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Enhancing supervision out of hours and at weekends

In partnership with Health Education England, East Kent University NHS Foundation Trust  redesigned their service model to provide the highest quality training and patient care and improve training and patient safety out-of-hours and on weekends.

Related themes

  • Handover
  • Out of hours care (24/7)
  • Rotas and scheduling


The pilot addressed specific issues with regard to training and patient safety; including trainee supervision, lack of opportunity for meaningful learning encounters and assessments, trainees undertaking inappropriate tasks and an increased length of stay at weekends.

How they did it

The pilot involved a new service model in medicine and the creation of a customised, electronic rostering system to run the revised rota for all medical trainees in the hospital. The new rota involved all trainees working for ‘hot’ periods of four weeks followed by ‘cold’ periods of six weeks.

During a ‘hot’ period, trainees worked at the front door in the ‘hot’ zones including accident and emergency, emergency admissions unit and the clinical decisions unit. This experience provided trainees with ample opportunities for repetitive behaviours and procedures to embed learning.

During the ‘cold’ period, trainees worked on the medical wards where they were able to maximise their learning opportunities by attending clinics, practising and observing procedures and undertaking Simulated Learning Environments (SLEs)/assessments. This also created an enhanced cold team working at weekends.

What they achieved

  • 6% reduction in length of stay across long term conditions and urgent care, with a reduction of 0.5 days in the overall length of stay
  • 12% increase in discharges per day compared with the previous year, with Saturday discharges increasing by 20% and Sunday discharges by 5.5%. Patients are being seen more promptly, more appropriately and procedures are being carried out in a more timely manner.
  • Increase in multi-professional team working and communication which led to an improvement in the Friday handover process.
  • Nurses were able to provide much needed and valued support to trainees, they felt empowered at weekends to make a significant difference to the patient experience and were able to work effectively as part of a new enhanced weekend team.
  • 21% increase in trainees who regularly received higher levels of supervision and feedback from senior colleagues. Trainees recorded, via survey and in focus groups, feeling better supported in both ‘hot’ and ‘cold’ blocks of working.
  • More opportunities for trainee doctors and nurses to develop leadership skills
  • Increase in completion of Workplace Based Assessments (WBAs) while on the ward (4%) and on shift (27%).
  • Focus group feedback demonstrated a near unanimous trainee view, that the ‘hot’ block experience is extremely valuable and that that the concentrated, intense block of on-call activity at the front door of the hospital provided excellent opportunities to develop competence in dealing with the acutely unwell patient. They also reported that it has provided them with real experience in terms of continuity of care.

What they’ve said

“The pilot enables trainees to experience important emergency situations, without getting pulled onto the wards, and similarly, trainees can focus on their ward-based training and development without being pulled into emergency situations.” President of the Royal College of Physicians

“The component of BTBC that had the greatest impact on patient care and safety was the introduction of a weekend cold team; so much so, that it has subsequently been difficult to imagine how the service managed without it. I think the key to its effectiveness was the presence of senior clinicians (SpR’s) and nurses in the team who could make decisions about patient care and discharges… shorter lengths of stay, and better urgent care of deteriorating in-patients, thereby liberating the on-call hot team to get on and manage the acute emergency admissions. As a consultant responsible for in-patients, as well as acute emergency admissions, this additional cover gave me a lot more confidence in the safety of patients.” Consultant

“The BTBC pilot was a great training experience. As a foundation doctor it gave me a varied experience with the opportunity to gain clinical experience whilst adequately supervised both in the ward and the acute setting. It was a comfortable safe environment to work in and ensured optimal clinical care for patients.”Trainee

Please look at the toolkit materials in the documents section below. The top tips and business cases have been developed by the BTBC team to support organisations to implement these changes and the case studies and project resources have been developed and approved by the project teams.

The top tips include lessons learnt that have been identified throughout the project. The business case will guide you through the management principles and communications and engagement activities. The case studies provide a detailed overview of the project. Feel free to adapt these resources to suit your projects.

Your organisation may have its own materials and templates that you can use or you may find the NHS Improving Quality (NHS IQ) learning handbook useful too.

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