Rapid improvement guide to the FOCUSED model
The FOCUSED model provides the overarching principles for streamlining site management processes to:
- better co-ordinate the maintenance of oversight
- reduce variation in processes
- ensure that all staff are aware of their role in maintaining safety and flow
- avoid escalation as well as maintain oversight during escalation.
Who is the model for?
The FOCUSED model specifically supports senior clinical and operational managers with co-ordination roles in an acute site, although the principles of co-ordinated site management apply to all inpatient healthcare settings.
These include, but are not limited to:
- chief operating officer (COO) and deputy COO
- site management teams
- emergency department (ED) consultant in charge
- ED nurse in charge
- ED patient flow co-ordinator
- clinical site/flow managers
- senior operational managers
- ward managers and matrons
- specialty clinical leaders.
Key principles
- Front door. Oversight of:
- performance
- demand and capacity in the ED, same day emergency care (SDEC) and assessment units
- escalation triggers
- performance against internal professional standards (IPS)
- patient plans in place
- 12-hour breaches
- senior clinical co-ordination
- ambulance arrivals/offloads.
- Operational oversight of the whole hospital. Oversight of:
- outliers
- staffing issues
- critical care capacity
- tertiary referrals/repats
- infection control and COVID-19 requirements
- diagnostics capacity
- unresolved patient delays
- actual versus potential discharges
- board/ward rounds
- continuity challenges.
- Challenge. Consider:
- demand and capacity for assessment
- alternative pathways (hot clinics, day case, SDEC, virtual wards)
- appropriate use of short stay
- bed requests
- IPS.
- Understand actions and agree accountability. Ensure:
- specific, time-bound and allocated actions from site meetings
- demand against predicted is understood
- actions are logged, circulated and followed up
- agreed operational pressures escalation levels (OPELs)
- review of service continuity challenges.
- Site plan and reporting. Be proactive;
- actions have owners
- OPELs have defined triggers
- maintain oversight of system escalation/response
- use SBAR (situation, background, assessment, recommendation).
- Escalation:
- maintain normal service
- enact system-wide OPEL escalation policy
- maintain board oversight
- identify roles and responsibilities
- link triggers to action cards
- understand interdependencies
- analyse escalation trends and actions
- responsive communication
- timely de-escalation.
- Discharge. Daily oversight:
- prioritise failed discharges
- identify today’s and tomorrow’s discharges
- visibility of discharge lounge
- monitor actual versus potential
- demand and capacity of discharge pathways
- monitor pathway 0 and 1
- monitor discharges before 12:00 and 17:00
- proactively manage repatriations
- patients have an expected date of discharge (EDD)
- timely board/ward rounds
- discharge off electronic systems at the point of discharge.
Works well with
- The SAFER patient flow bundle: this promotes a commitment to maintaining flow by reducing waste and preventing harm, complementing the principles of the FOCUSED model.
- The FOCUSED self-assessment tool: a practical resource that enables a site to self-assess against the principles of good site management and determine priority areas for focus.