Introduction

A series of ‘urgent and emergency care improvement guides’ have been designed for providers and systems to consider embedding as good practice to reduce ambulance handover delays.

The contents have been drawn from the Winter Improvement Collaborative which was set up to identify solutions to the problems facing the system over the winter period.

Members of the collaborative were asked to co-design a series of plans and potential improvement measures, to be adapted and trialled at local level.

Throughout the process there were opportunities to understand what is working and what is proving challenging, and to iterate the approach to ensure it has maximum benefit.

The learnings from the programme cover a range of areas including the flow of patients within hospitals from emergency services to wards, streaming patients into the most appropriate services, and standardising operational processes to be as efficient as possible.

The example trust used in this document has been anonymised.

Each trust is different and will need its own bespoke approach; examples are provided to inform local decision-making and action.

Specialty support to UEC flow

Overall description of the creation of internal professional standards (IPS)

• Every clinical service and specialty should have agreed internal professional standards that fit with each other
• Internal professional standards are a clear, unambiguous description of the values and behaviours expected within the organisation. They are most powerful when centred on patient care, are written collaboratively with clinicians and are openly championed by the Executive team.
• Clinical directors and heads of nursing/allied health professional (AHP) leads should be brought together from across the trust to help create a local set of standards that translate into professional standards which they, themselves, are empowered to be the champions and advocates for.
  • As part of the internal professional standards, each service should define steps of escalation when the standards are not being met.
  • The standards should be discussed and promoted throughout the organisation and especially when new staff start/locums attend to define simply ‘this is how we work here – every day, all day’
• Leaders (especially consultants and senior nurses/AHPs) should role model the standards in their routine and daily interactions with their teams so that the standards form part of their core behaviours and values. Role modelling and reinforcement will make standards stick and cause positive cultural ripple effects.
• Organisations should develop internal professional standards in line with their governance procedures so clear steps are articulated to show how in-day challenges in meeting them are escalated, and also to show how they are regularly reviewed on a more formal basis. Organisations should be regularly auditing the efficacy of internal professional standards.

Lessons learned from those who have implemented internal professional standards

• Staff engagement and meaningful listening is key in relation to enabling all staff to understand total risk along the UEC pathway.
• Internal professional standards must be clinically and operationally engineered through mutual collaboration and review.
• The key to success is not in the writing of internal professional standards but in the consideration of escalation, clinical advocacy and in the audit, review and organisational learning when they are not met.
• Medical director oversight with the support of the clinical directors/chief operating officer/director of nursing (chief nurse) is key to maintaining conversations to support real improvements.
• Enabling all staffs understanding of the risk to patients is key in accomplishing change.

*This list is not exhaustive; further enablers and barriers can be provided. For more support please contact england.ImprovementDelivery@nhs.net.

Supporting documents used by other trusts:

• Trust contingency strategy
• Board assurance framework (BAF)
• Patient flow standard operating procedure (SOP)
• UEC Improvement action plan
• Project plan and/or organogram
• UEC risk presentation
• Risk log/register
• Project quality metric checklist
• UEC data dashboard.

Of the top performing organisations for ambulance handover delays, 11 had strong clinically supported embedded internal professional standards cultures.

These organisations, when compared to the rest of the country on a combination of key UEC measures, performed in the top quartile on the following combined UEC metrics:

1. Emergency admissions
2. 4 hour performance
3. 12 hours in emergency department (ED) performance
4. Conversion rate from ED
5. Total time to treatment
6. Over 60 minute HHO delays
7. Medical 0 day %
8. Medical <2 day LoS
9. Surgical 0 day %
10. Bed occupancy.

Consistency in the internal professional standards between these 11 organisations include:

• leaders state that their internal professional standards models are key to their organisational and care provision success
• clinically and operationally designed
• clinically role modelled
• executive empowered
• clear escalation that works
• strong staff engagement
• strong ongoing communication
• board level reporting and monitoring.

Internal professional standards efficacy cannot be easily tracked through just one or two performance metrics. There are many contributing factors which help or hinder performance.

However, we can easily see that there appears to be a direct correlation in successful UEC performance from those organisations who have well defined, clinically led internal professional standards that are used to frame their collaborative culture.

These trusts all have the following in common:

• Defined internal professional standards which were created collaboratively with clinicians.
• A consistent culture of ‘we’, ‘us’ and ‘trust’.
• ED streamers, ambulance staff, HCPs empowered to contact specialities through open access criteria to refer patients to areas other than ED.
• Monitor and empower internal professional standards compliance
• Have clinical leaders who are visible and role model values (such as internal professional standards) in practice.

Roles and responsibilities that enabled intervention delivery

Chief operating officer (COO)

• SRO for maintaining triumvirate oversight – operational.
• Manages PMO team.
• Project lead for comms, performance and data.
• Daily point of contact for project team.
• Daily end of day huddle attendance.
• Empowered reactive decision making to ensure traction.
• Liaison with trust board and CEO.
• Lead on disseminating actions following audit/huddle findings where internal professional standards have not been met against daily operational challenge.

Medical director

• SRO for maintaining triumvirate oversight – clinical and risk.
• Project lead for signing off each clinical service’s internal professional standards and escalation framework.
• This includes ensuring consistency, equity and parity.
• Further, the MD should lead a clinical director oversight group which is responsible for dissemination, role modelling and clinical championing.

Chief nurse/AHP lead

• SRO for maintaining triumvirate oversight – quality and risk.
• Critical friend lead for reviewing each service’s internal professional standards and escalation framework.
• Daily end of huddle attendance.
• Responsible for ensuring that occasions of non-compliance are audited and raised.
• Further the ND should lead a heads of nursing oversight group which is responsible for dissemination, audit, role modelling and clinical championing.

Roles critical in implementation

• Project management office (PMO)
  • DCOO lead with ops nurse (clinical area liaison and staff engagement)
  • service manager (GANTT chart oversight/performance oversight/reporting), full time to roll out.
• Comms (staff engagement)
• Data analysis (performance)
• Divisional triumvirate (engagement and SOP design)
• Patient representatives (PALS).

Critical implementation path

Week 1 – process

• Exec role allocation and review of current internal professional standards/SOP/FCP/streaming/direct access documentation
• Create definition of project outcome.

Lead: COO, MD, DoN/chief nurse

Weeks 1 to 3 – process

• Full service internal professional standards review performed collaboratively with divisional triumvirates.

Lead: PMO lead, SROs

Weeks 2 to 4 – policy

• Collaboratively design an internal professional standards for each service and metrics to be monitored/methods of audit.
• Significant staff engagement exercises.

Lead: PMO lead, SROs

Week 2 ongoing – comms

• Co-ordination of engagement events and range of mixed media staff comms encouraging collaboration and feedback.
• Strong focus on culture – ‘this is the way we want to work here.’

Lead: PMO lead, SROs, Comms

Implementation onwards – comms

• Daily meetings and weekly PMO/SRO project meetings.

Lead: PMO lead, SROs, Comms

Weeks 2 to 4 – Data/Business informatics (BI)

• Metric checklist to include qualitative and quantitative measures chosen collaboratively.

Lead: PMO lead, SROs, divisional reps

Implementation onwards – Data/BI

• Daily and weekly metric monitoring and reporting.

Lead: PMO lead, SROs, divisional reps.

This list is not exhaustive. You may wish to consider adherence to internal professional standards. Please contact england.ImprovementDelivery@nhs.net for more support.

Supporting roles and responsibilities

National, regional and system

The following table represents a list of ‘responsibilities’ that were shared by members of the collaborative on subjects that were barriers/ enablers to implementing this intervention. These have been allocated against suggested roles that could provide support on these items.

The collaborative has worked with subject matter experts in the national UEC team who have developed suggested actions that regulatory/national/regional/system/local teams may wish to consider in supporting solutions to those asks and, ultimately, would be at their discretion.

National responsibilities

• Share good practice on the provision of specialty clinical advice services.
• Mandate around specialty in reach standards.

Action that could be taken:

• National UEC team to work with Winter Collaborative on the guidance, advice and case studies around speciality clinical advice.
• National UEC team to work with ECIST and the Collaborative of internal professional standards good practice document.

Regional responsibilities

• Ensure that all organisations have the staffing compliment to ensure speciality assessments can occur in a timely way.

Action that could be taken:

• Regional UEC team to work collaboratively with ICSs/trusts to produce a gap analysis of workforce deficit.
• This should then inform the creation of a regional workforce strategy.

System responsibilities

• Opportunity for systems to standardise internal professional standards and employ good practice peer reviews.

Action that could be taken:

• System medical director to work collaboratively with other clinicians to establish:
  • a system of internal professional standards
  • methodology for auditing compliance
  • a peer review/critical friend process.

Local responsibilities

• Ensure that there is engagement from both execs and clinicians to ensure compliance with internal professional standards.

Action that could be taken:

• Trust medical director to work collaboratively with divisional clinical leads to establish:
  • agreed internal professional standards
  • methodology for auditing compliance
  • a peer review/critical friend process.

Metrics

Top 6 metrics

Further metrics

Classification: Official
Publication reference: PRN00404