Background In 2018 a Wales-wide improvement project was launched to design an emergency department quality and delivery framework (EDQDF). The project aimed to combine top-down and bottom-up working to describe and implement what good looks like for emergency departments. The collaborative design of the EDQDF took place between 2018 and 2020; the project’s currently in its implementation phase. This evaluation asks about the barriers and enablers pertaining to implementation of the EDQDF, which was designed using the CAREMORE methodology, found to be a promising tool for collaborative improvement projects for health services (Nelson et al 2018).

Methods We interviewed 8 participants involved with the EDQDF (nurses n3; consultant paramedic n1; policy-maker n1; project managers n2; senior level manager n1). We thematized the data according to preconceived concepts and to identify emerging themes.

Results Strong emergent themes include: challenges of combining top-down/bottom-up working; interdependencies on other parts of the system as a barrier to implementation; staff pressures; the positive perception of a developing network for ED-staff.

Covid-19 significantly shifted the focus of the project to reconsider ‘access’ for patients, especially remote access to advice, ED appointments, or teletriage and streaming to alternative services. Some participants perceived this positively, others negatively.

When considering ‘patient access’, participants often referred to technological advancement as an answer to problems such as overcrowding, and regularly invoked the language of consumerism. Participants demonstrated a conflict between a desire for the slick operational models used by fast-food chains (participants often mentioned chains like Starbucks and domino’s pizza, for instance), and a recognition of the differences between the delivery of care and a consumer product.

Conclusion The primary barrier to implementation is considered to be the interdependent nature of the health system; ED pressures were perceived as symptomatic of failures elsewhere in the health and social care system.