Skip Navigation Archive: U.S. Department of Health and Human Services U.S. Department of Health and Human Services
Archive: Agency for Healthcare Research Quality
Archival print banner

This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: Let us know the nature of the problem, the Web address of what you want, and your contact information.

Please go to for current information.

Implementing Process Redesign Strategies for Improving Hospital Care

Slide Presentation from the AHRQ 2009 Annual Conference

On September 19, 2009, Shinyi Wu made this presentation at the 2009 Annual Conference.

Select to access the PowerPoint® presentation (149 KB).

Slide 1


Implementing Process Redesign Strategies for Improving Hospital Care

September 15, 2009, presented at AHRQ Conference

Shinyi Wu, PhD

Assistant Professor, Epstein Department of

Industrial and Systems Engineering

University of Southern California & RAND


Slide 2


Co-authors, Sponsor, and Participants

  • Marjorie Pearson, PhD, @ RAND
  • Lisa Smith, RN, BSN, BS, @ UHC
  • Raj Behal, MD, MPH, @ Rush University Medical Center
  • Julie Cerese, RN, MSN, @ UHC
  • Helga Brake, PharmD, CPHQ, @ Northwestern Hospital
  • Joanne Cuny, RN, BSN, MBA, @ UHC
  • Ryan Mutter, PhD, @ AHRQ
  • Michael Harrison, PhD, @ AHRQ
  • The participating healthcare organizations


Slide 3


Why Redesigning Hospital Care?

  • Literature:
    • Hospital care at night is not as safe or patient-centered as care provided during weekdays
  • National Health Service (UK) Hospital at Night Model:
    • Found mismatch between activity at night and staffing structure (e.g., experience, competencies)
  • UHC "Improving Survival" project and pilot "Care @ Night" project
    • Identified third shift had a significantly lower survival rate, mismatch between patterns in admissions / discharges, and about 50% paging non-urgent


Slide 4


Test A Structured Process Redesign Intervention to Help Hospitals Improve Efficiency and Value

  • Design, deliver, and evaluate an intervention "24/7 Care Delivery Model"
    • Aimed to redesign care delivery in hospitals for efficiency and consistency around the clock
  • Intervention components:
    • Redesign strategies: modifying workload demand vs. adjusting staffing model
    • A structured approach to facilitate improvement
  • Compare overall and relative importance of redesign strategies
    • Demand vs. Demand+Supply

Slide 5


24/7 Redesign Strategies:

  • Four "demand" and a customized "supply" best practices
    • Developed from the NHS model, literature review, and advisory group recommendations


Slide 6


UHC Commit to ACTion Facilitation Approach

  • A set of implementation tools including best practices
  • Organizational commitment from each participating organization
    • Designated improvement team & a team leader with time commitment
    • Identified executive sponsor, a nurse champion, and a physician champion to provide support and resources
  • Collaborative learning facilitated via teleconference and emails
    • Separate facilitation by intervention arms
  • Operated as a member service, on voluntary basis


Slide 7


Commit to ACTion Implementation Process

Step 1:

Improvement Design

  • Identify Team
  • Complete Project Charter
  • Conduct Gap Analysis
  • Select Best Practices to Implement

Step 2:

Plan Implementation of Interventions.

  • Create an Implementation Plan for each intervention

Step 3:

Implement Interventions

  • Execute activities and implement best practices

Step 4:

Measure Results, Analyze Data, and Act on Results Performance Improvement Model

Step 5:

Standardize & Communicate

Slide 8


Evaluation Methods

  • Quasi-experimental design with three arms
    • 15 academic medical centers across the US
    • Demand intervention: 4 hospitals, including 4 meds & 2 surgical services, 10 nursing units
    • Demand+supply intervention: 6 hospitals, including 4 meds & 3 surgical services, 13 nursing units
    • External comparison: 5 hospitals, including4 meds & 4 surgical services, 12 nursing units
  • Implementation assessment
    • Triangulation and coding of data from CTA observations, document review, CTA data analyses, and two rounds of interviews
  • Impact assessment
    • Participants perceived impact and lessons learned
    • Diff-in-Diff analyses of efficiency and quality measures


Slide 9


Results: CTA Participation Was High But Took Longer

CTA collaborative call participation: average 90%, range 70% to 100%

Activities Planned wks Actual wks (supply wks)
Preparation   4
Design Improvement 3 7
Plan Implementation 2 6
Implement 24/7 strategies 4 5
Measure and analyze 3 10
Act on results 2 4
Measure, analyze, standardize & communicate 10 45 (38)
Total 24 81


Slide 10


Implementation Results

24/7 Strategy Level of 24/7 strategies at baseline in % (SD) % (SD) of 24/7 strategies implemented
Structured handoffs 57%
Discharge planning 32%
Common complaints
Paging Policy 9%

The comparison sites have high penetration of the same strategies.


Slide 11


Perceived Major Gains

  • Opportunities to communicate with and learn from other hospitals
  • Data to understand current practice and staffing gaps
  • Multidisciplinary perspectives and discussions
  • Demand strategies improved care routines, coordination, workflow, and decreased interruption
  • Supply strategies helped better distribute nighttime and weekend workload


Slide 12


Lessons Learned

  • Lack of geographical localization is the biggest barrier for 24/7 care redesign
  • Physicians' and leaders' buy-in and push for changes are important
    • Especially for complex care processes & clinical authorization
  • Key facilitators to changes
    • Senior leader support
    • Team leader facilitating implementation and successfully communicating to staff
  • Clearly presented data reports can be powerful tools
    • Even for making major changes in staffing arrangements


Slide 13


More Lessons Learned

  • 24/7 activities set the stage for continual and subsequent change efforts
  • Long-term, multi-factorial, pilot unit-based intervention is difficult
  • Recommendations from participants for others:
    • Engage frontline staff and direct care providers
    • Involve people with operation authority on the units
    • Orient team members and staff
    • Maintain constant communication with everyone
    • Recognize that active support from leadership may be needed


Slide 14


Conclusions & Implications

  • Hospital participation in CTA was high
    • The process was longer than anticipated
  • Resulted in some changes in care delivery systems and processes at all hospitals
    • Most clinical outcomes changed as expected, but not efficiency measures
  • Each of the 24/7 redesign strategies was implemented in some hospitals and had different effects on outcomes
    • Demand strategies improved efficiency and consistency of care processes
    • Supply strategies might be needed to improve care around the clock
  • Can 24/7 strategies be implemented without CTA facilitation?
Current as of December 2009
Internet Citation: Implementing Process Redesign Strategies for Improving Hospital Care: Slide Presentation from the AHRQ 2009 Annual Conference. December 2009. Agency for Healthcare Research and Quality, Rockville, MD.


The information on this page is archived and provided for reference purposes only.


AHRQ Advancing Excellence in Health Care