By Fraser Ferguson – @FraserAHP – National Improvement Advisor, The Scottish Government (In a previous life a Clinical Specialist Physiotherapist)
Improving unscheduled care across Scotland is a key ministerial priority for the Scottish Government; the aim is to ensure 95% of patients attending an Emergency Department (ED) anywhere in Scotland meet the four hour standard.
The four-hour standard measures the total time patients spend in ED rather than the time patients spend ‘waiting’ for treatment to begin.
The waiting time clock ‘starts’ when the patient arrives in ED and stops when they leave the department to be admitted, transferred to another provider (for example, where more specialist clinical care is needed) or discharged. Achieving the four-hour standard is associated with reduced inpatient mortality for ED admissions and a better and safer patient journey. Currently Scotland’s EDs are the best performing and have the lowest rate of people experiencing long (12 hour+) delays anywhere the UK.
The National Unscheduled Care – 6 Essential Actions Improvement Programme aims to improve the timeliness and quality of patient care from arrival to discharge back into the community.
So here is some introductory information on what the Six Essential Actions are, and my thoughts, as an AHP, on how AHPs can get involved with them.
Essential Action 1 – Clinically Focussed and Empowered Hospital Management
EA 1is about the clinical leadership and operational management of the hospital and its facilities.
- working to determine appropriate staffing levels linked to activity
- creation of clear escalation policies and
- appointment of an appropriate site director alongside medical and nursing chiefs of staff and duty managers across all health and social care or the quadrumvirate as they are known.
This is central to performance and management on a day to day basis within acute sector hospitals and working across a whole system approach.
How can AHPs get involved?
Find out who is your site’s quadrumvirate
Attend with an AHP the site huddle. It’s a great learning experience, and can allow you to see how the whole thing works and it will show you gaps where AHPs can support things. Do AHPs contribute to your huddle or even lead your huddle?
Essential Action 2 – Hospital Capacity and Patient Flow (Emergency and Elective) Realignment
EA 2 looks to establish and then utilise appropriate performance management and trend data to ensure that the correct resources are applied at the right time, right place and in the right format.
It’s not just ‘if you don’t count, you don’t count’ but also ‘what are you counting and what are you going to do about it?’
The initial work established a current footprint of flow into, through and out of the hospital to identify where capacity meets or does not meet demand. It examined where solutions such as streaming and high volume specialty pathways would improve flow and the hidden consequences of altering current systems.
Wider work in this area has centred around producing a combined elective and emergency capacity plan for each of the major sites as well as promoting increases in day-case surgery, for example.
How can AHPs get involved?
AHPs and their relationship with data has improved so much over the last few years. These Basic Buildings Blocks (BBB) can help show just how much impact AHPs services can make in supporting the 6EA. Can you prove your improvement impact? I bet you can. Link in with your local team for improvement and data support (see below) More BBB info here.
Essential Action 3 – Patient Rather Than Bed Management – Operational Performance Management of Patient Flow.
EA 3 examines processes that follow and facilitate the patient journey (or flow as it is often referred to) rather than about bed management. A key outcome is the focus on coordinated planning and implementation of appropriate discharge without delay. This includes focus on early morning discharges and increasing weekend discharges to be more in line with the proportions that happen Monday to Friday. This will require engagement with all departments such as laboratory, pharmacy and allied health professionals as well as discharge lounges and transport services.
This work stream is basically all about effective patient tracking through the pathway and is about operational management grip and control, from an unscheduled and scheduled care point of view, and from a patient centred point of view. These aspects should be coordinated to ensure optimum focus on effective discharge.
How can AHPs get involved?
Are your AHP teams and services best placed to help the focus on coordinated planning and implementation?
Are any AHPs involved in Daily Dynamic Discharge (DDD) work? Are they attending the morning Board Round? Are they leading them and if not why not? It should not be the Senior Charge Nurse leading these. Many successful Board Rounds are led by AHPs. Are AHP task being listed on the daily ward task sheet? Being involved in DDD is a win-win for AHPs. You can get more DDD info here
Essential Action 4 – Medical and Surgical Processes Arranged to Improve Patient Flow through the Unscheduled Care Pathway
EA 4 is to ensure internal hospital departments are geared with appropriate links to pull patients from the Emergency Department (for example, assessment units and acute receiving wards) with appropriate workforce and job planning to ensure that this becomes a reality. This action should ensure that there is prompt access to appropriate assessment and clinical intervention from specialists in the appropriate environment to enhance patient experience and establish care management plans promptly, minimising unnecessary waits and delays wherever possible.
How can AHPs get involved?
Where are your AHP specialists working? Are they always in the right place at the right time where their impact can be maximised?
Are they based in a front door team and/or supporting the back door or are they somewhere in the middle?
Essential Action 5 – Seven Day Services Appropriately Targeted to Reduce Variation in Weekend and Out of Hours Working
There is already a national programme for Seven Day Services led by a task force of clinical and operational experts and EA 5 aligns itself closely to this, supporting priorities that improve unscheduled care. The priority will be to reduce evening, weekday and weekend variation in access to assessment, diagnostics and support services focused on where and when this is required to: avoid admission where possible, shift emergency to urgent care, reduce length of stay, and improve weekend and early in the day discharges safely.
The activities of the seven day task force will also support aspects of EA 3 and 4.
How can AHPs get involved?
With Unscheduled Care (USC) being weekdays 6pm to 8am and from 6pm on a Friday until 8 am on a Monday, when are you AHP services operating? Are they able to support the peak demands on USC or are they mainly Monday to Friday 9 to 5? What about public holiday? when USC can be four days in a row?
Are there any quick wins where some AHP services can look to move a little and provide an impact in USC?
Essential Action 6 – Ensuring Patients are Optimally Cared for in their Own Homes or Homely Setting
Last, and by no means least, EA 6 considers how someone who has an unscheduled care episode can be optimally cared for, or discharged to their own home, as soon as possible or how they could received the correct care for them without even having to attend an acute hospital ED.
This work will align to other portfolios of work ongoing to enhance self-management and longer term focus on preventative care and improvements in access to self-directed care and enablement services for complex conditions and comorbidity will be supported by the introduction of Integrated Joint Boards and community care developments.
Managing the patient journey to promote living well and dying well at home includes a focus on patient led self-care and improved communication between the whole system health care team.
How can AHPs get involved?
What community based services are available in your areas? Have you links with them? Can you join up the acute based services with these community based services to help facilitate more care at home?
What about self care resources such as NHS inform, Know Who To Turn To. Are these promoted in your areas? Do they provide the sort of information that you as an experienced AHP you think is required?
How it works locally
In each acute hospital site in Scotland the 6EA Unscheduled Care Programme funds a full time Programme Manager, a Service Improvement Manager (SIM) and a Data Analyst with two sessions of Clinical Lead time to support this work. AHPs are having a great impact in 6EA so find out who your SIMs are locally and get in touch. Don’t hide you AHP light under a bushel.
If you don’t know who your SIM is then get in touch with your 6EA National Improvement Advisor – they are always helpful!
Who are the National Improvement Advisor Team?
North and East Scotland
Michael Fox Michael.Fox2@gov.scot
Andrea Jamieson Andrea.Jamieson@gov.scot
West of Scotland
Claire Bell Claire.Bell@gov.scot
Gerry Mooney Gerard.Mooney@gov.scot
Fraser Ferguson Fraser.Ferguson@gov.scot
You can follow @6EAScot here
Conference : 1 Essential Group Supporting ‘The 6 Essential Actions’
There is a national AHP USC Conference taking place in Stiring on Friday, October 5th. It will be full of USC and 6EA sharing and learning. Contact ann.ross2@ggc.scot.nhs.uk for more information and to book your free place. The hashtag for the event is #AHPUSC18 if you want to follow it on the day or after.
AHPs across health and social care. 