1. 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

2. 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

4. 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

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

6. 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

7. 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

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

9. 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

10. 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.

11. 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

12. 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

13. So far so good……………………..

14. 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

15. Meanwhile –Back at the Ranch…..

16. Meanwhile –Back at the Ranch…..

17. 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

18. 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

19. 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

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

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

24. 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

25. 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)

26. 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

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

28. Context External Pressures Recent Changes in structures
Imminent and future changes

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

31. Changes in National Structures
Design Authority
Implementation Authority

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

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

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

35. 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

36. 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

37. 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

38. What really happened to the Dinosaurs

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