"The 4D Approach"-An Effective Strategy to Improve Emergency Department Boarding and Operational Outcomes
Author Department
Emergency Medicine; Medicine; Nursing; Patient Care Services
Document Type
Article, Peer-reviewed
Publication Date
1-2026
Abstract
Emergency Department (ED) boarding is a nationwide issue that has detrimental effects on morbidity and mortality of patients in the ED. Literature suggests that boarding in the ED is directly correlated with left without being seen rates. To address these challenges at our institution, we implemented the "4D Approach": a homegrown change management methodology designed to drive systemic transformation. The "4D Approach" (Desire, Data, Direction, Dedication) involves building desire for change, organizing data to empower decision making, choosing a direction for hospital-wide alignment of goals, and nurturing dedication to the ever-evolving process. We found this approach to have an impact in reducing left without being seen rates and ED boarding despite increasing daily patient arrivals and admissions during the study period at a single tertiary care academic medical center.
Keywords: administration; boarding; change management; crowding; data; dedication; desire; direction; emergency department; healthcare; methodology; operations; strategy; system.
Recommended Citation
Antkowiak PS, Jamali S, Barkoudah E, Skura S, Adwan L, Reale C, Sills J, Lutfy-Clayton L, Rathlev N, Gemme S. "The 4D Approach"-An Effective Strategy to Improve Emergency Department Boarding and Operational Outcomes. J Am Coll Emerg Physicians Open. 2026 Jan 22;7(2):100325. doi: 10.1016/j.acepjo.2025.100325.
PMID
41625695