Clinical practice of emergency medicine/original researchEmptying the Corridors of Shame: Organizational Lessons From England's 4-Hour Emergency Throughput Target
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.
Section snippets
Study Design
This qualitative interview study was conducted between June and August 2008 as part of a mixed-methods study to determine the effect of the 4-hour target on patient outcomes (Safety of Time Targets in Emergency Medicine [SAFETIME]). The study received NHS Ethics Committee approval.
Selection of Participants
We employed a purposeful sampling strategy to maximize potential for a diversity of responses to the interviews. Using published results from the third quarter of 2007, all Acute Trusts in England were sorted into
Results
The 9 participating departments ranged in size from 40,000 to 90,000 annual visits. The Acute Trusts' performance on the target ranged from 75.6% to 95.2% in 2003 to 2004 and 86.2% to 99.1% in 2007 to 2008. Three Trusts had always done well on the target (“always done well”), 3 struggled for several years before meeting the target consistently (“struggled, now doing well”), and 3 were still unable to meet the target most of the time (“still struggling.”) All of the departments had made
Limitations
This study was conducted at a single point in time; it is possible that current performance on the target biased the quality of recall. However, the themes were consistent among the departments, regardless of performance, and fit well with the findings of our previous research on the influence of boundary-spanning activity on waiting times.40 It is possible that there was some response bias because we drew our interviewees from the pool of EDs that had agreed to the quantitative portion of the
Discussion
Our study demonstrates that, although aimed at improving the experience of emergency patients, the 4-hour target relies on, and influences, multiple parts of a health care organization. All participating EDs, regardless of their past or current performance, concurred on this priority; moreover, engagement of the whole organization was implicated in other salient themes. Delay in obtaining Trust-wide ownership of this target not only resulted in difficulty achieving and sustaining it but also
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Supervising editor: Donald M. Yealy, MD
Dr. Callaham recused himself from the decisionmaking on this article.
Author contributions: EJW, SM, and AC conceived the study, designed the interviews, and participated in the collection of data and interpretation of results. EJW and RLH were responsible for coding. EJW and SM were responsible for study supervision and drafting of the article. EJW, SM, AC, and RLH contributed to data interpretation and revision and finalizing of the article. EJW is the guarantor. All authors had full access to all the data (including taped interviews and coding) in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. EJW takes responsibility for the paper as a whole.
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. This study was supported by grants from the BUPA Foundation (TBF-08-023), the Society for Academic Emergency Medicine (United States) Scholarly Sabbatical Grant, and the College of Emergency Medicine (United Kingdom).
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