HiQuiPs: Quality of Care and the ED

In Education & Quality Improvement, HiQuiPs by Ahmed TaherLeave a Comment

You have just finished a busy ED shift on a warm summer evening and feel that you have been able to help a lot of people today. You plan to visit a patio and relax as you have earned it! On your way out you overhear a patient and their family members saying that they came to this ED because they heard it was “the best”, and they would never go back to the other ED as the care isn’t as good.  You think about this on your scenic drive to the patio and wonder why the patient thinks your ED is “the best”? How is “the best” being measured? Who makes that determination? And how can EDs in general have good quality? You think about elements like the ED size, how many patients are being seen, the rate at which they are seen, and how satisfied they are. Your mind wanders about many different elements, but how do you reconcile them? And where is a good starting point?

Welcome to our new HiQuiPs series, where we will cover a wide array of topics within the intertwined fields of Health Informatics, Quality Improvement, and Patient Safety as they relate to emergency medicine.  Quality of care is an integral starting point to our discussions. A previous two-part CanadiEM Quality Improvement series sought to define quality in healthcare, quality improvement and introduce some basic approaches.12 They discussed the classical definition from the landmark Institute of Medicine report which includes six domains that define quality of care which are safe, effective, patient-centered, timely, efficient, and equitable.3 

These are broad categories, but how do they translate to a practical assessment of the current quality of care in your ED and apply them to improvement initiatives? When you are driving your car you need to know how it’s performing – what the gas level is, how fast you’re going, indicators for your temperature, and oil, etc. But there are so many different elements pertaining to the ED that you can think of on your drive. So the first step is how to organize them.

Frameworks to Think About Healthcare Quality

When reading about quality measures, many terms often appear like benchmarking, indicators, and targets. Figure 1 provides a helpful framework that helps organizes some commonly used terms:

Commonly used terms in healthcare quality

Figure 1. Commonly Used Terms for Healthcare Quality. Reproduced from Cameron et al.4

One of the most widely used frameworks to organize quality measures is the Donabedian model, which classifies measures into the three categories: structural,  process, and outcome measures.5

Why is it important to know about this model? Well, it will frame how you think about quality and help communicate with others.  Structural measures are the easiest to measure and reflect the capacity of the system. Process measures are reflections of different elements of the continuum of care, and may coincide with guidelines or recommendations of care.6 Outcome measures reflect the impact of care on patients. These are more difficult to measure at times, but reflect what is ultimately intended by the provision of care. Another category of measures that is often included in quality frameworks are balancing measures, which reflect the unintended consequences of changing the system.7  A summary with examples is presented below:

Framework for Quality Improvement Measures
Structural MeasuresThe capacity of the systemNumber of ED beds; number of nurses, porters, or physicians on shift.
Process MeasuresWhat is done along the continuum of careTime to be seen by ED physician; percentage of patients receiving meal trays; length of time until consultant calls back.
Outcome MeasuresThe impact of the care or interventionPatient reported outcomes; number of unscheduled return visits.
Balancing MeasuresUnintended consequencesCost changes with intervention; impact on other patients; impact on other services.

On the next shift after meeting your friends on that patio, you see a patient that is critically ill with acute respiratory distress. After you intubate and stabilize them, the transfer to the ICU team takes much longer than expected. You return often to re-assess and continue to manage the care of this patient. You believe that this takes away from your ability to care for other patients effectively during your shift. You wonder about the quality of care this patient experienced as well as the other patients during your shift. You wonder what quality measures are being collected by your department.

There are numerous methods to collect data on quality. They vary in terms of scope and labour intensiveness as they pertain to different needs. Figure 2 is a summary of a variety of methods that can be used to collect quality data. Having a routine and standard way of quality data collection is essential to understanding the quality of care in your ED.

Figure 2. Methods of Data Collection for Healthcare Quality. Reproduced from Cameron et al.4

Emergency Department Quality Measures

Over the past decade, there has been an increasing role of ED quality data collection and public reporting across North America. Given the numerous options in quality measures, efforts have been made to standardize them. This would enable increased adoption, use, benchmarking, comparisons, and public reporting. Currently, there are two consensus-driven approaches for ED quality measures.

The first was published in a Canadian consensus paper, with a set of 48 indicators across nine categories: patient satisfaction, ED operations, patient safety, pain management, pediatrics, cardiac conditions, respiratory conditions, stroke, and sepsis or infection.8 The highest ranked measures in each category are shown in Figure 3:

Top priority indicators

Figure 3. Top Priority Indicators as ranked by a Canadian Consensus Panel. Reproduced by Schull et al.8

The second approach arose from the proceedings of the 2014 Emergency Department Benchmarking Alliance Consensus Summit with indicators across several categories: ED operational characteristics, hospital operational characteristics, timestamps and time intervals, proportion metrics and readmission measures, as well as ED utilization and staffing units.9  There are also many notable healthcare organizations which focus on healthcare quality which can be helpful if you are going more in depth.4

Regardless of the approach, there are evidence-based consensus driven measures that can be utilized. Maybe now you wonder about which ones are being used in your ED and how they are being used? Or how many are used locally and how many are reported to the Ministry of Health?

Now you are equipped with a basic approach to understanding healthcare quality measures and how they apply to the ED. With this new lens, you are eager to get started on a local quality improvement project in your ED. Now you just have to choose a project!

As you prepare for your QI project, you wonder where to get more information. Stay tuned for our next HiQuiPs monthly post, as we start a three-part series called: QI in the ED – Preparation, where we will cover general considerations, stakeholder engagement, elements of behaviour change, root cause analyses and much more!

This post was copyedited by Paula Sneath 

Click here for more articles in the HiQuiPs series!

**UPDATE (November 2020): The HiQuiPs Team is looking for your feedback! Please take 1 minute to answer these three questions – we appreciate the support!**


Chartier L, Mondoux S. QI Series Part 1 | What is Quality Improvement? – CanadiEM. CanadiEM. https://canadiem.org/what-is-quality-improvement/. Published February 15, 2017. Accessed May 30, 2018.
Chartier L, Mondoux S. Quality Improvement Series Part 2 | What is “Quality” in health care and how do we achieve it? CanadiEM. https://canadiem.org/qi-serieswhat-is-quality-in-health-care/. Published March 29, 2017. Accessed May 30, 2018.
Institute of Medicine, Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. 1st ed. Washington, DC: National Academies Press; 2001.
Cameron P, Schull M, Cooke M. A framework for measuring quality in the emergency department. Emerg Med J. 2011;28(9):735-740. [PubMed]
Donabedian A. The methods and findings of quality assessment and monitoring: an illustrated analysis. Journal for Healthcare Quality. 1985;7(3):15.
Types of Quality Measures. Agency for Healthcare Research and Quality. https://www.ahrq.gov/professionals/quality-patient-safety/talkingquality/create/types.html. Published 2015. Accessed May 31, 2018.
Science of Improvement: Establishing Measures . Institute for Health Improvement. http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementEstablishingMeasures.aspx. Published 2012. Accessed June 1, 2018.
Schull M, Guttmann A, Leaver C, et al. Prioritizing performance measurement for emergency department care: consensus on evidence-based quality of care indicators. CJEM. 2011;13(5):300-309, E28-43. [PubMed]
Wiler J, Welch S, Pines J, Schuur J, Jouriles N, Stone-Griffith S. Emergency department performance measures updates: proceedings of the 2014 emergency department benchmarking alliance consensus summit. Acad Emerg Med. 2015;22(5):542-553. [PubMed]

Ahmed Taher

Ahmed is an Emergency Physician at University Health Network and Mackenzie Health in Toronto. He completed the Toronto FRCPC Emergency program, and a Masters of Public Health program at Johns Hopkins Bloomberg School of Public Health with certificates in Quality Improvement & Patient Safety, as well as Public Health Informatics.

Sachin Trivedi

Dr. Trivedi is an Emergency Resident at the University of Saskatchewan. His interests include quality improvement and patient safety, point of care ultrasound and trauma.


Dr. Shawn Mondoux is an emergency physician at Hamilton Health Sciences (HHS) and faculty at McMaster University in Hamilton, Ontario. He obtained a masters of Quality Improvement and Patients Safety (QIPS) at the University of Toronto and serves as QI advisor to all projects within the ED. He has a strong interest in clinical QI work as well as the education of PGME learners in QI principles.

Lucas Chartier

Dr. Lucas Chartier is an emergency physician and Deputy Medical Director for the University Health Network (UHN) emergency department (ED). He is also UHN's inaugural Medical Director of Quality and Safety, the ED Lead for the Toronto Central Local Health Integration Network (TC LHIN) and the Chair of the Quality Improvement and Patient Safety (QIPS) Committee of the Canadian Association of Emergency Physicians. With training at McGill (MD CM), University of Toronto (FRCPC) and Harvard (MPH), he now tries to spread the QIPS gospel in all the ways possible!