LAUSR

Study objective: Emergency department (ED) crowding and patient boarding are associated with increased mortality and decreased patient satisfaction. This study uses a positive deviance methodology to identify strategies among high‐performing, low‐performing, and high‐performance improving hospitals to reduce ED crowding. Methods: In this mixed‐methods comparative case study, we purposively selected and recruited hospitals that were within the top and bottom 5% of Centers for Medicare & Medicaid Services case‐mix‐adjusted ED length of stay and boarding times for admitted patients for 2012. We also recruited hospitals that showed the highest performance improvement in metrics between 2012 and 2013. Interviews were conducted with 60 key leaders (physicians, nurses, quality improvement specialists, and administrators). Results: We engaged 4 high‐performing, 4 low‐performing, and 4 high‐performing improving hospitals, matched on hospital characteristics including geographic designation (urban versus rural), region, hospital occupancy, and ED volume. Across all hospitals, ED crowding was recognized as a hospitalwide issue. The strategies for addressing ED crowding varied widely. No specific interventions were associated with performance in length‐of‐stay metrics. The presence of 4 organizational domains was associated with hospital performance: executive leadership involvement, hospitalwide coordinated strategies, data‐driven management, and performance accountability. Conclusion: There are organizational characteristics associated with ED decreased length of stay. Specific interventions targeted to reduce ED crowding were more likely to be successfully executed at hospitals with these characteristics. These organizational domains represent identifiable and actionable changes that other hospitals may incorporate to build awareness of ED crowding.