CONCEPTS, COMPONENTS, AND CONFIGURATIONS
Teaching Emergency Department Administration: The In-Basket Exercise Kenneth V. Iserson, MD Clovis Shepherd, PhD Cincinnati, Ohio Borrowing from formats that have been successfully used in teaching administrators, we developed a limited, time-dependent simulation model, the In-Basket Exercise for teaching emergency department administration. The exercise is designed as an introduction to nonclinical decisions, management communication, and managerial control. Using selected material, and under time constraints, participants are asked to describe the options for several types of administrative items. These options and decisions are then discussed within a group. The In-Basket Exercise has been well received as a simple new tool for teaching emergency department administration where existing methods are generally deficient. Iserson KV, Shepherd C: Teaching emergency department administration: The in-basket exercise. JACEP 8:114-115, March, 1979.
emergency department administration; emergency physician, training
INTRODUCTION Emergency physicians often have a large a d m i n i s t r a t i v e responsibility. Clinical training alone is inadequate preparation for administration2 Emergency medicine residencies have struggled with methods of imparting this knowledge - - with little success. Physicians entering emergency medicine without a formal residency are ever/less well prepared. The Emergency Medidine Core Content as developed by the Graduate/ Undergraduate Education Committee of ACEP 2 includes a substantial list of administrative areas for the emergency physician to master. Yet, t r a i n i n g in administration has been mainly trial and error2 What little formal teaching exists usually deals with finances. 4 THE EXERCISE Borrowing from formats that have been successfully used in teaching business, hospital and nursing administrators2 we developed an In-Basket Exercise for the emergency department. A limited, time-dependent simulation of emergency department administration, the exercise is a judicious selection of items requiring decisions that might be found in an emergency department director's in-box. This s a m p l e is c u l l e d from a c t u a l items from t h r e e s e r v i c e s : a university-based emergency medicine residency, a teaching hospital, and a major nonteaching community hospital emergency department. The items vary in length and complexity, and include those items requiring routine decisions and those where the resident's personality, background, and prior experiences will direct the actions. The exercise is given to the participant as a sheaf of papers including. From the Division of Emergency Medicine, Cincinnati General Hospital and the Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, Ohio. Presented at the University Association for Emergency Medicine Annual Meeting in San Fraqcisco, May 1978. Address for reprints: Kenneth V. Iserson, MD, Department of Emergency Medicine, Carswell AFB, Fort Worth, Texas 76127.
8:3 (March) 1979
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memos, personnel applications, notices, phone messages, etc, in as realistic a form as possible. He is given a situation o u t l i n e - - detailing his position i n the hierarchy of the hospital, his general responsibilities, his associates, colleagues, a n d employees. He is g i v e n a t i m e cons t r a i n t of one hour or one and oneh a l f hours and a n e x p l a n a t i o n for the t i m e c o n s t r a i n t . As t h e r e s i d e n t works through the pile, he lists decision options for each item as well as the final decision or i n d e c i s i o n on special work sheets. Later, in a group, the items, options, a n d decisions are discussed u n d e r the guidance of a n experienced administrator. Ideas, reasoning, and experiences are exchanged. The level of i n t e r c h a n g e will depend upon the a d m i n i s t r a t i v e sophistication of the group. Because of the items selected, the discussion t e n d s to cover m a n y of the areas frequently encountered by the e m e r g e n c y p h y s i c i a n a d m i n i s t r a t o r . P e r s o n n e l d e c i s i o n s are stressed, as this is often an area of great concern a n d major problems. ~ Budgets, scheduling, and detail items are also touched upon in varying degrees. The interaction among the group can e x p a n d the awareness of options as well as improve interpersonal c o m m u n i c a t i o n skills in a n o n t h r e a t e n i n g , no-lose environm e n t Y I n effect, p a r t i c i p a n t s are s i m u l a t i n g the a d m i n i s t r a t i v e role.
THE TWO-PHASE PROCESS The goals of the two phases of the In-Basket Exercise are i m p o r t a n t to understand. The first phase, individual a n a l y s i s of items, forces participants to e x a m i n e t h e i r administrative styles. How do they h a n d l e frustration? How realistic are the alternatives developed? W h a t factors are considered in the analysis of alterna-
5o/115
tives? A l t h o u g h most professionals may i n t e l l e c t u a l l y u n d e r s t a n d principles of m a n a g e m e n t , they m a y not be able to a p p l y t h e s e to specific situations. This first phase is a selfassessment of how ready the particip a n t is to assume a n a d m i n i s t r a t o r ' s responsibilities. The second phase, group discussion, can increase participants' selfconfidence and expand awareness of a l t e r n a t i v e s a n d r e a s o n i n g . Every p a r t i c i p a n t is l i k e l y to find some items he would prefer to lay aside a n d deal with later. Also, every participant is likely to have some altern a t i v e s and reasons not considered by others. The group discussion helps p a r t i c i p a n t s realize t h a t most decisions are m a t t e r s of style and preference, a n d t h a t they are not isolated actions b u t form a p a r t of the overall a t m o s p h e r e a n d c h a r a c t e r of a n emergency department. The a d m i n i s t r a t o r - discussion l e a d e r is a i d e d by the use of t h e Group Leader's D i s c u s s i o n Guide, which details a n u m b e r of options for t h e i t e m s as w e l l as s e v e r a l q u e s t i o n s or c o n t r o v e r s i e s t h a t m i g h t arise. It also briefly suggests several formats for discussion of the material. The d i s c u s s i o n i t s e l f c a n take two or more hours, and r u n over one or more sessions, depending on the interest a n d desires of the group. This exercise e m p h a s i z e s nonclinical decisions, management c o m m u n i c a t i o n and m a n a g e r i a l control. It is not i n t e n d e d to replace or teach the f u n d a m e n t a l s of business. But it can and does point out to participants their own areas of administrative deficiency and may stimulate t h e m to f u r t h e r study. It also sugg e s t s to a d m i n i s t r a t i v e n e o p h y t e s whether they are suited, or even interested, in this aspect of emergency medicine.
JACEP
This exercise is easily adapted to both p r i v a t e e m e r g e n c y physicians a n d e m e r g e n c y m e d i c i n e residents. Items could be added or deleted to emphasize specific areas of difficulty. And, since it n e e d s no e q u i p m e n t o t h e r t h a n the I n - B a s k e t Exercise and Group Leader's Discussion Guide, it can be used in a n y setting.*
CONCLUSION The I n - B a s k e t Exercise is a n introductory step to a m u c h neglected, yet necessary, area of expertise for emergency physicians. We hope that, in the f u t u r e , i n s t r u c t i o n tools to teach, in g r e a t e r depth, the concepts of e m e r g e n c y d e p a r t m e n t administ r a t i o n will be developed.
REFERENCES 1. Jenkins AL (ed): Emergency Department Organization and Management. St. Louis, CV Mosby Co, 1975. 2. Emergency Medicine Core Content. JACEP 8:34-41, 1979. 3. Levy S, Loomba NP: Health Care Administration. Philadelphia, JB Lippincott Co, 1973. 4. Yanda RL: Doctors as Managers of Health Teams. New York, AMACOM, 1977. . 5. You Are Barbara Jordan: An InBasket Exercise on Nursing Service Ad-. ministration. Chicago, Hospital Research and Educational Trust, 1970. 6. Aram JD: Dilemmas of Administrative Behavior. Englewood Cliffs, New Jersey, Prentice-Hall, Inc, 1976. 7. Lopez FM Jr: Evaluating Executive Decision Making: The In-Basket Technique, AMA Research Study No 75. New York, American Management Association, Inc, 1966. *Authors will make the Group Leader's Discussion Guide available on request for cost of photocopying.
8:3 (M arch) 1979
Teaching Emergency Department Administration: The In-Basket Exercise Kenneth V. Iserson, MD Clovis Shepherd, PhD Cincinnati, Ohio Borrowing from formats that have been successfully used in teaching administrators, we developed a limited, time-dependent simulation model, the In-Basket Exercise for teaching emergency department administration. The exercise is designed as an introduction to nonclinical decisions, management communication, and managerial control. Using selected material, and under time constraints, participants are asked to describe the options for several types of administrative items. These options and decisions are then discussed within a group. The In-Basket Exercise has been well received as a simple new tool for teaching emergency department administration where existing methods are generally deficient. Iserson KV, Shepherd C: Teaching emergency department administration: The in-basket exercise. JACEP 8:114-115, March, 1979.
emergency department administration; emergency physician, training
INTRODUCTION Emergency physicians often have a large a d m i n i s t r a t i v e responsibility. Clinical training alone is inadequate preparation for administration2 Emergency medicine residencies have struggled with methods of imparting this knowledge - - with little success. Physicians entering emergency medicine without a formal residency are ever/less well prepared. The Emergency Medidine Core Content as developed by the Graduate/ Undergraduate Education Committee of ACEP 2 includes a substantial list of administrative areas for the emergency physician to master. Yet, t r a i n i n g in administration has been mainly trial and error2 What little formal teaching exists usually deals with finances. 4 THE EXERCISE Borrowing from formats that have been successfully used in teaching business, hospital and nursing administrators2 we developed an In-Basket Exercise for the emergency department. A limited, time-dependent simulation of emergency department administration, the exercise is a judicious selection of items requiring decisions that might be found in an emergency department director's in-box. This s a m p l e is c u l l e d from a c t u a l items from t h r e e s e r v i c e s : a university-based emergency medicine residency, a teaching hospital, and a major nonteaching community hospital emergency department. The items vary in length and complexity, and include those items requiring routine decisions and those where the resident's personality, background, and prior experiences will direct the actions. The exercise is given to the participant as a sheaf of papers including. From the Division of Emergency Medicine, Cincinnati General Hospital and the Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, Ohio. Presented at the University Association for Emergency Medicine Annual Meeting in San Fraqcisco, May 1978. Address for reprints: Kenneth V. Iserson, MD, Department of Emergency Medicine, Carswell AFB, Fort Worth, Texas 76127.
8:3 (March) 1979
JACEP
114/49
memos, personnel applications, notices, phone messages, etc, in as realistic a form as possible. He is given a situation o u t l i n e - - detailing his position i n the hierarchy of the hospital, his general responsibilities, his associates, colleagues, a n d employees. He is g i v e n a t i m e cons t r a i n t of one hour or one and oneh a l f hours and a n e x p l a n a t i o n for the t i m e c o n s t r a i n t . As t h e r e s i d e n t works through the pile, he lists decision options for each item as well as the final decision or i n d e c i s i o n on special work sheets. Later, in a group, the items, options, a n d decisions are discussed u n d e r the guidance of a n experienced administrator. Ideas, reasoning, and experiences are exchanged. The level of i n t e r c h a n g e will depend upon the a d m i n i s t r a t i v e sophistication of the group. Because of the items selected, the discussion t e n d s to cover m a n y of the areas frequently encountered by the e m e r g e n c y p h y s i c i a n a d m i n i s t r a t o r . P e r s o n n e l d e c i s i o n s are stressed, as this is often an area of great concern a n d major problems. ~ Budgets, scheduling, and detail items are also touched upon in varying degrees. The interaction among the group can e x p a n d the awareness of options as well as improve interpersonal c o m m u n i c a t i o n skills in a n o n t h r e a t e n i n g , no-lose environm e n t Y I n effect, p a r t i c i p a n t s are s i m u l a t i n g the a d m i n i s t r a t i v e role.
THE TWO-PHASE PROCESS The goals of the two phases of the In-Basket Exercise are i m p o r t a n t to understand. The first phase, individual a n a l y s i s of items, forces participants to e x a m i n e t h e i r administrative styles. How do they h a n d l e frustration? How realistic are the alternatives developed? W h a t factors are considered in the analysis of alterna-
5o/115
tives? A l t h o u g h most professionals may i n t e l l e c t u a l l y u n d e r s t a n d principles of m a n a g e m e n t , they m a y not be able to a p p l y t h e s e to specific situations. This first phase is a selfassessment of how ready the particip a n t is to assume a n a d m i n i s t r a t o r ' s responsibilities. The second phase, group discussion, can increase participants' selfconfidence and expand awareness of a l t e r n a t i v e s a n d r e a s o n i n g . Every p a r t i c i p a n t is l i k e l y to find some items he would prefer to lay aside a n d deal with later. Also, every participant is likely to have some altern a t i v e s and reasons not considered by others. The group discussion helps p a r t i c i p a n t s realize t h a t most decisions are m a t t e r s of style and preference, a n d t h a t they are not isolated actions b u t form a p a r t of the overall a t m o s p h e r e a n d c h a r a c t e r of a n emergency department. The a d m i n i s t r a t o r - discussion l e a d e r is a i d e d by the use of t h e Group Leader's D i s c u s s i o n Guide, which details a n u m b e r of options for t h e i t e m s as w e l l as s e v e r a l q u e s t i o n s or c o n t r o v e r s i e s t h a t m i g h t arise. It also briefly suggests several formats for discussion of the material. The d i s c u s s i o n i t s e l f c a n take two or more hours, and r u n over one or more sessions, depending on the interest a n d desires of the group. This exercise e m p h a s i z e s nonclinical decisions, management c o m m u n i c a t i o n and m a n a g e r i a l control. It is not i n t e n d e d to replace or teach the f u n d a m e n t a l s of business. But it can and does point out to participants their own areas of administrative deficiency and may stimulate t h e m to f u r t h e r study. It also sugg e s t s to a d m i n i s t r a t i v e n e o p h y t e s whether they are suited, or even interested, in this aspect of emergency medicine.
JACEP
This exercise is easily adapted to both p r i v a t e e m e r g e n c y physicians a n d e m e r g e n c y m e d i c i n e residents. Items could be added or deleted to emphasize specific areas of difficulty. And, since it n e e d s no e q u i p m e n t o t h e r t h a n the I n - B a s k e t Exercise and Group Leader's Discussion Guide, it can be used in a n y setting.*
CONCLUSION The I n - B a s k e t Exercise is a n introductory step to a m u c h neglected, yet necessary, area of expertise for emergency physicians. We hope that, in the f u t u r e , i n s t r u c t i o n tools to teach, in g r e a t e r depth, the concepts of e m e r g e n c y d e p a r t m e n t administ r a t i o n will be developed.
REFERENCES 1. Jenkins AL (ed): Emergency Department Organization and Management. St. Louis, CV Mosby Co, 1975. 2. Emergency Medicine Core Content. JACEP 8:34-41, 1979. 3. Levy S, Loomba NP: Health Care Administration. Philadelphia, JB Lippincott Co, 1973. 4. Yanda RL: Doctors as Managers of Health Teams. New York, AMACOM, 1977. . 5. You Are Barbara Jordan: An InBasket Exercise on Nursing Service Ad-. ministration. Chicago, Hospital Research and Educational Trust, 1970. 6. Aram JD: Dilemmas of Administrative Behavior. Englewood Cliffs, New Jersey, Prentice-Hall, Inc, 1976. 7. Lopez FM Jr: Evaluating Executive Decision Making: The In-Basket Technique, AMA Research Study No 75. New York, American Management Association, Inc, 1966. *Authors will make the Group Leader's Discussion Guide available on request for cost of photocopying.
8:3 (M arch) 1979
