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Emergency Department Operations in Top-Performing Safety-Net Hospitals

Nationwide, hospital emergency departments (EDs) are in crisis. The demand for ED services has increased steadily while capacity has shrunk, due largely to hospital closures. Many EDs are overcrowded, causing long waits for care and high rates of ambulance diversion. ED crowding may be even more acute at safety-net hospitals because of their historic mission and legal mandate to care for vulnerable and underserved individuals.

All hospitals, including safety-net hospitals, can implement operational management and process improvements to curb ED crowding, reduce long waits, and lower diversion rates. This report profiles five safety-net hospitals that have done so. The hospitals—Boston Medical Center in Boston, Mass.; Denver Health in Denver, Colo.; Memorial Regional Hospital in Hollywood, Fla.; Memorial Hospital West in Pembroke Pines, Fla.; and Virginia Commonwealth University Health System in Richmond, Va.—were selected based on their long-standing commitment to providing quality care for poor and vulnerable patients as well as their current performance on nationally recognized measures of care. These hospitals are maintaining their critical position in the community as the gateway point to care for underserved populations, while reaching and often exceeding state and national benchmarks for quality care.

We collected information from site visits and follow-up interviews to identify strategies to:

  • raise ED efficiency; 
  •  reduce the number of hours on diversion (when an ED closes its doors to patients arriving by ambulance because of overcrowded conditions); 
  •  improve ED throughput (the actual operations of the ED); and 
  •  improve ED output (the ability to move patients from the ED to other services or types of care in the hospital or community).

Key Findings: Successful Throughput and Output Initiatives
The study hospitals used a combination of interventions to promote the smooth and timely flow of patients through the ED and other departments, known as "patient flow." They have seen improvements in a number of measures, including greater patient satisfaction, better patient care, reduced waiting times, decreased costs/increased revenues, and less time spent on ambulance diversion. We identified five strategies to improve quality and efficiency in the ED. Some do not require significant investment and therefore could be undertaken by many hospitals, including those that are challenged financially.

  1. Reconfigure the ED to maximize efficiency. The study sites have undertaken a range of physical improvements in the ED, from a simple reorganization of ED triage and treatment rooms to a whole-scale redesign and rebuild. Even small redesigns such as identically equipping ED exam rooms or color-coding ED treatment room trays can produce efficiencies.
  2. Devise a pre-diversion system to alert staff of ED crowding. Several of the study sites devised systems to signal that the ED is nearing diversion status. The alert triggers a communication strategy throughout the hospital that inpatient beds are needed for patients in the ED, in order to make room for incoming ED patients.
  3. Install an electronic tracking system. Study sites that have installed electronic tracking systems have found them to be an invaluable tool for managing patient flow. A tracking system enables a manager to easily identify rooms that are empty, those that need to be cleaned, and those that house a patient ready for discharge.
  4. Identify individual(s) responsible for tracking patients. Some sites have created a "bed czar," or bed facilitator position, to oversee patient flow throughout the hospital. This individual is empowered to communicate with the ED, medical departments, and hospital floors to smooth and expedite patient transitions between departments and through discharge.
  5. Develop meaningful metrics. The hospitals emphasized the importance of developing metrics to measure, analyze, and improve performance. This strategy is crucial to establishing baseline performance and setting improvement goals. Hospitals can begin this work with a small set of measures, limited to specific departments or conditions, and expand as they gain experience and expertise.


These concrete strategies are key to success in improving ED performance. Yet to be effective, such interventions need to take place within a broader improvement strategy that entails:

  1. Recognition that ED crowding is a hospital-wide issue.
  2. Leadership provided by the CEO and other senior staff for ED quality improvement initiatives.
  3. Culture change that results in a sense of vigilance about pursuing change, reviewing metrics and outcomes, and constantly working to improve.
  4. Transparency and a willingness to showcase successes and shortcomings in terms of performance data.
  5. Commitment to quality for safety-net populations, with the recognition that safety-net hospitals are capable of aggressively pursuing improvement strategies.

Several lessons emerged that can guide other safety-net hospitals as they develop strategies to improve the quality and efficiency of care provided in their EDs:

  1. Safety-net hospitals can use performance metrics to improve quality and efficiency in the ED. Each of the hospitals can point to successful strategies they have implemented to improve an aspect of patient flow in the emergency department, with several identifying savings associated with these initiatives.
  2. Safety-net hospitals do not use common metrics to track performance in the ED. Hospital EDs generally lack a common set of metrics that could be used to benchmark their performance against other hospitals in their markets or in similar markets across the country.
  3. Current sources of publicly reported data should not be used as a proxy for measuring ED quality. We used two performance measures publicly reported on the Centers for Medicare and Medicaid Services Web site, Hospital Compare, as a proxy for quality in the ED: for heart attack patients, time from arrival to percutaneous coronary intervention (PCI) and, for pneumonia patients, time from arrival to initial antibiotics. However, we found that performance on these measures may not be a good proxy for ED quality because these measures reflect activities that often take place in conjunction with other departments (e.g., cardiac catheterization lab) and do not reflect the wide range of activities that occur solely in the ED. Without standard measures or composite measures of efficiency that include ED care, it is not possible to identify high-performing EDs, either within or outside of the safety net.
  4. Quality improvement efforts may not be as successful as regional policies in limiting ambulance diversion. County-wide or regional policies that prevent EDs from diverting ambulances force hospitals to focus on reducing wait times once patients arrive at their doors.
  5. Quality improvement in the ED requires the participation of the ED team as well as other hospital staff. Non-ED staff must help improve patient flow. To encourage them to do so, hospital leaders can underscore how the ED’s mission relies on collaboration with other hospital departments.
  6. Quality improvement in the ED requires investment. All of the hospitals profiled in this report have invested in the process of ED improvement with direct and in-kind resources. Quality improvement requires some investment of resources, is a long-term commitment, and entails the involvement of staff from across the organization.

Publication Details



L. Nolan, M. Regenstein et al., Emergency Department Operations in Top-Performing Safety-Net Hospitals, The Commonwealth Fund, July 2009.