Performance improvement should be proactive, rather than reactive. Waiting for escalation of patient and staff complaints is a poor mechanism to identify problem areas. Routine evaluation of all aspects of patient care, throughput, and primary and secondary client satisfaction improves and strengthens the contractual relationship with the hospital. The ED's performance on a wide variety of metrics, such as time to physician evaluation, time to discharge, lab turnaround, x-ray turnaround, number of inpatient boarding hours, and so on may be benchmarked against similar EDs and best practices to identify and target areas requiring improvement. Effective groups internally benchmark performance and actively solicit feedback from and provide feedback to key stakeholders and clients (emergency physicians, nurses, and staff, medical staff, administrators, etc) (Box 75-2).