If the new palliative care service is to be part of a larger health care facility (hospital, medical centre or community service) its management structure will be dictated by the existing system. It then becomes essential that the palliative care service has, at its head, someone with both an understanding of, and experience in, palliative care.
If the service is "free-standing" or "independent" then it is important to choose the most appropriate and efficient management structure. Basically there are 3 models
It is assumed that, whatever the management model, there is a Board of Governors / Trustees with overall legal responsibility for the running of the service. Under them and answering to them is a triumvirate of Medical Director (responsible for medical matters, education, research), a Nursing Director (responsible for nurses, domestic matters) and an Administrative Director (responsible for administration, finance, public relations). In this model management decisions are shared equally without one person having to bear too heavy a responsibility. The model breaks down if relations are poor between the directors or one dominates.
In this model there is a single Chief Executive Officer (CEO) / General Manager in overall charge of the unit and directly accountable and answerable to the Board of Governors /Trustees... Beneath him / her and answerable to the CEO are the Senior Doctor and Senior Nurse and, sometimes a third manager for Finance (and fund-raising). This is an effective model when the CEO is both an experienced and capable manager and knowledgeable about palliative and health care services generally. It can, however, leave medical, nursing and other staff feeling that their work and needs are not understood and that they are powerless to influence decisions. It places almost total power in the hands of one person.
This 3rd model is very different from the others. The person with control over all aspects of the service is the Chief Executive Officer, someone with management and administrative training and skills; from any background – medical, nursing, social work, management, commerce, law etc.
All clinicians are represented by a Clinical Director (usually alternating every two year between a nurse and a senior doctor) also responsible for research and education. Also reporting directly to the CEO is a general manager overseeing finance, fund-raising, and all non-clinical aspects of the unit.
The success of this model - whether it succeeds or fails – rests with the personality, the interpersonal skills and the management skills of the CEO. It can reduce the time that senior clinicians spend on committees but with only one clinical director there can be less-than-optimal communication and cooperation between the health professions and resentment that clinical matters were not brought directly to the CEO from the clinical discipline concerned.
The legal responsibilities of such a Board will be laid down in the statute books of the country where the service is based. They are legally binding. Membership is laid down by its Articles of Memorandum and Constitution.
The chairperson is usually someone with a track record of such leadership, coming from any of the learned professions or commerce or academia. It is useful if the members can represent medicine, nursing, law, local or national government, the general public, the media and the church. Sitting in on its meetings but not serving as trustees or governors or permitted to vote, can be the CEO and the nursing, medical and administrative directors.
This is one of the most useful committees yet seldom set up by those "getting started". Usually with 8-12 members, they should present general practice, hospital medicine, university, hospital and community nursing, social work, local clergy, professionals allied to medicine and specialist palliative medicine/care. Initially most members will be invited by the founders of the service because of their known interest in palliative care or their standing in their profession or locality.
Such a committee usually meets quarterly for the first few years of a new service then twice yearly when it is well established. The period that members serve is decided by them in consultation with trustees. The selection of a chairperson is also usually left to the trustees
The committee usually has no executive powers but is, as its name implies, an advisory body. It advises at the request of the clinicians of the new service and the Trustees / Governors on matters such as staffing, research, records, service provision and relations with other clinical services – anything that relates to the care programme of the new service. Some palliative care services have subcommittees of the Professional Advisory Committee advising on pastoral care and another advising on education.
By law every member of staff must be given a legally binding contract. This will be drawn up by the trustees and their representatives with the guidance of a legal / human resources adviser.
In addition it is useful for every member of staff, no matter how small the staff, to be provided with a handbook. In it will be given information about the aims of the service, its staffing, its management structure, its committees, uniforms, discipline and appeal procedure, lines of responsibility and communication, ethical guidelines etc.
Such a handbook is as much for the administrators / managers and trustees as for clinical staff members, enabling them all to feel part of this new and exciting venture. It should be so worded that readers feel welcome and excited to be part of something exciting.
Each manager, as in any company or organisation, will be responsible for the support of staff under their control and direction. Such support may be unobtrusive but nevertheless must be tailored to the different needs of each member of staff, and details of major issues and formal meetings recorded.
Staff morale in any palliative care service is largely dependent on:
The surprising answer is "probably not". People working in palliative care for the first time expect it to be stressful because of the number of deaths, the level of grief and anger but research has shown that most stress is related to the obsessive, high expectations, critical personalities of the staff members. A short session chaired by a psychologist or psychiatrist, held every two weeks in the first year of a new unit, is usually all that is needed.
The realistic aim of a palliative care service is not to produce perfect care but to offer care better than people have experienced before, care that is always under review and gets better all the time.
From the start of a new service each member of staff must be given the opportunity to develop their skills whether they are in management, teaching or bedside care. Modest courses might be held in the unit. Others may be day-release study days or residential courses, ranging from modest updates to advanced training leading to higher qualifications. Financial budgeting is obviously essential. Few aspects of staff support yield so many benefits as professional betterment.
Ideally, but not often done, is for Trustees to have occasional (say annual) study days when they are brought up-to-date with the working of the service and developments in palliative care generally, hear talks by staff members, and collaborating colleagues in local hospitals.
It is very easy for Trustees and members of staff to become islands, less and less aware of the outside world, ignorant about palliative care nationwide and worldwide. Every effort must be made to prevent this happening.