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Measurement and improvement of emergency department performance through inspection and rating: an observational study of emergency departments in acute hospitals in England
  1. Thomas Allen1,
  2. Kieran Walshe2,
  3. Nathan Proudlove2,
  4. Matt Sutton3
  1. 1 Manchester Centre for Health Economics, University of Manchester, Manchester, UK
  2. 2 Alliance Manchester Business School, University of Manchester, Manchester, UK
  3. 3 School of Health Sciences, University of Manchester, Manchester, UK
  1. Correspondence to Dr Thomas Allen, Manchester Centre for Health Economics, University of Manchester, Manchester M13 9PL, UK; thomas.allen{at}


Introduction Hospital inspection and the publication of inspection ratings are widely used regulatory interventions that may improve hospital performance by providing feedback, creating incentives to change and promoting choice. However, evidence that these interventions assess performance accurately and lead to improved performance is scarce.

Methods We calculated six standard indicators of emergency department (ED) performance for 118 hospitals in England whose EDs were inspected by the Care Quality Commission, the national regulator in England, between 2013 and 2016. We linked these to inspection dates and subsequent rating scores. We used multilevel linear regression models to estimate the relationship between prior performance and subsequent rating score and the relationship between rating score and post-inspection performance.

Results We found no relationship between performance on any of the six indicators prior to inspection and the subsequent rating score. There was no change in performance on any of the six indicators following inspection for any rating score. In each model, CIs were wide indicating no statistically significant relationships.

Discussion We found no association between established performance indicators and rating scores. This might be because the inspection and rating process adds little to the external performance management that EDs receive. It could also indicate the limited ability of hospitals to improve ED performance because of extrinsic factors that are beyond their control.

  • performance improvement
  • quality
  • statistics
  • emergency care systems, emergency departments

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  • Contributors TA, KW, NP and MS: design of this study. TA: conducted the analysis. TA, KW, NP and MS: drafted this article.

  • Funding This research was funded by the NIHR Policy Research Programme (PR-R11-0914-12001). The open access funding was provided by the Institute for Health Policy and Organisation, University of Manchester.

  • Disclaimer The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Correction notice Since this article was published online, the text from figure 1 has been added to the text and figure 2 and 3 have been renumbered as figure 1 and 2.

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