Health policy/concept
Emergency Department Operational Metrics, Measures and Definitions: Results of the Second Performance Measures and Benchmarking Summit

https://doi.org/10.1016/j.annemergmed.2010.08.040Get rights and content

There is a growing mandate from the public, payers, hospitals, and Centers for Medicare & Medicaid Services (CMS) to measure and improve emergency department (ED) performance. This creates a compelling need for a standard set of definitions about the measurement of ED operational performance. This Concepts article reports the consensus of a summit of emergency medicine experts tasked with the review, expansion, and update of key definitions and metrics for ED operations. Thirty-two emergency medicine leaders convened for the Second Performance Measures and Benchmarking Summit on February 24, 2010. Before arrival, attendees were provided with the original definitions published in 2006 and were surveyed about gaps and limitations in the original work. According to survey responses, a work plan to revise and update the definitions was developed. Published definitions from key stakeholders in emergency medicine and health care were reviewed and circulated. At the summit, attendees discussed and debated key terminology and metrics and work groups were created to draft the revised document. Workgroups communicated online and by teleconference to reach consensus. When possible, definitions were aligned with performance measures and definitions put forth by the CMS, the Emergency Nurses Association Consistent Metrics Document, and the National Quality Forum. The results of this work are presented as a reference document.

Introduction

The Institute of Medicine has defined 6 domains of quality of care: safe, timely, effective, efficient, equitable, and patient centered.1 Timeliness and efficiency are core attributes of emergency medicine, yet the details of which processes to measure and how to measure them are still a work in progress.2, 3 Time metrics (the time it takes for certain processes and subcycles of care) and proportion metrics (percentage of defects) have become de facto markers for quality in the literature. In February 2006, the first Performance Measures and Benchmarking Summit convened key stakeholders in emergency medicine to develop by consensus standards for emergency department (ED) operations and benchmarking terminology.4 Much has changed since the publication of the original standards, including new models of ED intake, growing evidence that ED crowding and prolonged length of stay are associated with lower-quality care and worse outcomes, and an intense national focus on measurement of health care quality.5, 6, 7, 8, 9, 10, 11 Length of stay, door-to-physician time, and left without being seen have been endorsed by the National Quality Forum as quality measures.12 Additionally, the Centers for Medicare & Medicaid Services (CMS) are testing 2 ED timing measures (length of stay and boarding time) and plan to include them in the hospital pay for reporting program in 2014 and publish results on the Hospital Compare Web site.13 Because interest in these metrics and how to improve them will be a growing concern for EDs, the Emergency Department Benchmarking Alliance organized a second summit to review and update critical terminology. The results are presented here.

As EDs, hospitals, and health systems work to improve the timeliness and efficiency of emergency care, it is critical that they use standard terminology and metrics to measure and benchmark performance. There are 3 compelling reasons to pursue standardization in this area: regulatory burdens, ED operations management, and research. Regulatory bodies, such as CMS and The Joint Commission (TJC), are beginning to include ED patient flow standards in their performance measurement and accreditation programs.14, 15, 16 It is imperative that further regulatory requirements use parameters developed by experts from within the specialty who understand its practice and the nuances of ED operations. Many EDs are implementing and testing techniques to improve ED patient flow and processes.17, 18, 19, 20, 21, 22 To advance the growing research on ED operations and quality improvement, standardized terminology and methodology are necessary.23, 24, 25

The Second Performance Measures and Benchmarking Summit convened to develop a set of metrics and definitions. The summit addressed the following objectives: (1) to develop a core set of metrics for ED patient flow and operations; (2) to define those metrics clearly, using timestamps, time intervals, and proportions; (3) to standardize the vocabulary relevant to the practice of emergency medicine operations, including operating characteristics, processes, and utilization (service units). The summit participants were tasked with drafting definitions for ED operations while maintaining consistency with previous work in this area. The vision was to standardize the language for industry-wide application.

Section snippets

Summit Methodology

The summit was organized by the Emergency Department Benchmarking Alliance, a nonprofit organization. It is a collaborative of 367 (EDs) with more than 14 million ED visits annually. The Emergency Department Benchmarking Alliance was founded in 1997 as an alliance of performance-driven EDs. It operates as a quality improvement collaborative and learning community, sharing performance data and operational strategies to identify best practices. The Emergency Department Benchmarking Alliance has

Operating Characteristics

To perform comparative analyses, EDs need to benchmark themselves against appropriate counterparts. EDs will use parameters to benchmark themselves, depending on the purpose of the comparison. Parameters currently in use to help EDs in this categorization are defined below:

Limitations

This work has several limitations. First, our methods did not adhere strictly to standardized qualitative research consensus processes such as the Delphi method, which has been used before in this type of work.38 However, the model used here follows many of the same principles, such as an iterative process, with in-person meetings and follow-up calls or e-mail discussions, and it was used successfully by the Emergency Department Benchmarking Alliance in the original Performance Measures Summit

Discussion

In response to the growing demand for measures of ED performance, we convened a summit of key stakeholders. With an iterative team process, time metrics for ED operations were reviewed, revised, and developed by consensus. We present definitions for critical and future ED timestamps, time intervals, and proportion metrics. Additionally, we define key processes and utilization metrics. These standardized definitions should help ED administrators, researchers, and regulators by providing a common

Conclusions

According to growing evidence that the timeliness of emergency care is associated with quality of care, there is internal and external motivation to improve ED operations. Common definitions of key terms, timestamps, and metrics will improve the comparability of ED operations research and publications. Without consistent definitions, it will be difficult to track, measure, and communicate in a meaningful way. This work provides all of the stakeholders in emergency medicine with the language to

References (43)

  • Crossing the Quality Chasm: A New Health System for the Twenty-first Century

    (2001)
  • L. Graff et al.

    Measuring and improving quality in emergency medicine

    Acad Emerg Med

    (2002)
  • P. Lindsay et al.

    The development of indicators to measure the quality of clinical care in EDs following the modified-Delphi approach

    Acad Emerg Med

    (2002)
  • S.J. Welch et al.

    Performance Measures and Benchmarking Summit

    Acad Emerg Med

    (2006)
  • D.B. Chaflin et al.

    Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit

    Crit Care Med

    (2007)
  • D.B. Richardson

    Increase in patient mortality at 10 days associated with emergency department overcrowding

    Med J Aust

    (2006)
  • P.C. Sprivulis et al.

    The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments

    Med J Aust

    (2006)
  • B.G. Carr et al.

    Emergency department length of stay: a major risk factor for pneumonia in intubated blunt trauma patients

    J Trauma

    (2007)
  • S.L. Bernstein et al.

    The effect of emergency department crowding on clinically oriented outcomes

    Acad Emerg Med

    (2009)
  • NQF endorses measures to address care coordination and efficiency in hospital emergency departmentsPress release

  • Specifications manual for national hospital inpatient quality measures v 3.2b

  • Cited by (124)

    • Emergency Department Operations II: Patient Flow

      2020, Emergency Medicine Clinics of North America
    View all citing articles on Scopus

    A podcast for this article is available at www.annemergmed.com.

    Supervising editors: Melissa L. McCarthy, ScD; Donald M. Yealy, MD

    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 as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist.

    Publication date: Available online November 10, 2010.

    Participants listed in Appendix.

    View full text