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Service Design & Delivery

Service Design & Delivery

Welcome to the Royal College of Emergency Medicine's Professional Affairs information pages. Here you will find resources and documents on Emergency Department Design and Delivery, Informatics, ECDS, Research, Workforce and AAC.

Service Design & Delivery

The Royal College of Emergency Medicine is dedicated to achieving the highest standards of practice and patient care. Designing and delivering services is at the heart of delivering these standards and the Service Delivery Cluster works to support this. Navigate the below tab menu to explore the resources that have been collated about emergency medicine service design, configuration and delivery. Find information on current services, delivery issues, what delivering quality looks like in emergency medicine, ED crowding, ED design and system integration and service configuration. There is a  separate page for workforce and informatics can be seen below. Payment mechanisms are within informatics.

Current Service Delivery Issues

Emergency Medicine is a relatively new specialty, celebrating only its 50th year in 2017. Great strides have been made in terms of improving the quality of emergency care that is delivered, and Emergency Departments are now an indispensable element of the urgent and emergency care systems.

There are significant challenges facing the teams who work in this field:

  • An increasing population means that more patients are attending EDs
  • Lack of alternative healthcare provision, or overstretch in other parts of the system, also drives demand upwards
  • Patients are presenting with more complex needs, and are often elderly, frail or vulnerable
  • Expectations are higher
  • Many facilities and informatics systems are now out of date
  • A combination of poor planning, and lack of investment in the Emergency Medicine workforce, means that there are significant workforce gaps, both medical and nursing
  • Emergency Department crowding caused by all of these factors, but most importantly by exit block, results in long waits in EDs and makes delivering high quality care very difficult

Service Delivery and Workforce Toolkit 2013: Tools to help address service and workforce pressures

Emergency Departments across the UK are facing considerable service pressures relating to workforce and activity. The College has published a toolkit with the aim of providing assistance to Emergency Medicine clinicians and Departments by listing in one place existing resources together with a description of new developments that we hope will help to address these pressures. It also provides an update on College work to support Emergency Departments and focus attention on finding solutions to the workforce challenges.

This is not a complete resource – where there are blanks the College is working hard to identify or develop resources/guidance, and we are grateful for all the suggestions and good practice examples provided by Fellows and Members to date. If you are aware of existing resources or new initiatives that could appear in this document please contact Sam McIntyre (sam.mcintyre@rcem.ac.uk). Download the toolkit here.

Delivering Quality and Models of Care

Models of Care

What does good look like? Safer, faster, better

The document Transforming Urgent and Emergency Care Services in England contains much useful advice.

Initial Assessment of ED Patients

Below is how the College believes an ED should be set up to initially assess patients when they present. See Initial assessment of Emergency Department patients toolkit (Feb 2017) for further details.

Assessment Emergency DepartmentClinics

The Guidance on Emergency Department follow up clinics can be found in the RCEM Clinic Guidance (Dec 2015) here

Quality Indicators

The new clinical quality indicators for Emergency Departments in England were announced in December 2010 and implemented in April 2011. The quality indicators (QIs) were developed by the Department of Health team in conjunction with clinicians from RCEM and RCN, with input from the RCEM Lay Advisory Group.

The five quality indicators are:

  • Left department before being seen for treatment rate
  • Re-attendance rate
  • Time to initial assessment rate
  • Time to treatment
  • Total time in A&E

ED Crowding

Crowding is the most important problem facing Emergency Departments worldwide. In the UK crowding in EDs is worsening. The visible effects are ambulances queuing outside emergency departments, trolleys on corridors within EDs, and long waits in EDs both to be seen and to be transferred out to a ward. The invisible effects are the harm caused to both patients and staff. This page contains some links to useful resources on crowding.

Key RCEM information and guidance

External Resources

Useful UK papers on crowding

System Integration and Service Configuration

This section contains information and resources regarding the configuration of emergency care services:

Revised operating framework – Regional Trauma Networks (20th Dec 2010)

Sir David Nicholson has launched the Operating Framework for the NHS in England 2011/12 setting out the key priorities for the NHS over the next year. Find the details here. Page 43 (para 4.52) details commitments to the NHS on the establishment of Regional Trauma Networks. Please note that there is a typo at the end of the first sentence, which should read 2011/12 (rather than 2010/11). All regions should be moving trauma service provision into regional trauma network configurations in 2011/12. Previous updates:

ED Design

Hub model

As part of the STEP campaign, the A&E Hub Concept proposes that additional services such as pharmacies and crisis mental health teams should be located alongside emergency departments to help tackle the increasing rate of type 1 A&E attendances – which has increased by nearly 2 million in a decade.

Design the Smartest ED (7-9- July 2014)

This document reports on a conference held at Downing College, Cambridge in July 2014. It facilitated a purposeful interdisciplinary dialogue between clinicians, and service and space designers. It created a supportive conference environment that is hoped to permeate through into the planning and design of projects (new or refurbishments) across the world. Its aim was to achieve a common understanding of ED in terms of process, space and people.

Accident & emergency departments – Planning and design guidance (30 April 2013)

The Department of Health has published planning and design guidance for accident and emergency departments. Building a new department or refurbishing an existing one happens rarely but when it does, it provides the opportunity to design a modern department that inspires and intuitively supports effective, efficient and safe patient care, with the flexibility to meet future developments in healthcare, technology and patient volumes. This guidance provides information on how to approach a new build or redesign, specifically aimed at senior emergency clinicians and designers so key to making a new build successful. It aims to facilitate purposeful dialogue between those responsible for service delivery and those responsible for design response, and is therefore essential reading for all those involved in planning and designing their department.

Reducing violence and aggression through ED design (29 Nov 2011)

Service Reviews

The College is established to advance education and research in Emergency Medicine and is the leading authority in the UK and Ireland in this field. The College is also responsible for setting standards of training and administering examinations in Emergency Medicine for the award of Fellowship and Membership of the College as well as recommending trainees for CCT in Emergency Medicine. The College works to ensure high quality care by setting and monitoring standards of care, and providing expert guidance and advice on policy to relevant bodies on matters relating to Emergency Medicine.

As part of this work the College undertakes reviews of emergency care services at the invitation of NHS organisations. A service review can help a failing ED to become good, and a good ED to become excellent.

Service reviews are conducted by at least two senior Faculty members of the College who are expert in this area. Depending upon the agreed Terms of Reference for a review we will provide a detailed assessment and key recommendations to support organisation needs. The visit will be supported by asking for a structured pre-visit series of materials to allow reviewers to manage the time efficiently and have maximum effect. Based upon the review visit we will provide a structured report covering the key domains of an Emergency Medicine service.

Find out more

If you wish to contact the College about arranging a service review, please contact the Quality Manager, Sam McIntyre, for more information sam.mcintyre@rcem.ac.uk, and see the documents below.

Informatics

Health Informatics is the internationally recognised and Department of Health term covering the use of resources, devices, and methods required to optimize the acquisition, storage, retrieval, and use of information in health and biomedicine. The number of Emergency Department attendances has been increasing rapidly over the last few years, which has focused attention on why this has occurred. The Royal College of Emergency Medicine Informatics page features Informatics information and resources including: clinical records, emergency care data set, informatics (and introduction), summary care record and syndromic surveillance. Use the navigation tab below to browse the resources available.

+ Informatics

Introduction

Health Informatics is the internationally recognised and Department of Health term covering the use of resources, devices, and methods required to optimize the acquisition, storage, retrieval, and use of information in health and biomedicine.

The number of Emergency Department attendances has been increasing rapidly over the last few years, which has focused attention on why this has occurred.

There are several aspects to the RCEM Informatics group work:

  • What information should be collected in Emergency Departments? [See Emergency Care Data Set (ECDS)]
  • How should diagnostic information be collected [See Emergency Care Data Set (ECDS)]
  • How should information be collected in Emergency Departments?
  • How should information from Emergency Departments be shared?
  • How should information be used to remunerate Emergency Departments? How can remuneration of Emergency Departments improve patient care, and what information is required for this? [SeeCasemix – how your ED is paid]

RCEM/RCN/HEE National EM census

In partnership with the Royal College of Nursing and Health Education England, RCEM is conducting a census to collect information about the full range of professionals that provide Emergency Care, and are asking all Emergency Departments in England for their help.

With the amount and range of work performed in Emergency Departments having increased, there is concern that workforce training may not have kept pace with clinical demand.

Those charged with ensuring a safe supply of trained clinical staff to deliver Emergency Care have faced a major hurdle in that there is very little information about the workforce as a whole. This survey aims to remedy that.

The data gathered will help providers to make more accurate predictions regarding the number and grade of staff needed in the future, as well as help ensure gaps in knowledge can be filled with suitable staff training.

By completing the survey, you will help to provide an accurate picture of the current workforce, where there are gaps in staffing, and the areas in which training is most needed. This will benefit the NHS as a whole and all providers of Emergency Care.

What is the format of the census?

We are performing this census in two stages to ensure that we only ask EDs to collect information that we do not already hold, and to minimise the data that hospitals need to enter.

Stage One

  • We will send you a short series of spreadsheets to complete
  • The data we are requesting is the sort of information that is available on the NHS Choices website e.g. names and GMC numbers of the doctors who work at your hospital.
  • When the spreadsheets have been completed, please keep a copy and a printout of the spreadsheets.
  • Send an electronic copy of the spreadsheets to admin@rcem2016census.org.

The spreadsheets and detailed instructions will be sent out via the local audit leads, but please contact us if you have any queries on the above email address.

Stage Two

  • We will merge the details you have given us with those we already hold and send a printed summary to the Director of the Emergency Department for final sign-off.
  • The data will then go into a secure central data warehouse that can be accessed by HEE, RCN and RCEM, and this data will be used to inform policy at a local and national level.

When will it take place and when can I see the results?
The census is taking place now and will close in the next few weeks. The results will be used to help the College accurately assess the workforce gap and lobby for recruitment and retention activities.

What will happen to the information?
All data is held securely on ISO 27001 computer systems certified to hold NHS patient level data i.e. the highest level of NHS security.

Will individuals be able to be identified in the published data?
Data from individual departments will only be available in aggregate form. The RCEM plans to map the workforce and provide a dashboard showing how workforce numbers compare across the UK. NHS Health Education England will use the data for workforce planning purposes.

If an organization requires a more granular breakdown of the data, the data request should be made to Health Education England who will handle it according to standards NHS Information Governance rules.

How long will it take staff in the ED to collect this information?
Departments that have completed this tell us that it takes approximately 3 hours of clerical time depending on what information is already available. All departments should have a record of their medical staff’s GMC numbers.

Who will I receive information from and who should I send it to?
All correspondence should be with admin@rcem2016census.org.

The information we are collecting will really make a difference to the way decisions are made regarding workforce and we would greatly appreciate your help and co-operation.

+ Casemix: How your ED is paid

National Tariffs

See here for details of the details of the National Tariff Payment System.

+ Clinical Records

Document naming standard

The Professional Record Standards Body (PRSB) has published a Document Naming Standard endorsed by RCEM in May 2019.

Standards for the clinical structure and content of patient records

The standards for the clinical structure and content of patient records were published in July 2013 by the Academy of Medical Royal Colleges. They were developed through extensive consultation to ensure that they address the requirements of clinicians, patients, carers and health information technology professionals.

They are needed:

  • to ensure that information can be recorded and integrated in electronic patient care records across professions, disciplines and specialities, while properly reflecting best practice
  • to generate data that can be used for service delivery and performance management, commissioning, audit and research from data recorded for patient care at the point of care.

These standards were developed for use by:

  • clinicians and healthcare professionals from across all clinical disciplines
  • those who develop and implement electronic or paper care records.

Download the standards for the clinical structure and content of patient records here.

Helping to reduce prescribing errors by developing standards for the design of hospital in-patient prescription charts

The Academy of Medical Royal Colleges together with the Royal Pharmaceutical Society (RPS) and Royal College of Nursing (RCN) has produced a report on standards for the design of hospital in-patient prescription charts. The Academy wishes to promote these standards throughout the NHS. The standards were developed by an inter-professional group of doctors, pharmacists and nurses drawn from the medical Royal Colleges, the RPS and the RCN, who reviewed hospital prescription charts from a variety of sources, examined the scientific publications in the area and consulted widely with colleagues in their own organisations and in the NHS using an extensive iterative approach before finalising the recommendations outlined in the report.

For full report and appendices please click here.

+ ED Commissioning & Funding

The Health and Social Care Act 2012 is the most extensive reorganisation of NHS in England to date. This may act as a powerful stimulus for optimising efficiency and cost effectiveness of care if managed effectively through Clinical Commissioning Groups (CCG). Whilst much of the infrastructure for commissioning is being built, the first 1-2 years will require close co-operation between stakeholders to create and bed down new systems. As witnessed with past events, failure to develop and support an integrated emergency care pathway can potentially result in parts of the pathway becoming overloaded and failing. The commissioning landscape at present can seem confusing to many. Regardless of the new arrangements, Emergency Departments are facing a continuous rise in attendance that shows no indications of declining in an era of reduced financial support, increasing costs of providing 24/7 care and a shortfall in the workforce required to deliver emergency medicine. This page acts as a resource base to support our Fellows and Members with commissioning.

Guidance on commissioning Emergency Medicine Services

Commissioning the delivery of high quality care in the Integrated Emergency Department – Guidance for Commissioners, clinicians & managers (18 November 2013).

This position paper by the Royal College of Emergency Medicine provides guidance for commissioners, clinicians and managers on how to deliver high quality care in the integrated Emergency Department. This guide recommends ten key recommendations that the College believes should always be considered when the configuration of local EDs are made.

Reconfiguration of Emergency Care system services – 10 Key Principles (31 May 2012)

This position statement by the College describes the principles that relevant stakeholders must consider when decisions regarding reconfiguration are being made. These will be especially relevant where stakeholders decide that part of reconfiguration will involve down grading or even closure of an Emergency Department.

Urgent and emergency care: a prescription for the future (18 July 2013) – The Royal College of Physicians, NHS Confederation, the Society of Acute Medicine and the Royal College of Emergency Medicine have set out ten priorities for action to address the challenges faced by urgent and emergency care services. These challenges include:

  • Rising demand and the changing needs of an ageing population
  • Lack of comprehensive, effective alternatives to hospital admission across seven-days
  • Complex discharge issues
  • Handover and flow
  • Recruitment into emergency and acute medicine.

Download full report: Urgent and emergency care: a prescription for the future

Download the press statement: Press statement from CEM

Specialised guidance on commissioning

Mental Health in Emergency Departments – A toolkit for improving care.

External commissioning guidance

Breaking the mould without breaking the system: new ideas and resources for clinical commissioners on the journey towards integrated 24/7 urgent care (1 Dec 2011).

This report has been published by the Primary Care Foundation in partnership with the NHS Alliance. This resource is designed to offer ideas and inspiration to everyone responsible for commissioning urgent and emergency care in the UK, in particular, the new clinical commissioning groups in England.

+ Emergency Care Data Set (ECDS)

To provide a more accurate, detailed and complete picture of all emergency attendances, the new Emergency Care Data Set (ECDS) has now launched. The ECDS replaces the Accident and Emergency Commissioning Data Set (CDS type 010).

The good news is Type 1 and 2 Emergency Departments in England are already implementing the mandated changes and submitting new data.

To help staff understand the importance of the ECDS and how they can help support the roll out of this data set, we have developed a simple animation. Please watch our short video and share this with your ED colleagues (including medical, nursing, clerical, reception, operations and management staff).

For more information about the ECDS, please view:

+ Summary Care Record

What is the Summary Care Record?

A Summary Care Record stores a defined set of key clinical data for every patient in England who has elected to have one. The majority of the population of England have had an SCR created by their GP practice and uploaded onto the National Spine. As of February 2015 almost 90% of the population, more than 50 million people have a Summary Care Record. SCRs can be accessed electronically by healthcare staff providing care to a patient in an urgent or emergency care setting, anywhere in England, any time of day or night. SCRs provide access to information held on GP clinical systems about, as a minimum, a patient’s medicines, allergies and any past drug reactions. The Summary Care Record is helping to improve safety, and the quality and continuity of care to patients.

Staff viewing a patient’s SCR must be able to demonstrate a legitimate relationship with the patient and must use a smartcard to access the SCR via the secure NHS N3 Network. All accesses will be auditable. The patient’s permission to view must be obtained before the SCR is viewed. If the patient is not able to give properly informed permission to view then a clinical decision can be made to access the record in the patient’s best interest, without first obtaining consent. Such accesses in the patient’s best interest will be recorded and can be investigated should any queries arise about the appropriateness of the access.

SCR information for NHS staff

How do organisations initiate SCRs?

SCR viewing can be achieved relatively easily and without incurring significant expense to the provider organisation. A web-based SCR application is available which can provide access to authorised healthcare professionals with a smartcard, via the secure N3 Network, to the Patient Demographic Service (PDS) and to SCRs on the National Spine. Alternatively, embedded information systems which are deployed by some urgent and emergency care providers may provide integrated SCR viewing capability. The same access controls apply. The Summary Care Record Implementation team at the Health and Social Care Information Centre will help organisations that are interested in introducing SCR viewing.

Contact the team at: enquiries@hscic.gov.uk

Further information

NHS Digital provides comprehensive implementation advice and up to date information about the benefits of SCR to patients and healthcare staff. See more here

+ Syndromatic Surveillance

Emergency Department Syndromic Surveillance System (EDSSS)

Public Health disease surveillance is the ‘systematic ongoing collection, collation, and analysis of data, and the timely dissemination of information to those who need to know it in order for action to be taken.

In recent years, syndromic surveillance has become an increasingly important tool for disease surveillance. Syndromic surveillance is the collection, analysis, interpretation and dissemination of health-related data, typically on a real-time (or near real-time) basis, to enable the early identification of the impact (or absence of impact) of potential human or veterinary public health threats which require effective public health action.

The EDSSS is a joint project between RCEM and the Health Protection Agency. The data that Emergency Departments routinely collect are anonymised and sent securely to a data warehouse where they are analysed to produce reports. No extra burden is placed on clinicians. Hospitals engaged in this project also have the opportunity to view their own data in real time.

Requests to joint the scheme or for access to data from the project should be sent to the RCEM representatives on the project:

  • Tom Hughes – tom.hughes@nhs.net
  • Tom Locker – tlocker@nhs.net

See the HPA website for more information about syndromic surveillance here.

+ Usability

RCEM Usability Survey

The RCEM Informatics committee is performing an audit of the usability of IT systems in Emergency Departments.

Why?

The usability (‘user experience’) of IT systems in emergency departments matters to clinicians as these clinical areas have high patient and clinician turnover. This means that training needs and the cost of learning how to operate the IT system is high.

The RCEM informatics committee often hears clinicians complain about their ED IT systems. This is a chance to collect the data that will indicate if usability is a significant issue.

How will it work?

The survey is conducted using a secure app on an Android tablet or phone provided by you. The software will automatically open up and configure itself on the Android device, will be hosted on the same fully secure servers that also holds the RCEM audit data and will be anonymised.

How much does it cost me?

Nothing.

Do I have to participate?

No – the audit is voluntary.

What will I get from the usability audit ?

Your system will be rated on a scale of 1-100, most IT systems will rate between 50 and 70. The responses will be collated and then feedback to trusts via the College Informatics Committee.

The System Usability Scale

The System Usability Scale (SUS) is a valid and reliable tool for measuring IT usability. It consists of a 10-item questionnaire with five response options for respondents; from ‘strongly agree’ to ‘strongly disagree’.

Originally created in 1986, it allows one to evaluate a wide variety of products and services, including hardware, software, mobile devices, websites and applications.

Benefits of using SUS

SUS is the industry standard, with references in over 1300 articles and publications. The benefits of using SUS include that it:

  • Is a very easy scale to administer to participants
  • Can be used on small sample sizes with reliable results
  • Is valid – it can effectively differentiate between usable and unusable systems

The System Usability Scale

Participants are asked to score 10 items with a response from ‘strongly agree’ to ‘strongly disagree’:

  1. I think that I would like to use this system frequently.
  2. I found the system unnecessarily complex.
  3. I thought the system was easy to use.
  4. I think that I would need the support of a technical person to be able to use this system.
  5. I found the various functions in this system were well integrated.
  6. I thought there was too much inconsistency in this system.
  7. I would imagine that most people would learn to use this system very quickly.
  8. I found the system very cumbersome to use.
  9. I felt very confident using the system.
  10. I needed to learn a lot of things before I could get going with this system.

Interpreting Scores

Though the scores are 0-100, these are not percentages and should be considered only in terms of their percentile ranking.

For a computer system with a Graphical User Interface, as with the vast majority of ED IT systems, the mean score is 75, and the standard deviation is 21.

Sample sizes as small as 5 per group have been shown to be surprisingly reliable.

For further information please contact audit@rcem.ac.uk

More reading on usability

Aaron Bangor, Philip T. Kortum & James T. Miller (2008) – An Empirical Evaluation of the System Usability Scale, International Journal of Human–Computer Interaction, 24:6, 574-594, DOI:  10.1080/10447310802205776

+ Further Information

Emergency care performance data and statistics

Royal College of Physicians, Health Informatics Unit

The Health Informatics Unit of the Royal College of Physicians has been pivotal in the development of standards for medical records. It co-ordinated a project that has produced Generic Medical Record Keeping Standards, and Standards for Content and Structure of inpatient notes that have been jointly published by the Academy of Medical Royal Colleges and the NHS Digital and Health Information Policy Directorate. See more here.

Additional Resources

Sources of legislation, to include:

  • the Computer Misuse Act 1990
  • the Data Protection Act 1998
  • the European Directive on Data Protection
  • the Access to Health Records Act 1990
  • And any subsequent revisions to this legislation.

Patient Safety

Information Commissioner’s Office

Data Security and Protection Toolkit

Hospital Episode Statistics

Hospital admission data are currently available through the Hospital Episode Statistics (HES) database which is a centralised data collection facility covering all NHS and private hospitals in England. Data from this system are available for use for surveillance activities, however the current availability of these data are not timely and are released with an approximate 6 month delay. Therefore, for use in a real-time system HES data are not suitable and more likely to be used for retrospective analyses or validation exercises. There are also costs involved with accessing these data. See more information on hospital episode statistics here.

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