Table 3.

Overview of included redesigns

	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