Most organizations have found that a discharge unit/lounge proves to be another "parking" area for patients rather than achieving its intended goal of expediting discharge from the floor. As with all changes, it's important to evaluate the benefits and pitfalls within the individual setting, with particular attention to the question: "Does the change provide support/improvement across the overall system or does it create an additional bottleneck area in another part of the system?"

We have found that this small sample is enough to detect improvement over time and is feasible to implement with limited resources. You should select your sample at a time of known high volume to ensure that you capture the peaks. It is not necessary that the sample be purely random. Remember that the goal is to collect enough data to learn if your tests of change are leading to improvement.

Median time is a more sensitive and less variable measure than the average or the percentage of patients meeting a defined goal or target. The median is less affected by extreme outliers, which can distort both the average (mean) and the percentage of patients meeting a goal.

A universal definition for "decision to admit" is difficult to create, due to differences among organizations’ processes that affect the point in time when the decision to admit a patient is made and accurately documented. Organizations should agree on a definition and apply it consistently. The overall goal is to determine if your ability to move patients from the ED into the inpatient setting in a timely manner improves over time.

Senior leader support and involvement from the outset are key. Involve senior leaders in developing aims, goals, and measures to ensure that the work of your team aligns with organizational strategic priorities. Just as you would with physicians, identify a senior leader "champion" for your work. Ongoing communication is another key. Include senior leaders in the information loop from the beginning. Be sure senior leaders receive copies of all team reports and updates. Send a newsletter out to every department, not just to the manager. Consistently keep pictures and progress in view of the organization in public and private publications. Market the aims, the tests, and the progress in 3- to 5-minute sound bites in the hallways or elevators with those who are in charge of the organization. Include data in every opportunity for communication. Owning the data helps you overcome anecdotal resistance in every meeting.

Emphasize the gains to be realized in other departments. Focus on "what’s in it for them" when asking other departments to join the improvement effort. Most importantly, focus on small tests of change rather than trying to institute a permanent change. If some staff members are vocal in their criticism or blame of the target unit, be sure to include them in the test. Even skeptics are more likely to work with you if they are assured that "this is only a test." The results of the test will speak for themselves: Did the test result in an improvement?

It’s also important to identify ways to overcome the "us versus them" mentality of departmental rivalry. Try exchanging employees from one unit to another (for example, the emergency department to the telemetry unit) for one shift. The manager of the other unit may pick the day and time to do this when adequate help is available. Convene a debriefing meeting an hour before the end of the shift and ask, "How could we organize things better to improve our care and preparation of the patients we send to you, based on what you have seen tonight?" This exercise sparks ideas for change, and introduces a degree of mutual understanding between departments. The culture becomes more conducive to cooperation and communication.