SUPPLEMENTARY INFORMATION:

Proposed Project

“Improving Patient Flow and Reducing Emergency Department Crowding”

AHRQ proposes to study implementation of strategies from the Urgent Matters (UM) Toolkit for improving patient flow in emergency departments (ED). UM, a Robert Wood Johnson Foundation (RWJF) funded initiative, began as a collaborative of 10 urban, safety net hospitals that experimented with a variety of strategies (now included in the “UM Toolkit”) designed to relieve ED crowding. The first phase of this initiative demonstrated that reductions in ED crowding were achievable without investment of significant financial resources. However, implementation of these strategies has not been widespread, and questions remain about how readily the strategies could be implemented in a more diverse group of hospitals, and the associated costs and outcomes of implementation. This study is funded by a grant from RWJF to AHRQ.

Six diverse hospitals have been selected for this study of the implementation of strategies from the UM Toolkit for improving ED patient flow. This study poses a common outcome goal across all six sites of improving patient flow and reducing ED crowding, but requires each hospital to select strategies that fit its own needs amid context. This approach rests on innovation research showing that organizational innovations are more successful when they are aligned with features of the adopting hospital. Participating hospitals will select strategies from the UM Toolkit that they believe will work best to address the particular problems they face. The six hospitals have agreed to participate in a collaborative run by the UM National Program Office (NPO) over the course of this study to facilitate the sharing of data and experiences while the project is under way.

This study will document the experiences of a diverse set of hospital EDs as they identify and implement ED patient flow improvement strategies. The six case study hospitals were selected to reflect diversity of size, ownership, teaching status, safety net status, and types of challenges with ED crowding.

Research methods will include observational site visits, in-person and telephone interviews, and the analysis of cost data. AHRQ's contractor for this study, Health Research & Educational Trust (HRET), will perform analysis of secondary data on ED performance measures; this secondary data will be provided to HRET by the Urgent Matters NPO. These qualitative and quantitative methods will be used to:

• Study the processes through which hospitals decide upon and adopt patient flow improvement strategies;
• Identify facilitators and barriers to the implementation and maintenance of these strategies;
• Document changes in patient flow, patient satisfaction, and staff satisfaction associated with the implementation of strategies and processes;
• Generate estimates of the costs of adopting the strategies;
• Identify issues associated with the reporting of ED performance measures, and
• Develop lessons for hospitals considering the adoption of patient flow improvement strategies.

The study will not be used to answer questions about causality or degrees of effectiveness (e.g to what degree did a ( printed page 2597) given intervention cause an improvement in patient flow?). Rather, the study seeks to enhance understanding of factors affecting decision-making and adoption processes that facilitate or hinder implementation. Insights and lessons learned about organizational, technical and resource challenges arising from these improvement activities may be of interest or benefit to others seeking to identify and adopt strategies to address similar problems in their EDs.

This study is being conducted pursuant to AHRQ's statutory authority to conduct and support research on health care and on systems for the delivery of such care, including activities with respect to: The quality, effectiveness, efficiency, appropriateness and value of health care services; quality measurement and improvement; and health care costs, productivity, organization, and market forces. 42 U.S.C. 299a(a)(1), (2), and (6).

Method of Collection

AHRQ seeks approval for the following data collection activities:

• In-person interviews will be conducted within two months of the implementation with up to 12 individuals at each of the 6 sites during two-day site visits to each of the hospitals.
• Telephone interviews will be conducted approximately 6 months after implementation with 12 individuals from each of the six hospitals (most or all of whom will be the same individuals interviewed in person).
• Each of the six hospitals will submit information on the costs associated with the planning, implementation, and maintenance of the patient flow improvement strategies on a monthly basis. One study team member at each site will record costs on an assessment instrument specifically designed for this purpose and tailored to each hospital's own organizational structure and patient flow strategies.

This assessment instrument will collect information on staff time devoted to the patient flow improvement initiatives as well as the costs of items or resources purchased to support the initiatives.

Estimated Annual Respondent Burden

Exhibit 1 shows the estimated annualized burden hours for the hospitalst time to participate in this study. In-person interviews will be conducted within two months of implementation with 12 administrative and clinical personnel from each of the six participating hospitals and will require about one hour. Telephone interviews will be conducted approximately six months thereafter with 12 individuals (administrative and clinical) from each hospital and will take about 45 minutes. Monthly cost assessment data will be collected from each participating hospital each month and will require about one hour. The total estimated burden for participation in this study is 198 hours.

Exhibit 2 shows the estimated annualized cost burden for the respondents' time to provide the requested data. The total cost burden is approximately $6,536.

Estimated Annual Costs to the Federal Government

Exhibit 3 shows the total and annualized cost to the government for this eighteen-month study.

Request for Comments

In accordance with the above-cited Paperwork Reduction Act legislation, comments on AHRQ's information collection are requested with regard to any of the following: (a) Whether the proposed collection of information is necessary for the proper performance of AHRQ's health care research and health care information dissemination functions, including whether the information will have practical utility; (b) the accuracy of AHRQ's estimate of burden (including hours and costs) of the proposed collection(s) of information; (c) ways to enhance the quality, utility, and clarity of the information to be collected; and (d) ways to minimize the burden of the collection of information upon the respondents, including the use of automated collection techniques or other forms of information technology.

Comments submitted in response to this notice will be summarized and included in the Agency's subsequent request for OMB approval of the proposed information collection. All comments will become a matter of public record.

74 FR 2596