NEAT decline — Donabedian, run chart and PDSA

(a) Donabedian. Structure = resources (staffing roster, cubicles, equipment). Process = care delivery metrics (NEAT compliance, door-to-antibiotic, door-to-ECG). Outcome = results that matter to patients (mortality, 7-day revisit, patient experience) — e.g. hospital overcrowding is associated with higher mortality among adults admitted via ED.^[3][1] Structure enables process, which drives outcome.

(b) Run chart. A shift of six consecutive points on one side of the median is a probability-based rule for special-cause variation — not random noise. Investigate assignable causes (e.g. access block, staffing, process redesign failure). Do not “tamper” with common-cause points as if each is a crisis. Sustained deterioration matters clinically: hospital overcrowding and prolonged ED waiting times are both associated with increased mortality.^[5][1][2]

(c) PDSA for door-to-doctor. Plan: aim (e.g. median door-to-doctor reduced by 15 minutes in ATS 3), measures, written prediction. Do: small test (e.g. one shift rapid-assessment streaming). Study: compare run chart to prediction. Act: adopt/adapt/abandon; scale if successful. Address output-side access block in parallel — overcrowding is associated with increased mortality, so ED-floor fixes alone will not hold.^[4][1]

(d) Unintended consequences. Gaming (premature discharge, decision-to-admit timed to the clock, short-stay unit inflation — exam doctrine of gaming); rushed, incomplete assessment to meet the target. Four-hour pressure carried quality-and-safety costs even where flow improved, so critique the metric, not timely flow itself.^[6][2]