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International Journal of Health Care Quality Assurance

Evidence-based re-engineering: re-engineering the evidence: A systematic review of


the literature on business process redesign (BPR) in hospital care
S.G. Elkhuizen, M. Limburg, P.J.M. Bakker, N.S. Klazinga,
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engineering the evidence: A systematic review of the literature on business process redesign (BPR) in
hospital care", International Journal of Health Care Quality Assurance, Vol. 19 Issue: 6, pp.477-499, https://
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Evidence-based re-engineering: Evidence-based


re-engineering
re-engineering the evidence
A systematic review of the literature on business
process redesign (BPR) in hospital care 477
S.G. Elkhuizen
Academic Medical Center, University of Amsterdam,
Department of Innovation and Process Management,
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Amsterdam, The Netherlands


M. Limburg
Academic Hospital Maastricht, Department of Neurological Medicine,
Maastricht, The Netherlands
P.J.M. Bakker
Academic Medical Center, University of Amsterdam,
Department of Innovation and Process Management,
Amsterdam, The Netherlands, and
N.S. Klazinga
Academic Medical Center, University of Amsterdam,
Department of Social Medicine, Amsterdam, The Netherlands

Abstract
Purpose Business process redesign (BPR) is used to implement organizational transformations
towards more customer-focused and cost-effective care. Ideally, these innovations should be carefully
described and evaluated so that best practices can be re-applied. To investigate this, available evidence
was collected on patient care redesign projects.
Design/methodology/approach The Ebsco Business Source Premier, Embase and Medline
databases were searched. Studies on innovations related to re-engineering patient care that used
before-after design as minimum prerequisites were selected. General characteristics, logistic parameters
and other outcome measures to determine the objectives and results and interventions used were looked
at.
Findings A total of 86 studies that conformed to the criteria were found: a minority mentioned
measurable parameters in their objectives. In the majority of studies, multiple interventions were
combined within single studies, making it impossible to compare the effects of individual interventions.
Only three randomized controlled trials were found. Furthermore, inconsistencies were noted between the
study objectives and the reported results. Many more issues were reported in the results than were
mentioned in the study aims. It would appear that publications were hard to find owing to a lack of
specific MeSH headings. Nearly 7,500 abstracts were scanned and from these it was concluded that clear
and univocal research methods, terms and reporting guidelines are advisable and must be developed in
order to learn and benefit from BPR innovations in health care organizations.
Originality/value This appears to be the first time available evidence about redesign projects in
hospitals has been systematically collected and assessed.
Keywords Business process re-engineering, Health education, Quality, Quality improvement
Paper type Literature review
International Journal of Health Care
Quality Assurance
Vol. 19 No. 6, 2006
The authors thank their internal reviewers, Jan Koning and Joeri Edens, for reading and selecting pp. 477-499
q Emerald Group Publishing Limited
the large numbers of abstracts and articles, and Thomas Plochg for critically reading an earlier 0952-6862
version of this paper. DOI 10.1108/09526860610686980
IJHCQA Introduction
19,6 In health care, business process redesign (BPR) is used to implement organizational
transformations towards more customer-focused and cost-effective care. Business
process redesign was developed by industry staff and can be defined as the
fundamental rethinking and radical redesign of business processes to achieve dramatic
improvements in critical contemporary measures of performance, such as cost, quality
478 and speed (Hammer and Champy, 1993, p. 32). Although BPR was originally
introduced as a major change to the total process flow, the concept has been used in
many different ways (Davenport and Stoddard, 1994; McNulty and Ferlie, 2002;
Locock, 2003). Despite an increasing number of redesign projects in health care, little is
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known about their effectiveness. Evidence-based medicine (EBM) teaches us that


practice should be based on sound evidence that has been derived from clinical data
captured in experimental studies of the highest quality and preferably also validated in
observational studies (Walshe and Rundall, 2001). In an effort to extend this topic, we
collected evidence on redesign projects in healthcare delivery. Against this backdrop,
we decided to review all interventions in patient flow or capacity planning directed
towards the process of patient care or health care outcomes. Our goal in this study was
a structured literature review of innovations related to re-engineering in patient care.
Anticipating the scarcity of randomized controlled trials (RCTs) (Campbell et al., 2000),
we also included non-randomized studies. In RCTs there is preferably no intervention
in the control group. However, environments change over time, and we deemed it
necessary to have multiple measurements in experimental and control groups in order
to provide evidence of effectiveness. Since many studies did not provide concurrent
controls, we considered a comparison between a before-and-after intervention situation
the minimum methodological prerequisite for inclusion (Figure 1).
To evaluate whether results meet expectations, redesign studies should have clearly
stated objectives (Bokhoven et al., 2003). Ideally, the objectives have been specified in
relevant parameters with unequivocal and measurable targets, which is one of the
aspects we wanted to examine in our review. We focused on interventions in patient
flow or capacity planning with the objective of improving health care services for
patients. Improvements should have been related to process characteristics and should
have resulted primarily in benefits for patients. For this reason, our review focused on
interventions in patient logistics and health care redesign with respect to logistic
parameters. From the literature we defined logistics as the organisation and coherence
of process with the aim of making available the right resources in the right place at the
right time, with acceptable effort and costs. For example, improvements in patient
logistics focus on the sequences of diagnostic examinations, coordination in
multidisciplinary patient care and capacity planning that should lead to quicker

Figure 1.
Design for redesign and
innovation studies
access, reduced waiting times and/or visits among others. The specific review Evidence-based
objectives were to report: re-engineering
.
the main characteristics of redesign studies in health care (publication year,
country or region, study setting and journal);
.
their contents (i.e. objectives for redesign in patient logistics and process
parameters targeted, intervention types, and types of results reported and
process parameters measured); and 479
.
research method and publication quality (their research designs, and
compatibility between stated objectives and reported results).
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Methods
We conducted a systematic review of the BPR literature. From a pilot study we learned
it was impossible to differentiate between successful and unsuccessful innovations.
Many publications contained little or no information on study design, intervention,
studied population or results. Reported results were mutually incompatible owing to
differing and often unclear definitions of measured parameters. Furthermore, there
appeared to be a strong publication bias in favor of successful case studies
(Easterbrook et al., 1991). Based on the pilot study, we redefined our inclusion and
exclusion criteria and ultimately defined our search strategy.

Search strategy
The Medline, Embase and Business Source Premier (BSP) databases were searched for
articles from 1989 through 2003. Inclusion and exclusion criteria are summarized in
Table I.
We searched the Medical Subject Headings database to find useful keywords (MeSH
headings) and selected 19 potentially relevant terms. Using these 19 headings, 50
recent titles and abstracts were retrieved for each heading (the publication dates
ranged from June 2002 through April 2003) and evaluated for relevance. If none of the
abstracts retrieved was useful the MeSH heading was discarded. More relevant MeSH
headings were found by looking at previous indexing MeSH headings using the Ovid
tool Scope Note. From the relevant abstracts, we derived free-text keywords (for
example, reengineer$, patient flow) to increase the specificity of our search strategy.
Corresponding keywords for Embase (subject headings) were found using Scope Note.
We entered all MeSH headings from our list and found the corresponding Embase
subject heading(s). A cross-check was performed by entering the Embase Subject
headings in Medline Scope Note to find additional MeSH headings. Ovid was searched
for the combination of the databases Embase 1988-2003 (to meet inclusion criteria, we
removed articles published in 1988 from the search result) and Medline 1989-2003. All
articles indexed by at least one of the MeSH headings (Medline) or subject headings
(Embase) were combined with articles containing at least one of the free-text keywords
in the title or abstract. The MeSH headings, subject headings and keywords used are
listed in Appendix 1.
For the BSP, the list with all the available standard keywords (subjects) was scanned
to find useful subjects. We searched for hospital-related subjects and for logistics and
planning-related subjects. The search strategy was directed at finding articles with at
least one logistics or planning-related subject combined at least one health-care related
subject. After performing our search with the selected keywords and MeSH headings,
IJHCQA
Inclusion criteria Exclusion criteria
19,6
Article should: Article focuses on:
contain abstract staff satisfaction and/or change only concern job
be published and available in public domain redesign or responsibility changes
address a process redesign with changing the organizational structure or
480 patient-relevant results redesigning at organizational level without
address an innovation in patient logistics, analyzing care processes
patient flow and/or process design with the changing the health structures at national levels
purpose of improving patient care in terms restructuring health care in developing countries
of process-related topicsa or non-industrialized countries
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contain a description of the intervention projects with main purpose of financial


contain quantitative data about at least one improvement and/or changes that only concern
logistic parameter logistic parameters are administration
time factors (length of stay, waiting time, change in software and/or hardware and IT with
access time) or capacity factors (resource no intended effect on patients
utilization, planning issues) material logistics with no intended effect on
have a randomized or non-randomized patients
control group design, a before-after design description of methods, models and theories
or an interrupted time series design without empirical data
have been published after 1 January 1989 the management of redesign and change projects;
and before 1 January 2004 redesign of the building
review articles
Note: aProcess changes may be supported by the introduction or redesign of Information Technology
Table I. solutions, and there may be organizational restructuring needed for implementing improved process
Inclusion and exclusion designs. There has to be a planned change in processes with a patient focus; changes in information
criteria flow with the objective of speeding up patient flow were included

articles were then selected based on the title and abstract. Two reviewers independently
scanned titles and abstracts to select studies for consideration. The abstracts selected by
at least one of the reviewers were thereafter evaluated by a third, main reviewer.
Together the three reviewers decided whether or not to obtain the articles full text. This
was done where the details in the text about interventions or measurements were
insufficient to make a decision about inclusion. Kappa statistics (Landis and Koch, 1977)
were applied to assess inter-observer variation between two reviewers. Full publications
of all selected abstracts were obtained (in electronic or printed form) to evaluate the full
text. The main reviewer read all the articles in English or German. A second and third
reviewer each read about half of all the articles in English. A fourth reviewer was
recruited to read the articles in German. Selections were compared and discrepancies
were resolved through discussions between the main reviewer and the other reviewer
who had read the article. Three additional reviewers read the articles in Spanish,
Swedish and Danish and translated parts of these into English. Based on these
translations, the main and second reviewers decided on inclusion. Inter-observer
variation between the main reviewer and the second, third and fourth reviewers was
assessed separately using kappa statistics (Landis and Koch, 1977).

Data collection and content analysis


A standard form was used for data extraction. This form contained the following
variables:
.
publication year; Evidence-based
.
country or region; re-engineering
.
study setting (in-hospital care, outpatient/ambulatory care, home care or a
combination of these); and
. study objective (as stated in the article, or when the objective was not explicitly
mentioned, derived from the context). 481
Study objectives and results
We collected the following process-related parameter(s) from the descriptions of the
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objectives: patients that leave without being seen (mostly used in emergency
departments), reduction of waiting times somewhere in the process, reduction of length
of stay/visit time, reduction of number of hospital visits and the flow-related
parameters mentioned in Figure 2.
In addition, we looked for other outcome benefits mentioned in the study objective
but that were not directly related to process parameters. The following categories were
found in the objectives:
.
patient satisfaction;
.
staff satisfaction;
.
medical outcomes;
.
resource utilization; and
.
cost reduction.

The same process parameters and outcome categories were used for reported results.

Interventions in studies
The intended intervention was derived from the articles, and from the verbatim text
when possible. Inspired by the Cochrane-EPOC classification for organizational
interventions (Effective Practice and Organisation of Care Review Group, 2002),
interventions were categorized for further analysis according to:
(1) Changes in structure:
.
changes in physical structure, facilities and equipment;
.
changes in the setting/site of service delivery;
.
cooperation with external services or communication and case discussion
with off site health professionals;
.
integration of services;
.
staff organization;

Figure 2.
Flow-related parameters
IJHCQA .
clinical multidisciplinary teams; and
19,6 .
revision of professional roles/skill mix changes.
(2) Changes in processes and process management:
.
changes in process sequences and organization of processes;
.
changes in capacity planning; and
482 .
presence and organization of quality-monitoring mechanisms.

Study method and quality


We evaluated study designs according to the taxonomy shown below (Shojania and
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Grimshaw, 2005; Eccles et al., 2003):


.
randomized controlled trial;
.
non-randomised control group design;
.
(interrupted time series design;
.
controlled before-after design; and
.
before-after design.

Furthermore, we noted whether all study groups were clearly specified according to the
number of patients and length of the measurement period. We also analyzed the
consistency in the relationship between objectives and results. A check was performed
for each process parameter mentioned in the objective to see whether the same
parameter was also reported in the results, and vice versa. The same check was
performed for the outcome categories in which the other objectives and results were
classified.

Results
Search strategy
We found 14 relevant MeSH headings in Embase and 16 relevant subject headings in
Medline; 33 free-text keywords were selected. Using a combination of at least one of
these headings and at least one of the free-text keywords as well as the inclusion
criteria (containing abstract and publication period), 6,243 abstracts were found. In
Business Source Premier, 41 logistic and planning-related subjects and 34 health-care
related subjects were identified. Using our search strategy of combining at least one
health-care related subject with at least one logistic or planning-related subject, we
found 1,185 articles that met our inclusion criteria (abstract and publication period).
Appendix 1 contains a list of all MeSH headings, subjects and keywords used. All 7,428
titles and abstracts were read by two reviewers, who selected 266 abstracts for further
evaluation (kappa 0.46). Full-text articles could be obtained for 263 abstracts; the
remaining three abstracts were excluded. Of the articles, 250 were in English, eight in
German, two in Spanish, two in Swedish and one in Danish. All articles were evaluated
by two reviewers, who selected 88 articles that met our inclusion criteria (see Appendix
2 for selected articles) in which 86 distinct studies were described (kappa for main and
second, third and fourth reviewers, respectively, was 0.59, 0.51, 1). Two studies were
described in two articles each (Fernandes et al., 1996, 1997, Caplan et al., 1998, 1999).
Data collection and content analysis Evidence-based
Table II summarizes the materials general characteristics (publication year, setting re-engineering
and country or region). Almost half of all the studies were performed in the US. Of the
European studies, a relatively large number of these were performed in the UK. One
paper did not mention the study location (Akosah et al., 2002).

Objectives and results in the studies 483


Frequently, the aim of the studies was stated as an effect evaluation of an intervention
for example, to evaluate the impact of a fast-track triage system for patients with
acute myocardial infarction (Pell et al., 1992, p. 83) without specifying the desired
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quantitative results. Sometimes a more specific target was mentioned in the study
design, such as comparison in delays for admission (Pell et al., 1992, p. 83). If so, we
used this for further evaluation of the study. In only six studies did we find an objective
clearly mentioning parameters and quantified aims for improvement: for example, In
April 2002, 75% of eligible patients should receive thrombolysis within 30 minutes of
arrival at hospital (Qasim et al., 2002, p. 1328). In 36 studies we encountered a specific
subject: for example, to reduce waiting time intervals (Spaite et al., 2002, p. 168), but it
was not quantified. All other articles mentioned non-specific study objectives such as
to develop team working and improve the service offered to patients (Grimes, 2000,
p. 99). In the objectives of 86 studies, 58 (67 percent) explicitly mentioned one
(46 studies) or two (12 studies) process-related parameters from our list (see Table III).
The most frequently found aim was to reduce the lengths of hospital stays, followed by
the goal of reducing waiting times. In eight studies we found parameters not included
in our list that had some relation to logistics: for example, the amount of time an
emergency department was overcrowded (Miro et al., 2003) or the number of
admissions during a certain time interval (Schwarcz et al., 1998). Of the 86 studies,
47 (55 percent) mentioned one or more outcome measures from our list in their
objectives. Twenty studies (23 percent) mentioned objectives that were categorized into
two or three outcome categories. Cost reduction and resource utilization were the most
frequently found outcome categories in the study objectives. In 13 studies, the terms
stated in the objectives could be categorized neither under process parameters nor
under one of our outcome categories. All articles reported successful projects, and by
definition (selection criteria), all articles reported results on at least one process-related

Publication date 1997-2003 61 articles (69 percent)


1991-1996 26 articles (30 percent)
1989 1 article (1 percent)
Setting Hospital 54 studies (63 percent)
Out-patient, ambulatory care or primary care 17 studies (20 percent)
Home care 1 study (1 percent)
Combination 14 studies (16 percent)
Country or region USA 42 studies (49 percent)
UK 18 studies (21 percent)
Remaining European countries 10 studies (12 percent)
Australia and New Zealand 7 studies (8 percent)
Canada 6 studies (7 percent) Table II.
Asia 2 studies (2 percent) General characteristics of
Unknown 1 study (1 percent) the studies included
IJHCQA
Found in the objectives of Found in the results of
19,6
Process-related parameters
Length of stay or visit time 29 studies (34 percent) 51 studies (59 percent)
Waiting times 16 studies (19 percent) 24 studies (28 percent)
Time to treatment 9 studies (10 percent) 12 studies (14 percent)
484 Access time 5 studies (6 percent) 4 studies (5 percent)
Number of patients that leave without
being seen (by physician) 2 studies (2 percent) 6 studies (7 percent)
Time to diagnosis 1 study (1 percent) 1 study (1 percent)
Number of visits None of the studies 5 studies (6 percent)
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Outcome measures
Table III. Cost reduction 25 studies (29 percent) 27 studies (31 percent)
Objectives and results in Resource utilization 21 studies (24 percent) 28 studies (33 percent)
the 86 studies included in Patient satisfaction 11 studies (13 percent) 25 studies (29 percent)
the review of BPR in Medical outcomes 11 studies (13 percent) 19 studies (22 percent)
hospital care Staff satisfaction 5 studies (6 percent) 12 studies (14 percent)

parameter. One (of 58 studies), two (of 26 studies) or three (of three studies) process
parameters were found in the studies. In 15 studies (17 percent) we found
process-related parameters that had not been included in our criteria, for example
different process times or the number of patients waiting. In 62 articles (71 percent), a
result addressing one or more outcome measures from our list was reported; 34 studies
(39 percent) mentioned results that were categorized into two or three outcome
categories. Resource utilization, cost reduction and patient satisfaction were the most
frequently found outcome categories in the reported results. Table III gives a complete
overview of the number of results found in each category.

Interventions
All interventions in the studies were categorized. We assigned 22 interventions to
exactly one of the categories. The remaining contained interventions belonging to more
than one intervention group. In one article we encountered up to seven different
intervention categories (Tunick et al., 1997). Four isolated categories were found in
some of the studies:
(1) change in capacity planning;
(2) changes in process sequences and organization of processes;
(3) changes in the setting/site of service delivery; and
(4) cooperation with external services or communication and case discussion with
off-site health professionals.

All other categories were found in combination with at least one other intervention.
Table IV gives an overview of the interventions found.

Study method and quality


In 23 studies (27 percent), an intervention group was compared with a control group.
Only three studies had an RCT design. As a result, in most studies the control groups
were not comparable to the intervention group. For example, patients sent to a special
Evidence-based
Intervention
category Number of studies Examples of interventions
re-engineering
Changes in process 48 studies (55 Introduction of pre-admission assessment for
sequences or percent) anesthesiology, sometimes combined with admission on
changes in the day of surgery (Hypnar and Anderson, 2001; Clark et al.,
organization of 1999; Caplan et al., 1998, 1999; Monagle et al., 2003) 485
processes. Introduction or modification of triage system in emergency
department combined with different medical trajectories
for various triage categories (Monagle et al., 2003; New,
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2000; Smart et al., 1999; Fernandes et al., 1996, 1997; Cain


et al., 1996; Fernandes and Christenson, 1995)
Introduction of fast-track procedures for well-defined
patient groups (Toncich et al., 2000; Kyriacou et al., 1999;
Moon et al., 2001; Ryan et al., 1996; Wright et al., 1992)
Changes in 27 studies (31 Introduction of separate clinics or separate areas for
physical structure, percent) distinct patient groups
facilities or Introduction of pharmacy service near patient ward to
equipment simplify discharge processes (McRobbie et al., 2003)
Extra equipment in emergency ward for early start of
diagnosis or treatment (Browne et al., 2000)
Revision of 28 studies (33 Transfer of tasks from physicians to nurses (Miro et al.,
professional percent) 2003; Clark et al., 1999; Lewis and Wilner, 1989; Wright
roles/skill mix et al., 1992)
changes
Change in the 25 studies (29 Introduction of rapid response clinic (Clow et al., 2002)
setting/site of percent) Moving care from hospital to home or other care setting
service delivery (Challis et al., 1991; Hernandez et al., 2003; Meyer et al.,
2002; Williams, 1994; Rupp and Doyle, 1993)
Advancing treatment to emergency ward (Qasim et al.,
2002; Smith and Gow, 1999)
Centralizing care or admission processes (Akosah et al.,
2002; Czuchry et al., 2000; Keyes and Biedron, 1995)
Staff organization 18 studies (21 Introduction of new roles (Spaite et al., 2002; Gamon et al.,
percent) 2002; Goering and Wilson, 2002; Toncich et al., 2000;
Sprayregen et al., 1998; Sanz and Pomar, 1998; Chimner
and Easterling, 1993)
Changes in allocation of staff, e.g. assignment of teams,
physicians or nurses to patient groups (Browne et al., 2000;
Cornwell et al., 2003; Cooke et al., 2002; Gilutz et al., 1998;
Hunter et al., 1993)
Changes in organization and scheduling (Racine and
Davidson, 2002; Hattam and Smeatham, 1999; Grimes,
2000; Fernandes et al., 1996, 1997)
Changes in 15 studies (17 Changes in staff scheduling (Hashimoto and Bell, 1996;
capacity planning percent) Racine and Davidson, 2002)
Changes in clinic scheduling (Clow et al., 2002; Prasad et al.,
1997; Huarng and Lee, 1996; Chandler, 1994)
Radiography scheduling ( Jackson and Andrew, 1996; Table IV.
Sprayregen et al., 1998) Interventions found in the
Changes in bed management (Tunick et al., 1997; Toncich 86 studies included in the
et al., 2000; Sanz and Pomar, 1998) review on BPR in
(continued) hospital care
IJHCQA Intervention
19,6 category Number of studies Examples of interventions

Case management 15 studies (17


percent)
Communication 14 studies (16 Changes in coordination with home care (Landi et al., 1999,
486 and case discussion percent) 2001; Hypnar and Anderson, 2001; Challis et al., 1991;
with off-site health Styrborn, 1995)
professionals or Telephone hotline for community physicians to discuss
cooperation with patient admissions with internal medicine physician
external services (Kossovsky et al., 2002)
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Introduction of orthopedic institute in primary care


(Hattam and Smeatham, 1999)
Direct communication between emergency departments
and coronary care units (Prasad et al., 1997)
Introduction of 8 studies (9
multidisciplinary percent)
teams
Introduction of 6 studies (7 Development of care guidelines as part of process redesign
quality-monitoring percent) (Newell et al., 1998; Velasco et al., 1996; Simons et al., 1999;
mechanisms Tunick et al., 1997)
Introduction of total quality management (Gilutz et al.,
1998)
Changes in medical 6 studies (7
record systems percent)
Integration of 4 studies (5 A breast-care center (Olivotto et al., 2001)
services or percent)
continuity of care
Table IV. programs

ward to avoid becoming bed-blockers were compared with patients in a less serious
condition (Petersen et al., 1997), and ambulance referrals were compared with a group
of referrals from general practitioners (Prasad et al., 1997). In 20 studies (23 percent),
measurements during several time periods (at least three) were compared. Half of the
86 studies (43 studies, 50 percent) used a simple before-after design. In a study with a
focus on quality improvement, the least we expected to find was information about the
study period and study population. Only 52 studies (60 percent) mentioned the number
of patients included and the study period. In seven studies (8 percent), nothing was
specified regarding measurements, population and study period, and only figures on
result parameters were given. In slightly more than half (48 out of 86) the process
parameters in the objective matched the process parameters reported in the results.
The 28 studies that did not state process-related goals reported primarily a length of
stay reduction. Two studies did not report results about the process targets that were
stated in their objectives (Schwarcz et al., 1998, Kerr and Kavanagh, 2002). In one study
the objective was to reduce waiting times and improve access, and the results
mentioned a reduction in time to treatment (only a part of all waiting times) and a
reduction in the number of visits (Kerr and Kavanagh, 2002). Another study expected
to eliminate unnecessary admissions, but did not report outcome data (Schwarcz et al.,
1998); 38 studies reported results about process parameters for which no goals had
been set beforehand.
Table V gives an overview of the consistency of logic and completeness in the Evidence-based
relationship between the outcome categories mentioned in the objectives and the re-engineering
categories found in the results. Of 67 studies mentioning outcome measures in their
objectives or in their results, only 30 articles consistently reported relevant results for
all mentioned outcome categories. In 33 articles, one or more outcome results reported
that had not been mentioned in the objectives. In eight articles, results were not
reported for subjects stated in the objectives. Some articles failed to report consistently 487
for more than one category of outcomes: for example, one study (Tunick et al., 1997) set
goals for improving patient satisfaction and reducing costs, and described some
initiatives to achieve these but did not report any results. Another case attempted to
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improve both cost effectiveness and clinical outcomes but only presented figures on
achieved cost reductions (Patterson et al., 1997, p. 99) One study aimed to reduce
resource utilization and costs, but only reported the reduction in resource utilization
(Rupp and Doyle, 1993).

Discussion and recommendations


We found 86 studies in care process redesign that met our inclusion criteria, but only a
minority mentioned quantifiable objective parameters. The methodological quality of
the studies was disappointing, and many showed inconsistencies between objectives
and reported results. Three RCTs were found. Knowledge on BPR is not clearly
documented, and accessing relevant studies appears to be difficult owing to multitude
locations and journals and lack of MeSH terminology. No specific MeSH headings for
finding BPR projects in hospitals were available. A total of 14 different MeSH headings
were used in Medline and 16 subject headings were used in Embase to search for
articles. In Business Source Premier, 41 logistics and planning-related subjects were
combined with 34 health care-related subjects. In order to select 88 articles, we had to
review the titles and abstracts of 7,428 papers, and read 250 articles in their entirety. It

Found in both Found in objective Found in result


objective and result but not in result but not in objective

Process parameter
Length of stay/visit time 29 22
Waiting time 16 8
Time to treatment 9 3
Access time 4 1
Left without being seen 2 4
Time to diagnosis 1
Number of visits 5
Other logistic parameters 7 1 8

Outcome category
Cost reduction 20 4 7 Table V.
Resources utilization 18 3 10 Comparison between
Patient satisfaction 10 1 16 objectives and results in
Medical outcomes 10 1 9 the 86 studies on hospital
Staff satisfaction 5 7 care process redesign
IJHCQA is clear that the processes for attaching keywords to articles are not well developed in
19,6 this area.
At the cost of specificity, we elected for a search strategy using broad inclusion
criteria. Abstracts were particularly unclear about the presence of quantitative data
and about the exact nature of the intervention. In cases of doubt, we obtained the
articles full text. By using this sensitive and systematic selection process, we
488 presumably retrieved the most relevant articles. Our search resulted in a relatively fair
kappa statistic.
Compared with the large number of abstracts, relatively few studies were identified.
Most articles were excluded owing to a lack of systematically described empirical data.
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Consequently, only 88 articles were eligible for review, in which 86 different studies
were described. Of this selection, 70 percent were published in the US or in the UK. We
found a relatively small number of articles from the rest of Europe or from Australia
and New Zealand. Only a minority mentioned quantifiable parameters, and if process
parameters were mentioned, the most frequent target was reducing length of hospital
stays (LoS). The most frequently mentioned outcome parameters were cost reduction
and resource utilization. Although LoS may certainly be advantageous for patients, the
driving force behind starting these projects frequently appeared to be cost reduction.
Parameters related to patient flow were almost never used. If hospitals really want to
introduce a patient-focused approach, a more integral view of the whole hospital
process should be taken into account. Relevant, more flow-related logistic performance
indicators should be considered, such as reducing access time, time to diagnosis, time
to treatment, or number of hospital visits (see Figure 2). In the majority of studies,
multiple interventions were combined, which made it difficult or even impossible to
analyze individually the effects of specific intervention types. This also limited the
possibilities of comparing interventions between hospitals and learning which
interventions have the greatest potential benefits.
Only a few RCTs were found. In practical terms, however, it is often not feasible to
use two different process organizations simultaneously and to randomly assign
patients to either an old or a redesigned care process (McNulty and Ferlie, 2002).
Processes in other hospitals are usually not sufficiently comparable to serve as useful
controls (Harten et al., 2000). To overcome these methodological difficulties, studies
frequently used a before-after design. The major design drawback is that existing
trends and accidental changes over time remain unrecognized. Also, we cannot assess
whether biases have been introduced, which would hamper the comparability of the
study groups. Therefore, when a randomized controlled trial design is not feasible, the
next best option would be a time series measurement design to rule out changes in the
study parameters over time (Eccles et al., 2003). Preferably, measurements should be
done for at least two different periods before the intervention and two different periods
after the intervention in order to exclude confounding variables. The inconsistency
between the study objectives and the reported results was another qualitative
deficiency. Many more results were reported than had been mentioned in the study
objectives (this happened in 57 studies). Also, ten studies mentioned targets for which
no results were reported.
We believe there is tremendous activity in this area of health care improvement and
innovation. Compared to the amount of activity, however, little has been published,
publications are hard to find and the evidence is scattered and almost impossible to
compare. One reason for this might be that many of these activities are performed by Evidence-based
companies that are not as likely as public organizations to make details about methods re-engineering
and results available in the public domain. Worthy of note is the virtual lack of reports
on negative studies. We are all probably aware of projects that failed to deliver the
intended results, but the literature does not provide any information on this subject. An
important contributing factor to this poor state of affairs is the lack of mature methods
for describing and reporting health care innovation results. This impedes learning 489
from other hospitals and interferes with the development of a mature discipline in the
research of redesigning hospitals or care processes. In the UK, the National Institute for
Clinical Excellence (see www.nice.org.uk) makes use of activities for disseminating
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clinical innovation but has not paid particular attention to communication methods. In
The Netherlands, the Good Healthcare Innovation Practice Institute (see www.ghip.nl)
has developed an outline for a common language in order to disseminate innovation
initiatives. The problems we encountered in identifying relevant studies may also be
attributed to underdeveloped terms. Many of the critical topics cannot be captured
appropriately in the present MeSH or subject headings. To support developments in
this field of research and to stimulate an exchange of experiences, there is a need for
more high-quality, accessible studies. We propose introducing some specific MeSH
headings to improve the tractability of redesign studies. Furthermore, we would like to
suggest BPR case-study authors follow the CONSORT statement where applicable
(Begg et al., 1996). This statement is originally meant to give guidelines for reporting
RCTs, but most topics are appropriate for other kinds of studies. Publications should
explicitly mention key features, including:
.
the research question;
.
methods (participants, test methods and statistical methods);
.
results; and
. a discussion about the applicability of study methods and results.

Only when accessibility and comparability of the studies increase can we learn from
experiences, build on these results and develop a mature research field. We agree with
Mittman (2004, p. 897), who wrote that researchers, journal editors and funding
agencies must co-operate to ensure that published evaluations are relevant,
comprehensive and cumulative. Not only do we need the evidence for
reengineering, we also need a reengineering of the evidence reported in these studies.

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cardiovascular surgery service, Joint Commission Journal on Quality Improvement, Vol. 23
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Turner, C. (1998), AMI team buckles down to improve outcomes, Hospital Case Management,
Vol. 6 No. 3, pp. 46-9.
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(1996), Cost containment in cardiac surgery: results with a critical pathway for coronary
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West, B., Bennett, J.A., Deegan, P.C., Merry, P., Watson, L., Jones, N.S. and Kinnear, W.J. (2001),
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Appendix 1. Search strategies


Embase and Medline
Used MeSH headings in Medline (OR):
.
Process assessment (Health Care);
.
Critical Pathways;
.
Hospital restructuring;
.
Patient Centered Care;
.
Organizational Case Studies;
.
Organizational Innovation;
IJHCQA .
Case Management;
19,6 .
Quality of Health care;
.
Waiting Lists;
.
Time Management;
.
Appointments and Schedules;
496 .
Time and motion studies;
.
Task Performance and Analysis;
.
Planning Techniques;
. Health Resources; and
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.
Length of Stay.

Used Subjects in Embase (OR):


.
Clinical Pathways;
.
Hospital Organization;
.
Patient Care;
.
Health Services Research;
.
Organization;
.
Patient Care;
.
Health Care Quality;
.
Hospital Admission;
.
Time Management;
. Hospital Management;
.
Task Performance;
.
Organization and Management;
.
Health Care Planning; and
.
Length of Stay.

Embase and Medline combined (AND) with one of the following free-text in the abstract or title:
reengineer$ or re-engineer$ or redesign$ or reform$ or restruct$ or (process adj4 flow) or work
flow or workflow or patient flow or patientflow or patient proces$ or (reduc$ adj5 waiting times)
or decreas$ resource utilization or fast track or fast-track or (optimi$ adj3 resource$) or (optimi$
adj3 flow) or (integra$ adj2 pathway$) or (integra$ adj2 care$) or (integra$ adj3 flow) or (integra$
adj2 patientflow) or (streamline$ adj2 pathway$) or (streamline$ adj3 flow) or (streamline$ adj2
patientflow) or (streamline$ adj2 care$) or system innovation or (implement adj3 changes) or
collabor$ care proces$ or (improv$ adj2 proces$) or (chang$ adj3 flow$) or (chang$ adj2
patientflow$) or (improve$ adj3 flow$) or (improve$ adj2 patientflow).

Business Source Premier


Used subjects in BSP (OR):
.
corporate reorganizations;
.
decentralization in management;
.
organizational change;
.
reengineering (management);
.
intervention (administrative procedure);
.
reforms; Evidence-based
.
relocation; re-engineering
.
revisions;
.
vertical integration;
.
bottlenecks;
.
business logistics; 497
.
business planning;
.
critical path analysis;
.
enterprise resource planning;
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.
flow charts;
.
input output analysis;
. just-in-time systems;
.
logistics;
.
measuring instruments;
.
needs assessment;
.
one stop shopping;
.
organizational structure;
.
planners;
.
process control;
.
production planning;
.
queuing theory;
.
resource allocation;
. resource management;
.
scarcity;
.
scheduling;
.
scheduling (management);
.
strategic planning;
.
succession planning;
.
supply & demand;
.
theory of constraints (management);
.
time management;
.
time study;
.
turnaround time;
.
work design;
.
work measurement; and
.
workflow.

Combined (AND) with one of the following health care-related subjects (OR):
.
ambulatory medical care;
.
day care centers;
.
health maintenance organizations;
IJHCQA .
health care networks;
19,6 .
HEALTH facilities Utilization;
.
health care reform;
.
health facilities;
.
hospital care;
498 .
hospitals;
.
hospitals-case management services;
. hospitals, voluntary;
.
inpatient care;
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.
integrated delivery of health care;
.
laboratories;
.
long term care facilities;
.
managed care plans (medical care);
.
medical care;
.
medical economics;
.
mental health services;
.
nurse & patient;
.
nurses;
.
nursing homes;
. nursing services;
.
patient education;
.
patients;
.
pharmaceutical services;
.
pharmacy management;
.
physician & patient;
.
physician hospital organizations;
.
physicians;
.
primary care (medicine);
.
public hospitals; and
.
rural hospitals.

Appendix 2. References for selected articles


Akosah et al. (2002), Aragon et al. (2002), Bachtel and Lyle (1992), Banerjee and Rhoden (1998),
Bhatti et al. (1999), Bluth et al. (1992), Browne et al. (2000), Cain et al. (1996), Calland et al. (2001),
Cameron et al. (2002), Caplan et al. (1998, 1999), Challis et al. (1991), Chandler (1994), Chimner and
Easterling (1993), Claesson et al. (2000), Clark et al. (1999), Clow et al. (2002), Cooke et al. (2002),
Cornwell et al. (2003), Czuchry et al. (2000), Dutton et al. (2003), Fernandes and Christenson (1995),
Fernandes et al. (1996, 1997), Gamon et al. (2002), Gebran (1994), Gilutz et al. (1998), Goering and
Wilson (2002), Grimes (2000), Hashimoto and Bell (1996), Hattam and Smeatham (1999),
Hernandez et al. (2003), Holland (1995), Huarng and Lee (1996), Huber et al. (1998), Hunter et al.
(1993), Hypnar and Anderson (2001), Inturrisi and Lambert (1998), Jackson and Andrew (1996),
Jano and Harlin (2000), Johnson and McCargar (1999), Kerr and Kavanagh (2002), Keyes and
Biedron (1995), Kossovsky et al. (2002), Kyriacou et al. (1999), Landi et al. (1999, 2001), Larsen et al.
(1994), Lewis and Wilner (1989), Mayo et al. (1996), McRobbie et al. (2003), Meyer et al. (2002), Evidence-based
Miro et al. (2003), Monagle et al. (2003), Moon et al. (2001), New (2000), Newell et al. (1998),
Olivotto et al. (2001), Patel et al. (2001), Patterson et al. (1997), Pell et al. (1992), Petersen et al. re-engineering
(1997), Prasad et al. (1997), Pritts et al. (1999), Qasim et al. (2002), Racine and Davidson (2002),
Rupp and Doyle (1993), Ryan et al. (1996), Sanz and Pomar (1998), Schwarcz et al. (1998), Sharieff
et al. (2001), Simon et al. (1996), Simons et al. (1999), Smart et al. (1999), Smith and Gow (1999),
Spaite et al. (2002), Sprayregen et al. (1998), Styrborn (1995), Toncich et al. (2000), Tunick et al.
(1997), Turner (1998), Velasco et al. (1996), Wagar and Ritzman (1995), West et al. (2001), White 499
et al. (2003), Williams (1994), Wright et al. (1992).
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Corresponding author
S.G. Elkhuizen can be contacted at: s.g.elkhuizen@amc.uva.nl

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