Hospital at night: an organizational design that provides safer care at night.

The reduction in the working hours of doctors represents a challenge to the delivery of medical care to acutely sick patients 24 hours a day. Increasing the number of doctors to support multiple specialty rosters is not the solution for economic or organizational reasons. This paper outlines an alternative, economically viable multidisciplinary solution that has been shown to improve patient outcomes and provides organizational consistency. The change requires strong clinical leadership, with organizational commitment to both cultural and structural change. Careful attention to ensuring the teams possess the appropriate competencies, implementing a reliable process to identify the sickest patients and escalate their care, and structuring rotas efficiently are essential features of success.

Creating teams for acute clinical services.

This article discusses how a project group at Guy's and St Thomas' NHS Foundation Trust, London, developed four multiprofessional teams that can provide first responses for acutely ill inpatients on both of the trust's hospital sites, 24 hours a day, seven days a week.

QUALITY IMPROVEMENT: Supporting a hospital in difficulty: -experience of a '-buddying' agreement to implement a new medical pathway.

Increased NHS regulation has identified many healthcare organisations with operational and/or financial difficulties. Although the causes are often complex, most cases are effectively managed internally with limited input from external agencies. How best to support the few organisations needing additional support has not been established. 'Buddying', in which senior clinical and managerial teams from a well performing organisation work with colleagues from an organisation in difficulty has been proposed as a potential solution. Previous reports suggest that these partnerships are generally valued by the organisation in difficulty but there is a paucity of measured operational benefit. In this article we present our experience of a 'buddying agreement' and its impact on the introduction of a new 'whole system' medical pathway (ie rotas, staffing, process) at an organisation in difficulty. We describe the process, problems, effect on operational performance, staff survey feedback six months post-implementation and the lessons learned. Factors critical to success were good communication; clear responsibilities, common values and strong governance; incorporation into an effective local improvement programme; targeting of specific issues; ability to influence people and foster relationships; adequate 'manpower' and gradual transition to local 'ownership'.