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While uncertainty during emergency response operations necessitates adaptive performance, emergency response organizations, such as the fire service, tend to constrain adaptive behaviors due to their highly formalized bureaucratic structures. Structural theories suggest that leaders can empower employees to bypass these constraints.

Using survey data from four US fire departments, this research tests whether mid-level supervisors can empower firefighters by increasing their ability to improvise during complex emergency response operations, and whether this enhances department adaptive performance. Moderated mediation is also performed to assess whether senior leaders must also be effective, empowering leaders in order to achieve heightened levels of empowerment and subsequent adaptive performance, as many senior leaders in the fire service are criticized for being overly bureaucratic, risk averse, and resistant to change.

The findings support compensatory effects and show how immediate supervisors are key to overcoming senior leader deficiencies and producing adaptive performance during conditions of high uncertainty and complexity.

The lack of response organizations’ success during complex incidents is often attributed to senior leaders who are risk averse, overly bureaucratic, and resistant to change (Wankhade and Patnaik, 2020). This study is the first to show how empowering leadership can help overcome these constraints to enhance adaptive performance under complex conditions in the fire service.

This paper aims to investigate the performances of decision-making process of emergency department’s nurses involved in the triage level assessment.

The authors developed a case study in two public hospitals in the South of Italy. The authors administered 25 clinical cases to nurses responsible of priority code assignment in the triage station. The authors simulated the attribution of the priority levels, and through a semi-structured questionnaire, the authors collected data and information about the cognitive process adopted for the final choice.

The quantitative and qualitative data allowed the authors to verify that there is an impact of the organizational context on heuristics used in the decision-making process.

The research limitations are that empirical data have been collected only in two emergency departments.

The practical implications of this paper are that organizations for improving business performances must consider the judgements are often the results of heuristics embedded in a specific structure of social and physical environment, according with the “ecological view” of rationality.

The authors’ methodological approach contributes to analyze the performances of the triage process, verifying if the eventual errors are linked to individual or organizational factors, but above all how organizational constraints influence decision-making processes in organizations and, consequently, business performances.

This paper aims to investigate the potential role of the Emergency Department (ED) layout in enhancing its functionality. It applies a performance-based building design (PBBD) approach to evaluate emergency department functionality and efficiency as the most important criterion behind the success of the hospital service.

A quantitative approach based on space syntax theory was adopted through four syntactic maps (isovist, axial, convex, and visibility graph analysis VGA), to depict three case studies in Erbil city hospitals by analyzing three different layout typologies of ED such as Podular, Ballroom and Linear through measuring wayfinding, accessibility, privacy, visibility, time spend-length of stay and corridor circulation as layout factors.

This paper provides empirical insights on how the ED layout typology factors significantly affect producing functionally efficient EDs, whereas the Ballroom ED layout typology is the most effective compared to others. Given the importance of ED in enhancing a healthy environment for patients and staff, study findings are valuable resource for health designers, who play a critical role in ensuring patients enjoy a healthy and safe environment.

This paper has attempted to identify the appropriate layout of ED for effective functional performance in hospitals. A syntactical analysis between three different ED layout typologies based on the layout variables has been analysed using the PBBD approach. There has been no attempt carried out so far to analyse the functional performance of the PBBD approach in different ED layouts using layout variables.

The purpose of this paper is to introduce a method of the bottleneck detection for Emergency Department (ED) improvement using benchmarking and design of experiments (DOE) in simulation model.

Four procedures of treatments are used to represent ED activities of the patient flow. Simulation modeling is applied as a cost-effective tool to analyze the ED operation. Benchmarking provides the achievable goal for the improvement. DOE speeds up the process of bottleneck search.

It is identified that the long waiting time is accumulated by previous arrival patients waiting for treatment in the ED. Comparing the processing time of each treatment procedure with the benchmark reveals that increasing the treatment time mainly happens in treatment in progress and emergency room holding (ERH) procedures. It also indicates that the to be admitted time caused by the transfer delay is a common case.

The current research is conducted in the ED only. Activities in the ERH require a close cooperation of several medical teams to complete patients’ condition evaluations. The current model may be extended to the related medical units to improve the model detail.

ED overcrowding is an increasingly significant public healthcare problem. Bottlenecks that affect ED overcrowding have to be detected to improve the patient flow.

Integration of benchmarking and DOE in simulation modeling proposed in this research shows the promise in time-saving for bottleneck detection of ED operations.

This paper aims to investigate the process performances in Emergency Departments (EDs) with a novel data-driven approach, permitting to discover the entire patient-flow, deploy the performances in term of time and resources on the activities and flows and identify process deviations and critical bottlenecks. Moreover, the use of this methodology in real time might dynamically provide a picture of the current situation inside the ED in term of waiting times, crowding, resources, etc., supporting the management of patient demand and resources in real time.

The proposed methodology exploits the process-mining techniques. Starting from the event data inside the hospital information systems, it permits automatically to extract the patient-flows, to evaluate the process performances, to detect process exceptions and to identify the deviations between the expected and the actual results.

The application of the proposed method to a real ED revealed being valuable to discover the actual patient-flow, measure the performances of each activity with respect to the predefined targets and compare different operating situations.

Starting from the results provided by this system, hospital managers may explore the root causes of deviations, identify areas for improvements and hypothesize improvement actions. Finally, process-mining outputs may provide useful information for creating simulation models to test and compare alternative ED operational scenarios.

This study responds to the need of novel approaches for monitoring and evaluating processes performances in the EDs. The novelty of this data-driven approach is the opportunity to timely connect performances, patient-flows and activities.

The purpose of this study is to establish empirical relationships between patient flow problems, healthcare service quality and patient satisfaction with emergency department (ED) service factors from the patient perspective.

In the overall study, of which the current investigation is a part, a mixed-method research approach was to achieve the research objectives. The results reported in this paper are based on a comprehensive questionnaire survey where a well-designed and reliable questionnaire was used to survey ED patients. This study conducted partial least squares structural equation modelling (PLS-SEM) by using Smart PLS software.

Results show that the respondents mostly agreed with the proposed concept of quality in ED and patients were less satisfied with ED services in general and with the internal and external environments in ED in particular. It was found that relationships between nine identified scales of patient flow problems, healthcare service quality, and patient satisfaction are significant. The findings reveal that the relationship between patient flow problems and patient satisfaction is positively mediated through healthcare service quality, which shows the predictive capability of the model, indicating high predictive relevance.

This research involves a relatively small sample from a single case study. The positive relationship between patient flow problems and patient satisfaction indicate practical significance of the model for guiding to improve overall patient satisfaction.

This research, through the involvement of both hospital staff and the patient, brings out a holistic approach in terms of operational excellence in a critical unit such as the ED. The empirically established relationships form the benchmarking and guide for developing guidelines for designing policies for service improvements of ED practices.

The purpose of this paper is to show how elements from queueing theory can be used to obtain objective measures of effective capacity in the triage function at Skaraborg Hospital in Sweden without direct observation of the function itself.

Approximately 30,000 patients arrived to the emergency department at Skaraborg Hospital in Sweden during 2011. The exact time of arrival and the exact time of triage were recorded for each patient on an individual level. Basic queueing theory uses arrival rates and system capacity measures to derive average queueing times. The authors use the theoretical relation between these three measures to derive system capacity measures based on observed arrival rates and observed average queueing times.

The effective capacity in the triage process is not a linear function of the number of nurses. However, the management of capacity seems well adapted to the actual demand, even though service levels vary substantially during the day and night.

This paper uses elements from queueing theory in an innovative way to measure the effective capacity of a service process without direct observation, thereby also avoiding the potential risk of the Hawthorne effect.

Patient length of stay (LOS) is an important indicator of emergency department (ED) performance. Investigating factors that influence LOS could thus improve healthcare delivery and patient safety. Previous studies have focused on patient-level factors to explain LOS variation, with little research into service-related factors. This study examined the association between LOS and multi-level factors including patient-, service- and organization-level factors.

This study uses a retrospective observational design to identify a cohort of patients from arrival to discharge from ED. A year-long data regarding patients flow trhoguh ED were analyzed using analytics techniques and multi-regression models. The response variable was patient LOS, and the independent variables were patient characteristics, service-related factors and organizational variables.

The findings of this study showed that older patients, middle triage and hospitalization were all associated with longer LOS. Service-related factors such as complexity of care provided, initial ward designation and ward transfer had a significant impact as well. Finally, prolonged LOS was associated with a higher ratio of patients per medical doctor and per nurse. In contrast, a higher number of residents in the ED were associated with longer patient LOS.

Previous studies on patient LOS have focused on patient-level factors, with little research on service-related factors. This study has addressed that gap by examining the association between LOS and multi-level factors including patient-, service- and organization-level factors. Patient-level factors included demographics, acuity, arrival shift, arrival mode and discharge type. Service-level factors consisted of first ward, ward transfer and complexity of care provided. Organizational factors consisted of three ratios: patients per MD, patients per nurse and patients per resident. The results add to the current understanding of factors that increase patient LOS in EDs and contribute to the body of knowledge on ED performance, operation management and quality of care. The study also provides practical and managerial insights that could be used to improve patient flow in EDs and reduce LOS.

The healthcare system has been under pressure to provide timely and quality healthcare. The influx of patients in the emergency departments (EDs) is testing the capacity of the system to its limit. In order to increase EDs' capacity and performance, healthcare managers and practitioners are adopting process improvement (PI) approaches in their operations. Thus, this study aims to identify the main PI approaches implemented in EDs, as well as the benefits and barriers to implement these approaches.

The study is based on a rigorous systematic literature review of 115 papers. Furthermore, under the lens of thematic analysis, the authors present the descriptive and prescriptive findings.

The descriptive analysis found copious information related to PI approaches implemented in EDs, such as main PIs used in EDs, type of methodological procedures applied, as well as a set of barriers and benefits. Aiming to provide an in-depth analysis and prescriptive results, the authors carried out a thematic analysis that found underlying barriers (e.g. organisational, technical and behavioural) and benefits (e.g. for patients, the organisation and processes) of PI implementation in EDs.

The authors contribute to knowledge by providing a comprehensive review of the main PI methodologies applied in EDs, underscoring the most prominent ones. This study goes beyond descriptive studies that identify lists of barriers and benefits, and instead the authors categorize prescriptive elements that influence these barriers and benefits. Finally, this study raises discussions about the behavioural influence of patients and medical staff on the implementation of PI approaches.