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.