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Using systematic change management to improve emergency patients' access to specialist care: the Big Squeeze
  1. Heidi Rafman1,
  2. Siang Ngin Lim1,
  3. Swee Chye Quek2,
  4. Malcolm Mahadevan3,
  5. Chanelle Lim1,
  6. Aymeric Lim4
  1. 1NUHS Way Department, National University Hospital (NUH), National University Health System (NUHS), Singapore
  2. 2Department of Paediatrics, National University Hospital (NUH), National University Health System (NUHS), Singapore
  3. 3Department of Emergency Medicine, National University Hospital (NUH), National University Health System (NUHS), Singapore
  4. 4Department of Orthopaedic Surgery, Yong Loo Lin School of Medicine, National University Hospital (NUH), National University Health System (NUHS), Singapore
  1. Correspondence to Heidi Rafman, Deputy Director, National University Hospital, 1E Kent Ridge Road, NUHS Tower Block Level 6, National University Health System, Singapore 119228, Singapore; heidi_rafman{at}


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.

  • Quality improvement
  • access to care
  • organisational change management
  • emergency delays
  • timely discharges
  • emergency department
  • management
  • quality assurance
  • emergency care systems
  • admission avoidance

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