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Abstract

  1. Top of page
  2. Abstract
  3. Introductory keynote
  4. Panel 1: systems and workflow redesign to improve health care
  5. Panel 2: improving coordination of care for high-cost patients
  6. Lunchtime keynote
  7. Topic-specific research agendas
  8. Conclusions
  9. References

ACADEMIC EMERGENCY MEDICINE 2011; 18:655–661 © 2011 by the Society for Academic Emergency Medicine

Abstract

In October 2009, the American College of Emergency Physicians (ACEP) convened a conference held in Boston, Massachusetts, to outline critical issues in emergency care quality and efficiency and to develop a series of research agendas and projects aimed at addressing important questions about how to improve acute, episodic care. The aim of the conference was to describe how hospital-based emergency department (ED) systems could provide solutions for broader delivery problems in the U.S. health care system. The conference featured keynote speakers Drs. Carolyn Clancy (Director, Agency for Healthcare Research and Quality) and Elliott Fisher (Director, Center for Health Policy Research at Dartmouth Medical School). Panels focused on: 1) systems and workflow redesign to improve health care and 2) improving coordination of care for high-cost patients. Additional sessions were conducted to develop five research agendas on the following topics: 1) health information technology; 2) demand for acute care services; 3) frequent, high-cost users of emergency care; 4) critical pathways for post–emergency care diagnosis and treatment; and 5) end-of-life and palliative care in the ED.

The state of emergency departments (EDs) in the United States has been described by the Institute of Medicine as a “growing national crisis.”1 Two issues affecting quality and efficiency include managing the increased number and complexity of visits in a constrained system and the interaction between the EDs and other parts of the health care system (i.e., the continuum of care).

In October 2009, a conference titled, “Improving the Quality and Efficiency of Emergency Care Across the Continuum: A Systems Approach” was convened by the American College of Emergency Physicians (ACEP) to discuss these important issues (Table 1). The conference was funded by an R13 grant from the Agency for Healthcare Research and Quality (AHRQ) and was also supported by funds from the Emergency Medicine Foundation and the Society for Academic Emergency Medicine.

Table 1.    Speakers and panelists at the October 2009 conference, “Improving the Quality and Efficiency of Emergency Care Across the Continuum: A Systems Approach”
NameTitleConference Role
  1. AHRQ = Agency for Healthcare Research and Quality.

Brent R. Asplin, MDChair, Emergency Medicine at Mayo Clinical College of MedicineConference Co-Chair, Moderator of Panel 1
Carolyn Clancy, MDDirector, AHRQIntroductory Keynote Speaker
David R. Eitel, MD, MBAPhysician Advisor, Case Management, Wellspan Health SystemPanel 1 Speaker (Improving operational awareness through the use of real-time key performance indicators)
Elliott Fisher, MD, MPHDirector, Center for Health Policy Research at Dartmouth Medical SchoolLunchtime Keynote Speaker
George Isham, MD, MSMedical Director and Chief Health Officer, HealthPartners, Inc.Panel 2 Speaker (Care coordination for high cost patients: an insurer’s perspective)
Eugene Litvak, PhDCEO, Institute for Healthcare Optimization; Adjunct Professor, Harvard School of Public HealthPanel 1 Speaker (Sharing and implementing best practices for improving hospital-wide patient flow)
Larry Nathanson, MDAttending Physician, Department of Emergency Medicine, Beth Israel Deaconess Medical CenterPanel 1 Speaker (Using information technology strategies to improve the quality of emergency care)
Susan Nedza, MD, MBAAdjunct Associate Professor, Northwestern UniversityPanel 2 Speaker (Care transitions: innovation in incentives, infrastructure, and information and knowledge)
Jesse M. Pines, MD, MBA, MSCEDirector, Center for Health Care Quality, Associate Professor of Emergency Medicine and Health Policy, George Washington University Medical CenterConference Co-Chair, Panel 1 Speaker (Improving throughput in the complex ED system), Moderator of Panel 2
Tammie Quest, MDAssociate Professor of Emergency Medicine, Emory UniversityPanel 2 Speaker (Coordinating emergency and palliative care)
Robert L. Wears, MDProfessor of Emergency Medicine, University of FloridaPanel 1 Speaker (Optimizing safety and reliability of handoffs: conventional versus unconventional wisdom)
Charlotte Yeh, MDChief Medical Officer, American Association of Retired Persons (AARP)Panel 2 Speaker (Creating systems for alternatives to hospitalization for older adults)

The aim was to determine how the processes of care delivery in the emergency care system could be designed and used more effectively to provide solutions for quality problems in the U.S. health care system, specifically how the ED operates, how EDs interact without outside entities, and how to make emergency care more efficient. The broad themes that emerged from the conference highlighted the importance of not only improving ED care, but also improving the value of emergency care delivery by increasing information sharing, making patients care partners, and when possible, finding alternatives to the ED. This article summarizes the content of the conference, which included keynote speeches, panels related to improving systems of care within the ED and care coordination, and research agendas.

Drs. Carolyn Clancy and Elliot Fisher served as the keynote speakers and provided comments on related topics, including AHRQ priorities related to ED care, and an overview of health care reform and health care variation, respectively. The conference panels were chaired by conference co-chairs, Drs. Jesse Pines and Brent Asplin, and had two major foci: improving operations within the ED (and hospital) and coordination of care for high-cost patients. Additional sessions focused on honing research agendas aimed at addressing five major issues: 1) health information technology; 2) demand for acute care services; 3) frequent, high-cost users of emergency care; 4) critical pathways for post–emergency care diagnosis and treatment; and 5) end-of-life and palliative care in the ED. These research agendas are published separately.2–6

The impetus behind this conference was to continue the conversation on advancing the research agenda for emergency care,7 expanding the scope “across the continuum” to explore not only improving the quality of care within the ED, but also the interaction of the ED with the broader health care community. The conference began with an ACEP Task Force, which was selected by the ACEP Board of Directors. Keynote speakers were chosen as thought leaders outside emergency care. Small group leaders were represented by academic emergency physicians.

Introductory keynote

  1. Top of page
  2. Abstract
  3. Introductory keynote
  4. Panel 1: systems and workflow redesign to improve health care
  5. Panel 2: improving coordination of care for high-cost patients
  6. Lunchtime keynote
  7. Topic-specific research agendas
  8. Conclusions
  9. References

AHRQ Priorities for Emergency Care

  •  Bioterrorism-preparedness funding (training providers, using information technology); tools aimed at pandemic preparedness and other rare events (finding alternatives and using facilities for disaster care); and training individuals for basic care in a disaster.
Current AHRQ Emergency Care Information Technology Projects
  •  The Mid-South eHealth Alliance (led by Dr. Mark Frisse in Memphis, Tennessee): tests an intervention that exchanges data on radiology and laboratory results, physician notes, and discharge summaries. Emergency physicians view data through a secure Web-based browser. Estimated savings to local EDs: $500,000/year.
  •  ParentLink (Children’s Hospital in Boston): ED kiosks let parents enter data on children’s symptoms, conditions, drugs, and allergies, with a focus on ear infections, head trauma, asthma, and urinary tract infections. Preliminary results: more than 90% of the time, parents who used ParentLink gave information that is used by ED providers.
Available Funding for ED Research
  •  The American Recovery and Reinvestment Act (ARRA) of 2009 includes $1.1 billion for comparative effectiveness research (CER); AHRQ has $300 million to use. CER involves using information to drive improvement through the construction of scientific infrastructure. AHRQ’s CER operating plan includes: 1) stakeholder input/involvement, 2) identifying promising interventions, 3) evidence synthesis, 4) evidence generation, 5) new research with a focus on underrepresented populations, and 6) research training and career development.

Panel 1: systems and workflow redesign to improve health care

  1. Top of page
  2. Abstract
  3. Introductory keynote
  4. Panel 1: systems and workflow redesign to improve health care
  5. Panel 2: improving coordination of care for high-cost patients
  6. Lunchtime keynote
  7. Topic-specific research agendas
  8. Conclusions
  9. References

Sharing and Implementing Best Practices for Improving Hospital-wide Patient Flow

Artificial Flow Variability (AFV)
  •  AFV is created when elective procedures are scheduled unevenly during the week.8 There are several effects: decreased access to care, delays in care delivery, external and internal diversion of patients (such as the ED), nurse understaffing/overloading resulting in lower quality and safety, decreased staff satisfaction, decreased retention/recruitment, and underutilization of assets leading to decreased revenue and increased cost.
High Costs of Capacity
  •  Some estimates: $2–$7 million for a new operating room plus $250,000/year in operating expenses, $1 million for a new inpatient bed plus over $250,000 in annual operating expenses, and $2 million for a new cardiac catheterization laboratory.
The Solution
  •  Reduce the AFV by load leveling the elective surgical schedule.
  • Cincinnati Children’s Hospital reduced ED waiting times, increased operating room capacity, and increased inpatient occupancy by 15% without adding resources. They avoided capital costs of $100 million, improved patient and provider satisfaction, and increased potential annual revenue by $137 million.

Improving Operational Awareness Through the Use of Real-time Key Performance Indicators

Ways to Think About Flow
  •  Toyota Production System (TPS), a.k.a. “Lean” thinking and tools.
  •  The first issue is to identify how patients currently flow through the hospital through process-flow mapping.
Sources of Waste in Health Care
  • Rework and repair results from a failure to prescribe the right treatment or care; 2) inventory is excessive material at any stage in production (inadequate bed assignments or excessive paperwork); 3) delay is an excessive wait; 4) conveyance is unnecessarily long movement of parts through a process stream (moving patients for testing or bed placement); 5) overproduction is unnecessary care (testing or treatment); 6) motion is wasted time spent looking for charts, medications, and supplies; 7) excessive process steps are found when patients experience multiple bed moves, retesting, or multiple testing; and 8) talent is not engaging people within an organization to improve quality.
Value-stream Mapping
  •  Divides time into value-added and non–value-added. Much of the time spent in the ED is not value-added.9
  •  Example: streamline admissions process where unnecessary phone calls were removed in assigning and transporting a patient by using express admission orders for low-risk admissions.
Broad Need for Systems Thinking in Emergency Care
  •  Health care needs to adopt the concepts of systems engineering and pair these concepts with information technology to fix systematic problems in services delivery.10

Improving Throughput in the Complex ED System

The ED Is a Complex System With Multiple Stakeholders: Silo Mentality in Hospitals
  •  EDs must handle variable volume and patients with variable resource demands (ankle sprains to acute myocardial infarction [AMI]).
  •  A small proportion of care is delivered by rigid policy (i.e., AMI care). In the majority of ED care, providers make decisions based on their own interpretation of loosely defined policies.
  •  The ED is a rigid or semirigid space with structural capacity limits, and it frequently operates above capacity, leading to long waits.
  •  The ED is dependent on the hospital, which has its own complexities.
  •  Each hospital unit operates as a silo and may not respond with higher utilization rates when the ED is congested.
Moving Bottlenecks
  •  At any point the bottleneck in an ED may be from different causes.
  •  Focusing on the process improvement for one particular process may not solve the systematic variability that leads to systematic congestion (the theory of constraints).
Queuing Theory to Improve Flow
  •  Interventions should be aimed at particular elements of flow in a queuing model.
  •  Activity time is difficult to change (i.e., to ask workers to work faster), but it is possible to control the number of servers through demand–capacity matching (i.e., higher numbers of staff at busier times) and greater space (i.e., flexible space); specifically, transition units or using inpatient hallways to board admitted patients.
  •  Improving the utilization rate and reducing non–value-added time can be accomplished through immediate bedding, physicians in triage, and bedside registration. Improved health information technology, wireless communication, and the use of fast tracks may also increase the amount of time that servers are “in use” and not idle.
  •  Reducing variation in service times can be measured and improved in real time by ED dashboards.

Using Information Technology Strategies to Improve the Quality of Emergency Care

Clinical Decision Support
  •  Real-time alerts about life-threatening allergies and interactions or reminders about new treatment guidelines.
  •  Can also assess risk: calculate the pretest probability of pulmonary embolism to integrate clinical decision rules into order entry systems.
  •  Research is needed to understand the role of ED clinical decision support and the best practices for implementation.
The Human–Computer Interface
  •  Poor user interface design reduces productivity in many EDs with information systems.
  •  ARRA 2009 will expand the amount of information accessible to EDs via electronic health records (EHRs).
  •  This may help close the “information gap” noted in up to one-third of ED visits. However, more effort will be needed to review increased data. The typical Medicare patient is seen by an average of seven doctors in four practices.11,12
  •  Systems should be developed to automatically summarize relevant portions of multiple EHRs to best leverage the advantages of this emerging technology.
Harnessing Real-time Data for Quality Improvement
  •  There is a need for a “black box” data recorder in the ED.
  •  Other possibilities include ED dashboards, exploring other ways to intelligently couple sensors with therapies (e.g., titrating vasopressors in sepsis, insulin in diabetic ketoacidosis, oximetry/capnometry for ventilators).

Optimizing Safety and Reliability of Handoffs: Conventional Versus Unconventional Wisdom

Conventional Wisdom on Handoffs
  •  1) Handoffs are similar across the continuum of care, 2) handoffs are hazardous, 3) handoffs are about information transfer, 4) handoffs are “low-hanging fruit” and easily fixed by standardized data sets and checklists, and 5) doctors know how to fix handoffs.
  •  “Communication failure” is a wastebasket diagnosis. There are hindsight and outcome biases (failures are identified later and it is often blamed on the handoff) and length-biased sampling (observations are chosen with a probability in proportion to their length, e.g., length of stay).
Challenging the Conventional Wisdom
  •  Challenge 1: Handoffs are heterogeneous and depend on whether the participants share common ground. For example, handoffs among ED providers are different than those between ED providers and hospitalists. Providers and patients share the least common ground.
  •  Challenge 2: Handoffs can be a source of rescue. While having two controllers in a system leads to potential conflict, a handoff can be “fresh eyes.”
  •  Challenge 3: Handoffs are about more than just information transfer. There are several transfers including responsibility, authority, and “stance.”
  •  Challenge 4: Handoffs are not an easy problem.
  •  Challenge 5: Physicians’ skills to remedy the problems with handoffs are insufficient. The standard data set approach is also insufficient, because of the condition-specific variability and trajectory variability, depending on where the patient is in his or her workup.
Foundational Work on ED Handoffs Is Needed
  •  This may include: 1) understand the role of context; 2) how do people manage goal conflicts and tradeoffs? (e. g. tradeoffs between completeness vs. salience and time invested in handoff vs. time reinvestigating patient); 3) what dimensions might be useful in standardization? 4) advantages (or not) of interdisciplinary handoffs; 5) developing explanatory connections between interventions and improvements; and 6) how might handoffs be better supported?

Panel 2: improving coordination of care for high-cost patients

  1. Top of page
  2. Abstract
  3. Introductory keynote
  4. Panel 1: systems and workflow redesign to improve health care
  5. Panel 2: improving coordination of care for high-cost patients
  6. Lunchtime keynote
  7. Topic-specific research agendas
  8. Conclusions
  9. References

Care Transitions: Innovation in Incentives, Infrastructure, and Information and Knowledge

New Care Transitions Measures Developed by the Physician’s Consortium for Performance Improvement (PCPI)
  •  PCPI care transitions measures are facility-level measures designed to promote team accountability and safer care that focus on discharges from inpatient facilities and EDs.
  •  Transition quality after hospital discharge is a key determinant of readmission within 30 days. The PCPI transitions measures include a transition record at the time of hospital and ED discharge.
  •  The goal of the transition record is to facilitate communication regarding important hospital events to the patient, family members, and subsequent ambulatory care providers.
  •  A fully reconciled medication list is required at the time of inpatient discharge.
Infrastructure Needs to Promote Quality Care Transitions
  •  These include integrated delivery models, capturing standardized clinical information, and improving interoperability of information systems.
  •  The goal is free flow of patient-centered and patient-controlled information across systems.

Creating Systems for Alternatives to Hospitalization for Older Adults

The Burden of Disease and Emergency Care for Elders
  •  Aggressive care coordination is needed to reduce potentially preventable hospitalizations.
  •  The frail elderly population is a particularly challenging group.
  •  United Health Group and AARP Services Inc. developed several care management pilot programs for heart disease, diabetes, and high-risk cases. Launched in 2008, the programs optimize management of chronic disease and provide social support. Services range from health information about lowering the risk of complications from heart disease and diabetes, to in-home monitoring, care coordination nurses, individualized care plans, depression screening, and social services interventions to address nutrition and transportation needs.
A Holistic Systems Model for Care Coordination
  •  This includes four steps: 1) widening the lens (understanding the macrodeterminants of health), 2) knowing the population, 3) creating an enabled environment, and 4) fostering care partnerships.
An Enabled Environment for Care Coordination
  •  This includes services such as home visits, assistance with referrals, and medication management. Technological support for in-home monitoring and continuous access to information via online personal health records are also important elements.
  •  Care coordination will be most effective when patients are partners in the process of decision-making and care coordination. This partnership should be driven by patient and family preferences.

Coordinating Emergency and Palliative Care

A New Model for Palliative Care in the ED
  •  Palliative care is not synonymous with end-of-life care.
  •  Palliative care interventions begin when a serious illness is diagnosed.
  •  Throughout serious illness, the balance of interventions gradually shifts from life- prolonging care toward palliative care; however, both types are present when the point of hospice care is reached.
  •  “Death trajectories”: patients with serious illness create not only a prolonged demand on the delivery system, but also present opportunities for improving palliative care.
  •  The intersection of palliative and emergency care today leaves patients, families, and providers frustrated by gaps in care, poor communication and coordination of services, and unnecessary reliance on aggressive interventions. Conflicts about withdrawing or withholding interventions are common, and training for these is inadequate.
A Proposed Solution
  •  The Education in Palliative and End-of-Life Care in Emergency Medicine (EPEC-EM) program is a 2-day “train-the-trainer” approach to improving core palliative care skills.13

Care Coordination for High-cost Patients: An Insurer’s Perspective

ED and Hospital Care as a Failure of Primary Care
  •  The system has failed many high-cost patients.
  •  The appropriateness of ED use: some patients receive ED care for conditions that could be managed by a primary care physician, particularly on nights and weekends.
Potential Solutions
  •  A stronger emphasis is needed on population-based prevention of complex and chronic disease.
  •  The ED should be viewed as an integrated component of a system designed to manage complex problems.
  •  EDs should be expected to provide superior service at an affordable price.
  •  Payment reforms are needed to encourage delivery system redesign.
  •  There should be a linkage of EHRs from ED and hospital systems to ambulatory providers in the community.
Complex Patients
  •  Active management is needed through system redesign, care coordination, effective communication, case management, health literacy, and team-based care.

Lunchtime keynote

  1. Top of page
  2. Abstract
  3. Introductory keynote
  4. Panel 1: systems and workflow redesign to improve health care
  5. Panel 2: improving coordination of care for high-cost patients
  6. Lunchtime keynote
  7. Topic-specific research agendas
  8. Conclusions
  9. References

Regional Variation in Health Care

  •  “Paradox of plenty”: areas with high spending on health care services have worse outcomes.
  •  Types of services that vary between high- and low-cost regions: much of the difference comes from supply-sensitive interventions (i.e., inpatient days, days in the intensive care unit, office visits, imaging, and other diagnostic tests).
  •  Additional spending in high-cost regions does not lead to survival gains, functional gains, improved satisfaction with hospital care, or better access to primary care.
  •  Physicians in the high-cost regions report worse communication, greater challenges coordinating care, and (ironically) a greater perception of scarcity.

Characteristics of Systems With Low Spending

  •  A four-level framework for organizing reducing unnecessary variation: 1) aims, 2) microsystems, 3) accountable care organizations (ACO), and 4) environment.
  •  The “triple aim” of improving population health, improving care (safety, outcomes, and satisfaction), and lowering costs over time.
  •  ACOs interface with a population and are responsible for health status, outcomes, and costs.
  •  Payment reform is a fundamental requirement for ACOs and is the most important aspect of reforming the system.

More Investment Is Needed in Evaluation

  •  More investment is needed in demonstration projects to experiment with delivery system reform and to develop ACOs.
  •  Bundled payment and medical home pilots should be a central to reform efforts, with experiments on how to best share the value of cost reductions with delivery systems and patients.

Topic-specific research agendas

  1. Top of page
  2. Abstract
  3. Introductory keynote
  4. Panel 1: systems and workflow redesign to improve health care
  5. Panel 2: improving coordination of care for high-cost patients
  6. Lunchtime keynote
  7. Topic-specific research agendas
  8. Conclusions
  9. References

The afternoon sessions consisted of five break-out groups, each of which developed a research agenda.2–6 The papers are:

  • 1
    Enhancing Systems to Improve the Management of Acute, Unscheduled Care5
  • • 
    There is insufficient capacity in both the ED and the primary care system to handle all of the acute, unscheduled care.
  • • 
    A research agenda is proposed to improve the understanding of differences between the ED and personal physicians regarding access, cost, and quality.
  • 2
    Frequent Users of ED Services: Gaps in Knowledge and a Proposed Research Agenda3
  • • 
    The research agenda includes: 1) creating an accepted categorization system for frequent users, 2) predicting which patients are at risk for becoming or remaining frequent users, 3) implementing both ED- and non–ED-based interventions, and 4) conducting qualitative studies of frequent ED users to explore reasons and identify factors that are subject to intervention.
  • 3
    Using Information Technology to Improve the Quality and Safety of Emergency Care4
  •  A research agenda includes the introduction of information technologies into ED care, specifically relating to: 1) interoperability; 2) patient flow and integration into clinical work; 3) real-time decision support, handoffs, and safety-critical computing; and 4) the interaction between information technology system and work system properties.
  • 4
    Critical Pathways for Postemergency Outpatient Diagnosis and Treatment: Tools to Improve the Value of Emergency Care2
  •  The research agenda outlines alternatives to hospitalization for ED patients. Included is a comparison of existing ED-based observation units with alternative outpatient rapid diagnostic evaluations, which should be assessed not only for clinical effectiveness, but also for cost-effectiveness and patient satisfaction.
  • 5
    Developing a Research Agenda in End-of-life Care in Emergency Care6
  •  A research agenda for end-of-life care in the ED that addresses: 1) which patients are in greatest need of palliative care services in the ED, 2) what is the optimal role of emergency providers in directing resource utilization in palliative care patient, and 3) how the integration and initiation of palliative care in the ED may affect subsequent health care utilization and outcomes.

Conclusions

  1. Top of page
  2. Abstract
  3. Introductory keynote
  4. Panel 1: systems and workflow redesign to improve health care
  5. Panel 2: improving coordination of care for high-cost patients
  6. Lunchtime keynote
  7. Topic-specific research agendas
  8. Conclusions
  9. References

Systemwide crowding and care coordination are two of the most important issues facing EDs today. “Improving the Quality and Efficiency of Emergency Care Across the Continuum: A Systems Approach” provided a deep assessment of the current state of hospital and ED operations, as well as the challenges of coordinating care for high-cost patients. Many opportunities exist to leverage the resources and expertise of the emergency care system to improve the overall quality of U.S. health care delivery. These proceedings and the associated research agendas are designed to address important challenges and opportunities for the current and future practice of emergency care.

References

  1. Top of page
  2. Abstract
  3. Introductory keynote
  4. Panel 1: systems and workflow redesign to improve health care
  5. Panel 2: improving coordination of care for high-cost patients
  6. Lunchtime keynote
  7. Topic-specific research agendas
  8. Conclusions
  9. References
  • 1
    Institute of Medicine. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: National Academies Press, 2006.
  • 2
    Schuur JD, Baugh C, Hess E, Hilton, E, Pines JM, Asplin B. Critical pathways for post-emergency outpatient diagnosis and treatment: tools to improve the value of emergency care. Acad Emerg Med. 2011; 18:e52e63.
  • 3
    Pines JM, Asplin B, Kaji A, et al. Frequent users of emergency department services: gaps in knowledge and a proposed research agenda. Acad Emerg Med. 2011; 18:e64e69.
  • 4
    Handel D, Nathanson L, Wears RL, Pines JM. Using information technology to improve the quality and safety of emergency care. Acad Emerg Med. 2011; 18:e45e51.
  • 5
    Braithwaite S, Asplin BR, Pines JM, Epstein SD. Enhancing systems to improve the management of acute, unscheduled care. Acad Emerg Med. 2011; 18:e39e44.
  • 6
    Quest T, Asplin BR, Cairns CC, Hwang U, Pines JM. Research priorities for palliative and end of life care in the emergency setting. Acad Emerg Med. 2011; 18:e70e76.
  • 7
    Neumar RW. The Zerhouni challenge: defining the fundamental hypothesis of emergency care research. Ann Emerg Med. 2007; 49:6967.
  • 8
    Managing Patient Flow. In: Hospitals: Strategies and Solutions. 2nd ed. LitvakE. (ed). Oakbrook Terrace, IL: Joint Commission Resources, 2009.
  • 9
    Eitel DR, Rudkin SE, Malvehy MA, et al. Improving service quality by understanding emergency department flow: a white paper and position statement prepared for the American Academy of Emergency Medicine. J Emerg Med. 2010; 38:709.
  • 10
    Reid P Compton WD, Grossman JH, Fanjiang G (eds). Building a Better Delivery System: A New Engineering/Health Care Partnership. Available at: http://www.nationalacademies.org/onpi/030909643X.pdf. Accessed Mar 5, 2011.
  • 11
    Stiell A, Forster A, Stiell I, et al. Prevalence of information gaps in the emergency department and the effect on patient outcomes. CMAJ. 2003; 169:10238.
  • 12
    Pham H, Schrag D, O’Malley A, et al. Care patterns in Medicare and their implications for pay for performance. N Engl J Med. 2007; 356:11309.
  • 13
    Northwestern University. Education in Palliative and End of Life Care Project. Available at: http://www.epec.net/. Accessed Apr 26, 2011.