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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)


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



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


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