18948
Effect of establishing a clinical governance system on the timely discharge index of the emergency department of Ayatollah Kashani Academic Medical
Center in Shahrekord (2011)
Shahideh Allahverdi
1*, Fatemeh Azizian
2, Vajihe Khajeali
31 MSc health services Administration.Shahrekord University Medical Sience [email protected]
Tel:0098-9132849943
2 MSc health services Administration.Shahrekord University Medical Sience [email protected]
Tel:00989132807434
3 MSc health services Administration.Shahrekord University Medical Sience [email protected]
Tel:0098-9140204007
*Writer,s responsible ABSTRACT
Introduction: The nature of work in the emergency department is such that for saving the lives of patients, high quality care must be provided in the shortest possible time. Clinical service governance is a concept that encompasses all activities related to the promotion, review, evaluation and monitoring of the quality of services provided to patients. The aim of this research was to determine the effect of establishing a clinical governance system on the timely discharge index of emergency department of Ayatollah Kashani Academic Medical Center in Shahrekord.
Methods: This research was a cross-sectional, applied, descriptive and correlational study, which was conducted in 2011 on 300 cases of emergency patients of Ayatollah Kashani Hospital in Shahrekord. The population under study was the patients of that center, sampling was done randomly. The collected data were analyzed in two stages before and after the intervention through paired t-test and descriptive statistics in Excel and Spss software.
Results: The frequency of timely hospital assignments before the establishment of the clinical governance system in the emergency department increased to 254 and after the establishment of the system to 284. It showed an increase in the rate of timely discharge from 84.6% to 94.7% of emergency patients. The number of timely assignments according to the standard definition before the establishment of the clinical governance system increased from 174 cases and after that to 200 cases, which showed the growth of the index from 58% to 67%. The average triage time before assignment was 365 minutes before the establishment of the clinical governance and 295 minutes after that.
Discussion and Conclusion: Improvement and growth of timely discharge frequency showed the effect of establishing clinical governance on timely discharge or assignment of emergency patients. By strengthening and supporting clinical governance programs, it is possible to maintain a positive trend in the timely discharge index.
Keywords
Clinical governance, timely discharge, Emergency
Introduction
Due to the special nature of emergency procedures in terms of complexity, frequency, time urgency of services, etc., hospital emergencies as the patient's first point of contact with the country's health care system and the patient's main entrance to the hospital services system play an important role in reducing mortality and restoring health to the people and creating satisfaction with the country's health care system. Considering the listed features, organizing and optimizing hospital emergencies as a foundation in improving the quality of emergency medical services is inevitable [1]. The emergency department is of special importance due to the largest, most diverse, busiest and most sensitive department of the hospital [2]. The nature of work in the emergency department is such that for saving the lives of patients, high quality care must be provided in the shortest possible time. Repeated monitoring of service quality and satisfaction of emergency department clients as one of the important indicators is essential [3].
According to the global agreement on the comprehensiveness of the clinical services governance program and its ability to meet the needs of the health system, a program has been prepared so that this system can be implemented in all health care units affiliated to medical universities. In designing this program, the main indicators of establishing a quality improvement system in the organization have been considered. In any case, improving the quality and implementing the clinical services governance system is a task that is performed and objectified in the environment.
In this model, 7 themes of public and patient participation, risk management, staff management, use of information, clinical effectiveness, clinical censorship and staff training have been announced by the Ministry of Health and Medical Education for hospitals. It has been notified to all medical universities of the country since 2010 [4].
Establishing clinical governance to improve the quality of clinical services and maintain patient safety is one of the requirements of hospital evaluation. To ensure that the quality of health care is done using the highest possible standards, it is necessary to develop performance indicators to determine the current situation, compare with standard indicators and determine the progress of the program during the year [5].
Because limited research has been conducted on the clinical governance, this research addresses the practical impact of establishing clinical governance programs, including patient participation, staff training, staff management, on emergency performance, and the performance index of timely discharge. Clinical governance allows clinicians in the UK to manage a comprehensive strategy for improving quality in provider organizations, albeit with broad expectations that have led to increased external accountability [6].
Clinical governance includes concepts such as improving the quality of information, enhancing patient participation, improving teamwork, and implementing evidence-based medicine, and is like an umbrella covering everything that helps maintain and improve patient care standards. This encompasses all quality improvement activities that are done by the clinical staff in their daily care. Clinical governance also provides a framework within which quality improvement activities take place in a coordinated and integrated manner [7].
At present, in most emergency departments and hospitals of the world, special committees called quality improvement committees are established, which continuously and in the form of continuous quality improvement programs, conduct standard studies in the emergency departments and interpret their results based on the conditions and characteristics of the same section and offer suggestions for improving the current situation. Researchers have shown that one of the most important indicators used in the evaluation of emergency centers is the waiting time for patients to receive diagnostic and therapeutic services. Unfortunately, very little research has been done in Iran to evaluate the quality of emergency services and the status of services provided in this unit. Data analysis showed that the average time of patient admission to the emergency department to transfer to other wards was about 4 hours, arrival time to discharge was about 7 hours and arrival time to final diagnosis was 72 minutes [8].
Zare Mehrjerdi, Hobubati, and Safaei Nik (2011) [9] conducted a research entitled improving the waiting time of patients referred to the emergency department using discrete event simulation. The results showed that the maximum waiting time was the time interval between requesting the test and receiving it. By performing simulations and testing of five different scenarios, Scenario 5 is more economically attractive due to the addition of only 3 additional personnel and the reduction of required waiting times. According to the results of the research for reducing the waiting time of patients, we recommended the implementation of the patient triage process in the emergency department and the use of emergency medicine specialist for medical diagnosis and order diagnostic procedures in the early stages and also a laboratory expert for emergency patients to accelerate the process of receiving the test result.
Jabbari et al. (2011) [10] conducted a research entitled "How long do patients who refer to the emergency department of Al-Zahra Hospital spend to receive services? They showed that due to the fact that screening physician visits were performed without special prioritization for patients, it is necessary to establish a triage system in the emergency room of Al-Zahra Hospital. The comparison of the average times obtained for performing paraclinical services shows the great distance between the current situation and the standard, which indicates the serious need to improve the process in the field of paraclinical services. To prevent the problem of crowding, it is necessary to take appropriate measures, including prioritization of beds for hospitalization of emergency and non-emergency patients, appointing a person in charge of coordination, applying the 30-minute rule, establishment of temporary storage unit, direct admission of patients, scientific review of the number of ICU and CCU beds.
Farkashhahi (2010) [5] conducted a research entitled the effect of establishing clinical governance on the indicators of the ICU ward of Shohada Hospital in Kermanshah. Using an evaluation checklist, he measured the level of antibiotic use, average stay, and the prevalence of nosocomial infections in two stages before and after the implementation of the clinical governance program. The results showed that after the establishment of the clinical governance system in the ICU, the consumption of third generation antibiotics has decreased compared to the previous period. Also, the average stay has decreased from 5.48 to 3.52 and the prevalence of infection has decreased from 1.8 to 1.06.
18950 Hosseini, Shaker, Basir Ghafouri, and Shokraneh (2008) [11] conducted a research at Haft Tir Martyrs Hospital in Tehran, entitled the time study of patients' workflow in the emergency department and the factors affecting it. From the files of 649 patients, we extracted and analyzed the demographic information, type of disease, how to go to the emergency department, necessary times, requesting or not requesting tests and visits to other services. The results showed the average time between triage and doctor's visit and Doctor's visit and patient's assignment and the average total time between triage and assignment in this center is standard. Referral, request tests and visit for surgical services is of effect on these times.
Tabibi, Najafi and Shoaei (2007) [12] carried out a research for determining the waiting time for emergency services in selected hospitals of Iran University of Medical Sciences. Using a questionnaire that was designed based on the form "Emergency Services Workflow Timing" of the Ministry of Health, Treatment and Medical Education, we collected the information of 249 patients referred to the emergency department of Rasoul Akram Medical Center and Firoozabadi Hospital. The results showed that the waiting time for providing services in the hospitals under study is long, so it is necessary to review and improve the processes of providing services to patients in the emergency department as well as training service providers.
McCland-Jones Siegel and Pins (2011) [13] carried out a research entitled "Measuring the Quality of the Emergency Department with a Time-Based Test" in six US hospitals and collected the practical aspects of emergency department time-based actions to measure it. The average time for admission and actions of patients was between 327 to 663 minutes and until discharge of patients it was 143 to 311 minutes. In university hospitals, emergency operation time was longer and workload was higher. These reports had advantages such as promoting the process and quality improvement program, improving accountability and improving practical standards. This was done through multidimensional access to the information system and solving problems related to data collection.
Zang, Ma, Lai, and Bryant (2011) [14] conducted a research entitled "A simulation study of improving the quality of care in the emergency department of a social hospital", a study on computer simulation and improving emergency care in one state of the United States. This model simulates the ability to assess the quality of care in terms of patient's stay, waiting times, and patients' escape; it has been done by comparing the information collected in the emergency department. The results showed that in order to better guarantee the clinical results, more nurses are needed, and a CT scan machine in this department. In addition, this model showed that the components of the nursing team policies can lead to a significant improvement in the emergency. This model sample provided a quantitative and measurable tool for continuous quality improvement and control follow-up in the emergency department as well as applicable methods for other hospital departments.
Kenazick and Baker (2011) [15] conducted a research entitled "Improving operational efficiency in the emergency department of Michigan Children's Hospital" and described the operational efficiency model used in this hospital to change the existing system; it is considered as a level three emergency department. The results showed that the average admission time was reduced in 83% of cases, the discharge ratio without visit was reduced to 91%, the average stay in the ward was reduced to 48%, the waiting time for a doctor's visit was improved and the death waiting room was eliminated.
In a research entitled "Patients' participation in clinical governance", Friedman (2006) [16] examined patients' participation in Luthan and Dan Stable hospitals, which are covered by the national medicine system. This research showed that patients and caregivers are seen as a valuable resource. There are also formal mechanisms in these centers to assist and cooperate with patients' representatives for attending hospital committees. These people are involved in the provision of services, which is one of the rules and arrangements of clinical governance.
Research method
This research was a cross-sectional study, which was performed in 2011 on the emergency department of Ayatollah Kashani Hospital in Shahrekord. Preliminary information before the intervention was collected in the first 5 months of 2011 by studying 300 cases of emergency patients. Interventions and executive programs were implemented in the second half of 2011, and finally information after the intervention was collected by studying 300 cases in March 2011.
In terms of research method and result, it was an applied research and based on the purpose of the research, it was a descriptive correlational study.
Implementation of clinical governance system in the emergency department of Ayatollah Kashani Academic and Medical Center
Considering the hospital's commitment since 2010 to the establishment of the clinical services promotion system and the design of a specialized committee to carry out its executive affairs, a plan was developed in the form of an operational program in 2011. In this program, by evaluating the situation before the intervention, which was obtained by measuring timing indicators, the strengths and weaknesses were identified; it was decided to be in line with 4 themes (patient participation, staff training, staff management, information use) from among 7 themes of clinical governance.
Then, intervention programs were formulated and implemented through the committee to provide standard methods emphasized by the clinical governance system.
In this research, the current status of the timely discharge index was first measured through forms. Then, using the applicable themes of clinical governance in the emergency department, including patient participation, implementing a staff management program, providing training programs and increasing staff skills, creating information access processes and recording the required information systematically with the participation of the management team of the hospital and emergency staff, we embark upon improving the performance of the emergency department in terms of the proposed indicators. Finally, after the implementation of the clinical governance program, we measured the results of the indicators with the same initial measurement tool and extracted the effect of the clinical governance system on the improvement of emergency timing indicators.
The operational program was implemented by the hospital clinical governance committee and the emergency management team. The program developed for the department includes the following:
1-Table Of Action Planing az a Interventional Plan
Operational goal: Establishment of clinical governance system in the emergency department Actions and activities:
Title Department Evaluation results Working procedure (practical actions)
Name of the theme of clinical governance 5 Information
management and information use
- Failure to register triage information in HIS program
- Lack of accurate insertion of time information and average service delivery times
- Lack of familiarity of doctors and nurses with the importance of recording times
- Manual completion of emergency services workflow form information - Incoherence of the information system in the department
1- Designing the workflow form of emergency services and creating the possibility of computer
monitoring and reporting
2- Forming a committee and a briefing meeting with the technical manager and the emergency head nurse
3- Investigating and following the HIS deployment system in triage
4- Educating employees about the importance of time information and how to record them
- Use of
information - Staff training
18952 The research population was patients of academic and medical center. The research environment of Ayatollah Kashani academic and Medical Center was Shahrekord and the research sample was the patients of the emergency department of this hospital. Due to the high number of patients, sampling on this group was done by random method. To calculate the minimum sample size of medical records using Cochran's formula, we obtained the following values:
.05 z(0.975)=1.96 N =3700 p=50%
α =
D is the maximum error.
D=6%
n(0)=(N(z(1- α/2)^2*p*(1-p))/(N(d^2))=(3700(1.96)^2*.5*.5)/(3700*(.06)^2)=249
The size of desired sample
n=(z(1- α/2)^2*p*(1-p))/d^2
n=267
Therefore, considering the considerations, the sample size of emergency cases was 300.
Information about the timely discharge index was collected through the emergency services workflow form approved by the Ministry of Health, which according to the instructions is attached to the patients' medical records. At first, before the implementation of the clinical governance program of the emergency department, the mentioned index was collected in the first half (five months) of 2011.
Also, after the implementation of the clinical governance system program, the mentioned indicators were re-measured by similar methods.
Information about timing indicators was collected through reporting of the emergency services workflow table in patients' files and the result was collected in the approved form No. 1 of emergency services workflow timing. Each form number 1 contains 10 rows with the number of characteristics of 10 patients. Information on this form includes:
name and surname of the patient, date, time of referral to the triage, time of admission, appointment (evening, morning, night), type of action (prompt, immediate, and outpatient), diagnosis (case and type of disease), time of the first visit to the doctor time of starting the first medical or nursing procedure. Finally, in a total of 30 forms for 300 patients, the information was studied and recorded by the researcher. The average time of patient assignment or discharge from the emergency department is the result of the difference between the recorded time of patient entry into triage and the time of departure and transfer from the ward, death, or discharge.
In this research, using non-parametric statistical method of paired t-test and descriptive statistics (mean, frequency and percentage) for the variable: we studied the average waiting time, and analyzed it using SPSS19 and EXCEL software.
Results
The interpretation of the results obtained from the timing of emergency workflow before and after the establishment of the clinical services governance system according to Table 1 is as follows: The first column of this table is the average difference after the establishment of the clinical services governance system and before its establishment (
2 1
d
). On the other hand, the estimated value of Sig statistic for the triage time index until the timely assignment of the hospital is less than 0.05% at the 95% confidence level. Also, the value of t-statistic is outside the range of -1.96 to + 1.96. (Critical value of this statistic is at 95% confidence level). This means that the null hypothesis that there is no significant difference for this index before and after the establishment of the clinical services governance system is rejected and therefore the establishment of the clinical services governance system has a significant impact on this index. In other words, based on the effect of the establishment of the clinical services governance system on the average assignment time, the research hypothesis (H1 test) was confirmed.
Table 1: Results of paired t-test for timely emergency discharge index
Component Difference of pairs T
statistic
Degree of freedom
Significance level
Hypothesis Mean Standard
deviation
Mean Deviation Triage to
assignment (minute)
-69.86429 479.89237 28.67905 -2.436 279 .015 Confirmed
The interpretation of the results obtained from the number of cases of timely assignment of emergency before and after the establishment of the clinical services governance system according to Table 2 is as follows: The frequency of
timely assignments in the hospital before the establishment of the clinical governance system in the emergency was 254 cases, which increased to 284 cases after the establishment of the system. This index showed the growth of timely discharge rate from 84.6% to 94.7% of emergency patients. Also, the number of timely assignments according to the standard definition before the establishment of the clinical governance system increased from 174 to 200 cases after the establishment of the system, which showed the growth of the index from 58% to 67%.
Table 2: Frequency of discharge rate (timely assignment) of emergency patients before and after the establishment of the clinical governance system
Variable Status Frequency Percentage
timely assignment of the hospital
After the establishment of the clinical governance system
482 7249
Before the establishment of the clinical governance system
452 8248
Standard timely assignment After the establishment of the clinical governance system
422 89
Before the establishment of the clinical governance system
492 58
Due to the fact that examining the tests of the hypothesis of the effect of clinical governance on the number of cases of timely assignment does not need to use the t-test, in confirming or rejecting the hypothesis test, the results have been presented in the form of descriptive statistics of frequency. This means that the null hypothesis that there is no significant difference for these indicators before and after the establishment of the clinical services governance system is not rejected; in other words, if the research hypothesis (H1 test) is based on the effectiveness of the establishment of the clinical services governance system, these two hypotheses are confirmed. Therefore, the establishment of the clinical services governance system has affected the number of assignments in terms of the standard set in the hospital and also in terms of the standard of the Ministry of Health. It has been shown in Table 3.
Table 3: Frequency of timely discharge index (assignment) in the hospital emergency department Components Before the establishment
of the clinical governance system
After the establishment of the clinical governance system
Hypothesis
Number of timely assignment of the hospital
452 482 Confirmed
Number of timely standard assignment
492 422 Confirmed
Discussion and conclusion
The mean time to triage before assignment was 365 minutes before clinical governance establishment and 295 minutes after that. In emergency workflow timing index, t-statistic was significant, which indicates the confirmation of the hypothesis and finally the effect of establishing clinical governance on the average time of assigning patients.
The rate of timely discharge (assignment) of emergency patients according to the definition of the hospital after the establishment of the clinical governance system was higher in hospital and standardly. In the timely discharge index (assignment) before the establishment of the clinical governance system, 84.6% of patients were discharged from the emergency department (assignment) in time and 94.7% after the establishment of the clinical governance system.
Before the establishment of the clinical governance system, 58% of patients and after the establishment of the clinical governance system, 67% were discharged from the emergency department (assignment) according to the standard definition. In the timely discharge index (assignment) of the patient, the number of timely assignments in the hospital before the establishment of the clinical governance system was 254 and 284 after the establishment, and the number of timely standard assignments before the establishment of the system Clinical governance was 174 and 200 cases after
18954 the establishment. This significant difference indicated the confirmation of the research hypothesis test and finally the effect of establishing clinical governance on timely discharge or assignment of emergency patients. Timely standard assignment is 6 hours of discharge, it is considered as the standard notified by the Ministry of Health.
In a research, Jabbari et al. (2011) [10] examined the average waiting time of emergency patients in Al-Zahra Hospital.
These times included the time of the patient's arrival to the visit (about 8 minutes), the patient's arrival time to the first treatment (48 minutes), the waiting time for paraclinical services (59 minutes), and the average patient stay in the emergency department (353 minutes). Also, the percentage of patients receiving services at the standard time was specified separately for each time index. The result of this research in terms of patient retention time is almost similar to the average patient assignment time, and in both cases the standard time has been observed.
McClelland, Jones, Siegel, & Pins (2011) [13] conducted a research entitled "Measuring the Quality of the Emergency Department with a Time-Based Test" in 6 American Hospitals and collected practical aspects of the timing actions of the emergency department to measure it. The average time for admission and actions of patients was between 327 to 663 minutes and until discharge of patients it was prolonged from 143 to 311 minutes. In university hospitals, emergency operation time was longer and workload was higher. These reports had advantages such as promoting the process and quality improvement program, improving accountability and improving practical standards. This was done through multidimensional access to the information system and solving problems related to data collection. The average time from admission to emergency discharge in this research and its finding (143 to 311 minutes) are consistent with our research.
In a research, Zare Mehrjerdi, Hobubati, and Safaei Nik (2011) [14] examined the waiting time of patients referred to the emergency department using discrete event simulation for improvement. The results showed: 5 minutes from the time of entering the emergency department to the time of entering the doctor's room, 30 minutes from the time of entering the examination room to the time of leaving it, 14 minutes from the time of entering the electrocardiography room to the time of leaving this room, 3 minutes from entering the injection room until leaving the room, 23 minutes from entering the radiology department until receiving the result, 106 minutes from entering the laboratory unit until receiving the test result. The results of this research were completely different from ours in terms of the type of times under study.
Hosseini, Shaker, Basir Ghafouri, and Shokraneh (2008) [11] conducted a research at Haft Tir Martyrs Hospital in Tehran, with the subject of timing analysis of patients' workflow in the emergency department and the factors affecting it. From the records of 649 patients, we extracted and analyzed the demographic information, type of disease, referral to the emergency department, necessary times, requesting or not requesting tests and visits of other services. The average time interval between triage to doctor's visit is 22 minutes, doctor's visit to assignment is 210 minutes, assignment to patients' departure is 51 minutes and triage to assignment is 243 minutes. These times do not have a statistically significant relationship with the patient's gender, type of disease and shift work, but they are associated statistically with the way of entering the emergency department, requesting imaging and examination, between requesting surgery and neurosurgery and the intervals of triage to doctor's visit and doctor's visit to assignment. This research showed that the average time between triage and physician's visit and physician's visit to assignment and the average total time between triage and assignment is standard in that center (Trauma). Referral, requesting tests and visits of surgical and neurosurgery services are effective on these times. The research is consistent with the present one only in terms of examining the average time of triage to assignment, and in both cases the time results were standard and similar.
Hafizi Moghadam, Vaubi (2009) [17] examined the waiting time for emergency visits in the emergency department.
The results included presenting the average visit times by each specialty. The results of this research are different in terms of the type of calculated time index and in our research this index has not been calculated.
Tabibi, Najafi and Shoaei (2007) [12] conducted a research to determine the waiting time for emergency services in selected hospitals of Iran University of Medical Sciences. They collected the information of 249 patients referred to the emergency department of Rasoul Akram Medical Center and Firooz Abadi Hospital. The results showed that the waiting time for providing services in the hospitals under study is long, so it is necessary to review and improve the processes of providing services to patients in the emergency department as well as training service providers. In this research, all times calculated in both stages before and after the establishment of clinical governance are standard, which differs from the present research in terms of the type of indicators under study.
Sturo et al. (2008) [18] conducted a research entitled "Reducing laboratory workflow time improves emergency department performance and reduces the gap in emergency medical services". Using a high-level model in a large urban emergency department in the United States, they examined the effect of reducing working time in emergency medical services, and the extent of discrepancy or gap and the patient's length of stay. The results showed that the laboratory workflow time was reduced from 120 minutes to 10 minutes. The relevant model proposes the obligation to improve the effectiveness of the emergency by reducing the laboratory workflow time. Therefore, the mentioned
indicators are important but should be evaluated with a view to the future. The emergency department should pay attention to processes that improve workflow time, like experimental care. The findings of this research are completely different from the present one in terms of the type of timing index and the result.
Zohour and Pilevarzadeh (2003) [8] conducted a research on the speed of service in the emergency department of Bahonar Hospital in Kerman. The results showed that the average distance between the accident and the patient entering the doctor's room was about 67 minutes, the distance between the patient's entry into the doctor's room until the start of the examination was 4 minutes, the distance between requesting a test and receiving a result was 40 minutes, the distance between requesting a CT scan to get a result was 31 minutes, delay for the first consultation was 60 minutes, delay between the start of the examination and the final diagnosis was 72 minutes, 10 minutes and 21 minutes for patients' stay in the emergency room and large operating room until the start of surgery, respectively. Comparison of indicators with international standards has shown the low speed of services in the emergency department of Kerman.
This research is completely different from ours in terms of the type of time indicators.
In a research on the causes of high retention of patients in the emergency department of the hospital, Sabz Ghobai et al. (2009) [19] stated that the main reason was the patient's lack of education, the absence of an empty bed and the lack of assignment by professors and assistants. Therefore, in order to reduce the stay of patients in the emergency department of academic hospitals, it is necessary to consider a specific program for visiting senior assistants and professors. The presence of general departments also seems to be helpful. The difference between this research and ours is in their result and identifying the reasons for non-transfer of patients and lack of assignment.
Since limited research has been conducted in the field of clinical governance, in this research, the researcher addressed the practical impact of establishing clinical governance programs such as patient participation, staff training, staff management, and the use of information on the timely discharge rate index.
Considering the position and importance of clinical governance and applying the teachings of this system based on quality and assessment of emergency performance indicators, this research showed that the clinical governance system has an effect on the index of timely discharge of emergency. In this research, the implementation of the themes used by clinical governance, including training, staff management, use of information, and patient and companion participation could be a basic response to the needs of the emergency department. With the implementation of this system, the results of the timely discharge index of emergency were improved. In fact, this system has the ability to cover and manage all aspects of the emergency, including inputs, processes, and outputs. Therefore, by strengthening and developing the programs defined in clinical governance, it is possible to improve the quality of emergency department services and improve performance. This strengthening and development is achieved by increasing the level of participation of patients and staff and work teams, improving the staff management system, increasing the level of staff capability, strengthening information systems and improving processes.
According to the research findings on the effect of clinical governance system on the index of timely discharge, we suggest: Establishment of electronic health record system and hospital information system to access information and promote clinical governance program and reduce problems due to lack of information and reduce entry errors and record information. The triage hospital system should be designed and deployed to record accurate and complete triage information, and emergency workflow timing, and finally the possibility of analyzing and monitoring this index. The triage process and recording patient information should be promoted. The statistical results of determining patients' assignment in hospital sessions should be analyzed and the factors affecting it should be identified and followed up.
Capable and specialized managers should be employed for the affairs of the emergency department.
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