Table 1

Suggested quality indicators for EDs grouped by the domains of structure, process and outcome

Quality question	Structure measure	Process measure	Outcome measure
Facilities adequate?	Capacity indices, such as the number of resuscitations/majors cubicles for the patient case mix (in relation to local guidelines) Specific areas for vulnerable groups (eg, children, mentally ill and confused elderly) Presence or absence of functional equipment to ensure patient safety Adequate security Disaster/major incident plan	Maintenance logs for equipment Regular cleaning records and inspections Regular stock inventory Regular testing/rehearsal of disaster plan	Patient experience Incidence of hospital-acquired infection Recorded incidents of assault/injury on staff members
Numbers and skill mix of staff adequate?	Total number of staff and skill mix (in relation to local guidelines) Staff turnover and sickness levels Number of new patients per staff member (with reference to staff seniority) in unit time Number of patients waiting to be seen (by triage category)	Times to be seen by decision maker Times from arrival to discharge from ED Proportion leaving without being seen	Complaints and critical incidents
Is there a culture of quality?	Is the leadership committed to quality and accountability? Is the leadership ‘satisfied’ or constantly improving? Does the ED have clinical autonomy and an ability to develop its own evidence-based practice? Quality or safety committee is seen as part of the essential administrative structure? Is ED quality seen as a holistic health service issue?	Hospital leadership visible in clinical areas Hospital-wide quality initiatives (eg, care transitions and hand washing) ED-led quality initiatives and guidelines Effective dashboard of quality and safety that is locally available and acted upon Quality of ED decision making monitored and acted upon (eg, through errors and adverse events) Adequate communication with primary care and other community services	Patient experience Patient empowerment/ability to participate in own care Medication errors
Data support adequate?	Is there a system in place to facilitate monitoring of the process and outcome measures described in this table?	System generates reports that support departmental quality management ICT regularly maintained and developed appropriate to evolving emergency care needs	Patient experience Objective measures show continuous quality improvement Contributions to public health in the local community (child protection, police liaison, etc)
Key process measures in place?		Time from arrival to cubicle Time to decision maker Time to analgesia Audit against other EDs and national guidelines Left without being seen rate Bed turnovers	Patient experience Survival/functional status for time sensitive conditions (eg, stroke, MI, sepsis) Time intervals in journey Diagnostic errors Avoidable patient returns to the ED
Access block present?	Proportion of time that patients are on trolleys in corridor Frequency with which meal rounds and drug rounds are required in the ED	Time to offload patients from ambulances Trolley waits above a locally agreed threshold Time to admission from decision to admit Median length of stay for all patients Left without being seen rate	Case mix survival measures for high mortality conditions Length of stay and complication rates for hospitalised patients Proportion returning to ED within 7 days Incidence of hospital-acquired infection (depending on length of stay in ED)
Evidence-based practice resulting in appropriate care and optimal results?	Presence of clinical pathways to support best evidence-based practice Appreciation of cost-effectiveness	Pathway compliance Times to critical interventions such as reperfusion or antibiotics Regular audits of use of key investigations/treatments of high-risk/high-volume conditions	Patient mortality (general or specified conditions) Risk-adjusted outcomes (eg, from registry data) Other clinical outcome data Proportion returning to ED within 7 days
Patient experience measured and acted upon?	Use of patient feedback tools Inclusion of patients on hospital boards	Changes implemented on the basis of patient feedback	Progressive improvements in patient feedback Equitable access for different races/gender and minority groups
ED staff experience measured and acted upon?	Feedback at ED staff appraisals Use of staff feedback tools, including other specialties Training and education programmes for ED staff	ED staff empowered and supported by management/leadership team Changes implemented on the basis of staff feedback	Progressive improvements in staff feedback Improving trainee and student feedback in training departments

ED, emergency department; ICT, information and communication technologies; MI, myocardial infarction.