title: Using systems thinking to identify workforce enablers for a whole systems approach to urgent and emergency care delivery: a multiple case study.
abstract: 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.
  
  
  
  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.
  
  
  
  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.
  
  
  
  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.
authors: England Centre for Practice Development, Faculty of Health and Wellbeing, Canterbury Christ Church University, North Holmes Road CT1 1QU, Canterbury, UK.
authors: Kim
authors: K
authors: Manley
authors: England Centre for Practice Development, Faculty of Health and Wellbeing, Canterbury Christ Church University, North Holmes Road CT1 1QU, Canterbury, UK. anne.martin@canterbury.ac.uk.
authors: Anne
authors: A
authors: Martin
authors: England Centre for Practice Development, Faculty of Health and Wellbeing, Canterbury Christ Church University, North Holmes Road CT1 1QU, Canterbury, UK.
authors: Carolyn
authors: C
authors: Jackson
authors: England Centre for Practice Development, Faculty of Health and Wellbeing, Canterbury Christ Church University, North Holmes Road CT1 1QU, Canterbury, UK.
authors: Toni
authors: T
authors: Wright
mesh_terms: D003625:Data Collection; D004632:Emergency Medical Services / Q000458:organization & administration*; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D004739:England / Q000453:epidemiology; D006301:Health Services Needs and Demand; D006801:Humans; D007857:Leadership; D058996:Quality Improvement; D013597:Systems Analysis
keywords: Facilitation; Integrated competence framework; Leadership; Multiple case study; Urgent and emergency care; Whole systems working; Work based learning; Workforce development