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QA with Mark Monaghan

What is the best thing about being NEAT?

The answer to this for me is that at last our health system and hospital leaders have a mandate to address access block at a hospital and system level, with the great difference being that it is no longer viewed as a problem caused and owned by EDs. This is a very important step for our health system.

What were the key success factors in the implementation of the 4 hour emergency access target in WA?

I think WA has been successful in that they have demonstrated that this is achievable. We have done a lot of good things, we still have a lot of things to sort out, and we have made mistakes, but that is great for the other states and territories as there is much to learn from and we can articulate the things to avoid.

Certainly using a robust methodology, mapping current practice, obtaining good data and investing in clinical leads and program leads at the sites was a great model. A dashboard of safety and quality indicators is also vital to a healthy program.

If there is one thing that should be avoided in implementation of the NEAT, what is it?

There are a few things to avoid, but the most important is to avoid processes without integrity. More timely access to emergency care is a very positive quality improvement in itself, but efficiencies should never be gained at the expense of quality clinical care. The initial decisions, management and disposition from ED prepare the ground for best care of the patient as they go through the hospital system, so it is vital not to compromise on them. 

A really good example of this concerns one of our most effective initiatives which was to introduce 'navigators' into the ED to monitor and facitilate patient movement through the department . These 24/7, level 3 nurses watch the time line of every patient and are essential in avoiding time wastage by encouraging early booking slips, early referral, decision making and when ready, to make sure patients move upstairs quickly. This initiative improved our performance about 15% overnight, and it has been great for us, but as I will go on to decribe there is the potential here to have a very negative impact on morale and safety if this is not managed well. 

It seems that in most EDs two hours is the ideal time to have made a disposition decison if you want an admitted patient to get up to the ward by 4 hours. So, there is some logic in guiding you navigators to touch base with the ED doc at 2 hours to see where things are headed.  However, if the patient has been in the waiting room for most of that, and they are complicated, this may well not be enough time to make a good quality assessment. There is the potential if this role is not well managed to have doctors, particulary junior ones,  pushed into making decisions earlier than is safe for the patient. So this comes down to the ethos of the program at that site. We have an understanding at our hospital that if the clinician doesnt feel they have had enough time, then that is respected and the navigator will catch up with them later on. This is essential on many levels, and the hospital managers need to recognise this and empower their clinicians to make the call on whether moving a patient is safe. It also behoves us as ED clinicans to be as efficient and as excellent as we can be. The importance of these principles cannot be overstated.

Is there anything else we should know?

The final thing I would say is that the final target of 90% is hard, but doable and safe, and will if done well result in hospitals that look completely different operationally and work much better for our patients. Its a great opportunity for us and we should grab it.

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