We use a reliable, valid triage scale (such as the Emergency Severity Index).

We have a protocol for replying to patients who contact the emergency department for medical advice.

We establish staffing schedules based on historical patient flow.

We follow a formal process to increase staffing during peak times and when patient flow exceeds normal capacity.

We collaborate with the admissions department regarding patient flow and decompression procedures to minimize overcrowding and boarding.

We assign a qualified healthcare provider to monitor and reassess patients in the waiting room.

We have protocols in place for the transfer of trauma, obstetric, pediatric and behavioral health patients to other facilities, when necessary.

We follow a formal process for responding to emergent obstetrical events.

We provide a safe environment for patients who have altered mental status or who are identified as being at risk for harm to self or others.

We have a guideline for the administration and monitoring of procedural sedation and analgesia in the emergency department.

We follow established guidelines and recommendations for opioid prescriptions in the emergency department.

We follow established protocols when diagnosing and treating patients who present with symptoms that are known indicators of high-risk conditions, such as (but not limited to) aneurysm, heart attack, stroke, meningitis and ectopic pregnancy.

We encourage providers to conduct handoff discussions at the patient’s bedside.

We monitor, track and trend wait times, as well as the number of patients who leave without being seen or against medical advice (LAMA)

We have a procedure for managing radiology over-reads.

We follow a standardized process for communicating diagnostic and test results to patients post-discharge.

We adopt standard patient safety goals and quality metrics.

We monitor for compliance with established emergency services protocols, guidelines, and policies and procedures.

We perform RCA on sentinel and/or serious reportable events.