Coping with crowding: Enhancing work flow to reduce hospital crowding

Approximately one-third of U.S. hospitals report going on ambulance diversion in a given year, while up to half report crowded conditions in the emergency department (ED). Crowding can increase the frequency of medical error and create other quality deficiencies. The recent Institute of Medicine report on emergency medicine and the Joint Commission on the Accreditation of Healthcare Organizations' patient flow accreditation standard reinforce the urgency to address crowding.

We recently completed a scan of patient flow initiatives as part of a national improvement effort. It revealed numerous work flow strategies based on specific operations management techniques with rapid improvement testing or enterprise-wide methodologies adopted from other industries. Regardless of specific interventions, these initiatives usually include four domains: performance measurement, demand forecasting, flow redesign and capacity management. Most initiatives seek functional increases in inpatient capacity.

Successful initiatives are distinguished by an organization-wide commitment to measurement, transparency in data reporting and sustained management attention. Reductions in ED crowding require strategies that go far beyond the ED; focus on transitions between ED and inpatient units and maximizing inpatient capacity appear necessary for improvement. However, comparisons between approaches are difficult given the lack of common performance measures.

Health systems can take tangible, immediate steps to improve flow and reduce crowding. Efforts would be enhanced by more rigorously controlled trials of patient flow interventions in the context of uniform performance measures used for public reporting.