Improving unscheduled care: six essential actions

Essential action 1 - clinically focussed and empowered hospital management

Ensuring clinically focused  management teams have a strong understanding of - and control over - each site, 24 hours a day, 7 days a week. It involves the development of clear escalation policies and processes along with the appointment of a site director who can make decisions relating to all specialties, supported by medical and nursing chiefs of staff. These managers will ensure on a daily basis that there is a balanced approach to the operational management of patient flow, facilities management and appropriate staffing linked clearly to patient safety and activity.

This is key to ensuring daily capacity is aligned to meet demand and sites are able to quickly identify underlying systemic issues and effectively deliver sustainable improvements.

Essential action 2 – hospital capacity and patient flow (emergency and elective) realignment

To establish the use of meaningful, robust data, to determine and ensure demand and capacity are in balance at all stages of the patient pathway. Minimising delays and ensuring patients are cared for in the right place, at the right time, is vital to the attainment of optimal patient flow. Initial analysis will establish current/baseline metrics relating to capacity, demand and performance, which will aid in the identification of areas of misalignment, therefore providing a focus for improvement work to deliver a balanced system with optimal patient flow.

Further work in this area includes the modelling and simulation of improvement options, and extending the analysis scope to review and create elective and emergency capacity plans.

Essential action 3: patient rather than bed management – operational performance management of patient flow

This Essential Action focuses attention on the operational management of patient flow as opposed to ‘bed management’. Placing emphasis on the co-ordinated creation of a multi-disciplinary, patient-centred discharge plan as soon as possible after admission, and then on the timely, synchronised execution of the plan each day, prevents delay and ensures that patients are treated and discharged without delay.  This will require engagement with all supporting departments and services such as laboratory, pharmacy, allied health professionals, discharge lounges and patient transport services.

This workstream promotes effective patient tracking throughout the journey and supports operational management (‘grip and control’) of the plan at an individual level, and - across all patients - the effective balancing of capacity and demand at a system level.

Essential action 4: medical and surgical processes arranged to improve patient flow through the unscheduled care pathway

This Essential Action will ensure that appropriate clinical pathways are in place across internal hospital departments giving patients an optimal Unscheduled Care journey from attendance to discharge. This will require effective processes built around Flow, Workforce and Planning in order to ensure prompt access to assessment, diagnostics and clinical intervention from specialists.

Essential action 5: seven day services appropriately targeted to reduce variation in weekend and out of hours working

To reduce variation in service and care provision across 7 days, the enhancement of ‘out of hours’ to improve the patient journey and prevent unnecessary waits and delays. Not every service needs to be available 24/7 but understanding the need and impact of the current provision will be key to determining improvements and innovations required locally.

The activities of Essential Action 5 link closely to other essential actions, primarily Essential Action 4.

Essential action 6: ensuring patients are optimally cared for in their own homes or homely setting

This essential action will consider how someone who has an unscheduled care episode can be optimally cared for, or discharged to their own home, as soon as possible.

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.

The patient journey should be managed 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.