title: National targets, process transformation and local consequences in an NHS emergency department (ED): a qualitative study.
abstract: BACKGROUND
  In the attempt to reduce waiting times in emergency departments, various national health services have used benchmarking and the optimisation of patient flows. The aim of this study was to examine staff attitudes and experience of providing emergency care following the introduction of a 4 hour wait target, focusing on clinical, organisational and spatial issues.
  
  
  METHODS
  A qualitative research design was used and semi-structured interviews were conducted with 28 clinical, managerial and administrative staff members working in an inner-city emergency department. A thematic analysis method was employed and NVivo 8 qualitative data analysis software was used to code and manage the emerging themes.
  
  
  RESULTS
  The wait target came to regulate the individual and collective timescales of healthcare work. It has compartmentalised the previous unitary network of emergency department clinicians and their workspace. It has also speeded up clinical performance and patient throughput. It has disturbed professional hierarchies and facilitated the development of new professional roles. A new clinical information system complemented these reconfigurations by supporting advanced patient tracking, better awareness of time, and continuous, real-time management of emergency department staff. The interviewees had concerns that this target-oriented way of working forces them to have a less personal relationship with their patients.
  
  
  CONCLUSIONS
  The imposition of a wait-target in response to a perceived "crisis" of patients' dissatisfaction led to the development of a new and sophisticated way of working in the emergency department, but with deep and unintended consequences. We show that there is a dynamic interrelation of the social and the technical in the complex environment of the ED. While the 4 hour wait target raised the profile of the emergency department in the hospital, the added pressure on clinicians has caused some concerns over the future of their relationships with their patients and colleagues. To improve the sustainability of such sudden changes in policy direction, it is important to address clinicians' experience and satisfaction.
authors.forename: Paraskevas
authors.initials: P
authors.lastname: Vezyridis
authors.affiliation: Faculty of Medicine & Health Sciences, University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH, UK. stephen.timmons@nottingham.ac.uk.
authors.forename: Stephen
authors.initials: S
authors.lastname: Timmons
mesh_terms: D001291:Attitude of Health Personnel; D017598:Efficiency, Organizational; D004636:Emergency Service, Hospital / Q000458:organization & administration* / Q000592:standards; D004739:England; D005260:Female; D006291:Health Policy; D006749:Hospital Design and Construction; D006751:Hospital Information Systems; D006801:Humans; D007400:Interprofessional Relations; D007407:Interviews as Topic; D008297:Male; D010564:Personnel, Hospital / Q000523:psychology; D010817:Physician-Patient Relations; D024382:Professional Role; D036301:Qualitative Research; D013222:State Medicine; D013997:Time Factors; D017748:Time Management; D019037:Urban Health Services / Q000458:organization & administration* / Q000592:standards; D014850:Waiting Lists; D057188:Workflow