As clinical director of the Emergency Department, Joshua Kosowsky was given a broad mandate to lead the entire redesign process that began in 2009 – from concept to implementation with a clear challenge of dramatically shortening patient wait times and improving every single metric of care. Not a single existing aspect of emergency care was left intact – Kosowsky and his team reinvented traditional roles and set aside long-standing emergency medicine concepts, such as nursing triage and acuity-based units. The early results were impressive: ED walk-outs dropped from a historic rate of 2.5 percent to an all-time low of 1 percent. Average length of stay dropped to 3.6 hours, an astounding 30 percent lower than the average in FY’09. The mean time from patient arrival to bed was 18 minutes, 72 percent lower than the FY’09 average, and the Press Ganey scores jumped to the 88th percentile – the best ever in the ED.