Using systems thinking to identify workforce enablers for a whole systems approach to urgent and emergency care delivery: a multiple case study

Background: Overcrowding in emergency departments is a global issue, which places pressure on the shrinking
workforce and threatens the future of high quality, safe and effective care. Healthcare reforms aimed at tackling this
crisis have focused primarily on structural changes, which alone do not deliver anticipated improvements in quality
and performance. The purpose of this study was to identify workforce enablers for achieving whole systems urgent
and emergency care delivery.

Methods: A multiple case study design framed around systems thinking was conducted in South East England across
one Trust consisting of five hospitals, one community healthcare trust and one ambulance trust. Data sources included
14 clinical settings where upstream or downstream pinch points are likely to occur including discharge planning and
rapid response teams; ten regional stakeholder events (n = 102); a qualitative survey (n=48); and a review of literature
and analysis of policy documents including care pathways and protocols.

Results: The key workforce enablers for whole systems urgent and emergency care delivery identified were: clinical
systems leadership, a single integrated career and competence framework and skilled facilitation of work based learning.
Conclusions: In this study, participants agreed that whole systems urgent and emergency care allows for the design
and implementation of care delivery models that meet complexity of population healthcare needs, reduce duplication
and waste and improve healthcare outcomes and patients’ experiences. For this to be achieved emphasis needs to be
placed on holistic changes in structures, processes and patterns of the urgent and emergency care system. Often
overlooked, patterns that drive the thinking and behavior in the workplace directly impact on staff recruitment and
retention and the overall effectiveness of the organization. These also need to be attended to for transformational
change to be achieved and sustained. Research to refine and validate a single integrated career and competence
framework and to develop standards for an integrated approach to workplace facilitation to grow the capacity of
facilitators that can use the workplace as a resource for learning is needed.

Keywords: Urgent and emergency care, Whole systems working, Leadership, Workforce development, Multiple case
study, Facilitation, Work based learning, Integrated competence framework