DOI: 10.1001/jamanetworkopen.2026.13391 | PubMed: PMID 42154467
Emergency departments routinely track quality measures: door-to-provider time, length of stay, return visits, medication administration, and dozens of others. However, knowing your performance is only half the equation. The harder question is what benchmark should you be aiming for?
Comparing with the national average may tell you where you stand, but “average” is not necessarily synonymous with good care. At the other extreme, setting every target at 100% adherence or zero failures may be unrealistic, and can direct substantial resources toward marginal gains.
A recent study by Alpern and colleagues in JAMA Network Open offers a different approach [1]. Using more than 5.3 million pediatric emergency department visits from the Pediatric Emergency Care Applied Research Network (PECARN) Registry, the investigators established Achievable Benchmarks of Care (ABCs) for common measures of pediatric emergency care. Rather than defining excellence theoretically, they asked a pragmatic question: What level of performance are the best-performing clinicians already achieving in real-world emergency departments?
The Study
The investigators performed a cross-sectional analysis of 5,302,587 visits from 2017 through 2024 across 12 emergency departments participating in the PECARN Registry: nine pediatric EDs and three affiliated community sites. The analysis included 925 clinicians. PECARN has also published a brief summary of the study [2].
The authors evaluated measures spanning several important domains of pediatric emergency care:
- Initial assessment and vital-sign documentation
- Timeliness and ED throughput
- Return visits and other quality and safety measures
- Asthma care
- Pain assessment and treatment
- Antibiotic stewardship
Many of these are familiar quality metrics already endorsed or prioritized by organizations involved in pediatric emergency care. The important innovation was not the measures themselves. It was how the target for each measure was established.
What Is an “Achievable Benchmark”?
Instead of using the mean or median as the standard, the investigators identified the highest-performing clinicians who collectively cared for approximately 10% of eligible visits. Performance among this high-achieving group was then used to calculate the benchmark.
For binary measures, the investigators used an adjusted performance fraction designed to prevent clinicians with small numbers of eligible encounters from disproportionately influencing the benchmark. Continuous measures were ranked using median performance. The result is a target grounded in achievable excellence. The distinction matters. Whereas the mean tells an ED what everyone else is doing, an ABC provides evidence of what high-performing clinicians are already capable of doing under real clinical conditions.
The table below shows selected measures from a condensed list provided by the study’s lead author, chosen as the most important or interesting targets for change.
| Performance measure | Achievable benchmark |
|---|---|
| ED flow (throughput) | |
| Time to provider, all patients | 20 min |
| ESI 2 | 13 min |
| ESI 3 | 19 min |
| ESI 4 | 22 min |
| ED length of stay, all patients | 114 min |
| Discharged | 110 min |
| Admitted or transferred | 268 min |
| Clinical care | |
| Systemic corticosteroids for asthma | 97.8% |
| Time to first beta-agonist for asthma | 29 min |
| ≥2-point pain reduction with long-bone fracture | 80.5% |
| After the visit | |
| Return visit within 48 hours | 1.6% |
Where Is the Opportunity to Improve?
Performance was not uniform across sites. For example, the proportion of children with long-bone fractures achieving at least a 2-point reduction in pain ranged from 61.4% to 92.6% across sites. Systemic corticosteroid administration for asthma ranged from 93.1% to 99.2%. Vital-sign documentation also showed substantial variation. In contrast, return visits resulting in admission and antibiotic stewardship showed relatively little variation.
That pattern may offer important direction for quality improvement. Measures that are relatively close to the clinician’s locus of control, such as asthma treatment and fracture pain management, showed meaningful differences between average site performance and what the site’s best-performing clinicians could achieve. That changes the quality-improvement conversation. If clinicians in the same ED, caring for similar patients within the same system, are consistently achieving better performance, the question becomes less “Can we do this?” and more “What are they doing differently, and how can we make that the default?”
Throughput Is Different
Door-to-provider time and length of stay deserve more cautious consideration. The study found substantial variation in throughput benchmarks between sites and between pediatric EDs and affiliated community settings. Interestingly, throughput performance worsened over the study period.
Unlike giving corticosteroids for an asthma exacerbation, ED length of stay is only partly controlled by an individual clinician. Crowding, staffing, boarding, diagnostic resources, consultation availability, inpatient capacity, and patient volume all can influence throughput. The authors appropriately note that future benchmarks may need to account for volume and capacity.
For example, a 110-minute benchmark for a discharged pediatric patient should not automatically become an inflexible performance mandate for every ED. It is better interpreted as a reference point: this level of performance has been demonstrated, and a substantial gap from it should prompt examination of the systems contributing to that gap.
Why Benchmarking Against “Average” Isn’t Enough
Quality dashboards frequently compare a clinician or department with an institutional or national mean. That approach is intuitive but has an obvious weakness: the average describes current performance; it does not necessarily define desirable performance.
Imagine an ED with a median time to provider of 38 minutes. Learning that the network average is 36 minutes tells the department that it is slightly slower than its peers. Learning that high-performing clinicians and systems can achieve approximately 20 minutes asks a much more useful question: what would have to change to close that gap?
The same concept applies to clinical care. An asthma corticosteroid benchmark of 97.8% is not an aspirational number invented by a committee. It reflects performance that clinicians in actual emergency departments have demonstrated.
ABCs therefore occupy a useful space between two imperfect targets:
“Be average” ← Achievable excellence → “Be perfect.”
A Benchmark Is a Starting Point, not a Report Card
There are important limitations. The PECARN Registry sites are predominantly pediatric centers, along with affiliated community sites. They do not represent the general EDs that care for most children nationally. Differences in pediatric volume, staffing, resources, geography, and pediatric readiness may affect whether a particular benchmark is immediately attainable in another setting. The study also relies on electronic health record data. Documentation does not always represent care, and EHR-derived measures cannot capture every element of clinical judgment or patient outcome.
These benchmarks therefore should not be interpreted as universal thresholds separating “good” from “bad” EDs, or good from bad clinicians. They are something more useful: empirical targets showing what high-performing clinicians and systems have demonstrated is possible.
The Bottom Line
Emergency medicine has no shortage of quality measures. What has often been missing is a meaningful answer to the question, “What should our target be?” This article provides one approach. By deriving benchmarks from high performers across more than 5.3 million pediatric ED encounters, the study team moves the target away from both average performance and theoretical perfection and toward achievable excellence.
For clinicians and ED leaders, the most useful question may not be whether your department meets every benchmark tomorrow. Instead, look at the measures where your performance differs most from what high-performing clinicians have already demonstrated. Determine which gaps are driven by individual practice and which are driven by systems. Then ask: What is keeping excellent care from becoming our usual care?
References
- Alpern ER, Ramgopal S, Olsen CS, et al; PECARN Registry Study Group. Achievable benchmarks of care in pediatric emergency departments. JAMA Netw Open. 2026;9(5):e2613391. PMID: 42154467. doi:10.1001/jamanetworkopen.2026.13391
- Woods JM. What excellent care looks like: new benchmarks. Pediatric Emergency Care Applied Research Network (PECARN). Published June 23, 2026. https://pecarn.org/pecarn_news/what-excellent-care-looks-like-new-benchmarks/
Jason M. Woods, MD
Associate Program Director, Pediatric Emergency Medicine Fellowship
Section of Emergency Medicine, Department of Pediatrics
University of Colorado School of Medicine and Children’s Hospital Colorado
@jwoodsmd
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