The Establishment and Management of an Observation Unit Jared Conley, MD, PhD, MPH a,b, *, J. Stephen Bohan, MD, MS b , Christopher W. Baugh, MD, MBA b ESTABLISHING AN OBSERVATION UNIT Creating a dedicated area within a hospital to cohort observation patients is an essential best practice that enables safe and efficient care. As national and local trends continue to increase demand for observation services, clinicians increasingly understand the benefits of an OU. Accordingly, OUs are becoming increasingly common in larger hospitals in the United States. This article explores the key ele- ments to consider when establishing an OU, such as location, size, staffing, and workflows. Common areas of debate, such as open versus closed design, alterna- tive uses for OU beds, and the care of behavioral health patients, are also dis- cussed. With a better understanding of these considerations, department and hospital leaders can establish and sustain service excellence for their observation patient population. Disclosure Statement: The authors have no conflicts of interest. a Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA; b Department of Emergency Medicine, Brig- ham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA * Corresponding author. Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114. E-mail address: jconley@mgh.harvard.edu KEYWORDS  Observation unit  Observation medicine  Clinical management  Clinical workflow and design KEY POINTS  Careful design of the observation unit (OU) process, location, and layout enables optimal clinical care and finances.  Several acute medical and surgical conditions are amenable to the OU clinical pathway; developing and maintaining protocols to guide patient selection and clinical care are crit- ical to successful management of these conditions.  Ongoing OU management requires a strong, collaborative leadership model; appropriate staffing; and a robust monitoring system for quality, safety, and finances. Emerg Med Clin N Am 35 (2017) 519–533 http://dx.doi.org/10.1016/j.emc.2017.03.002 emed.theclinics.com 0733-8627/17/ª 2017 Elsevier Inc. All rights reserved.