Litvak E, McManus ML, Cooper A. Root cause analysis of emergency department crowding and ambulance diversion in Massachusetts. Boston University Program for Management Variablity in Health Care Delivery. 2002.

Based on the data from two Massachusetts hospitals, report provides a quantitative analysis of the effect of different factors on emergency department overcrowding. It demonstrates that artificial variability has a major impact on hospital throughput.

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Litvak E, Long MC, Cooper A, McManus M. Emergency department diversion: Causes and solutions. Academic Emergency Medicine. 2001;8(11):1108-1110.

An exploration of the two types of variability experienced in the hospital setting, natural variability and artificial variability, and how queuing theory can be used to manage natural variability while artificial variability should be eliminated to improve flow of patients.

Litvak E, Long MC. Cost and quality under managed care: Irreconcilable differences? The American Journal of Managed Care. 2000;6(3):305-312.

This article puts forth a variability-based methodology to aid in understanding the limits of health care expense reduction and its effect on quality. It also introduces the concept of the variabilities.

Hoffenberg S, Hill MB, Houry D. Does sharing process differences reduce patient length of stay in the emergency department? Annals of Emergency Medicine. 2001;38(5):533-540.

This article looks at the effectiveness of determining best demonstrated practices for reduction in length of stay in the emergency departments (ED) of a large multi-hospital system and sharing the found differences with all EDs in the system.

Derlet RW, Richards JR. Overcrowding in the nation's Emergency Departments: Complex causes and distrubing effects. Annals of Emergency Medicine. 2000;35(1):83-85.

An article discussing the “complex web of interrelated issues” responsible for emergency department overcrowding.

Bryant J. ER crowding in growth cities. Atlanta Business Chronicle. 2003.

An article about the crowding of emergency departments in cities with quickly growing populations.

Bagust A, Place M, Posnett JW. Dynamics of bed use in accommodating emergency admissions: Stochastic simulation model. BMJ. July 17, 1999; 319 (7203):155–158.

Investigates how insufficient capacity in acute care hospitals affects patients requiring emergent admission.

Andrulis DP, Kellerman A, Hintz EA, Hackman BB, Weslowski VB. Emergency departments and crowding in United States teaching hospitals. Annals of Emergency Medicine. September 1991;20(9):980–986.

This study finds that overcrowding in the emergency department adversely impacts hospitals regardless of ownership.

Aiken LH, Clark SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002;288:1987–1193.

A study of the impact of nurse staffing levels on mortality and failure-to-rescue rates, as well as nurse job satisfaction.

Besserman E, Teres, D, Logan A, Brennan P, Cleaves S, Bayly R, et al. Use of flexible intermediate and intensive care to reduce multiple transfers of patients. American Journal of Critical Care. 1999;8(3):170-179.

Described here is a method for small-cycle quality improvement: Plan-Do-Study-Act. Mostly concentrates on Adult Intensive Care Unit and the IHI Breakthrough Series.