Report on follow up visit to Ninewells Hospital

Summary of Progress on Recommendations

CMO recommendation:

To improve communication link consultants from all specialties that interact with the emergency department should be identified.

Clinical Leads have been identified for all specialities and services, and meet regularly at the Clinical Leads Group.

The Emergency Medicine multi-disciplinary team confirmed that their clinical lead had contacted link consultants in all receiving specialties to discuss collaborative working and improving communication between the services. I was provided with a number of examples in which this improved communication and collaboration had provided the opportunity to review and improve existing patient pathways, such as within Orthopaedics, which resulted in clarity and agreement on the experience level required of the doctor giving an opinion on call.

The Medicine multi-disciplinary team confirmed that communication had improved, with frequent discussions between the link consultants from ED and the Acute Medical Unit. They advised that they now felt there was a strong, collaborative relationship with the Emergency Department with an agreed feedback and escalation protocol now in place. Joint monthly lead consultant meetings and morbidity and mortality meetings are in place.

The surgical lead confirmed that discussions with emergency medicine had taken place, and work was on-going through the Acute Care Interface Forum, to promote collaborative working between the services and create a joint understanding of the required linked models to deliver seamless and high quality patient care. Although progress with regard to improved communication and collaborative working between the ED and the general surgical service has not progressed at the same pace as medicine, it was noted that NHS Tayside is currently undertaking a "Shaping Surgical Services' review, the output of which will provide the opportunity for increased collaborative working and improved communication.

CMO Recommendation:

The ED team should consider disseminating positive outcomes from their ED model across NHS Tayside to ensure whole hospital 'buy in' and improve collaborative working.

The Emergency Medicine multi-disciplinary team advised that they have made significant progress in disseminating positive outcomes from their ED model, and now ensure that quality markers relating to clinical outcome and patient safety are added to existing measures of flow. A new multi-disciplinary QI group has been established, with other specialties being invited to attend where relevant. A number of collaborative projects have been undertaken to review and improve patient care. In addition monthly and weekly multi-disciplinary meetings are held, with the discussions, actions and outcomes collated in minutes which are distributed to all participants and shared on staff notice boards.

CMO Recommendation:

The existing draft document - 'Guide to Tayside EDs for doctors interacting with Emergency Medicine', should be shared with all stakeholders and a collaborative approach taken in its development. The agreed final document should be shared with all existing healthcare staff who interact with the ED within NHS Tayside

There should be specialty specific operating procedures drawn up with ED and receiving teams which ensure adherence to the principles of the ED model and ensure optimal patient care as they progress through the system. Staff should meet regularly and these meetings should also be attended by nursing and other staff working between ED and the receiving units.

The emergency medicine clinicians advised that the existing draft document has been reviewed in relation to emergency medicine. The organisation have accepted that this document does require a wider remit and should describe the flow of all unscheduled care admissions and therefore will include specialty specific operating procedure prepared collaboratively with ED and the receiving specialties. This collaborative piece of work across all specialties will be sponsored by the lead consultants and will be discussed and progressed through the Acute Care Interface Forum.

CMO Recommendation:

Emergency department consultants should have a participative role in the induction of new medical, nursing and other relevant healthcare staff to ensure understanding of the agreed operational model within the emergency department.

The emergency medicine clinicians advised that rapid progress had been made, with the Clinical Lead for Emergency Medicine presenting at hospital induction for newly appointed trainees in August 2015. The Clinical Lead now has a regular slot on the programme. In addition the emergency medicine consultants have offered 'tours' of the department, hosted by an Emergency Medicine Consultant. They advised that the tour for new anaesthetic trainees had allowed description and discussion on the ED system and has led to better understanding and working relationships.

CMO Recommendation:

Early work in NHS Tayside on 'whole system patient pathways of care' should be continued taking into account these recommendations. It is important that each individual unit or department see themselves as part of the larger 'hospital team' ensuring best patient care including flow through the hospital.

The work on 'whole system patient pathways of care' has continued, with this working group evolving into smaller more focused groups. In particular the Acute Care Interface Forum, established in November 2015, has brought together clinicians within emergency medicine, acute medicine, and surgical receiving to discuss and review the unscheduled care pathways. It is recognised that there has been a divergence of views regarding the existing ED processes and this forum facilitates discussion and collaborative working between the main receiving specialties and their Emergency Medicine colleagues.

CMO Recommendation:

The concerns raised by whistleblowers who come forward should continue to be investigated as previously through the existing channels within the east of Scotland deanery and escalated to the GMC if appropriate.

I am satisfied that the concerns raised by whistleblowers have been investigated through the existing channels within the east of Scotland deanery as required. A copy of the resulting action plan, containing many actions which align to my initial recommendations, has been supplied.