Using systematic change management to improve emergency patients' access to specialist care: the Big Squeeze.

Background: Delayed access to specialist care for emergency patients is associated with increased risk of morbidity and mortality, and increased patient anxiety.

Objectives: (1) To provide timelier access to inpatient and urgent outpatient specialist care for emergency patients. (2) To influence multiple stakeholders to modify their traditional practices and sustain changes.

Setting: National University Hospital of Singapore, an academic medical centre with 997 beds in Singapore and over 34 sub-specialties.

Methods: A set of six interventions was implemented to meet three goals: (1) provide timely access to urgent outpatient specialist care requested by the emergency department ED; (2) increase early inpatient discharges (in order to better match timing of emergency admissions); and (3) provide earlier defined care by inpatient specialists at the ED. An eight-step organisational change management plan was implemented to ensure all specialties complied with the changes.

Results: The goals were achieved. (1) Specialist outpatient appointments given within the timeframe requested by the ED doctor increased from 51.7% to 80.8%. (2) Early discharges increased from 11.9% to 26.6% and were sustained at 27.2%. (3) 84% of eligible patients received earlier defined specialist care at the ED. The change management achieved excellent clinician compliance rates ranging from 84% to 100%. However the median wait for admission remained unchanged.

Conclusion: The interventions reduced the time for ED patients to access specialist outpatient and inpatient care. The systematic organisational change management approach resulted in sustained compliance.