Trust develops a single clerking system where a junior doctor fully clerks a patient and presents to a senior for review, reducing waiting time and improving patient experience

* Please describe the challenges or problems your solution set out to solve.

The re-clerking of patients by a specialty junior after A+E have already clerked them, causes unnecessary delays for our patients to receive a specialty senior review (ST3+). National guidance shows the association between longer waits for this and problems of impaired flow, longer length of stay, and increased mortality for patients.

We developed single clerking, where the first junior doctor (A+E or specialty) seeing the patient does a full, high-quality clerking, first time. This expands the clerking team available, and optimises safety and efficiency, providing patients with a quicker initial full clerking (including full drug-chart) and senior review.

Youtube: https://www.youtube.com/watch?v=N54HvyRynig&t=86s&list=PLuVl_N14jxdjKSXiUTupGGk5sC8aoZj8&index=3

* Please describe the actions you took to achieve your result.

 Single clerking has been the greatest success within our acute service for reducing our patient waiting times for an initial full clerking (including drug chart), a specialty senior review (ST3+), and a decision to admit (DTA). Single clerking removes the traditional middle step of re-clerking the patient by a specialty junior. Our patients are now fully clerked in 1/3 of the time they used to be with the traditional model, and see a senior decision maker within 1/2 the time – benefiting their care and key clinical and organisational outcomes. 

Over many months, all specialties, Divisional Leads, Education Leads, and Executives have collaborated alongside our human factors, medico-legal, safety, quality and coding teams to embed this service redesign, make it usual practice and ensure the best possible delivery and documentation of care. 

There is an open invitation for staff to contribute their feedback for continual improvement and advice has been incorporated from recent interviews with 200 staff and patients. Patients valued seeing a senior specialty doctor quicker and not repeating their story multiple times. 

Single clerking, with its process of A+E or specialty juniors seeing patients as they arrive to A&E (either direct or via GP) and only doing one clerking, helps expand the pool of doctors on duty who can crosscover. e.g. when the surgical SHO is in theatre – A+E can fully clerk the surgical patient. As all our doctors fully clerk to the same high standard, we work as a consistent, unified acute service. 

Single clerking also provides exceptional education opportunities. A+E juniors can maintain and develop skills fully clerking specialty patients, present directly to a specialty senior, and receive real-time feedback and portfolio assessments. Specialty juniors can be first to see patients rather than A+E and develop experience in initial resuscitation. Senior A&E doctor time is freed up from having to clerk as many patients which allows them greater oversight of the department. Senior specialty time is also reserved for reviewing rather than clerking – again aiding quality of care. 

One form for documentation makes it easier for nurses to see where key information is, helps us hit CQUIN targets and facilitates audit. One place only to prescribe has improved medicines safety. 

The key thing is all the improvements have been cost free - by better utilising existing staff - which improves overall productivity, patient satisfaction, flow and staff job satisfaction. 

* Please list the most significant results 

Compared with traditional clerking, single clerking has: 

* Reduced time from registration to initial full clerking to 83 minutes from 217 minutes.

* Reduced time for initial specialty ST3+ review from time of registration to 264 minutes from 621 minutes.

* Enabled our average wait for a doctor in the last 3 months to be <50 minutes despite winter pressures.

* Reduced medication errors.

* Improved quality of care – e.g. >85% of patients with sepsis are getting antibiotics within 1hour of arrival

thanks to proforma prompt.

* Improved quality of education; high junior doctor feedback scores within the last year’s GMC survey. 

* Describe how your project has spread to other teams, departments or organisations 

We are delighted that medical directors and acute teams nationwide have contacted us for advice and resources to help establish our single clerking and acute service model at their hospitals. One group have arranged a site visit with us in February and we hope to show many more Trusts how to implement single clerking. 

We constantly evaluate single clerking and ensure it incorporates latest national standards. We hope our proforma file can be shared and adapted for other organisations. 

Our content is shared via NHS Improvement and we have a video supporting dissemination within our hospitals and nationally.