Mastering RCEM SLO 12: Manage, Administer, Lead.
Executive Summary
Achieving Specialty Learning Outcome (SLO) 12 requires a transition from clinical competency to system leadership. This document synthesizes the RCEM CARES strategic framework (addressing system pressures) with the EMLEADER development programme (building personal capability).
Critical Takeaways:
Strategic Alignment: Operational decisions must align with the RCEM CARES pillars (Crowding, Access, Retention, Experience, Safety) to advocate effectively for resources and safety.
The EMLEADER Mindset: Leadership is not a title but a practice. You must demonstrate proficiency across the programme's core domains: Leading Self, Leading Teams, and Leading Systems.
Governance as Safety: Moving from "admin" to "assurance"—using incidents and complaints to drive the Quality Improvement (QI) agenda.
Compassionate Leadership: Retention is a critical safety issue. Leadership must focus on staff wellbeing to maintain a functioning workforce.
1. Operational Management: The "Shop Floor" Leader
Aligned with EMLEADER Domain: Leading Systems
The Emergency Physician in Charge (EPIC) does not just manage patients; they manage risk across the entire system.
1.1 Managing Flow with RCEM CARES
Use the CARES framework to structure your operational awareness and escalation:
Crowding: Recognize crowding not just as "busy" but as a clinically toxic environment.
Action: Trigger "Full Capacity Protocols" early. Do not absorb risk solely within the ED; redistribute it to the hospital (reverse-triage/boarding).
Access: Monitor "Exit Block."
Action: Quantify the harm. When escalating to site managers, use specific language: "We have X patients waiting >12 hours; this increases mortality risk by Y% (3)."
Safety: The primary goal of flow management is to minimize the harm of delay.
1.2 The Huddle (The "Team Pitstop")
Effective huddles are the practical application of Leading Teams.
Structure:
Review: Current capacity, sickest patients, staffing gaps (HALT factors).
Forecast: Expected ambulance arrivals vs. bed state.
Plan: Specific tasks delegated to specific people.
Tone: The leader processes anxiety and reflects calm. This regulates the team's emotional state.
2. Leadership and Culture
Aligned with EMLEADER Domains: Leading Self & Leading People
RCEM identifies Retention as a key pillar. Leadership style directly impacts whether staff stay or leave.
2.1 Compassionate Leadership
This is the antidote to burnout. It involves four behaviors:
Attending: Paying attention to staff (listening with fascination).
Understanding: Finding a shared understanding of the difficulty they face.
Empathizing: Feeling their distress without being overwhelmed by it.
Helping: Taking intelligent action to help (even if the action is small, like ensuring they get a break).
2.2 Leading "Self"
You cannot lead others if you are unregulated.
Self-Awareness: Recognize your own "stress signature" (e.g., becoming withdrawn, raising voice).
Role Modeling: If the Consultant panics, the Registrar freezes, and the Nurse rushes. If the Consultant pauses, the team thinks.
2.3 Conflict Resolution: The "Clean Language" Approach
When conflict arises (e.g., specialty refusal), avoid accusation.
Instead of: "You are refusing this referral."
Try: "My main concern is patient safety because [X]. Help me understand your perspective so we can find a safe plan."
3. Administration and Governance
Aligned with EMLEADER Domains: Leading Service & Leading Quality
3.1 Experience (Patient & Staff)
RCEM CARES emphasizes Experience. Governance is the mechanism to improve this.
Complaints: View complaints as "unsolicited user feedback." When drafting responses:
Acknowledge the distress (empathy).
Explain the clinical context (facts).
Detail the improvements made (restoration).
Incidents (Datix): Encourage reporting as a tool for visibility, not blame. "If it isn't on a Datix, it didn't happen" in the eyes of management.
3.2 Quality Improvement (QI)
Move beyond audit (checking standards) to Improvement (changing systems).
Model: Use the PDSA (Plan, Do, Study, Act) cycle.
Integration: Link QI projects to CARES objectives. For example, a project to "Streamline Triage" directly supports the Safety and Access pillars.
4. Practical Learning Aids
Mnemonic: The "CARES" Bedside Check
When managing a department under pressure, ask:
Crowding: Are we unsafe? Do I need to escalate?
Access: Is flow blocked? Who needs to know?
Retention: Are my staff hungry, late, or stressed? (Check breaks).
Experience: Are patients informed of delays? (Manage expectations).
Safety: Is the waiting room visually triaged?
The EMLEADER Matrix for Reflection
Use this to evidence your SLO 12 ePortfolio entries:
References
Royal College of Emergency Medicine. RCEM CARES: The next phase. London: RCEM; 2021.
Royal College of Emergency Medicine. EMLEADER Framework. London: RCEM; 2022.
Jones S, et al. Association between delays to patient admission from the emergency department and all-cause 30-day mortality. Emerg Med J. 2022.
West M, Bailey S. Leadership and Leadership Development in Health Care: The Evidence Base. London: The King's Fund; 2015.
Here is the RCEM CARES Shift Leader Checklist, designed to be printed, laminated, and attached to your ID badge or lanyard.
This tool condenses the complex requirements of SLO 12 and the strategic focus of RCEM CARES into actionable prompts for the "Shop Floor" leader.
✂️ Front Side: OPERATIONS & FLOW (The "Hard" Skills)
Focus: Managing Crowding, Access, and Safety
| RCEM CARES: SHIFT LEADER PROTOCOL |
| 1. START OF SHIFT (The Setup) |
| $\square$ Sitrep: Total number in dept? / Resus capacity? / Wait to be seen? |
| $\square$ Staffing: Review skill mix (Junior/Senior balance). Identify gaps. |
| $\square$ Safety: Who are the sickest 3 patients? Is there a plan? |
| $\square$ Huddle: Introduce yourself. Set the tone (Calm). Assign breaks now. |
| 2. HOURLY SCAN (Crowding & Access) |
| $\square$ Input vs. Output: Are ambulances offloading? Is "Exit Block" occurring? |
| $\square$ Trigger: If >X patients waiting or offload delay >15m $\rightarrow$ ESCALATE. |
| $\square$ Reverse Triage: Move stable patients out of Resus/Majors to create capacity. |
| $\square$ Waiting Room: Visual check. Is it safe? Does it need a senior review? |
| 3. ESCALATION (The "Ask") |
| $\square$ Site Manager: "We are unsafe." State the risk, not just the number. |
| $\square$ Specialties: "This is a flow and safety critical issue. I need your review." |
✂️ Back Side: PEOPLE & CULTURE (The "Soft" Skills)
Focus: Retention, Experience, and Leading Teams
| EMLEADER: TEAM & WELLBEING |
| 1. RETENTION (Staff Care) |
| $\square$ HALT Check: Is the team Hungry, Angry, Late, or Tired? |
| $\square$ Hydration: Have I had a drink? Has the triage nurse? |
| $\square$ Civility: Correct rudeness immediately but privately. |
| 2. EXPERIENCE (Conflict & Comms) |
| $\square$ Conflict (DESC): Describe behavior $\rightarrow$ Express concern $\rightarrow$ Specify change $\rightarrow$ Consequences (Safety). |
| $\square$ Relatives: Update them early. "We are crowded, but we are safe." |
| $\square$ Debrief: After any arrest or traumatic event. Even 3 minutes helps. |
| 3. END OF SHIFT (The Handover) |
| $\square$ The "Clean" Handover: SBAR format. Don't dump problems, handover plans. |
| $\square$ Thank You: Specific praise for 1-2 team members before leaving. |
| $\square$ Datix: Did a system fail? Log it. (No Datix = It didn't happen). |
Implementation Tip
To make this effective:
Copy the tables above.
Resize them to fit a standard ID card size (approx 8.5cm x 5.5cm).
Print back-to-back on cardstock.
Laminate and punch a hole for your lanyard.
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Effective escalation shifts the conversation from subjective emotional appeal ("We are busy and stressed") to objective, evidence-based communication of patient risk.
Here are specific, incisive escalation phrases, categorized by the target audience, to reinforce the Access pillar of the RCEM CARES guidance.
🗣️ Escalation Phrases: Securing Access and Flow
1. Escalating to Site/Hospital Management (Corporate Risk)
This language emphasizes the failure of the whole system to mitigate harm and draws upon professional and institutional responsibility.
| Focus | Objective Phrase | Why it Works |
| Crowding/Safety | "We have [X] patients waiting greater than 12 hours. This is a known determinant of increased 30-day mortality and is now a corporate safety risk." | Cites evidence (SLO 12 requires evidence base) and moves the risk to a higher level. |
| Bed Capacity | "The ED cannot safely absorb any more risk. We require [X] immediate beds to safely meet incoming demand and fulfill our Duty of Candour requirement." | Links operational failure directly to GMC/statutory compliance. |
| System Failure | "We are now in full capacity protocol. Please confirm what specific actions will be taken outside of the ED in the next 30 minutes to mitigate the rising risk." | Requires a commitment and pushes the solution ownership away from the ED leader. |
| Immediate Action | "I need an ETA for the next two discharges. If we cannot discharge, we need to activate a pre-planned surge capacity area now." | Demands a specific timeframe and triggers pre-agreed action plans. |
2. Escalating to Specialty Teams (Shared Responsibility)
This frames the issue as a clinical delay specific to the patient's condition, making it difficult for the receiving team to deflect.
| Focus | Objective Phrase | Why it Works |
| Delay Harm | "The patient is medically fit for your ward, but their clinical risk is specifically related to delay in your assessment/treatment. What is the exact time we can expect you to attend?" | Centers the conversation on the patient and demands a commitment to time. |
| Prioritisation | "I have presented the facts. If you feel this patient is safe to wait here for 4 hours, I require you to come and personally document the decision and assume clinical responsibility for the wait." | Forces the consultant/registrar to co-own the clinical decision-making risk. |
| Review Standard | "Our current standard for specialty review in this condition is 60 minutes. We are now at 120 minutes. We require a verbal plan in 15 minutes to prevent a further safety incident." | Uses governance standards (audit/guidelines) as leverage. |
3. Escalating to Internal Flow/Nursing Leads (Task Clarity)
Use the SBAR framework (Situation, Background, Assessment, Recommendation) for clear, fast, and directed internal communication.
| SBAR Component | Objective Phrase | Why it Works |
| S/A (Situation/Assessment) | "We have lost our last clean bed in Majors, and we have a crashing patient arriving in 5 minutes. The department is unstable." | Declares a state of operational instability requiring immediate action. |
| R (Recommendation) | "I need you to secure the discharge for Mrs. Smith (Bed 5) and move the last stable patient in Resus to the Observation Area, within the next 10 minutes." | Provides clear, time-bound tasks to the internal flow lead. |
| Prioritising Care | "I am pulling the triage nurse to assist in Resus for 15 minutes. Can you ensure the next two ambulance patients go to the same holding bay to maintain visual oversight?" | Demonstrates decisive risk management and resource allocation. |
Key Strategic Takeaway
The goal is to demonstrate clinical leadership by making the hospital system accountable for managing the risk that its lack of access creates. This is the essence of excelling in SLO 12 at the Consultant level.
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MEM-EM PODCAST
2.12 SLO 12 Manage, Administer, Lead
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