It’s common knowledge that COVID-19 had a huge and unprecedented impact on healthcare, and quantifying that impact fell to the CQC. That’s why earlier this year, they issued a report on how urgent and emergency care services were affected by the pandemic during winter 2020 and discussed the actions they took to provide constructive support.

Part of this support was the Patient FIRST framework which was introduced in October 2020 as a tool to help support those working in NHS trusts and the wider health and care system to understand learnings from the pandemic and share good practice.

The framework contains examples of actions that could be taken at a departmental, trust and wider system level to maximise capacity, maintain effective patient flow, and keep staff and patients safe.

Taking stock

By early November 2020, the CQC implemented their ‘transitional regulatory approach’ in response to the pandemic. Informed by this and by the situation reports data and information from local inspections teams, they identified 13 emergency departments for inspection from winter 2020 and created a report that looked at five of them.

The inspections were based on risks and highlighted the tough circumstances that providers faced during the pandemic, so it was unsurprising that they found concerns with waiting times, delays, quality and safety amongst other issues.

For example, all of the inspected hospitals were undergoing (or had recently undergone), physical changes to their urgent and emergency care departments, which meant changes in their use of spaces to triage and direct patients down COVID and non-COVID pathways. While this worked well for some hospitals, it caused confusion and crowding for others and hampered patients’ ability to maintain a safe social distance. This impacted flow, which in turn caused delays and increased contagion risks.

The report also explained how some hospitals struggled with patient assessment and triage because their processes were not well-embedded, and how inspectors witnessed patients waiting too long for triage because of ineffective systems to identify whether patients were in pain or deteriorating.

Most of the departments had avoided queuing patients in corridors to prevent overcrowding, but this had a knock-on effect in that some patients were being held in ambulances to wait for treatment or until a place could be found for them on the ward. These delays negatively affected ambulance crews’ wellbeing and their ability to respond to other calls from patients in the community.

Inspectors did witness queuing in corridors at one hospital, which raised separate concerns as it didn’t allow for adequate social distancing and patients’ privacy and dignity was sometimes compromised. In some departments, changes to the use of space caused problems for mental health services, with private rooms for patients with mental health needs now being used for donning and removing personal protective equipment, and the replacement room was not suitable.

Some of the inspected hospitals were unable to meet the intended staffing levels because of a shortage of staff. In addition, the effects of COVID on the staff themselves meant that staffing challenges in the emergency department were causing delays. In one example, a staffing shortage at night meant that incoming staff had to deal with the increased pressure of higher numbers of patients in the morning and delayed discharges. In other hospitals, staff struggled to reach senior staff for support, and felt restricted in their capacity to press ahead with initiatives that were designed to reduce delays, such as pathway development.

Finally, the report explained how all of these factors had a strong impact on staff morale, with some frontline teams describing how they felt hampered in their ability to provide well-timed care and felt unsupported by other departments and the executive team.

Struggling with Risk

All of the issues identified in the report were ultimately linked back to the leadership and governance for each service, including the oversight they had and what actions and mitigations they took to manage the risk. While Managers were generally able to describe the three biggest risks to their departments, they did not include the repeated delayed handovers of patients from ambulance crews as one of their biggest risks.

Although they were aware of the issue, they did not appear to take ownership of the risk or have a system to mitigate it. What this meant in practice was that site meetings didn’t result in any actions for patients who had been in the department for 12 hours, illustrating clearly how poor oversight and governance contributed to the delays.

A joined-up solution

The report was thorough, and what it highlighted time and time again was the critical need for Trusts to be able to function quickly and efficiently in the midst of a crisis, whether this is when they are carefully creating their COVID action plans or when reacting quickly and flexibly to unforeseen changes.

In this instance, it showed how inefficient triage due to ineffective systems is a serious area of concern, highlighting the fact that hospitals need a quick and reliable way to escalate exceptional problems to the board as soon as possible. After all, issues such as patients waiting in corridors and failures to protect patient privacy and dignity can only be properly addressed if the Trust has the ability to mitigate these occurrences urgently.

The report identified hospitals where there was no clear governance structure in place and where risks were not effectively managed in real-time. However, it is possible to keep the emergency department risk register up to date, ensure that it reflects existing and emerging risks in real-time, and improve action plans and mitigation by automating the process of assurance that what needs to get done, is getting done.

With the right digital risk management solution, these concerns can be properly managed by allowing issues such as delays in patient admission to be instantly reported to the senior management team as an escalated priority risk. After all, when the pandemic is causing changes on a near-daily basis, quarterly risk reports written on static documents or Excel spreadsheets simply aren’t agile enough. Trusts need a robust, integrated risk and action management platform that gives them the ability to rapidly deploy and easily use clear monitoring to see bottlenecks and blockages in real-time.

Furthermore, such a system needs to bring all the critical information together in a single view so that anyone in the Trust – from ward to board - can get an accurate, 360-degree picture of performance, thus enabling them to make better decisions, faster.

But while having real time oversight of the Trust’s currently identified risks is invaluable, the CQC report showed that there was also a problem with purely reactive actions that happened at speed, but which had no system to support the process. This leads to a failure to anticipate risks, which in turn had a serious impact on areas such as staffing.

That means that Trusts need a platform that can also map the impacts from one team to another, so that knock-on effects such as staffing shortages can be predicted and planned for to help staff feel more valued, engaged, supported and empowered.

COVID undoubtedly threw up more and bigger healthcare challenges than anyone could have foreseen, and the CQC report emphasises the “extremely challenging circumstances” that providers faced during the pandemic. But one thing it also makes clear is that many Trusts would have found those challenges easier if they had an effective system in place to address known risks and issues and facilitate joined-up working against their collective risk-based goals in near real-time.

Robert Hobbs

Chief Executive Officer

InPhase’s Chief Executive and Founder, Robert has been the visionary leading InPhase to be one of the UK's leading providers of management, governance and assurance solutions, and helping organisations align their actions and goals more easily and efficiently with InPhase's suite of integrated apps.