Implementing performance improvement in New Zealand emergency departments: the six hour time target policy national research project protocol

Abstract

BackgroundIn May 2009, the New Zealand government announced a new policy aimed at improving the quality of Emergency Department care and whole hospital performance. Governments have increasingly looked to time targets as a mechanism for improving hospital performance and from a whole system perspective, using the Emergency Department waiting time as a performance measure has the potential to see improvements in the wider health system. However, the imposition of targets may have significant adverse consequences. There is little empirical work examining how the performance of the wider hospital system is affected by such a target. This project aims to answer the following questions: How has the introduction of the target affected broader hospital performance over time, and what accounts for these changes? Which initiatives and strategies have been successful in moving hospitals towards the target without compromising the quality of other care processes and patient outcomes? Is there a difference in outcomes between different ethnic and age groups? Which initiatives and strategies have the greatest potential to be transferred across organisational contexts?Methods/designThe study design is mixed methods; combining qualitative research into the behaviour and practices of specific case study hospitals with quantitative data on clinical outcomes and process measures of performance over the period 2006-2012. All research activity is guided by a Kaupapa Māori Research methodological approach. A dynamic systems model of acute patient flows was created to frame the study. Consequences of the target (positive and negative) will be explored by integrating analyses and insights gained from the quantitative and qualitative streams of the study.DiscussionAt the time of submission of this protocol, the project has been underway for 12 months. This time was necessary to finalise both the case study sites and the secondary outcomes through key stakeholder consultation. We believe that this is an appropriate juncture to publish the protocol, now that the sites and final outcomes to be measured have been determined.

Waiting management at the emergency department – a grounded theory study

“…A recent Swedish study showed that 38% of ED patients spend more than 4 hours at the ED with the oldest age group waiting the most [3]. Many jurisdictions have wait time reduction strategies [4], and some have goals to maximize waiting times at EDs to 4–6 hours [5]. Patients have to be cared for fast to ensure diagnosis and treatment.…”

Performance Improvement Priorities From the Perspective of Emergency Department Staff in Iran’s Hospitals

“…This department has sensitive and exceptional position in the hospital and health care system because of the need for rapid, high-quality and effective conduction of multiple and complex processes (1). The most extensive and vital emergency services are provided at this department.…”

Better performance on length-of-stay benchmarks associated with reduced risk following emergency department discharge: an observational cohort study

“…Internationally, several jurisdictions, such as England, 15 Australia, 16 Ireland, 41 New Zealand, 13 and several Canadian provinces, 22,42 have enacted ED LOS benchmarks and targets, implemented with varying combinations of incentives and/or sanctions. Benchmarks vary widely, for example, in England (up until 2011) 15 and Australia, 16 the wait time benchmark has been < 4 hours for ED patients, whereas Canadian provinces generally have different benchmarks for high-acuity patients (ranging from 4-12 hours) and low-acuity patients (ranging from 2-4 hours).…”

“…Several jurisdictions that have adopted them have seen substantial improvements in ED patients meeting targets. [13][14][15][16] However, such initiatives may result in unintended adverse consequences by encouraging rushing of patient care or gaming of data. 13,17 The selection of ED LOS benchmark thresholds has been arbitrary rather than evidence-based, 18 and empiric data linking performance on benchmarks with patient outcomes has been lacking.…”