Emptying the Corridors of Shame: Organizational Lessons From England's 4-Hour Emergency Throughput Target

Study objective

Since 2005, 98% of patients treated in England's emergency departments (EDs) must be discharged or placed in a hospital bed within 4 hours of arrival. Using a qualitative approach, we describe lessons learned from implementing the 4-hour emergency throughput target.

Methods

This was a qualitative study of EDs in England, purposively sampled for a range of size and performance on the target. Leadership of EDs at 9 Acute Trusts (hospitals) were interviewed between June and August 2008. Using content analysis, we analyzed semistructured interviews to identify salient themes.

Results

Twenty-seven interviews were coded. Respondents agreed on the following themes. (1) Interdependency: Even with extensive ED process re-engineering, widespread Trust involvement was essential to meeting the target. Additionally, lack of recognition that it was a “Trust target” contributed to conflicts between staff, concerns for patient safety, and lost opportunity for organizational improvement. (2) Contrasting change management strategies: ED leadership used collaborative strategies, whereas change in the rest of the hospital required a top-down approach. (3) Burden and benefit for staff: Nursing perceived the greatest burden from the target but also acquired enhanced authority, skills, and roles. (4) Costs: Although most EDs are now within range of the target, consistent performance while balancing patient safety remains tenuous.

Conclusion

Achieving the 4-hour target requires hospital-wide support. Lack of organizational ownership contributes to negative effects on staff, incomplete process improvement, and risk to patients. These lessons have widespread implications for all targets and may help explain why some health care targets fail to achieve their aims.

Introduction

In 2005, to address severe emergency department (ED) crowding, England's National Health Service (NHS) mandated that 98% of ED patients be treated and either discharged home or admitted to a ward within 4 hours of arrival.1, 2 Although often attributed to government embarrassment from cases such as that of 94-year-old Rose Addis, who remained in an ED for 3 days in 2002, this target was part of a series of reforms the Labour Government announced when it took office in 1999.1, 3 The target has since become a key performance standard for Acute NHS Hospital Trusts.^⁎ Department of Health figures show considerable improvement, from 77.3% of patients spending less than 4 hours in EDs in 2002 to 2003 to 97.2% of patients spending less than 4 hours there in 2008 to 2009.⁴

Before the target's implementation, the NHS established the Emergency Services Collaborative, which urged Acute Trusts to adopt a systems approach, challenge traditional ways of working, and use innovative strategies to improve care.⁵ Although the Collaborative provided suggestions for new ways of working, Trusts were free to adopt those practices they believed worked best for them.6, 7 The target was instituted in a graduated fashion, and Acute Trusts received financial rewards for meeting the target at each threshold. (The last performance incentive was awarded for reaching the 98% threshold in the January to March 2005 quarter.) Target performance is reported on a public Web site for the Acute Trust as a whole, and responsibility for the target rests with leadership of the Acute Trust, not the ED.⁴ Persistent failure of an Acute Trust to achieve the target can result in undesired attention from the Ministry of Health, replacement of the Trust's Chief Executive, and failure to achieve the financially advantageous status of “Foundation Trust.”

Targets and performance measures in health care are proliferating worldwide as a means to improve the quality and value of care delivered to patients.8, 9, 10, 11 The United States monitors hospital performance on a growing array of disease-specific measures, with payment increasingly contingent on meeting them.12, 13 Targets in England and Wales largely focus on reducing time to treatment and include the 18-week wait for elective surgery, 2-week wait for cancer referrals, and the target of an 8-minute ambulance response time. Emergency care throughput targets of 4 and 6 hours are already being trialed in Canada, New Zealand, and Australia.14, 15, 16 Mounting evidence of the dangers of ED crowding makes it likely that some form of regulatory oversight of ED throughput will eventually reach the United States; indeed, voluntary reporting of ED length of stay measures is already planned.17, 18, 19, 20, 21, 22, 23 It is expected that targets will improve clinical outcomes, but a clear benefit for patients is not always realized.24, 25 Targets also risk unintended consequences; gaming or cheating is often suspected, but targets can have consequences that negatively affect patients, including effort substitution (in which incentivized activities take precedence over equally important nonincentivized ones), distortion of clinical priorities (in which patients who have waited the longest take priority over those with more acute needs), or simply “improving the figures, but not the care.”26, 27, 28, 29, 30, 31, 32, 33, 34, 35

Creating change within health care organizations is notoriously difficult, and there are few qualitative studies providing insight into how organizations respond to an imposed target.36, 37 Examination and dissemination of successful strategies and potential pitfalls in meeting targets can be useful to those framing the targets and organizations trying to implement them. Moreover, it is possible that the effectiveness of the organizational response to a target contributes to how much patients benefit and whether unintended consequences occur.

We undertook a qualitative study of the implementation of England's 4-hour emergency throughput target to determine what lessons organizations can apply to successfully meet health care targets and avoid unintended negative consequences.