4 May 2016

Overcrowded EDs and Population Health

Unsurprisingly, yet another study has linked ED inefficiency with poorer population health outcomes. This time from George Washington University, the study found that the most crowded quartile of EDs had a much lower rate of adoption for common techniques that reduce overcrowding, such as bedside registration and surgical schedule smoothing. This finding is made more concerning by the fact that adoption of these techniques is increasing across hospitals as a whole. While the general adoption trend is positive, the hospitals most in need are also the ones improving the slowest.

Dr. Jesse Pines, a professor of emergency medicine and health policy at GWU and one of the study's authors, believes that a lack of resources is partially to blame. In an interview with the Washington Business Journal, he argued that cost can often be a barrier to adoption, saying that “the places that have been effective at reducing crowding have had to invest a lot of time and money into it.” If CMS were to penalize hospitals based on ED crowding in the future, it could potentially exacerbate the problem.

We agree with Dr. Pines, but also want to highlight the myriad options available for low-cost efficiency improvements in EDs. In most of the cases we've seen at our hundreds of partner hospitals, major investments in time and infrastructure aren't necessary to achieve significant efficiency gains. More often than not, some small tweaks to existing processes can deliver very high returns. The challenge is figuring out what those tweaks are, and how they should be systematized.

Process and Communication Errors

Most efficiency drains fall into one of two categories: process and communication. Let's start with communication. Contrary to popular belief, miscommunication is one of the leading causes of ED errors. Fortunately, it is also one of the easiest to solve. In our work – and particularly in Dr. David Mishkin's communication drill practice – we have found that simple changes in the way ED teams communicate information to one another can significantly reduce error rates and increase efficiency. Even just a few hours of communication drills can have a noticeable impact.

Process errors can be more challenging, but still require less investment than one might think. While large investments in software, systems and infrastructure are a necessary part of the complete solution, many process problems can be solved without them. Perhaps the best example of this principle is Kaizen, a continuous process improvement methodology that invites all members of a team to collaboratively design solutions to process problems.

One of the core ideas of Kaizen is that the people who regularly execute processes are also the ones with the best ideas on how to improve them. Giving these individuals a forum in which to share and develop their ideas consistently leads to more effective and lower cost solutions than top-down approaches. We have seen this play out in hundreds of our partner hospitals and are even beginning to apply the concept to less concrete processes, such as employee engagement.


Dr. Pines is right to emphasize the importance of large scale, top-down efforts to address ED inefficiencies. However, equal emphasis should be placed on the simple process and communication errors that are at the heart of many common efficiency drains in the ED. In many cases, solving these problems using Kaizen and other employee-driven methodologies is more attainable and cost-effective goal than a top-down overhaul.

If you're interested in learning more about how we have used Kaizen, communication drills and other strategies to improve ED efficiency, please check out our “The Evolving Emergency Department” white paper.