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Table 3 Overview of included redesigns

From: Towards an organisation-wide process-oriented organisation of care: A literature review

  Denver Health (DH) Flinders Medical Center (FMC)
Setting A 398-bed hospital in Denver, United States A 500-bed teaching general hospital in Adelaide, Australia
Aim redesign To improve patient safety and satisfaction, efficiencies and cost reductions, and job satisfaction To improve patient flow through the emergency department (ED), medical and surgical patients
Study design Uncontrolled before-after study, including an analysis of positive and negative antecedent conditions Uncontrolled before-after study
Evaluation period 2003 to 2008 2003 to 2007
Redesigned services Clinical care and administrative processes Clinical care (first emergency care, then surgical care, medical care)
Applied approach Coordination mechanism approach Coordination mechanism approach
Measures to change working procedures Not reported Not reported
Outcomes in general Reductions in operating room expenses; fewer dropped patient calls; cost savings Positive results for redesign at the emergency department (less congestion; reduced throughput time); No outcomes reported for the elective surgical care process redesign
Outcomes on indicators   
Finances No quantitative figures reported No quantitative figures reported
Operational efficiency No quantitative figures reported Length of stay:
   - Time spent at the ED: ↓ (from 5.4 hours to 4.8 hours).
   - Length of stay of emergency admissions: ↓ by one day.
   Throughput time:
   - The number of patients leaving the ED without waiting to be treated: ↓ (approximately from 4% to less than 2%)
   Patient volume:
   - Patients seen at the ED: ↑ (from 140 to a range of 180 to 210 patients per day [managed within the same physical space and with similar staff-patient ratios]).
   - Emergency admissions: ↑ (from 1,200 to over 1,600 a month).
Patient Satisfaction No quantitative figures reported No quantitative figures reported
Patient Safety No quantitative figures reported Adverse events:
   - Number and types of serious adverse advents throughout the hospital a year: ↓ (from 91 to 19)
Factors for success The change strategy was built on ideas that were developed and tested in preceding projects; Leader of transformation was a clinician, who drew on her professional status and familiarity with clinical practice; Political and financial support of the city; Training of nurses, clinicians and middle managers in Lean improvement techniques; Previous (positive) experience with change management Leadership by senior executives; Clinical leadership; Team-based problem solving; A focus on patient journey; Access to data; Ambitious targets; External facilitators to break down the 'silo' mentality and facilitating multidisciplinary teamwork; Organisational readiness; Selection of projects - start the redesign process with a problem that obviously needs to be fixed; Strong performance management; A process for maintaining improvement; Communicating the methodology and results in many different ways, i.e., Lean thinking days
Challenges To manage system-wide changes while horizontal communication across occupations, departments and sites is impeded; To promote the use of industrial techniques to clinicians while they lack experience working with these problem solving and quality improvement techniques; To manage shortcomings in IT infrastructure in providing data for RIEs; To mobilise (financial) resources needed for the redesign while the hospital has safety net obligations (cannot delete services) To manage the tension between the bottom-up approach of Redesigning Care and the more usual 'command and control' (top-down) process adopted by healthcare managers who, once the problem is identified, see their role as coming up with a solution that front-line staff then have to implement