{'fraction_non_alphanumeric': 0.022569832402234636, 'fraction_numerical': 0.009385474860335195, 'mean_word_length': 5.251396648044692, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
What U.S. emergency care value transformation can learn from Canadian efforts to improve emergency department throughput.

I n this issue of Academic Emergency Medicine, Rotteau et al. detail findings from interviews with local stakeholders across 10 hospitals in Ontario, Canada, participating in an emergency department (ED) process improvement program aimed at improving ED patient flow. The authors identified several factors linked to program success, including having strong support from hospital executives, forming teams focused on tasks and outcomes, and creating accountability for sustaining interventions. They concluded that incorporation of these factors into planning and executing similar interventions could boost chances of success. The broader question was how to successfully transform multistakeholder, multidisciplinary environments, like hospital EDs. The answer to the transformation question is rapidly becoming central to health care organizations in the United States as new pressures mount from payers to reduce costs and improve quality. The catalyst is the Affordable Care Act of 2010, which supports new payment models that will reward organizations that can deliver care more efficiently. In early 2015, the Secretary of Health and Human Services, Sylvia Burwell announced an accelerated plan to move away from traditional fee-for-service payments. There is a target for 30% of Medicare payments to be reimbursed by 2016 in alternative payment models, such as accountable care organizations, which will increase to 50% by 2018. For the remaining fee-for-service payments, 85% will be tied to quality by 2016 and 90% by 2018. These new targets have upped the stakes as health care organizations start realizing that transformation just may be a necessary step in economic survival. Yet, transforming clinical practice is not an easy job, and in particular revamping ED practice is a particular challenge, as EDs have their own unique set of conditions. Emergency departments are highly complicated units to manage because of the large daily and seasonal fluctuations in care demands. Some surges occur predictably, and some do not, making it essential to have extra space and staff in reserve, as well as back-up plans to maintain performance. EDs also rely on perhaps the broadest group of health professional stakeholders to function efficiently, from emergency physicians and nurses, some who work many and others who work few hours per week, along with nonphysician staff such as technicians, administrative, and other services. Beyond ED staff, a myriad of other stakeholders and departments are required for efficient ED functioning, such as laboratory, pharmacy, social work, and radiology services, along with non-ED physicians and hospital floor staff. In many cases, incentives of stakeholders in hospitals are aligned; but in other cases, they are not. For example, EDs are in the “speedy care” business, while other interdependent units that EDs rely on and outside physicians tend to care less about speed and more their own workflows, ensuring that their own units run efficiently. This can lead to delays not just from poorly planned processes, but from different goals. Finally, EDs have many more hours in a day to transform than other health care settings: EDs run 168 hours a week, compared to 40 hours for a standard clinic. In the study by Rotteau et al., these challenges in transforming complex EDs became clear in the context of a multihospital ED throughput improvement program. In the beginning, most participants felt that their organizations lacked the structure, resources, or experience to successfully transform. This was reflected by initial cynical responses from frontline staff who had seen many prior improvement efforts fail. Indeed, many EDs today find themselves so challenged with the day-to-day that transformation may seem unrealistic. To enhance chances for successful transformation, team selection and make-up were critical. It was important to have representatives from both the ED and the inpatient teams and a variety of staff roles from administrators to frontline clinicians. Engaging frontline clinicians, particularly inpatient physicians, was a major challenge. However, this was overcome with the active involvement of physician leads within departments. The author has no relevant financial information or potential conflicts of interest to disclose. A related article appears on page 720.