In this edition of the American Journal of Emergency Medicine, authors Mullins et al [1] expose that some of our “best” hospitals are, in fact, dysfunctional. Their measurement is wait times in the emergency department (ED), but this is not an ED issue. A crowded ED is a sign of a dysfunctional hospital. The evidence from the scientific literature, government analysis, and the lay press is clear [2-7]—longwaits (and crowding) in the US EDs are primarily due to large number of inpatients kept in the ED awaiting an inpatient bed. When 10%, 20%, 50%, or even 80% of treatment spaces in an ED are filled with inpatients, time to treatment for all patients increases. There are many causes for inpatients remaining in the ED (often termed boarding)—some hospitals have closed inpatient beds because of shortage of nurses and some fill their inpatient beds preferentially with higher profit elective surgical cases and transfers from outside institutions, leaving the less profitable emergency patients to accumulate in the ED. Regardless of the cause, the result is a crowded ED. There are consequences to excessive waits and boarding of inpatients in the ED, all of them bad. We know that the boarding of inpatients in the ED leads to delay in care of all patients in the ED; lower patient satisfaction; higher rates of patients leaving without care; and, most importantly, higher mortality and morbidity for those patients who are waiting and those who seek care [2-7]. A recent abstract by Drew Richardson of Australia suggests that mortality is increased by 0.3% per hour of waiting in the ED. That suggests that patients held in an ED for 600 minutes may have a 3% increase in mortality [8]. Although Dr Richardson has not determined the cause of this increase, the article byMullins et al [1] suggests that many quality measures follow the same trend as wait times; increased infections and increased readmissions are more common in institutions that perform poorly on the ED to inpatient floor flow measures. So if waiting is bad for patients, why do we permit it? It may be that our hospitals do not recognize how bad the situation has become. Crowding is relative. When I served as ACEP President a few years ago, I had the opportunity to visit many EDs and talk to physicians across the nation. Crowding and long waits for inpatient beds are concerns for most emergency physicians. Some complained about 1 or 2 inpatient boarders, whereas others had become accustom to 40 to 60 inpatients. While some were concerned when patients stayed for 2 to 4 hours after being admitted, others were happy if they only stayed 1