Implementing performance improvement in New Zealand emergency departments: the six hour time target policy national research project protocol

The study design is mixed methods; combining qualitative research into the behaviour and practices of specific case study hospitals with quantitative data on clinical outcomes and process measures of performance over the period 2006-2012. All research activity is guided by a Kaupapa Māori Research methodological approach. A dynamic systems model of acute patient flows was created to frame the study. Consequences of the target (positive and negative) will be explored by integrating analyses and insights gained from the quantitative and qualitative streams of the study.At the time of submission of this protocol, the project has been underway for 12 months. This time was necessary to finalise both the case study sites and the secondary outcomes through key stakeholder consultation. We believe that this is an appropriate juncture to publish the protocol, now that the sites and final outcomes to be measured have been determined.In May 2009, the New Zealand government announced a new policy aimed at improving the quality of Emergency Department (ED) care and whole hospital performance. The 'Shorter Stays in ED' target stipulates that "95% of patients will be admitted, discharged or transferred from an ED within six hours by July 2009" [1]. This target was supported by the National ED Advisory Group, made up of senior ED clinicians and managers [2]. They advised the policy initiative based on observational studies from overseas showing that overcrowding or long waits in ED were associated with poorer outcomes for patients such as increased mortality [3-5]. Similar ED time targets have been recommended by health reformers in Australia [6] and follow the lead of the English National Health Service which introduced time targets for ED in 2001 [7]. In the UK, official monitoring indicated that these targets were successfully met at the national level by 2004 [8]. This contrasted with the lack of improvement in ED waiting times in Scotland, Wales and Northern Ireland over the s