD, Brock DW, Cook DJ, Danis M, Luce JM, Rubenfeld GD, et al; for the TaskForce on Values, Ethics, and Rationing in Critical Care (VERICC). Rationing inthe intensive care unit. Crit Care Med 2006; 34(4); 958–963. PMID 16484912Ward NS, Teno JM, Curtis JR, Rubenfeld GD, Levy MM. Perceptions of costconstraints, resource limitations, and rationing in United States intensive careunits: results of a national survey. Crit Care Med 2008; 36(2): 471–476. PMID18216601Luce JM, Rubenfeld GD. Can health care costs be reduced by limiting intensive care atthe end of life? Am J Respir Crit Care Med 2002; 165(6): 750–754. PMID1189763821

3/ CONTROL, AUDIT AND QUALITY IMPROVEMENTControl refers to the processes an ICU physician-manager sets up to ensure thatwhat is planned actually occurs.Audit is part of the control process and involves the: ‘gathering of information aboutand the monitoring of activities, comparing actual with expected results and,intervening to take corrective action by changing inputs or processes when actualresults are not what was predicted or planned’.Control is a means by which the physician-manager is assured that the ICU achievesits objectives. Thus, ICU managers continuously monitor and evaluate theirprogrammes and, they intervene with change strategies when needed to ensure theunit’s objectives are reached. For example, the ICU physician-manager needs tomonitor unit utilisation activity (such as admissions, discharges, length of stay) on aregular basis. If such monitoring identifies that an activity, such as bed days used, isgreater than assumed when the operating budget was designed, the physicianmanagerneeds to identify strategies that either reduce unit activity or, increase theunit’s budget (to cover the increased workload required by greater than anticipatedutilisation).There are three different types of control: output (outcome) control; process control;input (structural) control.Inpute.g. specific ICUtrained doctorsProcesse.g. adherence toguidelines andbundlesOutpute.g. standardisedmortality ratesOutput (outcome) controlOutput control is also called feedback control. This is a retrospective process thatinvolves measuring issues such as quantity and quality of care in the ICU. Anexample of output control would be the length of stay or mortality risk adjusted forillness severity.Process controlProcess control monitors integrative conversion processes that generate outputs.With regard to quality improvement, monitoring the use of clinical practiceguidelines by clinicians or adherence to care bundles would be an example of processmonitoring.22

Input (structure) controlInput control is also called feedforward control. With input control, the managermeasures ICU inputs as a means of controlling ICU objectives. An example is theapplication of research that shows physicians with intensive care medicine trainingprovide better ICU outcomes. In comparing outcomes from different ICUs, utilisationwould be expected to be different from those that employ only ICU physicians(inputs) for care provision.For each step in the control process there are clearly defined indicators. Functions ofindicators include measurement of current status (evaluation), description of changes(monitoring) and triggering of events that require intervention (alarm). Indicatorsshould be:Important: link to clinical relevant outcomes.Valid: refers to the degree to which an indicator reflects what it issupposed to measure.Reliable: refers to the extent to which an indicator achieves the sameresult when assessed by different raters (inter-rater reliability) or thedegree to which repeated measurements provide the same result (intraraterreliability).Responsive: refers to whether the indicator is sensitive to changeintroduced by a quality improvement process.Interpretable: refers to whether the indicator is easily understood by thekey stakeholders.Feasible: refers to whether the indicator can be collected with availableresources.Berenholtz SM, Dorman T, Ngo K, Pronovost PJ. Qualitative review of intensive careunit quality indicators. J Crit Care 2002; 17(1): 1–12. Review. PMID 12040543Rubin HR, Pronovost P, Diette GB. From a process of care to a measure: thedevelopment and testing of a quality indicator. Int J Qual Health Care 2001;13(6): 489–496. PMID 11769752Rubin HR, Pronovost P, Diette GB. The advantages and disadvantages of process-basedmeasures of health care quality. Int J Qual Health Care 2001; 13(6): 469–474.PMID 11769749Frutiger A, Moreno R, Thijs L, Carlet J. A clinician’s guide to the use of qualityterminology. Working Group on Quality Improvement of the European Societyof Intensive Care Medicine. Intensive Care Med 1998; 24(8): 860–863. PMID9757933Brook RH, McGlynn EA, Cleary PD. Quality of health care. Part 2: measuring quality ofcare. N Engl J Med 1996; 335(13): 966–970. PMID 8782507See ESICM Flash Conferences: Andreas Valentin. Quality Indicators in the ICU.Berlin 2011.Hans Ulrich Rothen. How to keep quality of care while saving money. Berlin 2011.23

Q. You are asked by your local health authority to create ‘indicators’ forall ICUs in the region, focusing on process control and input control. Byasking ICUs to regularly report on indicators, their goal is to determine ifcompliance with such indicators improves outcomes.– Define ‘indicator’– Identify a ‘process’ control indicator– Identify an ‘input’ control indicatorA.An indicator is a measure of a specific component of a health improvement strategy.An indicator can reflect an activity implemented to address a particular health issue,for example, the number of regional ICUs that are ‘closed’ versus ‘open’.An indicator reflecting ‘process’ control would be the number of regional ICUs thathave developed a process which leads to adoption of ‘evidence-based’guidelines/pathways to improve quality and safety of patient care.An indicator reflecting ‘input’ control would be the number of regional ICUs that are‘closed’ versus ‘open’ with regard to supervision of patient care by a qualifiedintensivist.Quality improvement activities are also part of the control mechanisms used by anICU physician-manager. Quality improvement has been associated with increasedcompliance to care bundles and improved patient outcomes. Quality improvement isdescribed as ‘the implementation of systematic, data-driven interventions designed tobring about an immediate improvement in healthcare in a specific practice setting’.Processes of care that are part of quality improvement include evaluation of patientsfor thromboembolic prophylaxis, steps to reduce catheter-related bloodstreaminfections, and ventilator-associated pneumonia. Initiating a new qualityimprovement programme or improving a pre-existing programme requires a numberof steps to ensure the programme is successful. The basis for a successful qualityimprovement programme is strong motivation, teamwork and leadership.Information technology and checklists are useful tools providing clinical reminders,facilitating the use of clinical practice guidelines and reducing errors. A systematicapproach to setting up a quality improvement programme is outlined below:Identify opportunities and resources.Develop a project plan including key stakeholders, resources, a task list,budget and timeline.Collect information on the current care being delivered and the potentialbarriers to an effective quality improvement programme.Generate a data collection system.Generate a data reporting system.Implement strategies to change behaviour: a multifaceted approach usingreminders, prompts and educational tools is useful. Targeting barriers tochange (see ‘Barriers’ table below) while adapting to the local setting arethe most effective means of inducing and sustaining change.Evaluating and sustaining the quality improvement programme: modifybehaviour change strategies, sustain interdisciplinary leadership andcollaboration and obtain support from hospital management.24

Curtis JR, Cook DJ, Wall RJ, Angus DC, Bion J, Kacmarek R, et al. Intensive care unitquality improvement: a “how-to” guide for the interdisciplinary team. Crit CareMed 2006; 34(1): 211–218. PMID 16374176Review the two articles below to determine the impact of quality improvementinitiatives in the ICU.Garrouste-Orgeas M, Soufir L, Tabah A, Schwebel C, Vesin A, Adrie C, et al;Outcomerea Study Group. A multifaceted program for improving quality of carein intensive care units: IATROREF study. Crit Care Med 2012; 40(2): 468–476.PMID 21963581Scales DC, Dainty K, Hales B, Pinto R, Fowler RA, Adhikari NK, et al. A multifacetedintervention for quality improvement in a network of intensive care units: acluster randomized trial. JAMA 2011; 305(4): 363–372. PMID 21248161Pay for performance initiatives are increasingly being linked with quality measuresand improvement in intensive care. Challenges include selecting evidence-based andfeasible quality measures, integrating multifaceted behaviour change strategies, anddeveloping sophisticated informatics infrastructure for timely audit and feedback.Khanduja K, Scales DC, Adhikari NK. Pay for performance in the intensive care unit–opportunity or threat? Crit Care Med 2009; 37(3): 852–858. PMID 19237887Quality control involves inspecting for problems in the ICU service. For example, astatistical sample would be inspected (e.g. the last 25 patients discharged from theICU) to determine readmissions (also called ‘feedback control’). Such audits shouldbe undertaken on a regular basis. It must be remembered that stopping poor practice(inappropriate discharges) usually requires a follow up intervention if the auditedpractice is felt to be inadequate.Quality assurance encompasses control beyond just inspection. It is a structuredapproach to preventing quality problems through planned and systematic activitiesthat include: planning, reviewing, monitoring and documentation (‘feedforwardcontrol’). An example of quality assurance is the regular assessment of ICU stat labequipment, also called monitoring of technical standards for testing performance, toshow suitable accuracy of the results provided.Continuous quality improvement promotes continuous improvement throughthe application of group decision-making methods and statistical tools. A goal of anICU’s quality improvement programme might be to meet and exceed patient andpatient family satisfaction by examining and improving systems and work processes.25

Thijs LG. Continuous quality improvement in the ICU: general guidelines. Task ForceEuropean Society of Intensive Care Medicine. Intensive Care Med 1997; 23:125–127. PMID 9037654For more information on these topics see the PACT module on Quality assurance andcost-effectiveness.There is an increasing commitment from governmental bodies to gather datadescribing activities of individual ICUs using national and international dataregistries. There are many uses for information collected in these registries,including: Types of patients admitted to ICUs (admitting diagnosis and severity ofillness). Risk adjusted outcomes. Intensive care utilisation trends over time. Identification of high-risk groups for complications. Quality indicators and quality improvement initiatives. Patient safety data. Conducting research (e.g. clinical trials).Examples of critical care registries from United Kingdom, Australia and New Zealandand Canada:http://www.icnarc.org http://www.anzics.com.au/core http://www.ccctg.caTHINK Consider the advantages and disadvantages of collecting data in a centralisedregistry.Examples of the types of indicators that can be monitored in a national (orinternational) approach to data collection are shown in the table below. Risk adjusted mortalityPatient Pressure ulcersoutcomes Nosocomial infection ICU readmission rate Nutrition supportProcesses DVT prophylaxis Multi-drug resistant organisms Length of stayUtilisation Transfer delays (interval between time ready for transfer fromICU to actual transfer) Occupancy Low-risk admission rate Very high risk (or death within six hours) admission rate Patient-care hours compared to workload measureFinancial Total budget Patient/family satisfaction with careSatisfaction Staff turnover Absenteeism rateData that can be measured and shared between ICUs for the purposes of qualityimprovement and utilisation/performance management.26

By collecting these data, individual ICUs are able to benchmark their activity andoutcomes with those achieved by units of similar size and activity.Benchmarking is the process of measuring the performance of individual ICUs againstother reference ICUs. Benchmarking requires effective and objective markers ofperformance (or quality) that can be used within or between ICUs.Q. Why benchmark ICUs?A. Benchmark analysis allows ICUs to identify their strengths and weaknesses with a view toimplementing change (if needed) to improve ICU performance.Benchmarks chosen must be relevant for health managers, physicians and patients.Q. List up to five markers of performance (or quality) that can be used tobenchmark ICUsA. Examples of performance (or quality) markers include: Complication rates related to patient care (e.g. catheter-related blood streaminfections) Adherence to guidelines and policies (e.g, surviving sepsis bundles) Risk adjusted ICU and hospital mortality Risk adjusted length of stay Patient and family satisfaction ratesQ. What are the challenges of benchmarking ICUs and how can they beovercome?A. Comparison of unadjusted outcomes among ICUs is unsatisfactory primarily due todifferences in ICU and patient characteristics. To adjust for these differences, statisticalmodels can be used to generate predicted outcomes, i.e. case-mix or risk adjustedbenchmarks that are compared with observed outcomes.For more information on benchmarking see the PACT modules on Clinical outcomeand Quality assurance and cost-effectiveness.Garland A. Improving the ICU: part 1. Chest 2005; 127(6): 2151–2164. PMID 15947333Garland A. Improving the ICU: part 2. Chest 2005; 127(6): 2165–2179. PMID 15947334Woodhouse D, Berg M, van der Putten J, Houtepen J. Will benchmarking ICUsimprove outcome? Curr Opin Crit Care 2009; 15(5): 450–455. PMID 19633547Flaatten H, Moreno RP, Putensen C, Rhodes A (eds). Organisation and Management ofIntensive Care. Berlin: MVV Meizinisch Wissenschaftliche Verlagsgesellschaft;2010. ISBN-978-3-941468-27-6Zimmerman JE, Kramer AA, McNair DS, Malila FM, Shaffer VL. Intensive care unitlength of stay: Benchmarking based of Acute Physiology and Chronic HealthEvaluation (APACHE) IV. Crit Care Med 2006; 34(10): 2517–2529. PMID1693223427

Controlling the ICU frequently involves change. Examples of changemay include introduction of a central line care bundle, an enhancedrecovery programme or responding to an increase in service capacity.Change is an active process in which it must be anticipated that‘resistance’, which can include questioning the need for the change,will be encountered. Without understanding and managing inadvance the effect(s) of proposed change on the ICU staff, aphysician-manager will find it difficult to achieve the benefits of thechange proposed. Barriers that may resist change are outlined below.Successfulphysicianmanagerslearnhow to diagnose'forces of change'– and how toguide successfulchangeBarriersStructuralbarriersResourcesLeadershipScientificPersonalbarriersIntellectualPerceptionAttitudeMotivationOrganisationalbarriersPoliticalEconomicSocial and culturalDescriptionStaff/time/financial/educationalLack of support, reinforcement and controlNot all recommendations are applicableLack of knowledge or insufficient knowledge toapply it correctlyLack of confidence in evidence for changePolitically or economically motivated resistanceConfusion over purpose of changeDoubts that it will improve outcomeFear of the unknown/new additional workNo benefit to changePower relation between organisations/teamsLack of internal culture to promote changeImplementation is expensive – staff/time/facilitiesSense of security and habit in the pastTeam does not share the ambitionSuccessful adoption of a change in practice or working requires appreciation of thebarriers and an implementation plan.Figure 1 in the following paper describes one model for implementing change.Grol R. Personal paper. Beliefs and evidence in changing clinical practice. BMJ 1997;315(7105): 418–421. PMID 9277610http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2127297/pdf/9277610.pdf28

The above model could be used to implement a new protocol for theholding of daily sedation in the intensive care unit. There is a good evidence basis forthe intervention and it is likely to be relevant to the local ICU population. Exclusioncriteria for a ‘sedation hold’ would need to be clearly documented and agreed upon. Aprotocol would need to be designed regarding timing and nature of how the sedationhold was to be performed, and the subsequent actions in accordance with the clinicalresponse. Following this, barriers to implementation would be identified and targetedwhich might include nursing and physician staff reluctance. An educationalprogramme could be established to highlight the benefits to patient care andreductions in length of mechanical ventilation, and intensive care stay that may occursecondary to introduction of the proposed change. Following introduction, therewould be ongoing review of acceptance and uptake of the intervention and whether itwas achieving the desired outcomes. Ongoing barriers to change would be highlightedand additional interventions designed to improve compliance with the desired goal ofa daily sedation hold in all patients in whom it is not contraindicated.Grol R, Grimshaw J. From best evidence to best practice: effective implementation ofchange in patients’ care. Lancet 2003; 362(9391): 1225–1230. PMID 14568747Q. Outline effective strategies you can use to change physician behaviour?A.Mini sabbaticals that allow clinicians to spend time in other critical careunits learning how to practise evidence-based healthcare.Personalised feedback (also called ‘audit’) on performance, either incomparison with that of others or against explicit standards.Computer-assisted decision-making, that provides reminders and easyaccess to evidence-based guidelines.On-the-job training of practical skills.Use of opinion leaders or ‘educational influentials’ (colleagues whoseperformances are respected).A single approach to changing behaviour is unlikely to be effective. Changingbehaviours and practices requires a combination of different strategies to be usedsimultaneously.Berenholtz S, Pronovost PJ. Barriers to translating evidence into practice. Curr OpinCrit Care 2003; 9(4): 321–325. PMID 1288328929

The rationale for computerised physician order entry (CPOE) is strong, particularlythe conclusion that improved patient safety results from this technology. As the ICUphysician-manager, your colleagues are diverse in both age and knowledge of computers andinformation technology. This means that introducing CPOE could be met with significantresistance from ICU physician co-workers because the new technology will require that theydo things differently, which can be uncomfortable. If you do not create a change managementstrategy, successful implementation of CPOE may not happen. Think about the challengesyou would meet, if you were asked to institute a CPOE system in your ICU.Ash JS, Stavri PZ, Dykstra R, Fournier L. Implementing computerized physician orderentry: the importance of special people. Int J Med Inform 2003; 69(2-3): 235–250. PMID 12810127Q. Answer the following as true or false.a/ The intensity of forces for and against change will likely determine thelikelihood of change.b/ Employees tend to resist change when there is a lack of specificinformation about the change.c/ Extensive communication with employees is one approach to lesseningresistance to change.d/ When implementing changes, revolution is better than evolution.A.a/ Trueb/ Falsec/ Trued/ FalseA more simplified model of change is described by the PDSA (Plan Do Study Act)cycle:http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/plan_do_study_act.htmlMore information about PDSA cycles and their theory can be found on the websites ofboth the UK and US health improvement organisations.http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/plan_do_study_act.htmlhttp://www.ihi.org/knowledge/Pages/HowtoImprove/default.aspxRather than introducing new policies across the whole unit, with the risk of failureand non-acceptance, the aim of the PDSA cycle is to temporarily trial a change on asmall scale, assess its impact and adapt accordingly. There are a number ofadvantages to small scale testing:30

Involves less time, money and risk.Promotes staff learning and analysis.Motivates staff through involvement with idea development.Problems are identified and resolved prior to full roll-out, thus achieving‘buy-in’ from less enthusiastic staff.This model has been used successfully for a number of intensive care interventions,such as implementation of care bundles for central lines and ventilator-acquiredpneumonias. A group of intensive care medicine trainees used a repetitive PDSA cycleto design and modify a checklist for use prior to emergency out-of-theatre intubationsto reduce associated complications.http://saferintubation.com/Koll BS, Straub TA, Jalon HS, Block R, Heller KS, Ruiz RE. The CLABs collaborative: Aregionwide effort to improve the quality of care in hospitals. Jt Comm J QualPatient Saf 2008; 34(12): 713–723.PMID 19119725Bonello RS, Fletcher CE, Becker WK, Clutter KL, Arjes SL, Cook JJ, et al. An intensivecare unit quality improvement collaborative in nine Department of VeteransAffairs hospitals: reducing ventilator-associated pneumonia and catheterrelatedbloodstream infection rates. Jt Comm J Qual Patient Saf 2008; 34(11):639–645. PMID 19025084THINK Think about how you might start a patient improvement programme to improveglucose control on the ICU. Questions to think about might include, what are you trying toaccomplish, how will you know if the change is an improvement, what changes can bemade that will result in improvement?31

4/ POLICIES, GUIDELINES AND PROCEDURESPolicies and guidelines are developed to describe best practice and help clarifydecision-making in the ICU. The term guidelines and policies are often usedinterchangeably but are clinically distinct. Policies are rules set by organisationsthat must be adhered to whereas guidelines are sets of best practices that aresupported by consensus opinion.You will find reference sources for some examples of key guidelines developed by theEuropean Society of Intensive Care Medicine and Society of Critical Care Medicine inthe websites below.http://www.esicm.orghttp://www.sccm.orgWell implemented guidelines can impact on patient outcome. Review the articlesbelow and determine the impact of successful implementation of these guidelines.Ferrer R, Artigas A, Levy MM, Blanco J, González-Díaz G, Garnacho-Montero J, et al;Edusepsis Study Group. Improvement in process of care and outcome after amulticenter severe sepsis educational program in Spain. JAMA 2008; 299(19):2294–2303. PMID 18492971Levy MM, Dellinger RP, Townsend SR, Linde-Zwirble WT, Marshall JC, Bion J, et al;Surviving Sepsis Campaign. The Surviving Sepsis Campaign: results of aninternational guideline-based performance improvement program targetingsevere sepsis. Crit Care Med 2010; 38(2): 367–374 PMID 20035219Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, et al. Anintervention to decrease catheter-related bloodstream infections in the ICU. NEngl J Med 2006; 355(26): 2725–2732 PMID 17192537Guidelines: The ICU physician-manager should ensure guidelines are updatedregularly according to the best available evidence and regularly audit adherence toguidelines. Despite good evidence of best practice, some studies have shownconsistently poor adherence to guidelines. Studies in the United States andNetherlands suggest that at least 30–40% of patients do not receive care according tocurrent scientific evidence, and that up to 20% of care is either not needed orpotentially harmful. Furthermore, even when we think we are delivering goodhealthcare according to evidence, we are frequently not doing so. In a study ofGerman ICUs, perceived adherence to low-tidal volume ventilation (6 mL/kg) forARDS/ALI was 79.9%. When practice was observed, 80.3% were receiving tidalvolumes >8 mL/kg.McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, et al. The quality ofhealth care delivered to adults in the United States. N Engl J Med 2003;348(26): 2635–2645. PMID 1282663932

Brunkhorst FM, Engel C, Ragaller M, Welte T, Rossaint R, Gerlach H, et al; GermanSepsis Competence Network (SepNet). Practice and perception–a nationwidesurvey of therapy habits in sepsis. Crit Care Med 2008; 36(10): 2719–2725.PMID 18766100Q. Not all guidelines are successfully implemented. List five reasons forpoor adherence to guidelines?A. Reasons may include Lack of enforcement Lack of knowledge No incentives Lack of resources/time/administrative support Lack of strong leadershipAs part of a regular audit, Dr Red, the director of an ICU, discoversthat Dr Pink is not using guidelines adopted by the ICU team to ensure ‘bestpractices’ are used with regard to enteral feeding. Dr Red had previously empowereda multidisciplinary ICU team to review literature and determine evidence torecommend a ‘standard’ approach to enteral feeding after admission to the ICU.During an annual performance review, Dr Red discusses with Dr Pink his failure touse the enteral feeding guideline.While acknowledging an ICU team hasrecommended it as a unit guideline, Dr Pink replies it is not consistent with histraining and he does not believe it.Dr Pink was not part of the original multidisciplinary team that produced theguideline. In order to encourage his participation Dr Red suggests that Dr Pink leadanother multidisciplinary team to update the guideline. Dr Red asks Dr Pink toupdate the literature review, critically appraising the evidence and bringing furthernew evidence to the basis of the guideline. Dr Pink is also asked to ensure colleagueshave an adequate chance to discuss the evidence before the new guideline islaunched.Dr Pink states he is not sure how to set about a systematic critical appraisal. Dr Redsuggests critical appraisal skills training as part of Dr Pink’s personal developmentplan for the year.As a result of being asked to lead the guideline development andreceiving skills training to assist in the analysis of the evidence Dr Pink successfullydelivered a new guideline that he and his colleagues could agree to. A subsequentaudit showed all were complying.See ESICM Flash Conference: Julian Bion. Why and when should care be guidelinedirected?Barcelona 2010.Policies: Every ICU should have clearly defined policies. These responsibilities aredefined in documents referred to as hospital bylaws or policy documents. Policiesshould be standardised and periodically reviewed and updated by staff. Hospitalbylaws/policy documents govern the transition between the organisation’s objectivesand its daily operation. Examples of hospital bylaws/policies may include:33

Policies for granting of specific clinical privileges (the process of reviewinga physician’s credentials to determine the authority and responsibility tobe granted to a physician for making independent decisions to diagnose,initiate, alter, or terminate a regimen of medical care) for physiciansworking in the hospital.Policies directly relating to direct patient care (e.g. end-of-life care,admission and discharge, infection control, blood product administration).Operational policies (e.g. health and safety, complaints, flexible working,major incident planning).Review your hospital bylaws/policy documents.Local policy development should include appropriate stakeholders (e.g. seniorclinicans, hospital management and other clinical units that could be affected byapplication of the policy). Employing ‘evidence’ to support this decision-makingensures the best opportunity for their acceptance. The ICU physician-manager mustcommunicate ‘upwards’ (to groups such as senior management and the medicaladvisory committee) and ‘downwards’ (to other departments who use ICU resources).Procedures are actions prospectively determined to guide the unit’s staff in definedsituations. They outline steps that an ICU staff member must take to perform a task,and provide them with direction in the performance of their duties.Review the guidelines and procedures for critical care on the following website,http://www.lhsc.on.ca/critcare/icu. Identify where similar guidelines and procedures thathave been recorded for your ICU.34

5/ HUMAN RESOURCE MANAGEMENTPhysician-managers should work closely with their hospital’s human resourcedepartment. Human resource management includes staff recruitment, selection,performance reviews, development and training, understanding and implementingemployment legislation and welfare.HiringICU staffing needs are determined by demand for ICU services and employeeturnover. Each member of the ICU workforce should have a job description. Thisincludes a job title as well as a description of the individual’s duties andresponsibilities. A suitable candidate is selected from a pool of applicants using jobqualifications as a guide. Training, experience and ability of potential candidatesmust be considered. The following are used when selecting new staff:Application forms – provide historical and background information aboutthe applicant such as education, training, previous jobs.Testing.References and letters of recommendation.OrientationThe physician-manager needs to ensure that new ICU employees are provided withan orientation programme that includes:Information about the ICU and its organisational structure, the hospital’sfire and safety programme, employees’ health service and assistanceprogrammes, and services provided by the human resource department.Explanation of key policies and guidelines.Information about the philosophy, mission, vision, values of the hospitaland the ICU (ideally, these will be documented in a hospital handbook orintranet).RetentionIt is not enough to simply select and recruit new staff. The ICU physician-managermust also pay attention to retention activities, some of which include:Appraising each employee’s job performance.Developing, supporting and promoting employees according to identifiedneeds.Administering compensation and benefits.Providing employee assistance and career counselling.Ensuring health and personal safety.Performance reviewsReview of staff performance is an important role of the ICU physician-manager. A jobplan should be agreed for each ICU physician during the hiring process, and reviewed35

and agreed yearly. This establishes a contract for the delivery of work between theemployer and employee. In addition to the job planning process, the physicianmanagershould undertake regular appraisals.Job planning is a systematic activity designed to produce clarity of expectation forthe ICU physician and their employer about the use of time and resources to meetindividual and service objectives. A job plan should include the ICU physicians’ mainduties and responsibilities, the scheduling of commitments, the support needed infulfilling the job plan, and personal objectives, including any continuing medicaleducation and training, and their relationship with wider service objectives.36

Figure: Example of a job planAppraisals provide feedback to the physician about progress on the team, identifyopportunities where coaching for improvement may be required and allowopportunities to discuss future professional development progress. The mainobjectives for appraisals are to:Optimise the skills and knowledge required to maintain and improveperformance – to identify the ‘professional development’ needs of thephysician.Consider changes or developments in the fields in which the physicianwishes to participate – to identify the ‘personal development’ needs of thephysician.Provide adequate evidence to allow revalidation by national medicalregulatory bodies in some countries (e.g. United Kingdom).37

Figure: Example of a personal development template which can used as part of theappraisal processAs part of an appraisal review, a multisource feedback may be performed.There are common elements between these two processes and some information maybe duplicated. There are, however, differences between the two processes that areoutlined in the table below.Multisource feedback, also known as 360 feedback, provides a sample of attitudes andopinions of colleagues on the clinical performance and professional behaviour of theindividual. It may also include feedback from external sources, patients and a part onself-evaluation. Its main objective is to help the person receiving the feedback to planand map specific paths in their personal and professional development.Job PlanningAppraisalDriver Employer National regulatory body& Personal EffectivenessPresent at meeting Physician and medicalmanager (+/- non-medicalmanager)Physician and appraiser(usually a physician)EmphasisService delivery and patientcare. The job plan review isperformance assessment ofrecent past and the job plan isa forward plan for futureperformanceFramework Physician job planning –Terms and Conditions ofService38Personal and professionalstandards and developmentframework in thelocal/national/internationalcontextNational regulatory body (insome countries)Atmosphere, ethos Businesslike Developmental, supportive,creativeStandard Benchmark Commitments and duties to Professional standardsemployerOutcomeTimetable and agreedservice/patient objectivesFigure: Differences between job planning and appraisalPersonal development plan –improved skills and personaleffectiveness to deliver care

Providing opportunities for physicians to learn new skills is important for a highperformingICU. With any performance review, development plans for individualphysicians can be identified and training proposed. Given the increasing importanceof management and leadership, the ICU physician-manager should considermanagement development as a type of training; this increases the capabilities ofphysicians by developing skills such as leadership, motivation, communication andproblem-solving.Conlon M. Appraisal: the catalyst of personal development. BMJ 2003; 327: 389–391.PMID 12919998Etherington J, Innes G, Christenson J, Berkowitz J, Chamberlain R, Berringer R, et al.Development, implementation and reliability assessment of an emergencyphysician performance evaluation tool. CJEM 2000; 2(4): 237–245. PMID17612448Employee assistance programmesEmployee assistance programmes (EAPs) help employees with problems thatadversely affect their work. They include help for substance abuse, legal, financialand emotional problems. Employee assistance can also be provided by careercounselling and health education and promotion. Educating employees can enablethem to better manage their own health. Some health education and promotionservices are: stress management, nutrition counselling and weight reduction, andsmoking cessation. By implementing health education and promotion programmes,ICU physician-managers improve productivity and contribute to the positive climaterequired to retain physician colleagues.You are told by one of your senior nurses that a physician colleaguehas been behaving erratically when taking calls in the evenings. You are aware that hehas been losing weight for a number of months, does not eat with the team and hasdeveloped a tremor. You are concerned one of the likely explanations is that he hasbecome dependent on alcohol, following a family tragedy 18 months ago.Q. What is your responsibility as a physician-manager, as well as acolleague?A. Patient safety should come first. The doctor should be removed from clinical dutiespending further review and the clinical service will need to be covered. You must get expertadvice and assistance at an early stage. Be certain that your hospital has a policy in place forproviding you with assistance in identifying and supporting a colleague who may have adependency problem. Your local or regional physicians’ group for monitoring professionalstandards should also have a process in place to assist you in this task. As a colleague it isimportant to maintain confidentiality and be supportive.39

6/ THE ROLE OF THE PHYSICIAN-MANAGERA physician with a management role is generally appointed by a hospital’smanagement structure (for example, by the Chief Executive Officer). Historically, aphysician selected for the role has been assumed to bring management andleadership skills to the position because of previous academic or clinical successes.Although this may well be the case, competency in leadership and managementcannot be assumed simply because a physician has achieved academic and clinicalsuccess. Promotion and appointment to the physician-manager role is not onlydependent on excellence in clinical skills and respect of colleagues but also oneffective managerial and leadership skills. Unlike general managers, most ICUphysician-managers have not followed traditional business training, such as Mastersin Business Administration. This is likely to change and appointment to futureintensive care management roles may require formal demonstration of competencein healthcare management and leadership.In being appointed, the ICU physician-manager should be provided with a jobdescription and resources to manage tasks identified in the job description. Thephysician-manager should agree on specific responsibilities, such as developingobjectives for the ICU and ensuring that the ICU contributes to the hospital’s overallobjectives. Without agreement about what the hospital wants a physician-manager toaccomplish, disagreements can occur over successes. Furthermore, the physicianmanagerneeds to ensure that a regular performance review is carried out by hospitalmanagment to ensure that the hospital objectives are being achieved by his/hermanagement/leadership activities.The job description of an ICU physician-managerA Job Description for an ICU Chief of Service (or Director orDepartment Head) integrates the roles and functions describedabove. An example is provided below.If a job descriptionis not provided –ask for one.An example of a job description for an ICU physician-managerThe physician-manager/leader of the Critical Care service (which could also bereferred to as a Programme or Department or Division) will be accountable to thehospital’s Chief of Staff, and will:1. Determine clinically related and administrative activities of the ICU serviceincluding, but not limited to, the quality of patient care provided by members of theICU staff.2. Where ICU ‘Rules and Regulations’ are desired, the physician-manager willdevelop and implement these ‘Rules and Regulations’ and ensure they support thehospital’s performance improvement plan.3. Recommend the number of qualified and competent physicians required to provideICU clinical service needs.40

4. Recommend the criteria for clinical privileges that are relevant to the care providedin the ICU.5. Determine qualifications and competence of ICU personnel who are not licensedindependent practitioners (for example, postgraduate trainees) who provide patientcare services.6. Transmit recommendations concerning appointment, reappointment, delineationof clinical privileges, and disciplinary action with respect to members of the criticalcare service, to appropriate hospital authorities.7. Develop and implement programmes for: orientation of new members; credentialsreview and privileges delineation for appointment and reappointment; continuingmedical education; utilisation review; and evaluation of practice.8. Maintain continuing review of the professional performance of physician memberswith clinical privileges in the ICU, and maintain appropriate documentation.9. Assess and recommend to the relevant hospital authority, space issues for patientcare services and technology provided by the ICU.10. Assist in the development and enforcement of hospital policies and Medical StaffBylaws, Rules and Regulations, especially as they apply to the ICU.11. Perform such other duties commensurate with his/her office, as may from time totime be assigned by the Chief of Staff or the hospital.‘Pay for Performance’ Research has demonstrated that linking compensation to theachievement of specific objectives has been accompanied by better-qualityperformance by the physician-manager and his/her team. Data suggest this approachworks not only for typical managerial tasks (e.g. developing evidence-basedguidelines to improve a ICU’s performance), but also for academic productivity (e.g.the quality of teaching provided to intensive care trainees).Tarquinio GT, Dittus RS, Byrne DW, Kaiser A, Neilson EG. Effects of performancebasedcompensation and faculty track on the clinical activity, research portfolio,and teaching mission of a large academic department of medicine. Acad Med2003; 78(7): 690–701. PMID 12857687Reece EA, Nugent O, Wheeler RP, Smith CW, Hough AJ, Winter C. Adapting industrystylebusiness model to academia in a system of Performance-based IncentiveCompensation. Acad Med 2008; 83(1): 76–84. PMID 18162757THINK List the advantages and disadvantages of ‘Pay for Performance’ for managerialproductivity41

Roles and functions of an ICU physician-managerRolesThe ICU physician-manager has three primary roles: interpersonal; informational;decisional.InterpersonalIn this role, the ICU physician-manager is a ‘figurehead’ for the ICU team, liaisingwith stakeholders internal and external to the ICU, and influencing decision-making.For example, the physician-manager will represent the ICU at hospital andnational/regional meetings.InformationalIn this role, the ICU physician-manager monitors activities that are important to theICU, disseminates knowledge to the ICU team (and other relevant stakeholders), andacts as a spokesperson for the ICU. For example, the physician-manager willcommunicate within the ICU deliberations from hospital committees and consensusconferences.DecisionalIn his/her decision-making role, the physician-manager manages conflict, allocatesresources to support the ICU’s objectives and negotiates with other decision-makersboth inside and outside the hospital.Q. What role is the ICU physician-manager providing in the followingcircumstances?a/ Attends a local health authority meeting that is discussing clinical andacademic ICU needs for the future.b/ Chairs a meeting to discuss and decide on the amount of resourcesthat will be allocated to purchasing information technology for the ICU.c/ Attends a meeting with the hospital’s senior management team todescribe the ICU’s clinical activities for the last year and anticipatedstresses on the ICU’s budget in the coming year.A.a/ Informationalb/ Decisionalc/ InterpersonalAttend a senior hospital management meeting and observe the different rolesindividuals take.FunctionsThe ICU physician-manager is responsible for five principal functions: planning;organising; staffing and directing; controlling; decision-making and problem-solving.42

PlanningEvery physician-manager must ensure the ICU has a plan describing ‘where the ICUis going’ and ‘how the ICU intends to get there’. As a roadmap for managing dailyissues, a plan prepares the ICU to deal with future challenges (having thought aboutkey issues in advance results in better responses when they occur). Good planningbegins with an analysis of issues relevant to the ICU service, for example, how trendsin service delivery and financing are affecting the ICU. A completed plan includesobjectives, policies and procedures to guide the ICU’s daily activities.Set aside time to speak to the ICU Physician-Manager and/or Nurse Manager todiscuss the future plan of your ICUOrganisingThe ICU physician-manager determines what activities should be carried out in theICU, how they should be delegated and who has the responsibility for doing them.Organising involves the determination of how clinical authority and responsibility aredivided between different ICU professionals (e.g. physicians, nurses, respiratorytherapists, physiotherapists). Organising also requires creation of a formalcommunications procedure, so that everyone understands ‘who does what’.See the PACT module on Communication.Staffing and directingThe ICU physician-manager hires and manages people for the tasks required by theICU on behalf of the hospital. An example of this function is the hiring of intensivecare physicians and establishing/communicating/ monitoring of the ICU physicians’duty call schedule. Other activities in the staffing and directing function include theprovision of opportunities for professional development for the ICU staff, appraisals,review of job plans, staff motivation and counselling.ControllingThe ICU physician-manager is responsible for ensuring that processes are in place tomeasure and report on the ICU’s clinical, educational and academic performance.Accounting, planning, budgeting, quality control, clinical governance and utilisationmanagement are important parts of the controlling function.Clinical governance is used to describe a systematic approach to maintaining andcontinuously improving the quality of patient care within a health system. Clinicalgovernance is composed of the 7 key elements: education and training, audit, clinicaleffectiveness and research, risk management, patient and public involvement,information management, and staff management.43

Scally G, Donaldson LJ. The NHS’s 50 anniversary. Clinical governance and the drivefor quality improvement in the new NHS in England. BMJ 1998; 317(7150): 61–65. PMID 9651278Q. Define the meaning of clinical governance and list five managerialactivities consistent with this objective.A. Clinical governance means that you will strive to create in your ICU ‘the culture, thesystems and the support mechanisms’ supporting good clinical performance and ensuringthat quality improvement is embedded into your unit’s routine.You ensure:All clinicians have the right training, skills and competencies to deliver the careneeded by patients.Processes to improve the quality of care are in place throughout the unit.Techniques are established to anticipate and prevent potential problems.A comprehensive risk management system is in place.Mechanisms which monitor and improve existing practices are in place.Systems to recognise and act on poor performance are developed.One of the key compontents of clinical governance is riskmanagement.Patients admitted to ICU are at particular risk of medical errors dueto the severity of their illness, large workload, time constraints, highcomplexity of interventions and the multitude of healthcareprofessionals involved in patient care. The Sentinel EventsEvaluation study documented the number of critical incidents thatoccurred during a 24-hour shift in ICUs across 29 countries. In thisstudy of nearly 2000 patients, critical incidents were found to affectapproximately 20% of patients. The most frequent errors wereassociated with medications, lines, catheters and drains, equipment,airway and alarms.It is widely accepted that the major cause of medical errors aredeficiencies in systems and organisation design, rather thanindividual employees. Patient safety research has demonstrated thatpoor teamwork, high workload, burnout, lack of clear leadership, andcommunication errors are important causal factors in criticalincidents. Learning from errors, sharing the knowledge gained fromthese lessons and an organisational commitment to promoting safepractice is an integral part of good risk management and has beenshown to improve patient outcome.Risk management is aboutidentifying, assessing,analysing, understandingand acting on risk issues inorder to reach an optimumbalance of risk, benefitsand costs.A critical incident is anoccurrence that harmed,or could have resulted inharm of a patient.Much of the knowledgearound patient safety hasbeen drawn from theaviation industry. Thegoal of aviation is safe,efficient, and predictabletravel from one point toanother. There is noreason why ICUs shouldnot similarly promotesafe, efficient, andpredictable care fromadmission to discharge.44

Institute of Medicine. To Err is Human: Building a Safer Health System. Washington,DC: National Academy Press; 2000. ISBN-0309068371Valentin A, Capuzzo M, Guidet B, Moreno RP, Dolanski L, Bauer P, et al. Patient safetyin intensive care: results from the multinational Sentinel Events Evaluation(SEE) study. Intensive Care Med 2006; 32(10): 1591–1598. PMID 16874492Donchin Y, Gopher D, Olin M, Badihi Y, Biesky M, Sprung CL, et al. A look into thenature and causes of human errors in the intensive care unit. Crit Care Med1995; 23(2): 294–300. PMID 7867355Garrouste-Orgeas M, Timsit JF, Soufir L, Tafflet M, Adrie C, Philippart F, et al. Impactof adverse events on outcomes in intensive care unit patients. Crit Care Med2008; 36(7): 2041–2047. PMID 18552694Brindley PG. Patient safety and acute care medicine: lessons for the future, insightsfrom the past. Crit Care 2010; 14(2): 217. PMID 20236461Hugonnet and colleagues found that a higher staffing level was associated with a 30%reduction in infection risk in critically ill patients. Similarly, in a study of ICUresidents, reducing the number of work hours per week and limiting extended workshifts reduced serious errors by 26%.Hugonnet S, Chevrolet JC, Pittet D. The effect of workload on infection risk in criticallyill patients. Crit Care Med 2007: 35(1): 76–81. PMID 17095946Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, et al. Effectof reducing intern’s work hours on serious medical errors in intensive careunits. N Eng J Med 2004; 351(18): 1838–1848. PMID 15509817Q. Who is responsible for reporting critical incidents?A. Critical incidents can be reported by anyone in the organisation. All have a responsibilityfor reporting incidents that could have or did result in harm to a patient.Examples of evidence of a good safety culture in the ICU include: ICU staff are vigilant and aware of potential hazards All levels of the hospital organisation promote safe practice, direct theresources to address safety issues and encourage reporting of hazards andincidents Reports are addressed openly and fairly A comprehensive risk management system is in place that undertakesswift and thorough systematic investigations A proactive rather than a reactive approach to risk management High levels of reporting with sharing of the lessons learnt across theorganisation Staff receive feedback regarding any findings from incidents they havebeen involved in or reported themselves Good communication across professions and grades – ‘flat hierarchy’ Visible leaders (‘champions’) of patient safety within the ICU45

Identify a recent critical incident that has occured in your ICU. Identify factors thatcontributed to the incident and look at measures that could be put in place to prevent theincident from re-occuring.See ESICM Flash Conferences: Andreas Valentin. How to improve safety in the ICU.Berlin 2011.Jean-François Timsit. Impact of medical errors on mortality. Berlin 2011.Decision-making and problem-solvingThis function requires that the physician-manager identify and analyse situationsthat require a decision. The physician-manager also needs to evaluate alternativesolutions to address the problem, choose alternatives, implement solutions andevaluate results following implementation.Relationships of an ICU managerAn ICU physician-manager has distinct relationships within a hospital’sadministrative structure:Vertical relationshipIn a vertical relationship, the ICU physician-manager works in an establishedhierarchy, e.g. reporting to the hospital’s Chief Medical Officer.Horizontal relationshipAn example of a horizontal relationship is when the ICU physicianmanagercollaborates with another physician-manager who possessessimilar authority (e.g. the physician-manager of an emergencyservice or surgery). A horizontal relationship is created, for example,when the ICU and Surgery physician-managers collaborate tofacilitate enhanced or fast track post surgical recovery programmes.A horizontal relationship can also describe a co-managingrelationship e.g. between a physician and nurse manager. In a‘dyadic’ approach, managerial roles may be shared between such aphysician and nurse manager. Physician and nurse co-managersmight have different reporting relationships, for example, thephysician-manager to the Chief Medical Officer and the nursemanager to a Chief Nursing Officer.A horizontalrelationship requiresthat the physicianmanagerbeparticularly adeptwith inter- and intraprofessionalcollaborationThe term ‘dyadic’ isderived from theGreek word ‘dyad’meaning a group oftwo people. A dyadicrelationship occurswhen two people linkas a pair for thepurposes of providingmanagementexpertise. In the ICU,for example, thismight involvephysician and nurseleaders46

Q. What type of relationship, horizontal or vertical, exists between anICU physician-manager and a trainee who is doing a research elective onpatient safety in the ICU?A. The ideal relationship is a dyadic one where the physician-leader spends time coaching thetrainee, who is given latitude in the research project identified through specific goals andobjectives. In this approach, the trainee is more satisfied and performs at a high level.Hierarchy of hospital managementRegardless of the model for organising intensive care services in the hospital (forexample, as a Department, as a Programme or as a Division within a Department),the physician appointed as leader/manager for the ICU works in a hierarchy ofmanagement levels, as outlined in the table below.Examples of levels of management in a hospitalPhysician Directors can have more extensive authority if they assume responsibilityfor a wider field – for instance, all acute services.Management levelexamplesDirector or Vicepresident,PatientCare ServicesPhysician Director,Intensive CareServicesPatient CareManager, IntensiveCare ServicesTypePosition level in thehospital hierarchySenior High LargeMiddle Middle MediumFront line Low SmallDegree of authority& scope ofresponsibility47

7/ LEADERSHIP IN THE ICUAn effective physician-manager integrates leadership skills into his/her approach toall an ICU’s daily activities. In leading, the ICU physician-manager develops a visionfor the ICU’s future – and then creates the support needed from the ICU’sstakeholders to implement changes to achieve the vision. Other important leadershipactivities include motivating the ICU’s multi-professional team, as well as buildingenthusiasm and creating momentum in moving the team towards its agreed vision forthe ICU.Management and leadership are not the same thing although they are often usedinterchangeably. Leadership is just one of the many assets a successful ICUphysician-manager possesses. The aim of a physician-manager is to maximise theoutput of the ICU through administrative implementation. To achieve this, the ICUphysician-managers must plan, organise, staff, direct, control and problem solve. Incontrast, physician-leaders roles include creating a vision for the future, motivatingand inspiring the ICU team and assuming responsibility for ICU performance.Some of the differences are suggested in the table below. While some contend the twoskill sets are mutually exclusive, most would accept a single person can exhibitmanagement and leadership skills and there is cross-over between the two. The roleof an ICU Clinical Director requires both effective management and leadership.ManagementPlanning and budgetingEstablish agendasSet timescalesAllocate resourcesOrganising and staffingProvide structureRecruitmentEstablish rules and proceduresControlling and problem-solvingIncentiviseGenerate creative solutionsTake corrective actionLeadershipEstablishing directionCreate a visionSet strategiesAligning peopleCommunicate goalsSeek commitmentBuild teams and coalitionsMotivating and inspiringInspire and energiseEmpower individualsSatisfy unmet needsKotter JP. A Force for Change: How leadership differs from management. The FreePress; 1990. ISBN-0029184657, 978-0029184653Determine which of the following tasks require leadership skills and managementskills:1/ Writing a business case for additional intensive care beds2/ Auditing adherence to ICU guidelines3/ Creating a five year strategic plan for the intensive care unit4/ Supporting the ICU team in developing a new service5/ Ensuring the the medical staff rotas are written6/ Recruitment of a dedicated intensive care pharmacist48

Leadership in contextThere has been traditionally a strong focus on good leadership in high-hazardindustries such as the airline, energy and manufacturing sectors, where the entiresystem of organisation and culture, including team behaviour and leadership, isdesigned to enhance safety. Due to the complexity of the work, high-pressureenvironment and risk to patient safety, parallels have been drawn between healthcareand these high-hazard industries.Flin R, Yule S. Leadership for safety: industrial experience. Qual Saf Health Care 2004;13(Suppl II): ii45–51. PMID 15576692Helmreich RL. On error management: lessons from aviation. BMJ 2000; 320(7237):781–785. PMID 10720367There has also been political focus on strong and effective leadership within thehealthcare sector:‘It will be imperative that frontline clinicians and the widerworkforce have the leadership knowledge, skills and behavioursto drive radical service redesign and improvement. This willinvolve working in collaboration across health systems, indeveloping new models of care, and further developing the skillsof the entire workforce. The ability to influence and managechange at the frontline will be central to delivering this. There isno doubt that we must continue to develop the leadershipcapability within the system.’ David Nicholson, Chief Executiveof the National Health Service (NHS), United Kingdom.The traditional view of the leader at the top of the organisationwith followers below is outdated. In healthcare there isrecognition that leadership skills should be developed ineveryone and shared leadership is more effective. An openleadership culture is required, where people are encouraged totake personal responsibility and are not afraid to speak up with ideas.This ‘horizontal authority’, which is well described in the aviationindustry, creates a culture that empowers subordinates to speak upand encourages senior members to listen.There are amyriad ofdefinitions ofleadership, withthe conceptmeaning differentthings to differentpeople. Somecommon themesare thatleadershipinvolves: anindividualinfluencing agroup of peopletowards acommon goal.Künzle B, Zala-Mezö E, Wacker J, Kolbe M, Spahn DR, Grote G. Leadership inanaethesia teams: the most effective leadership is shared. Qual Saf Health Care2010; 19(6): e46. PMID 20472572Brindley PG, Reynolds SF. Improving verbal communication in critical care medicine. JCrit Care 2011; 26(2): 155–159. PMID 21482347Psychology research studies have shown that the skills and behaviours of teamleaders predict team performance. There is increasing evidence from the healthcare49

sector and ICU literature, of leadership and management effecting unit performance.Stockwell et al. demonstrated that the ability of senior physicians to effectively leadand communicate with the ICU team, manage resources, set high standards andprovide support on issues of performance and team development was associated withthe number of patient goals being completed.Boyle DK, Bott MJ, Hansen HE, Woods CQ, Taunton RL. Managers’ leadership andcritical care nurses’ intent to stay. Am J Crit Care 1999; 8(6): 361–371. PMID10553177Stockwell DC, Slonim AD, Pollack MM. Physician team management affects goalachievement in the intensive care unit. Pediatr Crit Care Med 2007; 8(6): 540–545. PMID 17906596Approaches to leadershipA number of different approaches to leadership have been described over the yearsand there is considerable overlap between the different approaches. Highlightedbelow are some of the principal leadership traits, styles and preferred behaviours.TraitThis is the concept of being ‘born to lead’. This is based upon the idea that thecharacteristics of a good leader are innate and cannot be learnt. While research hasfailed to demonstrate specific skills sets restricted to leaders, some common themesof self-confidence, initiative, intelligence and belief in one’s actions appear.SituationalThis is based on the work of Hersey and Blanchard and implies that effective leadersneed to adapt their style of leadership to the situation and the competency andcommitment of their followers. Despite its widespread use, there has been relativelylittle research to justify the theory.Hersey-Blanchard SituationalLeadership TheoryAdapted from:Hersey P, Blanchard K, Johnson D.Management of OrganizationalBehavior: Leading HumanResources. 9th Edition. UpperSaddle River, NJ: PearsonEducation; 2008. ISBN-0-13-017598-6.50

Q. Considering the quadrants of the above figure, indicate the differentleadership styles (directing, coaching, supporting, delegating) taken bythe ICU physician-manager in the following scenarios:1/ New junior intensive care doctor doing his/her first central venous lineinsertion procedure2/ Supporting the physiotherapists, occupational therapists, dieticians,psychologists in developing a post ICU rehabilitation service3/ Implementation of a new governmental policy in the ICU4/ Supervising an ICU resident in their postgraduate research projectA.1/ S1: Directing – characterised by one-way communication in which the leader definesthe roles of the individual or team and provides direction.2/ S4: Delegating – the leader is still involved in decisions but the responsibility is largelypassed onto the individual or team.3/ S3: Supporting – shared decision-making about aspects of how the task isaccomplished and the leader is providing less task behaviours while maintaining highrelationship behaviour.4/ S2: Coaching – the leader is providing direction, using two-way communication andproviding the socio-emotional support.Hersey P, Blanchard K, Johnson DE. Management of Organizational Behavior: LeadingHuman Resources. 9th Edition. Upper Saddle River, NJ: Pearson Education;2008. ISBN-0-13-017598-6Transformational and transactional leadershipTransformational leadership has been widely adopted in the healthcare setting withsome success and is considered a contemporary leadership style. The differencebetween transformational and transactional leadership are highlighted in the tablebelow.TransformationalIdealised influenceStrong emotions in followersIntellectual stimulationIndividualised considerationSupport and encouragementInspirational motivationCommunicate the visionTransactionalState what is expected offollowers’Explain how to meetexpectationsClearly state criteria forperformance evaluationProvide objective specificfeedbackAllocate rewards based onobjective achievementResearch suggests that an effective leader should have both styles of leadershipavailable to them and change according to the situation and context.Transformational leadership may lead to dependence on a leader, this has led to the51

theory of post-transformational leadership. This focuses on creating a climate oforganisational learning.Q. A transformational leader establishes a vision that guides the managerin achieving three things. What is NOT one of them?– Quality– Performance– Productivity– EfficiencyA. ‘Efficiency’. The transactional leader focuses on compliance with existing organisationalroles and trades reward for agreement with the leader’s wishes to do such things that wouldimprove efficiency.The different leadership approaches can be simplified into four basic styles:Autocratic – the ‘do as I say’ style. Good in crisis situations, not good forstaff commitment and productivity long-term.Democratic – emphasises teamwork and allows followers to contributeand take ownership of organisational objectives. Good for staffcommitment, job satisfaction and productivity.Laissez-faire – ‘hands-off style’, good for highly trained and motivatedstaff who know what they are doing.Situational – use of one of the above methods as appropriate to the contextencountered.Yukl G. Leadership in Organizations. 6th Edition. Pearson/Prentice Hall; 2006. ISBN-0131494848Goodwin N. Leadership in Health Care: A European prospective. Routledge; 2006.ISBN-0415343275, 978-0415343275Hartley J, Bennington J. Leadership for Healthcare. Bristol: The Policy Press; 2010.ISBN 978-1-84742-486-0Mullins L. Management and Organisational Behaviour. 8th Edition. Prentice Hall;2008. ISBN-978-0-273-70888-9Northouse P. Leadership: Theory and Practice. 5th Edition. Sage publications; 2009.ISBN-1412974887, 9781412974882As highlighted already, a wide variety of skills are required to be an effective leader.Effective leadership in healthcare focuses on the:Delivery of safe, high-quality and effective healthcare – ‘serviceexcellence’.Future strategic vision – ‘future focus’.A core set of personal qualities and attributes to support this – ‘personalqualities’.These are exemplified in the figure ‘Summary of leadership qualities’.http://www.scotland.gov.uk/Publications/2009/10/29131424/852

Particular focus is made of the personal qualities, and these are illustrated in moredetail in the Personal Qualities figure which relates to the UK National Health Service(NHS). http://www.scotland.gov.uk/Publications/2009/10/29131424/8Leadership attributes that contribute to successTo be successful, an ICU physician-leader needs to:Articulate a clear vision for the ICU ... and encourage co-workers to adoptthe vision.Create priorities and direction. This ensures focus for all the ICU’sactivities, clinical and academic (the latter including both teaching andresearch).Identify problems. The successful leader will then use evidence, whereapplicable, to develop possible solutions and pick one approach toimplement.Encourage and support efforts of the ICU staff to improve their skill setsthrough activities such as continuing education. The successful leaderprovides opportunities for members of the ICU staff to gain skills,especially those which are relevant to the ICU’s objectives.Constantly learn. As the environment in which critical care operates israpidly changing, a constant infusion of new knowledge (from thephysician-leader) is a prerequisite for the ICU to be successful.Balance the interests of all stakeholders … and be especially sensitive tomaintaining a commitment of the ICU for the public’s benefit.Starkweather DB, Shropshire DG. Management Effectiveness. In: Taylor RJ, Taylor SB,editors. The AUPHA Manual of Health Services Management. GaithersburgMaryland: Aspen Publishers; 1994. ISBN-10 0834203634Q. As a new physician-manager, you discuss with colleagues differentapproaches to including the public’s perspective in the ICU’s activities.One colleague suggests that you consider creating an ICU CommunityAdvisory Board. Think about an advisory board’s role in the ICU anddiscuss what purpose it might serve.A. A community advisory board could help in a two-way communication process. It mightkeep the community informed of the goals and objectives of the ICU and be a forum for opendiscussion of relevant significant issues, for example, changing attitudes to end-of-life care.Local citizens are appointed to represent the community, to act as liaison, to identify areas ofconcern to the community and to communicate the ICU’s activities to the community.53

Using power... effectively and judiciouslyIf an essence of leadership is the ability to influence followers, power is the potentialto exert influence. Power is the ‘ability (or potential) to exert actions that eitherdirectly or indirectly caused the change in the behaviour and/or attributes of anotherindividual or group.’Shortell, SM, Kaluzny AD. Essentials of Health Care Management: Delmar series inhealth services administration. Cengage Learning; 1997. ISBN 0827371454,978-0827371453. Chapter 9. Power and Politics in Health ServicesOrganizations.For the ICU physician-leader, power means that s/he is in a position to carry outhis/her own will, despite resistance from other members of the ICU team. Sources ofthe ICU physician-leader’s power can be categorised as follows:Legitimate power exists when it is derived from a physician-leader’sadministrative position in the hospital.Reward-based power exists when the physician-leader is able to rewarddesirable behaviours, for example, by changing physician remuneration.Coercive power occurs when the physician-leader has the ability to preventa colleague from achieving rewards they want.Expert power occurs when the physician-leader has knowledge valued bythe ICU (or hospital) which is considered important to the unit’sobjectives. An example of expert power occurs when a physician-leaderhas skills in health services research, and the hospital needs advice aboutimplementing performance management initiatives (the latter, a corecompetency of health services research training).Referent power results when a physician-leader creates admiration andloyalty, to the extent that power is thereby gained to influence others.Successful physician-leaders understand the importance of developing power. Thishappens through a leader’s ability to create opportunities, control resources and/orassist the hospital in successfully dealing with challenges faced by the hospital’sadministration. Exerting influence is best reserved for issues of high priority for theICU (where the greatest benefits can occur from its application). Stated differently,the effective ICU physician-leader knows how to use his/her power and influencejudiciously.Q. Give an example of each of reward-based, expert and coercive power,from the perspective of an ICU physician.A.Reward-based power, exists when an ICU physician-leader provides a colleague withsupport to attend a national meeting on quality improvement, acknowledging thecolleague’s leadership in developing a quality improvement project.Expert-based power exists when a physician-leader has studied and published onhealth services research, and is asked by the hospital to develop a comprehensiveprogramme on effective utilisation of ICU services.Coercive power exists when a physician-leader has the capacity to negatively reflecton the appropriateness of promoting a physician colleague.54

8/ MANAGING TEAMS AND TEAMWORK IN THE ICUA team can be defined as, ‘a distinguishable set of two or more people who interact,dynamically, interdependently, and adaptively toward a common and valuedgoal/objective/mission, who have each been assigned specific roles or functions toperform.’ Salas et al., 1992.Salas E, Dickson TL, Converse S, Tannenbaum SI. Toward an understanding of teamperformance and training. In: Swezey RW, Salas E, editors. Teams: TheirTraining and Performance. Norwood, NJ: Ablex Publishing Corporation; 1992Put more simply, teamwork is a dynamic process involving two or more peopleengaged in the activities necessary to complete a task.Why is teamwork important in intensive care?The ICU team is multi-professional and includes nurses, physicians, and allied healthprofessionals who are all involved in the daily care of the critically ill patient.Teamwork occurs when members of the ICU work together in such a way that theircollective skills are integrated to achieve a common goal. In the successful ICU team,members not only possess complementary skills, they can be collectively heldaccountable to the goals and objectives of the ICU (or to the specific project on whichthey are collaborating). Good multidisciplinary teamwork in ICU has been shown to:Reduce conflicts.Reduce burnout syndrome.Improve staff satisfaction and morale.Lead to better patient care.Wheelan SA, Burchill CN, Tilin F. The link between teamwork and patients’ outcomesin intensive care units. Am J Crit Care 2003; 12(6): 527–534. PMID 14619358Azoulay E, Timsit JF, Sprung CL, Soares M, Rusinová K, Lafabrie A, et al.; ConflicusStudy Investigators and for the Ethics Section of the European Society ofIntensive Care Medicine. Prevalence and factors of intensive care unit conflicts:the conflicus study. Am J Respir Crit Care Med 2009; 180(9): 853–860. PMID19644049Poncet MC, Toullic P, Papazian L, Kentish-Barnes N, Timsit JF, Pochard F, et al.Burnout syndrome in critical care nursing staff. Am J Respir Crit Care Med2007; 175(7): 698–704. PMID 17110646Williams M, Hevelone N, Alban RF, Hardy JP, Oxman DA, Garcia E, et al. Measuringcommunication in the surgical ICU: better communication equals better care. JAm Coll Surg 2010; 210(1): 17–22. PMID 20123326The ICU environment is characterised by high levels of complexity, workload andcomplex decision-making, with errors resulting in potential harm to patients. Recent55

focus has been on improved outcomes for patients from better teamwork andcommunication.http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085825See the PACT module on CommunicationResearch specific to intensive care, demonstrated that in a study of 2075 criticalincidents from 23 ICUs over a period of 24 months, poor teamwork contributed to32% of the incidents. In addition to improved patient safety, effective team working isassociated with better outcomes for patients and better staff satisfaction.Pronovost PJ, Thompson DA, Holzmueller CG, Lubomski LH, Dorman T, Dickman F,et al. Toward learning from patient safety reporting systems. J Crit Care 2006;21(4): 305–315. PMID 17175416In the article below, how was communication improved on the ICU?Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improvingcommunication in the ICU using daily goals. J Crit Care 2003; 18(2): 71–75.PMID 12800116Types of teamsDifferent team types have been identified according to the task to be performed.Medicine has traditionally focused on action teams. Increasingly there is a movetowards advice and project teams.Type of team Examples OutputsAdviceCommittee, reviewpanels, boardsDecisions,selection,suggestionsActionSurgical teams,Operations, patientProjectProductionICU teamsResearch groups,planning teamsMedicalmanufacturing,hospital receptions56carePlans, designs,investigationreportsMedical equipment

MotivationIn order to understand how to manage teams effectively, it is important tounderstand what motivates individuals within a team to perform.Motivation can be defined as ‘the degree to which an individual wants and chooses toengage in certain specified behaviours’.Mitchell TR. Motivation: New directions for Theory, Research and Practice. Academy ofManagement Review 1982; 7(1): 80-88An individual’s motivation to work can be broadly divided into three categories:Economic rewards – pay, benefits, pension rights and security. This is aninstrumental orientation to work.Intrinsic satisfaction – personal growth and development from work. Thisis a personal orientation to work.Social relationships – friendships, group working and status. This is arelational orientation to work.Adapted from:Mullins L.Management andOrganisationalBehaviour. 8thEdition. PrenticeHall; 2008. ISBN-978-0-273-70888-9The physician-manager needs to be sensitive to the requirement to motivate his/hercolleagues. Different individuals will respond to different rewards at different times.The effort an individual expends will depend on his/her perception that it willachieve an intended level of performance, and that attainment of this level ofperformance will lead to a particular need-related outcome.CohesionSuccessful and effective teams are likely to demonstrate cohesiveness. Strong andcohesive groups are likely to have high morale and productivity.57

Team members•number in team•turnover/stability•personalities/conflictTeam development•forming•storming•norming•performing•adjourningManagement•leadership•policies/guidelines•deliverance•perceived threatsTeamperformanceandcohesivenessEnvironment•support ‐ IT/technical•location•nature ofprojectA successful team is likely to have passed through several ‘stages’ in groupdevelopment and maturity. The model by Tuckman and Jensen identifies fivesuccessive stages of group development:Forming – orientation stage, who is in the group, what the purpose is,individual roles and responsibilities, establishment of identity in thegroup.Storming – conflict stage, disagreements between individuals on theobjectives and how to achieve them.Norming – cohesive stage, the members of the team develop ways ofworking together and establish rules and codes of conduct.Performing – the team has developed an effective structure,achievement of objectives is likely to be at its most effective.Adjourning – the team may disband because the task has beencompleted or members have left.Tuckman BW, Jensen MC. Stages of small group development revisited. Group andOrganization Management. 1977; 2: 419–427Mullins L. Management and Organisational Behaviour. 8th Edition. Prentice Hall;2008. ISBN-978-0-273-70888-9Characteristics of effective teamsCreating effective teams is an active process. Literature on teamwork suggests acommon set of requirements for an effective team:CommunicationLeadershipCoordinationDecision-making58

There is further elaboration on these characteristics below and a team performanceframework is highlighted in the figure.Adapted from:Reader TW, Flin R,Mearns K,Cuthbertson BH.Developing a teamperformanceframework in theintensive care unit.Crit Care Med2009; 37 (5): 1787-1793. PMID19325474Communication strategies to improve teamworkPoor communication has been shown to be associated with poor teamwork andadverse outcomes in a number of studies. Given the wide range of tasks within theICU, from admitting patients, diagnosing illnesses, developing treatment plans,performing complex procedures and making end-of-life decisions, it is clear that thecommunication strategy will vary with the task. Interventions to improvecommunication using a variety of techniques such as workshops and simulation arebeing designed and implemented. Examples of interventions to improvecommunication include SBAR (Situation-Background-Assessment-Recommendation), the ‘three Cs of communication’ (clear instructions, citingnames, and closing the loop) and ‘LOVE’ – Leadership, Ownership, Values andEvaluation.SBAR is used to provide a structured and standardised communication betweenhealthcare workers:Situation: state who you are, describe the reason for the call and situationof the patient.Background: give a brief summary of the background, vital signs,laboratory results.Assessment: what do you think is going on? Your clinical assessment.Recommendation: clarify what action you expect to be taken.59

The ‘LOVE’ programme is aimed at improving communication inside the team andto patients and their relatives. It is based on factors such as strong and positiveleadership, respect for individuals, and a rigorous evaluation of quality of care.Carlet J, Garrouste-Orgeas M, Dumay MF, Diaw F, Guidet B, Timsit JF, et al. Managingintensive care units: Make LOVE not war! J Crit Care 2010; 25(2): 359. e9–359.e12. PMID 20189752Haig K, Sutton S, Whittington J. SBAR: a shared mental model for improvingcommunication between clinicians. Jt Comm J Qual Patient Saf 2006; 32(3):167–175. PMID 16617948Smith JR, Cole FS. Patient safety: effective interdisciplinary teamwork throughsimulation and debriefing in the neonatal ICU. Crit Care Nurs Clin North Am2009; 21(2): 163–179. PMID 19460662For more information read PACT module on Communication.Use of effective leadership to improve teamworkEffective team leadership refers to the actions undertaken by a team leader to ensurethe needs and goals of the ICU team are met and are crucial for team success. Teamleadership is different from organisational or strategic leadership and relates toresponsibility for guiding a team through its work cycle. Physician-leaders shouldcreate shared common goals, delegate, empower individuals, supervise decisionmakingand guide the team to achieving more as a collective than would be possibleindividually. Outlined in the table below are examples of behaviours used by ICUteam leaders to lead teams during both normal and/or emergency situations(functional leadership behaviours) and behaviours adopted to create conditions thatenable effective team performance (termed team development behaviours).Functional LeadershipBehavioursInformation gatheringPlanning and decision-makingManaging team membersManaging resourcesTeam DevelopmentBehavioursProviding team directionEstablishing team norms (i.e.the rules governing interactionsbetween the team members)CoachingProviding organisationalsupportCoordination strategies used to improve teamworkComplex and urgent tasks in the ICU require integration of interdisciplinary teams ina rapid, complementary and sequential manner. Coordination may occur throughdirect verbal communication or through members’ situational awareness and sharedmental roles/objectives. Team members need to be able to communicate theirprogress and needs to the rest of the team so it can adapt accordingly.60

Effective decision-making strategies to improve teamworkDecision-making is still often perceived as a hierarchical process with more juniormembers of the team and other healthcare professionals often reluctant to make orchallenge decisions. Collaborative team decision-making has been shown to lead toimproved outcomes. The style of decision-making may change in response to thesituation, with a more directed approach being used in crisis/emergency situations.Reader TW, Flin R, Mearns K, Cuthbertson BH. Developing a team performanceframework for the intensive care unit. Crit Care Med 2009; 37(5): 1787–1793.PMID 19325474Reader TW, Flin R, Cuthbertson BH. Team leadership in the intensive care unit: theperspective of specialists. Crit Care Med 2011; 39(7): 1683–1691. PMID21460708Vivian L, Marais A, McLaughlin S, Falkenstein S, Argent A. Relationships, trust,decision-making and quality of care in a paediatric intensive care unit. IntensiveCare Med 2009; 35(9): 1593–1598. PMID 19554306See table below for concepts not specific to the ICU, but which feature inorganisational team psychology. They include: engendering professional efficacy,creating stable teams and leaders, developing trust and participative safety andencouraging team reflexivity.TermProfessional efficacyCreate stable teams and leadersTrust and participative safetyTeam reflexivityDescriptionProviding staff with sufficientresources to do their job well.Minimising turnoverEncouraging good workingrelationshipsListening, encouraging andrespect of team members. Actingsensitively.Reflecting and assessingperformance and progress. Teammeetings and ‘away days’.Using teams to solve problemsWhen using teams to solve problems, researchers have emphasised the collectivebrainpower of a team exceeds the capability or capacity of one individual or manager.One reason that teamwork is so important in intensive care is the speed at whichadvances have been occurring in this discipline – working as a team allows membersto keep each other up to date in a rapidly changing environment.Gray states the performance [P] of an individual or team has a function of threevariables, thus: P = M C/B, where [M] is the level of motivation, [C] is the level ofcompetency and [B] are the barriers needed to be overcome in order to perform well.61

Muir Gray JA. Evidence-based healthcare: How to Make Health Policy andManagement Decisions. 2nd ed. New York: Churchill Livingstone; 2001. ISBN-10 0443062889Despite many reasons for using teams to problem solve, it also usually takes longer tocomplete than when done by the physician-manager alone. Using a team-basedapproach is best considered when time is not an issue with regard to the problemrequiring a solution, and when the issue is complex.Comparisons of decision-making by groups vs individualsFactor Group IndividualType of problemWhen diverse knowledge When efficiency is desiredand skills are requiredAcceptance of decision When acceptance by groupmembers is valuedWhen acceptance is notimportantQuality of the solution When the input of severalgroup members canimprove the solutionWhen a ‘best member’ canbe identifiedCharacteristics ofindividualsWhen group membershave experienced workingtogetherWhen individuals cannotcollaborateOrganisational culture When the culture supportsgroup problem-solvingWhen the culture iscompetitiveAmount of time available When relatively more timeis availableWhen relatively little timeis availableAdapted from Gordon, JR. Organizational Behavior: A Diagnostic Approach. 6 th ed. PrenticeHall; 1998. ISBN-10: 0139228241. Chapter 6, p. 163.Q. A team-based, collaborative ward round structure, involving the use ofa structured communications protocol conducted daily at each patient’sbedside, has been advocated. How might it improve ICU organisation?A. It provides a forum for discussion of team goals and processes and helps to addresssystem-level concerns.In the reference below, following implementation of collaborative rounds, satisfactionrates improved and furthermore mortality rates of cardiac surgery patients declinedsignificantly from expected rates.Uhlig PN, Brown J, Nason AK, Camelio A, Kendall E. John M. Eisenberg Patient SafetyAwards. System innovation: Concord Hospital. Jt Comm J Qual Improv 2002;28(12): 666–672. PMID 1248160162

Q. Drawing from aviation crew resource management (CRM)programmes, provide an example of an educational technique wherebyteamwork in your ICU might be improved to enhance patient safety.A. The use of multidisciplinary simulation as part of CRM training can improve institutionalteamwork behaviours.A prospective multicentre evaluation measured changes in errors before and aftertraining on institutionalising teamwork behaviours. A statistically significantimprovement in quality of team behaviours was shown between the experimental andcontrol groups following training and clinical error rate significantly decreased.Morey JC, Simon R, Jay GD, Wears RL, Salisbury M, Dukes KA, et al. Error reductionand performance improvement in the emergency department through formalteamwork training: evaluation results of the MedTeams project. Health ServRes 2002; 37(6): 1553–1581. PMID 12546286Managing conflicts in ICUConflict in the ICU has been defined as ‘a dispute, disagreement, or difference ofopinion related to the management of a patient in the ICU involving more than oneindividual and requiring some decision or action’. ESICM Ethics CommitteeConflict is common within the ICU. Variable rates of conflict have been reported. In alarge multinational study, 72% of ICU staff reported a perceived conflict in theirprevious working week. Moreover, 83% of these conflicts were deemed harmful and53% as severe or dangerous.Azoulay E, Timsit JF, Sprung CL, Soares M, Rusinová K, Lafabrie A, et al.; ConflicusStudy Investigators and for the Ethics Section of the European Society ofIntensive Care Medicine. Prevalence and factors of intensive care unit conflicts:the conflicus study. Am J Respir Crit Care Med 2009; 180(9): 853–860. PMID19644049Conflict in the ICU may be intra-team, inter-team, team–family, intra-family,patient–team or patient–family in nature – outlined in the figure below. Team–family and intra-team conflict account for the majority.63

Adapted from:Fassier T, Azoulay E.Conflicts andcommunication gapsin the intensive careunit. Curr Opin CritCare. 2010; 16 (6):654-665. PMID20930623Studdert DM, Mello MM, Burns JP, Puopolo AL, Galper BZ, Truog RD, et al. Conflict inthe care of patients with prolonged stay in the ICU: types, sources, andpredictors. Intensive Care Med 2003; 29(9): 1489–1497. PMID 12879243Fassier T, Azoulay E. Conflicts and communication gaps in the intensive care unit. CurrOpin Crit Care 2010; 16(6): 654–665. PMID 20930623The most common source of conflict is related to disagreements about the goals oftreatment and end-of-life care.TeamInter-teamIntra-teamTeam–familyCause of conflictDelayed appropriate admissionInappropriate referralsICU life-sustaining care unlikely to be beneficial andpalliative care more appropriateFailure to develop consistent goalsChange in management plans with staff rotationPoor communicationOngoing active life-sustaining treatment felt to beinappropriate by some ICU team membersUndue pressure from families to continue active lifesustainingtreatment despite professional view offutility or against perceived patient’s wishesCultural, linguistic and religious barriersConcerns regarding discharge timingUnrealistic expectations provided by referring team64

Q. What is the potential impact of ICU conflict on the1/ Patient and their families2/ ICU team3/ OrganisationA. 1/ The impact of conflict on patients and their families has been shown to result in: delayed treatment delayed transition from active life-sustaining treatment to comfort care misunderstandings decreased patient/family satisfaction depression, anxiety and complicated grief for patients and their families2/ The impact of conflict on the ICU team has been shown to: increase burnout increase staff turnover, sickness compromise team cohesion lead to poor staff morale3/ The impact of conflict on the hospital has been shown to: increase medical errors increase complaints, litigation result in worse outcomes for patientsDealing with conflict is a critical skill. Effective management of conflict can aidpatients, clinicians and family members through difficult situations and lead topersonal and professional satisfaction. Principles of conflict management arereviewed in the citations below.Key MK. A method for mediating conflict among different mindsets. J Healthc Qual2000; 22(6): 4–8. PMID 11186039Marcus L. Renegotiating health care. Interview by Richard L. Reece. Physician Exec1999; 25(4): 18–23. PMID 10557480In dealing with conflict, the ICU physician-manager must be action-oriented. As soonas a problem is identified, the ICU physician-manager should investigate thebackground to the problem and begin its resolution process. Emphasis needs to beplaced on being objective in the review of circumstances surrounding the conflictissue. While sometimes difficult, it is vital for the physician-leader to remove emotionfrom the problem’s analysis. The following are guidelines to consider in conflictresolution:Minimise defensiveness, because it only serves as a barrier tocommunication.Separate fact from emotion, because individuals in conflict need toverbalise their version of the events.Gather facts from both sides of a conflict situation. Remember that conflictoften arises from a simple misunderstanding.Deal with conflict in a timely manner. If left alone, a smallmisunderstanding might build into a substantial problem that will distractthe entire ICU team.65

A stepwise approach to addressing conflict is presented in Table 4 in the followingreference. http://jama.jamanetwork.com/article.aspx?articleid=200521Back AL, Arnold RM. Dealing with conflict in caring for the seriously ill: ‘it was just outof the question’. JAMA 2005; 293(11): 1374–1381. PMID 15769971See the PACT module on Communication.Conflict in the ICU can be costly. Some problems are obvious, for example, whenquality problems arise as physician colleagues act on anger rather than actingcooperatively. Other costs are hidden, for example the impact of conflict on decisionmaking.While conflict is commonly considered to be negative and dysfunctional, functionalconflict can also exist. This can be useful for generating ideas, stimulating creativityand bringing people closer together. An organisation with no conflict is characterisedby no change and little motivation of the individuals.See ESICM Flash Conference: Elie Azoulay. Managing staff conflicts. Vienna 2009CONCLUSIONHealthcare organisations of the future are imposing greater demands foraccountability and performance that require physician-managers to become familiarwith new roles, and to demonstrate skills that have not been traditionally included inan intensive care physician’s postgraduate training. This module has described howintensive care physician-managers need to:Understand quality improvement in a manner that is consistent with thenew demands for clinical governance.Learn about healthcare financing and how to use budgets for planning andmonitoring.Know about problem-solving, conflict resolution, mentoring and coaching.Be lifelong learners, to provide transformational leadership and createvisions to move their ICU in new directions.66

APPENDIXAdditional resourcesIf you wish to learn more about management and leadership in healthcare, here areextra resources.TextbooksThe following are textbooks the authors consider to be excellent in contentdevelopment for physicians during career training in management and leadership.Shortell SM, Kaluzny AD (editors). Health Care Management: Organization Design &Behavior. 4th edition. Albany (NY): Thomson Delmar Learning; 1999. ISBN-100766810720Kotter JP. Leading Change. 1st edition. Boston (MA): Harvard Business School Press;1996. ISBN-10 0875847471Maxwell JC. Leadership 101: What Every Leader Needs to Know. Nashville (TN):Nelson Business; 2002. ISBN-10 0785264191Sperry L. Becoming an Effective Health Care Manager: The Essential Skills ofLeadership. Health Professions Press; 2003. ISBN-10 1878812866Hammon JL. Fundamentals of Medical Management: A Guide for the New PhysicianExecutive. 2nd edition. American College of Physician Executives; 2000. ISBN-10 0924674660Yukl G, Lepsinger R. Flexible Leadership: Creating Value by Balancing MultipleChallenges and Choices. San Francisco (CA): Jossey Bass; 2004. ISBN-100787965316Dye CF. Leadership in Healthcare: Values at the Top. Health Administration Press;2000. ISBN-10 1567931146Gabel S. Leaders and Healthcare Organizational Change: Art, Politics and Process. NewYork (NY): Kluwer Academic/ Plenum Publishers; 2001. ISBN-10 0306465574Zuckerman AM. Healthcare Strategic Planning. 2nd edition. Health AdministrationPress; 2005. ISBN-10 156793237167

PATIENT CHALLENGESYou are appointed the new physician-manager of a 12-bed multidisciplinary intensive careunit. You have been working for another hospital as assistant director of its ICU sincecompleting your residency training.Managerial practicesClinical governanceLevels of hospital managementQ. How would you go about agreeing on the objectives for your new physician-manager jobwith hospital management?A. Request a job description in which explicit ‘performance objectives’ are discussed andagreed on. You also want to identify the support the hospital will provide you in achievingthe objectives agreed to. For example, if the hospital wants you to lead an increase inresearch productivity for the unit, you might wish to negotiate some funding for you toinvest in new research projects and/or in the recruitment of new faculty with researchexpertise.Finally, you want to agree with the hospital’s management the performance measurementsthat will be used by the hospital to determine that you have achieved their expectations.Ideally, you want to ensure they plan to provide you with a regular performance review (atleast annually and maybe more frequently in the earlier stages of this new job).Beginning a new job is also an opportunity for you to discuss the support you want tobetter develop your management and leadership capabilities. It is not uncommon forphysicians to request support for training programmes that will help develop themanagement and leadership skills necessary to do the job well.Job descriptionPerformance reviewRole of the physician-managerRathert R, Taylor MW. The role of the health care leader. Past, present, future.Physician Exec 2001; 27(4): 48–49. PMID 1148189368

In accepting an appointment as a ‘physician-manager’, you are aware that the ICU hasbeen without a full-time leader since your predecessor retired ten months ago. In hisabsence, staff morale is reported to have fallen since the unit staff did not feel they hadsomeone to advocate for their needs with the senior hospital management.You plan a meeting with the ICU physicians and senior nursing staff shortly afterbeginning the new job. You might consider it useful to get together and hold a staffmeeting. As part of the staff meeting, you also want to give your new colleagues a chance toengage in a question and answer session. One of the first questions from a senior nurse is‘tell us about your ambitions for the ICU?’LeadershipQ. How do you respond to this question?A. You also want your new colleagues to understand you are committed to planning, tohelp them develop a creative vision for their ICU’s future. You also should consideracknowledging the process of developing and implementing this plan will be criticallydependent on their participation and support. As the new leader, you want to mobiliseyour colleagues’ planning efforts in an open process that honestly appraises the unit’sstrengths and weaknesses and then creates a plan that will make them feel part of a specialplace to work.Team buildingLeading changePlanningDeveloping a visionDifferent styles of leadership for different challengesSchaeffer LD. The leadership journey. Harv Bus Rev 2002; 80(10): 42–47, 127. PMID12389460In one of your first meetings with the senior nurse manager, you realise the ICUhas never undergone a strategic planning exercise. You are told that some of the ICUphysicians are sceptical of ‘business ideas’ being applied to an area which is as complex asthe ICU. ‘After all’ you are told, ‘strategic planning will take time away from otherimportant tasks’.69

Strategic planningQ. How do you respond to the scepticism expressed about taking time away fromimportant issues such as caring for patients, to develop a strategic plan?A. You need to convince your new colleagues that strategic planning is really an investmentin a process which will make the ICU a better workplace and ultimately, a better place inwhich to be a patient. Without a strategic plan, your unit’s workforce will not havedirection – for example they will not have had a discussion about how to invest theirresources and time in activities that will increase the unit’s profile in the hospitalenvironment or critical care community. Acknowledge that planning will take time, butthat the reflection it provides will create the understanding of how the ICU’s workforce willbe able to respond to future challenges.Resources and time managementNeed for planning in healthcareEspy SN. Planning to plan: the process of success for the future. Health Care StrategManage 1991; 9(12): 16–17. PMID 10115186You have been told by senior management that the ICU performance has fallen over theprevious 12 months, with the unit demonstrating an increasing length of stay despite yourcolleagues’ assurances that they are following protocols and guidelines carefully.Q. Describe what you would do with this problem? What might be a possible cause ofincreasing length of stay if the ICU physicians are in fact appropriately following dischargeguidelines?A. To confirm the hospital’s ‘opinion’ with regard to apparent increases in length of stay,you should review the ICU’s database comparing the same time over two or three years. Iflength of stay has in fact increased, you want to determine why. For example, changes inlength of stay may be beyond the control of the unit staff. You should always try to use‘evidence’ in discussions with senior management, especially around resource issues.Performance assessmentWhy and how to improve the quality of healthcare70

[No authors listed]. Rewarding for quality: new incentives emerge to improvehealthcare and promote best practices. Qual Lett Healthc Lead 2002; 14(12): 2–5, 8–10, 1. PMID 12599857You undertake a review of the hospital’s database and confirm that length of stay hasindeed increased by almost a full day over the last 12 months.Q. What patient data might you want to review to understand why length of stay hasincreased?A. You would want to determine if illness severity had increased over that period, given itsimpact on length of stay.Q. What process data might you want to review to understand why length of stay hasincreased?A. You also want to confirm that discharge guidelines are being followed, perhaps by doinga small, retrospective chart review. In addition, changes in accessibility of beds outside theICU to receive discharged patients could increase length of stay despite use of dischargeguidelines. This could be assessed by measuring the time between discharge orders writtenon the chart and when the patient is transferred.Measuring ICU performanceIn your first performance review, the senior hospital management team points outthat an element of your performance expectations was the development of a qualityimprovement programme. They explain that your predecessor had not considered qualityimprovement as an important aspect of his role. They ask you to develop a template for aquality improvement plan and to present it to senior management in three months.Performance reviewsICU quality improvement programmesQ. Given that ‘evolution is better than revolution’, how would you approach thepreparation of a quality improvement proposal to present to senior hospital management?A. A stepwise approach to setting up a successful ICU quality improvement programme isrequired.71

Q. Provide an outline of a stepwise approach.A.– Choose a project, identify opportunities and resources.– Develop a project plan including key stakeholders, resources, a task list, budget andtimeline.– Collect information on the current care being delivered and the potential barriers.– Generate a data collection system.– Generate a data reporting system.– Implement strategies to change behaviour.– Evaluate and sustain the quality improvement programme.Creating teams and teamworkHigh-quality health plans – national and local perspectivesEnthoven AC, Vorhaus CB. A vision of quality in health care delivery. Health Aff(Millwood) 1997; 16(3): 44–57. PMID 9141320In one of the meetings of the task team helping you develop a quality improvementprogramme plan, the team asks you about quality indicators for the ICU.Q. What is a quality indicator?A. A quality indicator is a qualitative or quantitative measure of the quality of care in theICU. Quality indicators have been described in three categories – input (structure), processand output (outcome).Quality indicatorsPACT module on Quality assurance and cost-effectivenessQ. Describe examples of structure, process and outcome quality indicators for your ICU.A. A structure quality indicator would be the percentage of time that the ICU had coverby an intensivist. A process indicator would be the number of central venous cathetersinserted which were compliant with the central line bundle and an outcome indicatorwould be the frequency of ICU readmissions after 48 hours of discharge or the frequencyof catheter-related blood stream infections.72

Outcome measures to underpin quality improvement programmesBlack NA, Jenkinson C, Hayes JA, Young D, Vella K, Rowan KM, et al. Review ofoutcome measures used in adult critical care. Crit Care Med 2001; 29(11): 2119–2124. Review. No abstract available. PMID 11700407You are told by senior hospital management that your unit’s budget exceeds whatwas allocated for the current fiscal year. They ask you to prepare an analysis of the reasonsfor the negative variance for subsequent review by the chief executive.Q. Describe the process of preparing this mid-year analysis of apparent budget negativevariance.A.. You would review categories of ‘budget indicators’ that are important in analysing acost centre’s performance, including:– Financial (e.g. cost per unit of service)– Staffing (e.g. hours paid)– Workload (e.g. number of patients admitted and their severity of illness index)– Supplies and drugs.Developing a response for the hospital management team should not therefore be difficultgiven your commitment to creating and following indicators and regularly reviewing theseindicators.Variance (analysis of)Budget monitoringIn preparation for the next year’s budget development exercise, the hospitalmanagement team sends you a budget workbook that assumes on the cost side:Wages will increase 5%Supplies and drugs will increase by 6% andUnit overheads (e.g. heat, power) will increase 3%On the revenue side, you are told your budget will increase by no more than 3%, leaving a‘gap’ of anticipated costs being greater than revenue.73

Q. Your unit is a partially ‘open’ unit, meaning some patients are cared for by their primaryattending physicians who are not trained intensivists. Additionally, you note that roundswith these physicians are not organised, occurring on an irregular basis. Describestrategies you might consider to reduce costs, and so stay within next year’s budgetplanning assumptions.A. Creating a ‘closed’ ICU will improve performance, both patient-related and budgetary.Additionally, team rounds improve staff satisfaction and reduce care costs. With this‘evidence’ from the health management literature, you can propose ‘closing’ the ICU sothat its patients receive primary care only from trained intensivists. This is based on theassumption that there are sufficient trained intensivists to create an appropriate staffingpool.Rational decision-making processesClosed vs open ICUsIn preparation for the next year’s budget, you are also aware that your colleagues arerequesting new technologies that may improve patient outcomes.Q. How do you accommodate these new technologies in next year’s budget?A. First, you could create ‘project teams’ to review each technology proposed. You canchallenge each team to review the ‘evidence’ to determine that adopting the technologieswill have a positive impact on either patient outcomes (improved survival, improvedsatisfaction) or unit utilisation outcomes (lesser length of stay, less costly stay period).Q. A project team then creates a business case to delineate the importance of adopting aspecific technology. What other elements might this business case include?A. The business case may also identify the risk to the unit of not adopting the newtechnology, for example, will patient safety be jeopardised. Each business case should alsoidentify the funding possibilities. For example, will the technology save money that thencan be used to pay for it?ICU and quality improvementBusiness case developmentPACT module on Health technology assessmentYou are invite to join a registry of ICUs in your country, the purpose of which is to sharedata describing the utilisation and performance (clinical and financial) of member units.You have a modest data collection system in your unit but you do not have the capacity tobenchmark with other units. Membership requires an annual fee to pay for central data74

support and hiring a data utilisation colleague to gather daily data from each patient and toinput it into central data repositories.ICU data registriesBenchmarkingPACT module on Quality assurance and cost-effectivenessQ. Should you take on further expenditure when the unit’s budget is already challenged fornext year?A. As a manager, you should commit to ensuring a good utilisation review mechanism is inplace. This means not only gathering data and comparing it internally, for examplecomparing this year’s performance to last year’s performance. It also means being able tobenchmark your unit’s performance with the performance of other units. Being part of aregistry of ICUs also allows sharing of ‘best practices’ that can improve your patient andbudgetary outcomes.On reflection, management and leadership skills are important attributes for aphysician-manager and leader. Management theory and skills are rarely addressed inmedical training and to a large extent are only beginning to be incorporated intopostgraduate specialty training programmes. In countries where the role of clinicians inmanagement is well established, it is useful to observe senior colleagues. Be prepared toask senior colleagues how and why they make management and strategic decisions.75