To reduce waits and delays and improve the patient and caregiver experience through achievement of the 98 percent operational standard of the NHS Plan target of a maximum four-hour wait for emergency access by December 2004.

The overall programme measure was the total patients seen, treated, discharged or admitted within four hours of arrival at Accident and Emergency (A&E). Through analysis of waits and delays, local improvement measures were determined that supported the delivery of the overall programme measure.

The programme was rolled out in six Waves from October 2003 to October 2004 across every hospital in England with a 24-hour A&E service (200 sites). Each Wave lasted 14 months. National reporting commenced in December 2003.

Many small scale process changes are required to deliver sustainable improvements which were tested and implemented through the use of the Model for Improvement and Plan-Do-Study-Act cycles.

The approach was to transfer learning across health economies within local programmes, then across the Wave, and then from Wave to Wave. Later Waves benefited from more accelerated learning and subsequent improvement as the high impact changes emerged through the programme:

Introduction of Patient Flows:

• Minor Injury and Illness
• Acute Assessment
• Medical Admissions and
• Surgical Admissions

Determined the systematic process steps required by the majority of patients (high volume runner groups). This focus allowed organisations to reduce variation through streaming based on total length of journey and complexity across whole systems reducing waits and delays.

Use of Lean Principles to redesign processes and systems to reduce waste, reduce batching, improve overall co-ordination and ensure that all steps add value from the patient perspective, and that systems are paced to match demand and required capacity.

• Prompt initial assessment and access to senior clinical decision makers
• Protocol driven diagnostics to ensure tests requested are key to supporting the immediate decisions about the patient journey
• Timely access to specialist opinion
• Reduce variation in admissions and discharges by day of week
• Improve strategic and operational bed management through measures such as proactive management of simple discharge to facilitate morning discharge to create capacity to match demand

The Emergency Services Collaborative (ESC) was a pan-England programme run by the National Health Service Modernisation Agency to:

• Achieve a 98 percent operational standard by December 2004 for patients to be seen, treated, discharged or admitted within four hours of arrival at Accident and Emergency departments
• Deliver improved performance from 79 percent (December 2002), which had remained static for over 12 months, by the end of the programme (October 2004) reaching 96.2 percent, and then 98 percent by December 2004

The programme continues to deliver sustained improvement, with Quarter 1 2005 reported at 98.1 percent (latest published Department of Health data) and 100 of the 155 Acute Trusts delivering over 98 percent consistently.

The following outlines our thinking at the start of the ESC in 2002 and how the experience of leading this programme and working with local improvement teams has informed our beliefs to date about the critical success factors for leading national and local improvement programmes:

• Tailor the approach to the local context, previous achievements and challenges.
  
• Clinical leadership is important but so is engagement of senior managers and executives who can equally affect the organisation’s ability to make sustainable change.
  
• Balance use of bottom-up change with spread of evidence-based, high impact changes to enable maximum achievement.
  
• Without clear links to strategic deliverables the programme cannot get the organisational priority deserved. However, focusing a programme to achieve delivery of one target does not help organisations to deliver balanced system improvements across elective as well as emergency care and enhanced whole systems working.
  
• Needs to be integral and targeted as soon as organisations fail to make improvements. Service improvement works best within a performance management framework.
  
• Organisations need considerable support to use redesign tools and techniques — their comfort zone is often fire fighting.
  
• Flow management works. However, even where this is recognised with senior management teams there is often still a disconnect with how services are organised (on a specialty or service model) which limits the impact of redesign.
  
• Work to proactively manage flows across complex systems
  
• There is no clear evidence of when to use which theoretical approach (e.g.. Lean vs. Theory of Constraints vs. Queuing Theory), and on balance some parts of all approaches are useful and appropriate. It is clear however that culture, leadership, engagement, and empowerment are more fundamental to the delivery of sustainable change.
  
• Essential — but needs to be based on rigorous diagnostics and within national framework to deliver high impact priorities. As well as journey time and other measures a greater focus is required on breach analysis at key stages of the patient journey, for example, time of arrival to four hours, time clinically ready for discharge to time of discharge.
  
• Must link to clinical outcomes to be clinically relevant and support governance.
  
• Whole systems programme of change should start with understanding demand and capacity, improving management of discharge to improve timeliness of bed availability.
  
• Attendance and admission avoidance will only deliver small percentage of overall performance improvement.
  
• Set performance trajectories on intelligent interpretation of local data, for example, breach analysis where simple changes required inform steeper trajectories and sites are rewarded for their overall improvement through continuous improvement rather than benchmarking against others (who may already be at required performance level and have not engaged in making any improvements to date).

Teresa Fenech, Director of Corporate Strategy
Clatterbridge Centre for Oncology NHS Trust
Teresa.Fenech@ccotrust.nhs.uk

[Storyboard presentation at IHI's National Forum, December 2005]