Applying a National Emergency Care Strategy -Empowering Local Leaders to take Control? (Lessons from across the water) Dr. Gerry McCarthy Clinical Lead for the National Clinical Programme for Emergency Medicine

The Clinical and Strategy Programmes Directorate Improve and standardise patient care Bringing together clinical disciplines to share innovative solutions Three main objectives Improve quality of care Improve access to all services Improve cost effectiveness

Emergency Medicine Programme Irish Committee for EM Training; EMP Medical Advisory IAEM EMP Working Group Regional Leads Paediatric EM Lead Nursing & ANP Co-leads Therapy Professional Pre-hospital Emergency Care National Ambulance Service Programme Manager Administrative Support EMP Medical Advisory Group Consultants in EM Emergency Nursing Interest Group (ENIG) All EDs Represented Dept of Health/SDU Director of Quality & Patient Safety Director of Programmes RCSI Irish Nat Board College of EM Office of Director of Nursing & Midwifery General Practise Liaison Committee Therapy Professions Committee Academic Committee IAEM Patient Representative Nursing Guidelines Group

The Mission Appropriately supported “Front Line” Clinicians designing the Model of Care to optimise: Quality Access Cost

Programme Management Organisation, direction and implementation of a portfolio of projects and activities to achieve outcomes and benefits that are of strategic importance Projects deliver outputs, Programmes deliver outcomes; programme management is concerned with doing the right projects

Emergency Care Pressures Resource Allocation Decisions Health System Policy General Practice Access Community Care Access Workforce Management Service and specialty Interfaces Acute Hospital Unscheduled care systems effectiveness Emergency Care 24/7 patient care need Patient and Population Health Outcomes 7

The Method Working Group Site Visits Clinical Advisory Group ENIG Report and Model of Care Inter-programme Working

To Improve the Safety and Quality of Care in EDs and Reduce Waiting Times for Patients Examples of programme objectives: Quality: Maximised access to consultant provided care resulting in decreased mortality and morbidity Attainment of quality targets (HIQA compliant) Access: Patients admitted or discharged within target time Triage completed within target time Patients with high-risk conditions to be assessed by a senior doctor. Decreased number of patients leaving without completion of treatment. Cost: Reduction in number of admissions Decrease in length of stay for in-patients referred from ED 9

Emergency Care System Solutions ELIMINATE ED CROWDING Governance and Management Implement Emergency Care Networks Ensure Emergency Care Networks are managed through active lines of governance Support high-quality, evidence-based emergency care with national standards, clinical guidelines, protocols & audit. Workforce Stabilise nurse staffing levels and skill mix; Increase Advanced Nurse Practitioner posts to 147. Increase Consultants in EM from 79 to 180 and stabilise Middle Grade staffing (c. 150 WTE) Ensure patient access to Therapy and Medical Social Work services in all Emergency Care Networks System Support Install fit-for-purpose information systems in all ECNs (EDIS), with supporting data analysis. Ensure all EDs have adequate infrastructure and equipment. Provide effective pre-hospital and retrieval medicine services in all Emergency Care Networks Training and Improvement Invest in ongoing training and professional development Redesign work practices to release clinician time for direct patient care. Support front-line teams in driving quality improvement.

Foundational Layers of EMP Quality Improvement Standards Tools, Protocols, Guidelines Medical, Nursing & ANP Staffing Models Supporting Fundamentals - Emergency Care System Governance ICT & Infrastructure Strategic Blueprint for Emergency Medicine Model of Care Emergency Medicine Programme 11

Three side solution to improve Emergency Care Improved Patient Care, 6-hour standard, Improved Patient Experience National Level Posts Emergency Care Networks ICT Defining Standards & KPIs ED & other teams Quality Improvement Model of Care - Standardisation of care Hospital Management Monitoring & management Hospital capacity

So far so good……………………..

EMP Key Milestones 2010 2012 2013 Oct 2010-Jan 2011 September 2010 Working Group Set up September 2010 2010 Oct 2010-Jan 2011 Best Practice Workshops 2011 ENIG Set up 2011 2011 Model of Care Design EDIS & Infrastructure Definition. 2012 June 2012 Programme Document Launch June 2013 August 2013 Supporting Tools & Models; HIQA Standards Front Line Quality Improvement

Meanwhile –Back at the Ranch…..

Meanwhile –Back at the Ranch…..

Meanwhile Back at the Ranch….. November 2010 2014 Troika arrived November 2010 2010 Model of Care AMP 2010 Feb 2011 Recruitment Moratorium General Election 2011 Money Follows the Patient Special Delivery Unit Tallaght HIQA Report 2011 Doctors follow the Money (and Sunshine/Ts & Cs) July 2014 New Minister Activity based Funding

Emergency Care Pressures Resource Allocation Decisions Health System Policy General Practice Access Community Care Access Workforce Management Service and specialty Interfaces Acute Hospital Unscheduled care systems effectiveness Emergency Care 24/7 patient care need Patient and Population Health Outcomes 18

3. Patient Pathway (Phase 1) Blue Print Self Management Patient information web site Patient 16 Ambulatory Ambulance Triage and/or EWS 23 3 Emergency Department Critical Care (ICU/CCU) Chronic Disease watch 17 Triage and/or EWS 12 13 2 GP/Primary Care Team 10 Acute Medicine Unit Initial Assessment Community Intervention Team & other care in the home services 11 Clinical Prioritisation: EWS 4 Regional patient navigation hub service 19 14 Surgical Assessment Unit Diagnostics 5 Out Reach Service 20 Working Diagnosis 6 Out patients 21 Elective Surgery Emergency Surgery 18 7 Rapid Access Clinics Specialist Units/Centres e.g. Stroke, Heart Failure, Epilepsy, PCI, etc Care plan 8 Day Care Centre 9 Rehab services 15 22 24 4 1 Discharge management Medical Short Stay Unit Admission Hospital retrieval/transfer 25 Care Home Services 2 EWS 3 26 Hospital Network Specialist Wards Hospice/ Palliative Care 27 Pathway enablement and sustainability

The Real Patient Pathway/A day in the life of an emergency physician

Romam vado iterum crucifigi Why are you guys always so cross?

Why is change hard? Inertia Habit Fear of unknown Suspicion : Benefits not proven ‘How to go about it’ looks difficult Too many people to convince - stakeholders

Systems Theory “If I had to reduce my message …. to just a few words, I’d say it all had to do with reducing variation.” (Bryce)

Is every ED the same? Reducing variation at the price of stifling initiative? Can apples and oranges share the same production line? Catchment area reflects patient profile Spread supporting/inhouse specialties affect workload Crowding

Clinical Microsystems What is needed from Group CEOs - Support for projects - Awareness -

Context External Pressures Recent Changes in structures Imminent and future changes

External Pressures Politics History Crowding Recruitment/Retention KPIs Performance Management Inter-Programme working

Changes in National Structures Design Authority Implementation Authority

Changes in National Structures Design Authority Implementation Authority Nat. Clinical Advisors

Changes in National Structures Design Authority Implementation Authority Nat. Clinical Advisors Hospital Groups

Changes in National Structures Design Authority Implementation Authority Nat. Clinical Advisors Hospital Groups Community Health Organisations

Imminent and Future National Developments affecting EM and EDs Ambulance Turnaround and Clinical Handover Trauma Networks IHRP Activity Based Funding Hospital Groups +/- Emergency Care Networks

Imminent and Future EMP Developments ICTS Ambulance Clinical Handover Protocol Mental Health Triage Post-triage Monitoring Clinical Microsystems Patient flow initiatives EDIS Emergency Care Networks

Emergency Care Networks Type A2 – Big & Busy Type A1 -Small number to receive “the sickest the quickest” Type A3 - Geographical necessity Type C -Local Injuries Unit (LIU) Type B -Local Emergency Unit

What really happened to the Dinosaurs

EM is what happens when we are busy making other plans!