www.sciedu.ca/jha Journal of Hospital Administration 2015, Vol. 4, No. 5 ORIGINAL ARTICLE Applying quality improvement principles to improve accident and emergency department overcrowding and flow in Rwanda: a case study Jean Claude Byiringiro 1 , Rex Wong *2 , Caroline Davis 2 , Jeffery Williams 3 , Joseph Becker 4 , Joseph Novik 5 , Christine Uwineza 1 , Chance Delphine Mukakamali 1 , Theobald Hategekimana 1 , Martin Nyundo 1 1 CHUK, Rwanda 2 Yale University Global Health Leadership Institute, United States 3 University of Illinois-Chicago, United States 4 Columbia University, United States 5 Brown University, United States Received: April 25, 2015 Accepted: June 23, 2015 Online Published: July 7, 2015 DOI: 10.5430/jha.v4n5p47 URL: http://dx.doi.org/10.5430/jha.v4n5p47 ABSTRACT Few case studies exist related to hospital accident and emergency department (A&E) quality improvement efforts in lower- resourced settings. We sought to report the impact of quality improvement principles applied to A&E overcrowding and flow in the largest referral and teaching hospital in Rwanda. A pre- and post-intervention study was conducted. A linked set of strategies included reallocating room space based on patient/visitor demand and flow, redirecting traffic, establishing a patient triage system and installing white boards to facilitate communication. Two months post-implementation, the average number of patients boarding in the A&E hallways significantly decreased from 28 (pre-intervention) to zero (post-intervention), p < .001. Foot traffic per dayshift hour significantly decreased from 221 people to 160 people (28%, p < .001), and non-A&E related foot traffic decreased from 81.4% to 36.3% (45% decrease, p < .001). One hundred percent of the A&E patients have been formally triaged since the implementation of the newly established triage system. Our project used quality improvement principles to reduce the number of patients boarding in the hallways and to decrease unnecessary foot traffic in the A&E department with little investment from the hospital. Key success factors included a collaborative multidisciplinary project team, strong internal champions, data-driven analysis, evidence-based interventions, senior leadership support, and rapid application of initial implementation learnings. Results to date show the application of quality improvement principles can help hospitals in resource-limited settings improve quality of care at relatively low cost. Key Words: Low resource setting, Hospital, Accident and emergency department, Patient flow, Quality improvement, Over- crowding 1. I NTRODUCTION Hospitals and other health care organizations worldwide have increasingly sought to improve patient care quality and opera- tional efficiency. [1–5] Quality improvement, the management science of continuous improvement in work processes, has become an expected competency in health care organizations * Correspondence: Rex Wong; Email: rex.wong@yale.edu; Address: Yale University Global Health Leadership Institute, United States. Published by Sciedu Press 47