With nearly 20 million visits per year, Emergency Departments remain one of the most critical pressure points within the healthcare system. Among the most frequently cited challenges is staff shortage. Less clear, however, is what types of professionals—and in what numbers—are actually required to ensure patient safety, clinical quality, and organizational sustainability.

The heterogeneity of care needs, combined with the wide array of organizational and logistical models layered over time, makes workforce estimation particularly complex. To date, there are no universally accepted staffing standards for Emergency Departments. The risk, therefore, is oscillating between generic calls for additional resources and theoretical benchmarks that are difficult to operationalize across structurally diverse settings.

Within the LOPS Network—SDA Bocconi’s managerial forum dedicated to Emergency Department organization—the debate has focused on moving beyond the notion of a “one-size-fits-all” standard toward the standardization of method. Rather than defining a single staffing ratio, the objective is to develop adaptable calculation criteria capable of accounting for case mix, patient volumes, clinical complexity, and process configuration at the level of each individual ED. Among the initial outputs is the proposal to identify “standard” time ranges for specific activities and integrate them with real-world volume and flow analyses.

Any robust capacity assessment and skill mix evaluation must begin with a deep understanding of actual workflows. As Michela Bobini, Assistant Professor of Practice in Government, Health and Not for Profit at SDA Bocconi and faculty member of the LOPS Network, notes: “There is a tendency to oversimplify the patient journey in the Emergency Department, overlooking several clinical and operational activities that absorb a significant portion of professionals’ time.” Discussions within the Network have highlighted, for instance, the need to properly account for activities such as communication with patients and caregivers, patient monitoring, reassessment, and inpatient handover. Nursing contributions, including patient intake and initial nursing management for selected case types, also remain systematically undervalued.

Clarifying processes is a necessary first step—but not sufficient. They must also be measurable. From this perspective, Francesca Lecci, Associate Professor of Practice in Government, Health and Not for Profit at SDA Bocconi and faculty member of the LOPS Network, observes: “The Emergency Department remains a ‘black box.’ Certain process phases are measured, primarily for institutional benchmarking purposes, but a management-oriented data culture is still lacking. Today, technologies capable of tracking patient flows and resource utilization times could shift the discussion from perceptions to evidence.”

Once required capacity for specific activities has been defined, the issue of appropriate skill mix emerges. Two cultural barriers need to be addressed. The first is normalizing the introduction of non-clinical roles within the Emergency Department. Some organizations have introduced non-clinical staff for administrative and front-desk functions; others have incorporated social workers to support socially vulnerable patients. However, adding new professional roles requires a redesign of coordination mechanisms. Without process reengineering, the risk is increasing organizational complexity without improving performance outcomes.

A further unresolved issue concerns the allocation of clinical responsibilities among physicians—emergency medicine specialists, internists, and other consultants. The LOPS Network adopts a neutral stance, promoting structured dialogue among scientific societies to foster cross-disciplinary perspectives and overcome siloed approaches.

As Lorenzo Fenech, Director of the LOPS Network and Associate Professor of Practice in Government, Health and Not for Profit at SDA Bocconi, emphasizes: “The point is not merely to quantify staffing gaps within the current model. The context is undergoing profound transformation, and the traditional Emergency Department model is no longer sustainable. Without a clear vision of how the organizational paradigm will evolve—and without a shared methodological framework—any capacity estimates or staffing standards risk becoming rapidly obsolete. The debate on headcount would remain ideological rather than managerial.”

From this perspective, the LOPS Network focuses on integrating robust evidence, enabling technologies, and process redesign capabilities—reframing the core question for the healthcare system: what level and composition of workforce are truly required, in light of actual operational workflows and the evolving needs of today’s Emergency Department patients?

SDA Bocconi School of Management