Accreditation Levels

In the criteria below, examples of ED physician leaders may include medical director, chair of the department or chief. ED nurse leaders may include ED nurse director or manager.

• ED physician leader is a qualified emergency physician or pediatric emergency physician.
• ED leadership includes an ED physician leader and ED nurse leader who collaborate to support operations within the department.
• The ED physician leader has direct authority of and is responsible for assessment of clinical privileges of physicians and PA/NPs working in the ED; the ED nurse leader has direct authority for the nursing staff in the ED.
• The ED physician leader is responsible for the ongoing practice evaluation of each NP and PA in the ED.
• The ED physician leader in collaboration with the ED nurse leader will develop the ED quality improvement plan which will include a process for oversight of clinical care in the ED either contemporaneously or retrospectively.
• ED physician and nurse leadership will ensure that all practitioners complete required continuing education requirements as a part of hospital credentialing.
• The ED physician leadership will establish confidential and appropriate processes for completion of exit interviews with physicians who leave the practice to determine the root causes of job transitions.
• Emergency physicians shall document all direct supervision encounters with patients but are not required to sign charts of patients they did not directly or indirectly supervise.
• In a designated trauma center, the shared roles and responsibilities of emergency physicians and/or residents with other members of the trauma team should be established in collaboration with trauma program leadership.

• A policy for formal onboarding and standardized training process for all ED staff members to ensure that staff optimize patient care in the emergency setting.
• A policy that plans for a timely reporting of all radiology study results to the ED.
• A policy that describes the notification of patients or their outpatient health care team (as available and as appropriate) of critical imaging results and incidental findings identified after patients’ discharge in a timely manner. This policy includes identified FTE(s) to complete this work and is not left as additional work for emergency physicians, NPs, or PA who are actively taking care of ED patients and has the support of both the emergency medicine group and the radiology group.
• A policy that includes specified time periods are tracked, collected, and shared with consultants. This includes specified time intervals from time of consult call to patient evaluation, and from time of patient evaluation to provision of care plan recommendations.
• A hospital disaster plan that includes a plan for adult and pediatric patient surge to the ED.
• A hospital policy or multidisciplinary plan to address ED boarding to include mitigation strategies.
  • Included in this plan should be a policy that states the admitting physician/team is responsible for all care of the patient once the admitting physician/service accepts the patient. The emergency physicians, however, do not yield the authority to prioritize all patient care activities while boarding in the ED and manages resources at their discretion.
  • Included in this plan should also be a policy that outlines who is responsible for the care of patients with primary psychiatric disease who are boarded in the ED (i.e., physician responsible and protocols for care).
• A hospital policy that allows emergency physicians to perform procedural sedation in accordance with ACEP guidelines (i.e., including propofol and ketamine, non-fasting, single physician with nurse).
• A policy that specifies that patients’ weights are recorded in kilograms.
• A policy that ED staff are permitted to eat and drink at specified workstations while on duty.
• A policy that specifies mandatory reporting of verbal and physical assault to the hospital.
• A policy that outlines security response and joint drills between ED and hospital security staff. The security response should include processes for when the ED is at heightened risk of safety threat (e.g., assault of health care workers, combative patients, or officer-involved shooting victim). In addition, the policy should detail approach to controlled access to the facility, processes for lock down, and rapid law enforcement response, in event of active shooter in the ED.
• A policy that qualified emergency physicians who are participating in continuing certification are not required to take additional life support courses (e.g., Basic Life Support (BLS), Advanced Life Support (ACLS), Pediatric Advanced Life Support (PALS), or Advanced Trauma Life Support (ATLS) certification) as a part of their credentialing.

Each ED shall have an emergency physician-led quality improvement (QI) plan which, in conjunction with nursing leadership, will include the following components:

• The ED must establish a multidisciplinary performance improvement committee responsible for continuously evaluating and improving clinical care, operational efficiency, patient safety, and overall quality outcomes. This committee should include representatives from various clinical and operational areas within the ED.
• The ED must establish baseline metrics and set performance targets for key phases of patient care (e.g., time from patient presentation to discharge for treat-and-release cases; time from patient presentation to the decision to admit; time from admission decision to the patient leaving the ED; and monitoring of frequency and duration of boarding of patients requiring admission, intensive care, behavioral health and/or mental health emergencies).
• The ED must have a system to select indicators for tracking performance improvement for critical illness and injury conditions in adults and children and a system to identify variance in performance.
• The ED must review its pediatric readiness status at least every two years, including participation in the National Pediatric Readiness Assessment (www.pedsready.org ). The ED must document the review and develop action plans to address any identified deficiencies.
• Regular reviews of the practice of emergency physicians, non-emergency physicians, PAs and NPs staffing the ED must occur. This review must include input from multiple sources such as chart reviews of criteria-based cases or cases referred from other clinical departments.
• Quarterly performance and quality measure reports for individual emergency physicians, physician assistants, and nurse practitioners should be provided. These reports must compare their performance to emergency staff peers in an anonymous manner and, when available, benchmark against national or regional data.

Emergency physicians, regardless of employment status, have the same rights and privileges as other members of the medical staff.

• Resources are in place to provide safety of staff, visitors, and patients.
• ED point-of-care ultrasound is available 24/7 for use by emergency physicians for diagnostics and for procedures as applicable.
• The ED has resources for victims of domestic/interpersonal violence.
• Translation services are available in person or via telehealth.
• There is a sanitary, private, non-bathroom area proximal to the ED for ED employees who are breastfeeding.