The Commonwealth of Massachusetts

Executive Office of Health and Human Services
Department of Public Health
Bureau of Health Care Safety and Quality
99 Chauncy Street, 2nd Floor, Boston, MA 02111
617-753-8000 

DEVAL L. PATRICK
GOVERNOR
TIMOTHY P. MURRAY
LIEUTENANT GOVERNOR
JUDYANN BIGBY, MD
SECRETARY
JOHN AUERBACH
COMMISSIONER	

Circular Letter: DHCQ 09-01-505

TO:		Chief Executive Officers
		Emergency Department Directors
		Acute Care Hospitals

FROM: 	Paul Dreyer, Ph.D., Director		

DATE:		January 23, 2009

RE:		Emergency Department Data Collection

The Department has been working on a data collection process to monitor the impact of the no-diversion policy and collect ongoing information on patient flow.  This letter provides instructions about the data hospitals are expected to report in order for the Department to track progress around the boarding of patients in the ED.

The measures to be collected were determined by the Boarding and Patient Flow Task Force (formerly the Boarding and Diversion Task Force) and are taken from the National Quality Forum (NQF) voluntary consensus standards for hospital-based emergency department care.  Measures chosen are already collected by hospitals, so reporting should not impose an administrative burden.  

There are three measures that will initially be reported:

•	Number of ED visits per month.
•	Median time from ED arrival to ED departure for admitted ED patients (NQF measure ED-001-08).
•	Median time from ED arrival to ED departure for discharged ED patients (NQF measure ED-002-08).

We are asking for the aggregated data for all patients, regardless of age, diagnosis or condition.  Hospitals are expected to report the data on the Hospital Capacity Website (formerly known as the diversion website), using your existing login.  An instructional document with screen shots and measure definitions is attached to this letter and will be available on the Department’s website, as well as on the hospital capacity site.

The first data set that needs to be reported is for the month of February, 2009.  The deadline for data reporting is March 15, 2009.  Data will then need to be reported monthly by the 15th of the following month.  We will be moving to quarterly submission in the future.

The Department and the Boarding and Patient Flow Task Force also need feedback on the feasibility of collecting a third NQF measure, admit decision time to ED departure time for admitted patients.  You will be receiving a Survey Monkey survey about this measure and any additional data points we should consider collecting.  Your input would be greatly appreciated.

If you have questions about the process or the measures selected, please contact Elizabeth Daake at elizabeth.daake@state.ma.us .  If you have data submission issues or need your hospital’s login information, please contact Dana Ohannessian at dana.ohannessian@state.ma.us.

The next scheduled call for feedback on the impact of the no-diversion policy is scheduled for Wednesday, February 18 at 3:00pm.  The dial-in number is 1-800-619-9642, passcode 28718.  If you will be participating in the call, we ask that you mute your line by hitting *6 when you are not speaking.