Inside the Black Box of Emergency Department Time Target Implementation in New Zealand

Abstract

Aimed at improving the quality of patient care in emergency departments, introduction of the 6 hour emergency department time target into public hospitals in New Zealand in 2009 provided an important opportunity to explore the implementation of public policy on the front line of public health services. It also enabled the opportunity to explore how targets work to promote change and improvement in service delivery, how they may result in unintended or adverse policy consequences, or result in varied policy impact across organisations. This thesis presents qualitative research on implementation of the 6 hour emergency department time target in New Zealand. Four case study hospital sites were investigated to explore how the target was implemented and its consequences, and to identify the influence of context on the implementation process and outcomes. Sixty-eight interviews with clinical and management staff in the ED and wider hospital were conducted across the four case study sites over two rounds of data collection in 2011 and 2012, at which time a small number of documents concerning target implementation was also collected. Data analysis was thematic. The findings from this research reveal that the thinking of staff implementing the target was shaped and constrained by their professional and hospital centred knowledge, perspectives and experience. Constrained thinking was also influenced by the medical institution and tensions between medical specialties in the acute hospital context. Addressing resistance, gaining buy-in and influencing change in staff behaviours, particularly of medical specialists in the hospital, were notable target responses. Process improvements and resource allocation, predominantly to the front of the hospital in the emergency department and other acute service units, helped speed the flow of patients through the ED and hospital. Pressure to achieve the target fostered change, learning and development, but also contributed to loss of morale, conflict and bullying. Pressure contributed to gaming of the target in the ED and to heightened concerns about quality of care for patients pushed through the hospital system more rapidly. Factors at the local level of the organisation to influence target implementation included major structural interventions and their timing, the demand for acute service and resources available to respond, political history of the organisation, leadership approach to the target, and heightened complexity of the organisation’s services and clinical specialties.