TRAINEE FOCUS Teaching and learning in an era of time-based access targets: Impact of a new model of care on junior medical officers April L WRIGHT, 1 Jonathan STAGGS, 1,2 Stuart MIDDLETON, 3 John BURKE, 4,5 Alex MARKWELL, 4,5 Victoria BRAZIL, 6,7 Rob MITCHELL 4,5 and Anthony F BROWN 4,5 1 UQ Business School, University of Queensland, Brisbane, Queensland, Australia, 2 Queensland Emergency Medicine Research Foundation, Brisbane, Queensland, Australia, 3 UnitingCare Queensland, Brisbane, Queensland, Australia, 4 Department of Emergency Medicine, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia, 5 School of Medicine, University of Queensland, Brisbane, Queensland, Australia, 6 Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia, and 7 Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia In order to address the challenges as- sociated with ED overcrowding and access block, governments in the UK then Australasia have implemented time-based access targets for emergen- cy presentations. 1–4 In 2011, the Council of Australian Governments (COAG) adopted a National Emer- gency Access Target (NEAT) for public hospitals, with the intention that, by 2015, 90% of ED patients would be admitted to a ward or discharged within 4 h of arrival. 4 The target has driven many Australian EDs to intro- duce models of care that facilitate early disposition decision-making. 5–7 Although data are emerging about the impact of NEAT on quality and timeliness of care, 5–11 little is known about its effects on the education and training of junior medical officers (JMOs). Trainees have voiced con- cerns about potential negative impli- cations, 11,12 but it is unclear if these have been realised. This article draws on qualitative data from a broader study to illustrate teaching and learn- ing practices before and after the intro- duction of a new model of care at a large metropolitan ED. Setting The Royal Brisbane and Women’s Hospital (RBWH) is a tertiary refer- ral centre with an annual ED census of 75 000. In 2013, RBWH ED im- plemented the Two-Hour Evaluation and Referral Model for Shorter Turn- around Times (Thermostat), a stand- ardised workflow model utilising ‘hot’ assessment zones and ‘cold’ step- down areas to provide accelerated team-based care. Patients undergo early consultant or registrar review in an attempt to finalise disposition within 120 min of arrival, after which they are transferred to a cold zone within the ED to await review by an inpatient unit. Although senior ED staff assume responsibility for decision-making and referrals, JMOs remain heavily in- volved in all aspects of patient care, including assessment, investigation re- quests, management and documenta- tion. The introduction of Thermostat was accompanied by a comprehen- sive change management process, in- cluding a pilot programme, training sessions and printed orientation materials. This article explores the impact of Thermostat on teaching and learn- ing. Discussion is grounded on data collected as part of a longitudinal qualitative study funded under an Aus- tralian Research Council Linkage Project grant (LP0989662). Data ob- tained before the introduction of Ther- mostat include over 600 h observation of clinical shifts and training sessions by independent researchers and 57 formal interviews with ED consult- ants, registrars, nurses and hospital executives. Data collected post- Thermostat include 160 h of observa- tion of clinical shifts and 25 interviews with consultants. Research method- ology followed a standard approach used in qualitative, field-based man- agement studies. 13 Pre-Thermostat As with many EDs, the ‘traditional’ model of care at RBWH relied on JMOs undertaking initial assessment and management of the undifferenti- ated patient and learning through ex- perience and subsequent discussion with a consultant or registrar. One con- sultant summarised the process to a Correspondence: Associate Professor April L Wright, UQ Business School, University of Queensland, 39 Blair Drive, St Lucia, QLD 4067, Australia. Email: a.wright@ business.uq.edu.au April L Wright, BBus, MBus, PhD, Associate Professor; Jonathan Staggs, BA (Hons), MBA, PhD, Postdoctoral Research Fellow, Research Manager; Stuart Middleton, BCom (Hons), BEcon, PhD, Strategic Project Officer; John Burke, MBBS, FACEM, Acting Di- rector, Senior Lecturer; Alex Markwell, BSc, MBBS (Hons), FACEM, Staff Specialist, Co-Director of Emergency Medicine Training, Senior Lecturer; Victoria Brazil, MBBS, MBA, FACEM, Senior Staff Specialist, Associate Professor; Rob Mitchell, MBBS (Hons), BMedSc (Hons), MPH&TM, Registrar, Associate Lecturer; Anthony F Brown, MBChB, FRCP, FRCEM, FACEM, Senior Staff Specialist, Professor. Accepted 25 May 2015 Emergency Medicine Australasia (2015) 27, 355–358 doi: 10.1111/1742-6723.12438 © 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine