Improving emergency care, Kent 2019-20

University Hospital Lewisham


An acute hospital in Kent initiated a transformation programme in response to decreasing performance and quality:

  • 4-hour performance (T1) in March 2019 ranked 112 out of 122 trusts
  • Front of the pathway was not functioning as needed, e.g. assessment areas had become “regular” wards, and medical clerking time ~4 hours
  • Ineffective grip of daily operations, e.g. DTA to admission time ~7 hours, patients being moved too often, and mixed sex breaches
  • Not enough discharges to accommodate demand, and high proportion (37%) of medically fit patients


We developed 4 workstreams to address the challenges faced by the trust:

‘One Version of the Truth’ (OVT)

A system-wide diagnostic to develop an accurate and granular picture of the root causes of poor performance in Emergency Care, and identify the areas of focus for the programme

Operational Discipline

Improving operational efficiency to provide improved flow and high-quality care

Introducing operational discipline to site management through 6 initiatives

Medical Model

Reviewing the bed requirements for each specialty and area of the pathway, and the adequacy of the current footprint to accommodate each specialty’s needs

Leadership, Engagement & Capability

Aligning leaders on the core purpose and building the tools and capabilities to engage their teams and the wider Trust in this shared vision


The Trust improved its relative 4hr performance (T1) ranking from 112 in Mar 2019 to 59 in Jan 2020 (out of 122 Trusts).

In addition, there were improvements in several other quality and safety indicators, e.g.:

aggregated patient delay

Decrease in aggregated patient delay by -6% compared to last year, and establishment of a Clinical Decision Unit

Acute Medicine
medical clerking time

Decrease in Medical clerking time from ~4 hours to ~2 hours and a significant increase in the average number of HOT Medical patients seen in SDEC

In-patient transformation
discharge lounge utilisation

Significant improvements in the quality of board rounds across the hospital and 100% increase in the utilisation of the discharge lounge

Site management
medical outliers

Decrease in the number of medical outliers from ~50 to less than 20

Site management
mixed sex breaches

Reduction in mixed sex breaches by 73%

Leadership, engagement and capabilities

The organisation is better prepared and operationally ready to deal with future challenges, e.g. increased pressures and complexities of COVID-19

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