• Bruce Siegel, Marcia J Wilson, and Donna Sickler.
• Department of Health Policy, The George Washington University School of Public Health and Health Services, Washington, DC, USA. siegelmd@gwu.edu
• Jt Comm J Qual Patient Saf. 2007 Nov 1;33(11 Suppl):57-67.

IntroductionApproximately one third of hospitals in the United States report increases in ambulance diversion in a given year, whereas up to half report crowded conditions in the emergency department (ED). In a recent national survey, 40% of hospital leaders viewed ED crowding as a symptom of workforce shortages. Many health systems are implementing a variety of strategies to improve flow and reduce crowding.Domains Of ImprovementVirtually all work-flow initiatives use operations management techniques that include some or all of four domains: performance measurement, demand forecasting, flow redesign, and capacity management. These are often implemented using rapid improvement techniques. Most initiatives tend to focus on functional increases in inpatient capacity.Implications For Practice And PolicySuccessful strategies to improve patient flow are distinguished by an organizationwide commitment to measurement, transparency in data reporting, and sustained management attention. Focusing on transitions between ED and inpatient units and maximizing overall hospital capacity appears necessary for improvement. Hence, reductions in ED crowding require strategies that go far beyond the ED.ConclusionHealth systems can take tangible, immediate steps to improve flow and reduce crowding. Efforts would be enhanced by more controlled trials of existing strategies in the context of uniform performance measures.

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