This self-assessment tool has been developed to help trust teams assess and provide board-level assurance on the safety, quality and delivery of non-elective care in the first 72 hours in hospital, based on the joint NHS England, Royal College of Physicians, Society for Acute Medicine, British Geriatrics Society standards for care of acutely unwell patients in their first 72 hours in hospital.
This document is aimed at the teams running services – normally a lead medic, nurse and manager – who would report to the trust board on safety, quality, and performance. An expectation of trust board oversight of these standards will be included in the Insightful provider board guide when it is updated in 2026/27.
The 3 questions teams need to answer are:
- How are we doing now – to what extent are the standards being achieved?
- What are the gaps or areas of concern?
- What are we doing about these gaps or concerns?
To help answer these questions, this document provides a set of insightful questions and data queries to ensure responses are validated by data, both qualitative and quantitative.
After an initial baselining exercise to be completed on publication of the standards and as part of Winter 25/26 assurance, this exercise should be completed every 6 months, as a minimum, with findings articulated in a formal board assurance report. As the standards are clinically focused, responsibility and overall leadership for delivery of the standards sits with the medical and nursing directors, with monitoring taking place through the trust’s quality governance framework.
Self-assessments and board assurance reports will not be collected and reviewed on a national basis but may be expected as part of regional and system performance monitoring arrangements, as well as nationally- or regionally-led performance improvement initiatives.
Self-assessment
In the first instance, teams should review the 15 standards and determine the extent to which they meet them on a rolling 6-month basis.
This exercise should include collection of quantitative and qualitative data to ensure that assessments are evidence-based and verifiable. Suggestions of table-top evidence, including data queries that trusts can run locally, are included in appendix 1 and mapped to each of the 15 standards.
Teams should also seek to use feedback from colleagues and to consider this evidence alongside the table-top review. Teams should not only ask colleagues if they feel the standards are being achieved but also seek their feedback on the proposed key lines of enquiry below. These questions have been developed by national and regional clinical colleagues whose roles involve completing these assessments and reviewing the responses to them.
Insightful questions
Early clinical decision making
- What are the barriers to completing clinical assessments, including the Clinical Frailty Scale, within the timeframe set out in the standards? What actions are you taking to address these?
Care navigation
- How do you ensure flow out of acute receiving areas? What happens if a patient’s length of stay exceeds 72 hours?
Care on the acute receiving area and continuity of care
- How would you describe the daily rhythm of the acute receiving area and who plays critical roles within it?
- How are specialties engaged in the non-elective pathway? How is specialty advice provided and who provides it (expert decision-maker/senior decision-maker)?
- How do you ensure the availability of expert clinical decision-makers in acute receiving areas and in specialties during weekdays and at the weekend, in daytime and nighttime hours?
- What happens if a patient hasn’t moved within 12 hours of a downstream specialty bed request?
Support services and 7-day working
- What are the gaps in access to support services 7 days a week?
Patients, families and carers
- How do you monitor the extent to which patients are involved in their care? When have you acted on patient and carer feedback?
Data recording and metrics
- How often do operational teams review their performance and agree improvement actions?
- How do operational teams routinely track delays, length of stay, mortality and readmission rates? How does this inform decision making?
- How do operational teams routinely monitor and act on patient safety events occurring in patients waiting for an inpatient bed?
Internal professional standards
- What are your internal professional standards, how are they updated and how are they monitored?
Data and measures
While several quantitative measures are proposed in this document, it is likely that some of the infrastructure to feed these is not in place in all trusts. This includes accurate treatment function coding of activity to identify which patients are cared for by acute medicine, for example, and potentially some time stamp recording.
Where data quality or completeness is not ideal, teams should still run the measures and surface any gaps to highlight these issues, which should support and encourage improvement. Accurate data is essential to understanding what is happening to patients and to improving care. These issues should be highlighted in any board assurance report and risks should be appropriately scored, mitigated and escalated to support appropriate resolution.
At a national level, a small number of measures will be developed to allow for benchmarking between providers and the identification of unwarranted variation. These measures will include an assessment of data quality and completeness, as this is likely to be sub-optimal initially. By surfacing this data, we expect this to improve over time to provide robust insight into patient care.
Measure 1: ED waits
Description
- the percentage of ED (type 1) patients who were admitted who waited more than 4 hours
- the percentage of ED (type 1) patients who waited for over 12 hours (admitted and non-admitted)
Comments
Monitors impact on key performance measures on 4 hours and 12 hours.
Measure 2: Admitted length of stay (LoS)
Description
a) Discharges within first 72 hours
The percentage of 1+ LoS non-elective admissions discharged within the first 72 hours.
b) Acute medicine mean 1+ LoS
- all patients
- patients discharged from acute medicine
- patients who go on to another episode/FCE/ward transfer
c) Distribution
The distribution of LoS in acute medicine.
Comments
Provides evidence of the overall impact of standards on flow.
Related to: Standard 11.
Measure 3: Data quality
Description
The percentage of non-elective medical patients with a TFC = 326 for their first episode of care.
Comments
Provides evidence of the improvement in data quality, which will give a greater understanding of what is happening to patients.
Related to: Standard 13.
Measure 4: Re-admissions
Description
The percentage of patients discharged within the first 72 hours who were re-admitted within 30 days of discharge and stayed for at least 1 day.
Comments
Balancing measure.
Teams should consider the most effective visualisation of data and seek to use statistical process control (SPC) charts wherever possible to support identification of normal variation versus special cause variation, trends and step changes. The Making Data Count programme provides more information about using SPC charts.
Supporting information
The UEC Hospital Policy page on FutureNHS (login required) gives information and practical examples to support improvement and transformation.
Board assurance
Trust boards should expect an initial baseline review to be completed for winter assurance for 2025/26, followed by formal reports on progress on implementing the standards every 6 months. This expectation will be outlined in the Insightful provider board guidance when it is next updated.
The report should be formulated by the service or divisional team (normally comprised of a medical, nursing and management lead), based on the self-assessment described above.
The report should be signed off and presented by the medical and/or nursing director.
A proposed template for this report is included at Appendix 2.
Boards should expect to see the key performance metrics below reported over time, preferably in a SPC format:
- 4 hour waits in ED for admitted patients
- 12 hour waits in ED
- the number of patients cared for in corridors
National data will support benchmarking on these measures, and boards may want to consider their performance against that of an appropriate peer group.
Boards should anticipate service-level action plans to address any deficits identified through the self-assessment process, accompanied by a risk assessment of the current position and associated mitigations. Boards may choose to delegate responsibility for tracking progress to a subsidiary committee, with a yearly update provided to the full trust board.
Appendix 1: Suggested evidence to support self-assessment
Use this guide to understand the types of evidence NHS trusts could use for each of the standards in their board report.
Standard 1: Initial and expert assessment
Standard
All patients should have a full assessment by a competent clinical decision-maker within 1 hour of referral from the emergency department (ED) or of arrival on the acute receiving area.
Any time-critical medications should be identified and prescribed with a plan for a pharmacy review within 24 hours of admission. This should complement, not duplicate, any previous assessment.
EDs and acute receiving teams should work together to deliver and document a streamlined assessment that builds on a shared clinical narrative.
All admitted patients should be assessed by an expert clinical decision-maker, normally a consultant, within a maximum of 6 hours during the day and 14 hours overnight.
Acute trusts should resource and plan the expert decision-maker workforce to maximise the day’s work by modelling cover for peak times.
Suggested evidence
- percentage of patients with full assessment within 60 minutes of referral from ED or arrival on acute receiving area
- percentage of patients with assessment by expert clinical decision-maker within target time
- may require notes audit if not captured electronically
- also consider SAMBA audit data as evidence
Target
- less than 1 hour (for initial assessment)
- less than 6 hours during the day / 14 hours overnight (for expert assessment)
Data report
Yes – local
Standard 2: Additional requirements for specific patient cohorts
Older people with frailty
Standard requirements:
- patients aged over 65 presenting to hospital as an emergency should be assessed by a competent clinical decision-maker within 30 minutes of arrival using the Clinical Frailty Scale (CFS) and the 4AT tool for delirium
- acute trusts should ensure that older people with frailty (CFS equal to or more than 5) have access to a senior clinical decision-maker with skills in managing frailty and multiple long-term conditions within 1 hour of referral during the day or before 10am the next day if overnight
- all older people with frailty (CFS equal to or more than 5) should be assessed by an expert clinical decision-maker in managing frailty, normally a consultant, within a maximum of 6 hours during the day and 14 hours overnight
Patients with long-term conditions
Specialty and/or specialist palliative care teams should be consulted when known patients present to ED with an exacerbation of a long-term condition, where appropriate. Advice should be sought on alternatives to admission including options for accessing support in the community.
Patients receiving palliative care and end-of-life care
- acute trusts should ensure patients who are receiving palliative care and end-of-life care or who have advance care plans can be identified to ensure their preferences and wishes are supported
- a mechanism should also be in place to identify patients who are likely to be in the last phase of life but whose needs are not yet recognised, with referral to their specialty team and/or specialist palliative care where appropriate
Suggested evidence
- percentage of patients aged over 65 with CFS and 4AT assessments within target
- percentage of patients with recorded long-term condition for whom a matching specialty referral was made
Targets
- less than 30 minutes (for initial frailty assessment)
- less than 1 hour or 10am (for senior clinical decision-maker access)
- less than 6 hours or 14 hours (for expert clinical decision-maker assessment)
- other targets to be locally agreed
Data report
Yes – local
Standard 3: Operational policies
Standard
Acute trusts must have operational policies that describe:
- how, by default, all acute admissions move from ED or directly from primary or community care to an acute receiving area as their first inpatient setting (the exceptions to this are where there is clear patient benefit from immediate specialty intervention, for example, acute stroke and STEMI)
- clear admission criteria and pathways for all commonly presenting clinical problems, as agreed with all specialties and regularly reviewed
- how care should be delivered for patients requiring shared care, ensuring that a single clinician is responsible for their overall care
- the escalation process if specialties disagree about responsibility or location of care
Suggested evidence
- written policies or procedures, and evidence of use
- policies should also say who is the single named clinician responsible for patients who are in the ED and who have been referred to a specialty but are awaiting an inpatient bed
Target
Not applicable
Data report
No
Standard 4: Clinical leadership of patient flow
Standard
Flow into and out of acute receiving areas should be clinically led to promote the right patient moving to the right specialty bed.
Acute trusts should have a designated consultant in charge who is responsible for the acute take, mirroring the EPIC role in ED and working with the nurse in charge and/or allocated navigation team to prioritise and co-ordinate patient care.
This includes bed allocation in acute receiving areas and maximising alternatives to admission, such as same day emergency care (SDEC) and virtual wards/hospital at home.
The consultant in charge should not cover additional clinical duties such as downstream wards or outpatient care.
Suggested evidence
- written policies or procedures, and evidence of use
- local description of consultant in charge role and responsibilities
Target
Not applicable
Data report
No
Standard 5: Senior clinical decision-maker availability
Standard
A senior clinical decision-maker or above in specialties with highest non-elective admission numbers/rates should be job planned/rostered to receive referrals and provide advice to primary and community care and hospitals 24/7.
This job planning/rostering may be networked across acute trusts where appropriate or required and should not negatively impact on the general internal medicine rota.
If a senior clinical decision-maker or above performs this role, they should have immediate access to an expert clinical decision-maker.
A clinical record of the discussion and agreed outcome must be entered into the patient’s clinical notes.
Suggested evidence
- specialty capacity and rosters for non-elective care on job plans for key admitting specialties
- evidence of specialty demand and capacity planning for non-elective care
Target
Not applicable
Data report
No
Standard 6: Continuity of care
Standard
Expert clinical decision-makers in acute receiving areas with accountability for individual patients should be job planned and rostered to ensure continuity of care across the first 72 hours and reduce multiple consultant episodes.
This may require annualised job planning across specialties, reconfiguring other commitments and considering part-time and job share arrangements.
Suggested evidence
- specialty job plans reflecting continuity
- rostering for acute receiving areas (for example, 12-hour shifts and 2+ consecutive days)
Target
Not applicable
Data report
No
Standard 7: Ward rounds and board rounds
Standard
After an initial board round, a targeted, consultant-led and multidisciplinary team (MDT)-supported ward round should take place every day for all patients on an acute receiving area, including at weekends and bank holidays.
An additional action-focused MDT meeting/huddle should take place at the end of the ward round.
There should be a second board round and, where clinically indicated, a consultant face-to-face review of high risk/priority patients every day: for example, in enhanced care areas or where this will confirm discharge decisions.
The same principles should apply to patients outlying acute receiving areas within the first 72 hours of admitted care, including in the ED.
Suggested evidence
Written policies or procedures, and evidence of use.
Target
Not applicable
Data report
No
Standard 8: Clinical huddles and handovers
Standard
Clinical huddles and shift handovers must be led by an appropriate senior clinical decision-maker and take place at a designated time and place, with MDT participation from the relevant incoming and outgoing shifts.
Handovers should be consistent and standardised and include the identification of high risk/priority patients and assessment of operational conditions.
Suggested evidence
Written policies or procedures, and evidence of use.
Target
Not applicable
Data report
No
Standard 9: Specialty response times
Standard
Where a patient requires urgent specialty opinion for acuity, clinical decision-making or discharge planning, the specialty senior clinical decision-maker should respond within a maximum of 2 hours of the request.
Patients referred to another specialty by the admitting team should be assessed by a senior clinical decision-maker (with access to an expert clinical decision-maker) within 4 hours during the extended day (as determined by demand and capacity modelling) or before 10am the next day if overnight.
Face-to-face assessment is usually appropriate for patients in hospital.
Suggested evidence
Time from specialty referral to consult:
- for referrals marked as urgent
- for all other referrals
Targets
- less than 2 hours (for urgent referrals)
- less than 4 hours or 10am (for other referrals)
Data report
Yes – local
Standard 10: Bed transfers
Standard
Patients requiring downstream specialty beds should be transferred within 12 hours of a bed request. If no bed is available, the specialty team should ensure daily review on the acute receiving area.
Specialty teams should know how many patients are waiting for a base ward bed at all times and work to deliver transfer within 12 hours of referral.
Patients should not move from downstream wards or ICU/ITU to acute receiving areas (reverse flow), except where areas support enhanced care or where this is locally agreed policy.
Suggested evidence
- time from bed request for downstream ward to patient moving
- if not electronically captured, should be audited with executive oversight
Targets
- less than 12 hours (for bed transfers)
- 0 ‘negative flow’ (for reverse transfers)
Data report
Yes – local
Standard 11: Length of stay on acute receiving areas
Standard
Any individual patient’s length of stay on an acute receiving area should not exceed 72 hours unless sanctioned by the responsible consultant and senior nurse in charge.
Acute receiving area length of stay is expected to be 24–48 hours and should be routinely measured, split by those who are discharged and those who are transferred to downstream wards.
Suggested evidence
Mean LoS on acute receiving units.
Target
National average less than 72 hours (more detailed splits of data will be available nationally).
Data report
Yes – local
Standard 12: Availability of support services
Standard
To ensure equity of provision of care and maximise discharge opportunities, all support services, including therapies, pharmacy and social services, should be available to acute receiving areas during extended-day working hours (for example, 8am to 8pm), 7 days a week.
Input in other areas should be prioritised for patients with an anticipated length of stay of less than 72 hours.
All areas providing acute and emergency non-elective care in the first 72 hours must have the same access to diagnostics, including imaging, in terms of availability and turnaround times, to support decision-making and prevent unnecessary admission.
These services should align to demand across the 7 days. Processes should be in place to prioritise patients who are acutely unwell or for whom discharge is investigation dependent.
Suggested evidence
- written policies or procedures, and evidence of use
- turnaround times for CT, MRI, or pathology compared to locally agreed standards
Target
Locally agreed.
Data report
Yes – local
Standard 13: Accurate recording of patient care
Standard
Patients’ care should be accurately attributed and recorded to the team delivering it.
For example, patients who are referred for care under acute medicine should have Treatment Function Code (TFC) 326 applied regardless of where they are physically located.
If a patient is transferred from an acute receiving area to a specialty ward, the TFC should be changed to reflect the patient’s responsible consultant.
This will enable better understanding of activity, support capacity planning and improve visibility via national reporting, reducing the need to rely on local (ward-based) reporting.
Suggested evidence
- the percentage of non-elective medical patients with a TFC = 326 for their first episode of care
- percentage of patients cared for on acute medical units recorded under TFC 326
Target
National average percentage TFC 326 recording.
Data report
Yes – national and local
Standard 14: Patient and carer experience
Standard
All patients and carers must be:
- treated with dignity, have their basic needs met – in terms of hydration, access to toilet facilities and food – and be offered adequate pain control when needed
- fully involved in decisions about their care
- kept regularly informed about waiting times and delays to their care
- clear about what they need to achieve to get home, when they should expect to go home and who to contact when they are at home
Suggested evidence
- written policies or procedures
- friends and family test
- notes audits
- patient feedback and interviews
Target
Not applicable
Data report
No
Standard 15: Compliance and governance
Standard
The site-level detail of all standards should be reflected in a written internal professional standards document, developed following discussion and agreement between hospital teams and owned at executive level.
Acute trusts must assure their board of compliance with the standards. This should be regularly reviewed and robust plans, owned at executive level, put in place to achieve compliance where necessary.
Suggested evidence
- written policies or procedures, and evidence of use
- board assurance report
Target
Not applicable
Data report
No
Appendix 2: Outline board assurance report
Executive summary
The executive summary should include:
- baseline position against 15 standards (full, partial or zero compliance)
- key performance measures (4 hours, 12 hours, LoS)
- overall assessment of the progress made against the action plan since the last report – highlight both successes in improving compliance with standards and areas that have been challenging
- requests for board support
Detail: standards – levels of attainment
For each standard, describe the progress made in improving levels of attainment since the last report.
Where possible, include evidence for the reporting period.
Impact
Key performance metrics reported over time, preferably in a SPC format:
- 4 hour waits in ED for admitted patients
- 12 hour waits in ED
- the number of patients cared for in corridors
- the proportion of NEL patients discharged within 72 hours
- the LoS in acute receiving areas
Where performance requires improvement, consider including a trajectory.
Ensure patient and staff experience are articulated.
Risk assessment
A scored risk assessment of provision, including mitigations and the anticipated risk scores after mitigation.
Escalations
Include any asks of the board.
Consider the estates, digital, and business intelligence support required alongside other organisational level actions.
Ensure any escalations reflect and are consistent with the risk assessment and mitigations.
Action plan – next period
Include action plans addressing identified areas for improvement.
Include what has been learned from other NHS trusts’ experiences.