Emptying the corridors of shame: organizational lessons from England's 4-hour emergency throughput target

Study objective: Since 2005, 98% of patients treated in England's emergency departments (EDs) must be discharged or placed in a hospital bed within 4 hours of arrival. Using a qualitative approach, we describe lessons learned from implementing the 4-hour emergency throughput target.

Methods: This was a qualitative study of EDs in England, purposively sampled for a range of size and performance on the target. Leadership of EDs at 9 Acute Trusts (hospitals) were interviewed between June and August 2008. Using content analysis, we analyzed semistructured interviews to identify salient themes.

Results: Twenty-seven interviews were coded. Respondents agreed on the following themes. (1) Interdependency: Even with extensive ED process re-engineering, widespread Trust involvement was essential to meeting the target. Additionally, lack of recognition that it was a "Trust target" contributed to conflicts between staff, concerns for patient safety, and lost opportunity for organizational improvement. (2) Contrasting change management strategies: ED leadership used collaborative strategies, whereas change in the rest of the hospital required a top-down approach. (3) Burden and benefit for staff: Nursing perceived the greatest burden from the target but also acquired enhanced authority, skills, and roles. (4) COSTS: Although most EDs are now within range of the target, consistent performance while balancing patient safety remains tenuous.

Conclusion: Achieving the 4-hour target requires hospital-wide support. Lack of organizational ownership contributes to negative effects on staff, incomplete process improvement, and risk to patients. These lessons have widespread implications for all targets and may help explain why some health care targets fail to achieve their aims.