Emergency-department (ED) overcrowding is common in countries across the globe. Patients must often wait hours before being seen by a doctor and far longer before being transferred to a hospital bed. The result is not merely inconvenience but rather a degradation of the entire experience—quality of care suffers, patients’ safety is endangered, staff morale is impaired, and the cost of care is increased.

Many hospitals have tried to reduce ED wait times, but their efforts usually fail to produce sustainable results, for two reasons. The first is the narrowness of most performance-improvement programs, which focus solely on the ED. Many of the factors that contribute to ED overcrowding occur in other parts of the hospital and thus are beyond the department’s control. Hospitals are complex, high-stress systems that require significant cross-departmental and cross-role coordination at all times. Even something as seemingly simple as transferring a patient can require the involvement of six to ten clinical and nonclinical staff members. Therefore, the only way to make substantial operational improvements in one part of a hospital is to implement corresponding changes in other areas.

The second reason that many ED-improvement programs do not produce long-lasting results is that they focus only on processes, not staff attitudes. If the changes are to be sustained, the staff must be willing to part with tradition and to collaborate across physical and organizational divides. The hospital’s culture must enable teamwork. Creating this type of culture is, in many ways, the most difficult part of improving ED performance.

Our work with hospitals in multiple parts of the world demonstrates that substantive, sustainable improvements in ED performance can be achieved: average wait times can be lowered by one-third or more, for example, often within a few weeks. There is no single “right” approach that can be applied at every hospital, but certain elements are essential for success. Although the performance-improvement program can begin with “quick wins” in the ED, it must also include the wider hospital organization. And significant effort must be put into a cultural shift: the staff must come to understand how seemingly small changes in their actions can improve patient care in other parts of the hospital. To reinforce this cultural shift, the hospital must refine its performance-management systems and enhance its staff’s capabilities to ensure that both buttress the improvement program. Leadership is also crucial: the hospital’s CEO and senior executive team must visibly support the program, and clinicians at the front line of care delivery, especially doctors, must champion the necessary changes.

A performance-improvement program of this type can also be implemented at the health system level to reduce wait times in multiple EDs. This approach can be particularly helpful, for example, when all the EDs in a city are overcrowded.

At many hospitals, ED overcrowding is a symptom of other problems. Thus, it can signal the need for changes that, if properly implemented, can improve patient care, raise staff morale, and lower costs—not only in the ED but throughout the hospital.

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