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 | Â | Â |
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 |