Targets for emergency department performance

The problem of crowding in emergency departments (EDs) in New Zealand has been a conundrum for more than thirty years. Crowding in EDs is associated with increased adverse clinical outcomes, patient dissatisfaction, patients leaving without being seen, and an increased chance of readmissions.

In 2009, the shorter stay target was introduced in New Zealand as a way to improve the patient flow and therefore, reduce the level of crowding. This target says that 95 percent of all ED patients should be admitted to hospital, discharged, or transferred within six hours of arrival.

The initial results seemed promising and suggested that the target did work. Emergency department managers were incentivised to act with the primary objective of meeting the shorter stay target. Patient flow was redesigned, new resources were allocated, and new facilities built. However, besides the honest improvements, the magical number turned out to be unreachable in some cases and emergency departments and DHBs were exposed to public criticism. In this regard, evidence has shown that some undesirable actions have contributed to accomplishing the target. These actions are against the ultimate objective of high-quality patient outcomes.

Counterproductive behaviours caused by the implementation of targets as a main measure of performance, can be compared to the unwanted side-effects of medicine. A medicine likely cures the illness, but can cause unwanted reactions such as dry mouth, drowsiness, etc. In the context of targets, they guide performers to some specific direction, but potentially with unwanted side-effects.

Consider the case that a school is measured by the result of its students in a particular test. If preparation for the test fails to achieve the target, a counterproductive behaviour may occur when teachers are instructed to focus on practising for the test, ignoring other subjects and deviating efforts from the institution’s true purpose: education. When corporations need to reach quarterly earnings and price per share stock, they may not reach the target through efficient performance, but by distorting accounting records of revenues and expenditures. If an operator has a target of accomplishment for a certain number of jobs in a limited period of time, most likely the operator will choose those jobs with a short processing time instead of those that may require long processes and could risk the accomplishment of the target.

The next leading question is how EDs’ six-hour target in New Zealand would be different from those from other fields and perhaps not reveal dysfunctional effects.

Evidence shows that although the shorter stay target in EDs is largely achieved through desired actions, there may be issues of effort substitution and gaming the target. In EDs, quality in care is the substituted effort. Because of the aim to reduce the time patients spend in the system, physicians might feel rushed and not complete physical exams or take much of a history. As a potential consequence, patients would likely return to visit the ED because the first treatment was not appropriate.

The other important dysfunctional effect is gaming. Gaming does not produce an improvement in the metric targeted and is harmful to the system as it uses resources to cheat, while not achieving any improvement. In EDs this can be seen when ambulances arrive at a crowded system, and because the patient is most likely going to exceed the six hours, the patient will wait in the ambulance where the clock doesn’t start counting yet. Once there is a certain confidence that the target will be accomplished, then patients are admitted to the ED. Hospitals often use gurneys without wheels as beds, also known as short stay units (SSU), so that patients who were waiting could be considered admitted to a hospital bed.

The literature has provided an extensive number of ED metrics and the pros and cons associated with them. However, there is no consensus on which of them are essential to building a unique framework that ensures quality of care to patients. This research will analyse the importance of these metrics, aiming to counteract the undesirable actions found in reaching the shorter stay target. As a result, we are going to develop a set of models to give guidance to service providers on how to achieve the new metric, or set of metrics, without neglecting other elements of the system.

For that reason, system dynamics is the first-stage methodology to be used in this research, as there are no studies that link the effects of these metrics and ways of gaming within a crowded emergency department. The interaction between metrics, ways of gaming and the use of resources will give a wider picture and understanding of the entire ED system, and overall, what patient outcome the current policy is delivering. In the second stage, finer grained models, such as stochastic control models will be used to highlight the key trade-offs in metric selection.

Finally, this research aims to develop a new policy, demonstrate why it may lead to a better patient outcome than the current one, which is based on an isolated shorter stay target, and provide recommendations for further next steps towards implementation in New Zealand.

John Cleveland is a PhD student at the University of Auckland Business School's Department of Information Systems and Operations Management.