The dynamic interaction of quality and efficiency in the emergency department: Squaring the circle?

This paper examines the relationship between clinical quality and organizational efficiency in emergency departments (EDs). Previous studies have often emphasized the incompatibility of quality and efficiency, or have neglected to account for their inter-relationships. Policy perspectives reflect normative prescriptions for throughput and reduced waiting times which do not always align with clinicians' foci or day-to-day practices. According to Merton's (1957) theory of "value-assimilation", medical students, for instance, are socialized to reconcile seemingly contradictory values. We aimed to explore ethnographically the possibility of the dynamic interactions of quality and efficiency in clinical practice. This study drew on empirical data from ethnographic field work, conducted over one year, including 234 hours of semi-structured observations and 56 semi-structured field interviews in the EDs of two tertiary-referral hospitals in Sydney, Australia. We found that seniority and experience of emergency clinicians intersect with the functions of role-modeling, performance management, and formal and informal learning, to facilitate the care of multiple patients as they progress through the ED. These practices fundamentally embed quality in the ED's enactment of efficiency. The relationship between clinical quality and organizational efficiency can be understood through a sociological lens that highlights the roles of interdependent clinicians in a clinical pecking order, working to provide care, and balancing the two. The paper is novel in expanding "value-assimilation" into the clinical domain, and strives to reconcile policy with everyday practice in emergency settings. It moves the debate about quality versus efficiency to one that emphasizes interdependence. Crown Copyright 2009. Published by Elsevier Ltd. All rights reserved.