The nature and necessity of operational flexibility in the emergency department

Hospital-based emergency departments (EDs), given their high cost and major role in allocating care resources, are at the center of the debate about how to maximize value in delivering health care in the United States. To operate effectively and create value, EDs must be flexible, having the ability to rapidly adapt to the highly variable needs of patients. The concept of flexibility has not been well described in the ED literature. We introduce the concept, outline its potential benefits, and provide some illustrative examples to facilitate incorporating flexibility into ED management. We draw on operations research and organizational theory to identify and describe 5 forms of flexibility: physical, human resource, volume, behavioral, and conceptual. Each form of flexibility may be useful individually or in combination with other forms in improving ED performance and enhancing value. We also offer suggestions for measuring operational flexibility in the ED. A better understanding of operational flexibility and its application to the ED may help us move away from reactive approaches of managing variable demand to a more systematic approach. We also address the tension between cost and flexibility and outline how "partial flexibility" may help resolve some challenges. Applying concepts of flexibility from other disciplines may help clinicians and administrators think differently about their workflow and provide new insights into managing issues of cost, flow, and quality in the ED.