Marcia J. Wilson

The Past, Present, and Future of Urgent Matters: Lessons Learned from a Decade of Emergency Department Flow Improvement

Over the past decade, emergency departments (ED) have encountered major challenges due to increased crowding and a greater public focus on quality measurement and quality improvement. Responding to these challenges, many EDs have worked to improve their processes and develop new and innovative models of care delivery. Urgent Matters has contributed to ED quality and patient flow improvement by working with hospitals throughout the United States. Recognizing that EDs across the country are struggling with many of the same issues, Urgent Matters-a program funded by the Robert Wood Johnson Foundation (RWJF)-has sought to identify, develop, and disseminate innovative approaches, interventions, and models to improve ED flow and quality. Using a variety of techniques, such as learning networks (collaboratives), national conferences, e-newsletters, webinars, best practices toolkits, and social media, Urgent Matters has served as a thought leader and innovator in ED quality improvement initiatives. The Urgent Matters Seven Success Factors were drawn from the early work done by program participants and propose practical guidelines for implementing and sustaining ED improvement activities. This article chronicles the history, activities, lessons learned, and future of the Urgent Matters program.

Enhancing work flow to reduce crowding.

INTRODUCTION Approximately one third of hospitals in the United States report increases in ambulance diversion in a given year, whereas up to half report crowded conditions in the emergency department (ED). In a recent national survey, 40% of hospital leaders viewed ED crowding as a symptom of workforce shortages. Many health systems are implementing a variety of strategies to improve flow and reduce crowding. DOMAINS OF IMPROVEMENT Virtually all work-flow initiatives use operations management techniques that include some or all of four domains: performance measurement, demand forecasting, flow redesign, and capacity management. These are often implemented using rapid improvement techniques. Most initiatives tend to focus on functional increases in inpatient capacity. IMPLICATIONS FOR PRACTICE AND POLICY Successful strategies to improve patient flow are distinguished by an organizationwide commitment to measurement, transparency in data reporting, and sustained management attention. Focusing on transitions between ED and inpatient units and maximizing overall hospital capacity appears necessary for improvement. Hence, reductions in ED crowding require strategies that go far beyond the ED. CONCLUSION Health systems can take tangible, immediate steps to improve flow and reduce crowding. Efforts would be enhanced by more controlled trials of existing strategies in the context of uniform performance measures.

A quality improvement framework for equity in cardiovascular care: Results of a national collaborative

&NA; Disparities in the quality of cardiovascular care provided to minorities have been well documented, but less is known about the use of quality improvement methods to eliminate these disparities. Measurement is also often impeded by a lack of reliable patient demographic data. The objective of this study was to assess the ability of hospitals with large minority populations to measure and improve the care rendered to Black and Hispanic patients. The Expecting Success: Excellence in Cardiac Care project utilized the standardized collection of self‐reported patient race, ethnicity, and language data to generate stratified performance measures for cardiac care coupled with evidence‐based practice tools in a national competitively selected sample of 10 hospitals with high cardiac volumes and largely minority patient populations. Main outcomes included changes in nationally recognized measures of acute myocardial infarction and heart failure quality of care and 2 composite measures, stratified by patient demographic characteristics. Quality improved significantly at 7 of the 10 hospitals as gauged by composite measures (p < .05), and improvements exceeded those observed nationally for all hospitals. Three of 10 hospitals found racial or ethnic disparities which were eliminated in the course of the project. Clinicians and institutions were able to join the standardized collection of self‐reported patient demographic data to evidence‐based measures and quality improvement tools to improve the care of minorities and eliminate disparities in care. This framework may be replicable to ensure equity in other clinical areas.

Assumed equity: Early observations from the first Hospital Disparities Collaborative

&NA; Disparities in healthcare represent a failure in the equity domain of quality. Although disparities have been well documented, little has been written about how hospitals might use improved data collection and quality improvement techniques to eliminate disparities. This article describes early findings from the planning phase of the first hospital‐based disparities collaborative. The authors also discuss the changes in policy and practice that may speed hospitals in placing disparities and equity on their quality agendas.

Interventions to Provide More Equitable Health Care: Emerging Evidence and Next Steps

Multiple studies have shown that racial and ethnic minorities often experience lower quality of health care when compared with white patients (Institute of Medicine [IOM], 2002). Even after taking into account various factors like differences in access to care and disease severity, racial and ethnic disparities in care remain, and are often associated with worse health outcomes (IOM; Mead et al., 2008).