Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals

Appendix D: Additional Readings

Bursting at the Seams
Marcia J. Wilson and Khoa Nguyen
Accessible at:
This report summarizes the experiences of 10 large hospitals that participated in Urgent Matters Learning Network (UMLN) I. There were several common factors that contributed to hospitals' success with the implementation of patient flow improvement strategies, including: (1) recognizing that ED crowding is a hospital-wide problem, not an emergency department (ED) problem; (2) building multidisciplinary, hospital-wide teams to oversee and implement change; (3) determining the presence of a "champion"; and (4) obtaining management's support. The report describes 17 key performance indicators that the hospitals used to evaluate their performance and provides examples of successful strategies.

Facilitators and Barriers to the Implementation of Patient Flow Improvement Strategies
Kevin Van Dyke, Megan McHugh, Julie Yonek, Dina Moss
Quality Management in Healthcare 20(3):223-233, July-Sept 2011.
Using a qualitative research design, this report identifies common facilitators and barriers to the implementation of patient flow improvement strategies at the UMLN II hospitals and successful approaches for mitigating barriers. Factors facilitating implementation included participation in the learning network and strategic selection of team members. Common challenges included staff resistance and entrenched organizational culture. Some of the challenges were mitigated through approaches such as staff education and department leaders' constant reinforcement. The findings indicate that several facilitators and barriers are common to the implementation of different strategies. Leveraging facilitators and developing a strategy to address common barriers may leave hospital and ED leaders better prepared to implement patient flow improvement strategies.

Hospital-Based Emergency Care: At the Breaking Point
Washington, DC: Institute of Medicine; 2007.
Available at:
This IOM report describes the emergency care system in the United States including its strengths, limitations, and future challenges. Numerous issues are covered, including the role and impact of the emergency department within the larger hospital and health care system, patient flow, workforce issues, and the quality of emergency care services. The report gives a number of examples of how crowding adversely affects emergency care and offers several recommendations for improving patient flow.

Hospital Quality Improvement: Strategies and Lessons from U.S. Hospitals
Sharon Silow-Carroll, Tanya Alteras, Jack A. Meyer
New York: The Commonwealth Fund, April 2007
Accessible at:
This report focuses on the dynamics of hospital performance and how hospitals achieve and sustain improvements over time. Case studies of four hospitals that made substantial improvements reveal a pattern: (1) a trigger such as a crisis or new leader serves as a "wake-up call" that prompts the hospital to make (2) organizational and structural changes such as multidisciplinary teams, quality-related committees, and technology investments, which facilitate (3) a systematic problem-identification and problem-solving process, resulting in (4) new treatment protocols and practices, which in turn result in (5) improved outcomes. Success strengthens commitment to quality improvement and turns this temporal pattern into an ongoing cycle. The entire process reflects the establishment, growth, and reinforcement of a culture of quality.

The Improvement Guide: A Practical Approach to Improving Organizational Performance
Gerald J. Langley, Ronald Moen, Kevin M. Nolan, et al.
San Francisco: Jossey-Bass Publishers, 1996.
In this book, the authors take Edward Deming's Plan-Do-Study-Act premise and provide demonstrations of rapid improvement initiatives with stories from business, law, and health care to illustrate the successes of this approach. Applicable tools and practical ideas couch the concepts in concrete experience. A resource guide to change concepts is included.

Improving Patient Flow and Reducing ED Crowding: Evaluation of Strategies from the Urgent Matters Learning Network II
Megan McHugh, Kevin Van Dyke, Julie Yonek, Embry Howell, et al.
Health Research & Educational Trust, Contract Final Report prepared for the Agency for Healthcare Research and Quality; 2011.
This report summarizes the findings from an evaluation of UMLN II. It describes the facilitators and challenges to implementation, the time and resources needed to implement patient flow improvement strategies, and the impact of the strategies on measures of patient flow.

Time and Expenses Associated with the Implementation of Strategies to Reduce Emergency Department Crowding
Megan McHugh, Kevin Van Dyke, Julie Yonek, Dina Moss
Journal of Emergency Nursing, forthcoming 2011.
This article describes the time spent and expenses incurred as the six UMLN II hospitals planned and implemented strategies to improve patient flow and reduce crowding. Eight strategies were implemented. Time spent planning and implementing the strategies ranged from 40 to 1,017 hours per strategy. The strategies were largely led by nurses, and collectively, nurses spent more time planning and implementing strategies than others. The most time-consuming strategies were those that involved extensive staff training, large implementation teams, or complex process changes. Only three strategies involved sizable expenditures, ranging from $32,850 to $490,000. Construction and the addition of new personnel represented the most costly expenditures.

Page last reviewed October 2018
Page originally created September 2012
Internet Citation: Appendix D: Additional Readings. Content last reviewed October 2018. Agency for Healthcare Research and Quality, Rockville, MD.
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