I would agree that this sounds like an issue of accountability of the division director to the department leader to deliver on clearly defined goals, deliverables and timelines which are mutually agreed upon by both the department leader and division director. Having these in writing at the time of a face-to-face meeting of both individuals may help to ensure understanding and eliminate misinterpretation. Perhaps this has already been done. Follow up meetings at key milestones or time periods to assess progress would be needed e.g. monthly or quarterly, and would also identify that appropriate supports are in place and barriers addressed to permit success. These would also be coaching opportunities. If progress is still sub-optimal, then the department leader will need to assess what the underlying issues are – key competencies missing, lack of commitment, internal issues in the division that haven’t been addressed etc. which may lead to a different conversation with the division director and appropriate interventions by the department leader to bring about the desired strong leadership and outcomes.
Challenging situation of disruptive behaviour in a senior established member of a department which can be an impediment to or even a threat to quality of patient care. Soon after AB’s return, a conversation should occur between the new Head and AB outlining expectations of behaviour in the “new” department, why that is important and what the potential consequences for transgression would be under the new leadership. Appropriate ongoing monitoring and step-wise feedback will be required. If there is no change in behaviour, in the end the Board may well have to decide which is more important – the presence of AB, or a high functioning department delivering high quality patient care. No one person is indispensable.
It sounds like the root cause of increasing capacity in the state run psychiatric facility is beyond your control to address in a reasonable time frame, and so these patients will continue to be in your facility for the foreseeable future. Have you considered cohorting them in an inpatient unit while awaiting transfer? This might improve their care through availability of specialized psychiatric nursing and medical staff, and improve care in the ED for the reasons you outline. If admitting them is not an option, then perhaps creating a specialized and segregated “crisis” unit within the ED staffed by psychiatric nursing. The latter is an option we have chosen for these challenging patients.