Executive summary

What is the FCA programme and its rationale?

Over the past 10 years the Health Foundation has supported the testing, development and evaluation of approaches to improving patient flow along care pathways. The most ambitious application of the approach is the FCA programme led by the Sheffield Teaching Hospitals NHS Foundation Trust, which aims to build a network of local FCAs across the UK that share a common purpose, language and method for improvement. The programme trains health and care staff in the team coaching, technical and relationship skills required to deliver continuous and sustainable improvement. It has a core programme team, the Central FCA, which is responsible for developing the content and approach for the FCA programme and overseeing the formation of local FCAs. The rationale for the programme is that patients typically experience care in condition-based pathways, and how they move along these pathways has considerable implications for patient experience, care outcomes and pressure on staff.

What are the key components of the FCA programme?

The FCA programme is based on a co-coaching model combined with elements of improvement science. Cohorts of 30 paired flow coaches are trained on a 1-year course. Coaching pairs comprise a clinical coach, who works in the pathway, and a flow coach whose day-to-day job role in the organisation is external to the pathway. The course curriculum has been successfully transferred for delivery by local FCAs and continues to be improved through iterative co-design with the FCA faculty. The paired coaches put their skills into practice while training, by jointly leading weekly Big Room meetings that bring together staff along the care pathway, enabling them to focus on the patient experience and assess, diagnose and iteratively test changes to improve patient flow. The views and experience of patients are central to the FCA model, with coaches using a range of skills and techniques to support meaningful input from patients in the improvement work. The Big Room meetings seek to make sure that each person in the room has a voice and is an equal partner in the improvement process, regardless of status or experience. This approach to flattening hierarchy, and the focus on jointly developing change ideas rather than imposing a predetermined solution, is unusual in health care improvement.

Who is involved in the FCA programme?

The aim of the FCA programme is to support the establishment of multiple FCAs across the UK, to scale up the approach and to build a networked community of practice to share learning. The local FCAs train further flow coaches in their organisation and surrounding area, and coordinate and support the work of local flow coaching pathway teams. In its first 5 years, the programme has scaled up to create a UK network of 10 local FCAs running flow improvements for a range of care pathways, with another three ready to start. Nearly 400 coaches, from over 30 NHS trusts and health boards, covering hospital, community and mental health services are trained and over 150 Big Rooms have been set up for over 85 care pathways, with several FCAs working on the same pathways, such as frailty, sepsis, cancer and diabetes.

What does the flow coaching training involve?

Flow coaches report consistently high levels of satisfaction with their training and almost unanimously feel well prepared to be a flow coach. The course includes:

  • technical quality improvement (QI) methods
  • measurement through statistical process control (SPC) charts
  • coaching skills, such as active listening
  • giving and receiving feedback
  • facilitation methods
  • time management.

An outstanding feature of the FCA programme has been the ability of the flow coaches to put the learning into practice by setting up Big Rooms to support continuous improvement across a range of care pathways, and sustaining this beyond the course.

Where has the flow coaching approach been applied?

A great strength of the FCA programme is the applicability of the approach across multiple clinical settings and sectors.

Flow pathway teams have reported reductions in waiting times from referral to appointment, less waiting time in clinics, reduced delays in discharge and a reduction in unnecessary procedures through the introduction of multi-professional assessments. They have also delivered better communication along the pathway and improved team culture. In addition, the emphasis on putting the patient at the centre makes sure that improvement is focused on issues that are important to patients, with greater understanding of the patients’ experience of the service. The programme effectively achieves QI where disruption of patient flow is responsible for poor patient experience, poor outcomes or inefficient use of resources.

The programme has also demonstrated its value in enabling services to adapt in response to COVID-19, which has required the development of new care pathways and improvements in the efficiency of existing pathways to tackle the waiting lists that have grown due to re-deployment of resources for COVID-19 care. Although flow pathway teams have helped to keep pathways running during COVID-19, many flow coaches have used their skills effectively to support wider organisational efforts to restart and redesign services after the first wave.

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