ED Accreditation Update

New standards make hospital leaders accountable for managing patient flow, nurturing relationships

While new requirements are not always welcomed in the ED, to be sure, managers and front-line providers do have reason to feel optimistic about new standards, unveiled by The Joint Commission (TJC), regarding how hospitals manage patient flow.

Recognizing that patient flow does not necessarily begin and end in the ED, the accrediting agency is taking firm steps to hold hospital leaders accountable for measuring all the components of the patient flow process, and for setting goals for improvement. Further, beginning in 2014, hospital leaders have been put on notice that they need to have referral options in place for the care of patients who present to the ED with behavioral health emergencies.

"Hospital leaders are going to have to establish relationships with community resources so that the ED can treat these patients and then move them to more appropriate settings," explains Jeannie Kelly, RN, MHA, LHRM, an expert on risk management and quality assurance at Soyring Consulting in St. Petersburg, FL. "You have to have these relationships at a higher level going on, so that all the parties can communicate and work with each other, and get out of the silos they are in now."

By providing hospital leaders with a year to gear up for these standards, it is clear that TJC recognizes that it will take time to forge relationships with other community providers. However, Kelly notes that it is also clear that the agency recognizes what busy EDs are up against on a daily basis.

"These people who work in the ED are overworked and stressed, and they are trying to shovel against the tide. There is a never-ending flow of people and problems coming in, and they are doing the best they can with what they have," she says. "I think The Joint Commission realizes this, so they are elevating the responsibility [for patient flow] and making hospital leadership more accountable."

Kelly adds that TJC is also being realistic about the time it takes to nurture ties with other provider organizations in a community. "The agency recognizes that physicians, nurses, and social workers can't just pick up the phone and establish this kind of community relationship. That has to come at a higher level."

Take note of added considerations

Already in place, as of January 1, 2013, are standards requiring hospitals to have written plans in place for the care and treatment of patients who present to the ED with emotional or substance abuse problems. "There are several things that have to happen," says Kelly. "ED providers have to assess these patients for their medical and psychological problems, and they have to determine what kind of placement or treatment they might need."

In addition, while these patients await discharge or transfer to another facility, they need to be in an environment that is safe and well-monitored so that there is no danger of a patient hurting him- or herself or others. "ED providers can generally not leave these patients alone or out of sight, so there is a lot that is required above and beyond a typical patient who might be boarded in the ED for one reason or another," adds Kelly. "They need a lot of extra care and extra considerations."

The sooner such patients can be transferred to a care environment that meets their needs, the better, says Kelly. This is where the community relationships become so important. "Knowing what kinds of resources are out there, and where these patients can be properly placed is paramount to the success [of these standards]," says Kelly. "Hospital leaders need to start initiating these relationships today."

While EDs are still struggling with the challenge of caring for behavioral health patients, Kelly observes that many clinicians and hospital administrators are encouraged that the issue is getting more attention by the public as well as accrediting organizations. "The reports of shootings by people who were unstable and didn't have access to community mental health resources have focused more attention on this," she says. "If we can get people the kind of health care they need, whether it is physical or mental health care, that will be a really good thing for the country."

Clear away barriers

Kelly notes that TJC surveyors will certainly want to document that hospitals have written policies and procedures in place regarding patient flow practices; however, she notes that the tougher test will be whether the hospitals are adhering to these procedures. "There can be barriers in place, such as crowding or not enough psych beds," she says. "It could be that someone has not been trained; they don't know what the psych resources are or they don't know what the plan is."

These are issues hospital leaders should consider when developing plans for complying with the patient flow standards. "There are many different barriers, and some of them are not real. Some are just perceived," says Kelly, noting that it is not uncommon for a busy nurse or case manager to say that there are no beds available without thoroughly checking whether that is really the case.

Beginning in 2014, accredited hospitals will need to measure and set goals for mitigating and managing the boarding of patients who come through the ED. Further, TJC is recommending that patients be boarded for no longer than four hours, based on safety and quality.


  • Jeannie Kelly, RN, MHA, LHRM, Health Care Consultant, Soyring Consulting, St. Petersburg, FL. Phone: 866-345-3887.