Book Review: The Definitive Guide to Emergency Department Operational Improvement and Quality Matters: Solutions for a Safe and Efficient Emergency Department

Abstract

The Definitive Guide to Emergency Department Operational Improvement and Quality Matters: Solutions for a Safe and Efficient Emergency DepartmentReviewed by Frank Zilm, FAIA, FACHAQuality Matters: Solutions for a Safe and Efficient Emergency Department. (2009).Shari J. Welch. Oak Park, IL: Joint Commission Resources (Softcover).The Definitive Guide to Emergency Department Operational Improvement. (2011).Jody Crane and Chuck Noon. New York, NY: CRC Press.A fundamental question in evidence-based design is where design begins. Is it in the strategic vision, the programming, or the translation into an architectural design concept?If we follow the somewhat worn edict that form follows function, it is logical that we should understand the operations of an emergency service before engaging a design solution. As with other areas of healthcare design, innovation and creativity are spurred by an understanding of the patient, staff, and organizational needs of a service.Two recent books on emergency service operations provide an interesting and informative contrast in content; one offers a wide breadth of exposure to emergency department (ED) issues and operations, and the other provides a deep-dive look into the world of Lean applications in the ED service.Quality Matters: Solutions for a Safe and Efficient Emergency Department uses a broad definition of quality to expose readers to a breadth of issues related to emergency care and management. The stated purpose of the book is to provide practical solutions to the ED environment by providing realworld examples of common problems that occur in most EDs (Welch, 2009, p. 2).Dr. Welch's initial focus is on establishing a quality improvement program. Her definition of quality in medicine includes service, clinical, and financial quality. The author identifies the five key components of a quality improvement program as (1) census data; (2) metrics; (3) operational data; (4) provider-specific data; and (5) focused audits/improvements. Topics addressed in service quality include benchmarking, standardization of processes, and statistical analysis of key ED data. Examples, drawing heavily on the LDS hospital system in Utah where she practices, provide useful illustrations of the concepts discussed.The chapter on demand capacity management presents some innovative ideas for smoothing the traditional ebbs and flows of patient arrivals. Could the ED use incentives to urge patients to come back to the ED for nonurgent complaints during lowcensus periods? Could the registration area for the hospital be used as a rapid medical screening area at night? Could the orthopedic rooms be used as a satellite intensive care unit (ICU, staffed by ICU staff) when the ICU is overcrowded?The chapter on statistical process control provides a basic introduction to the application of statistical techniques for process control. Queuing theory and other techniques are not covered in great detail.The chapter on management provides an interesting insight into a common stumbling block in planning new facilities. Teamwork is not a natural phenomenon for a physician. In fact, medical training and physician culture tend to promote rugged individualism. Anyone involved in improvement efforts can attest to the challenges inherent in leading physicians through change. Understanding the culture in which physicians are trained and practice helps in understanding the difficulties in changing physician behavior (Welch, 2009, p. 109). Amen. Her suggested strategies for addressing this problem include the use of data to make a case for change, appealing to competitiveness through feedback, getting physicians involved on the ground floor, aligning incentives with patient care, and using pilot studies. These are all potentially good techniques when combined with the most important identified component of her proposed change team: a respected physician who will campaign as a champion of the new approaches. …