BMJ Qual Saf 20:539-548 doi:10.1136/bmjqs.2010.042150
  • Quality improvement report

Impact of hospital-wide process redesign on clinical outcomes: a comparative study of internally versus externally led intervention

  1. Simon Bowler6
  1. 1Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Australia
  2. 2Statistical Analysis Unit, Health Statistics Centre, Queensland Health, Brisbane, Australia
  3. 3School of Population Health, Mayne Medical School, University of Queensland, Herston, Brisbane, Australia
  4. 4Central Nursing Office, Mater Adult Hospital, South Brisbane, Australia
  5. 5Mater Adult, Women's and Children's Hospital, South Brisbane Australia
  6. 6Mater Adult Hospital, South Brisbane, Australia
  1. Correspondence to Professor Ian A Scott, Department of Internal Medicine, Level 5A, Princess Alexandra Hospital, Ipswich Road, Brisbane 4102, Australia; ian_scott{at}
  1. Contributors IAS conceived and designed the study, undertook a preliminary systematic review of existing studies of clinical process redesign, assisted in data analysis and wrote the first draft of the manuscript. RW undertook all data analyses and created the graphical data displays. MJW created the control charts used to assess outcomes. MC suggested alterations to study design, determined the choice of statistical methods to be used, assisted in data analysis and suggested changes to the manuscript. MW, FB and SB provided additional explanation and data pertaining to the Mater Adult Hospital redesign programme.

  2. Provenance and peer review Not commissioned; externally peer reviewed.

  • Accepted 30 January 2011
  • Published Online First 8 March 2011


Introduction In response to increasing demand for hospital beds, institution-wide clinical process redesign has been advocated for improving efficiency.

Methods This retrospective, before–after study involved five tertiary hospitals in Queensland, Australia and assessed effects of externally led redesign over 6 months within two hospitals, comprising ward-based innovations led by consultancy-led standardised processes, and internally led redesign over 25 months in one hospital which implemented medical assessment and planning unit, 23 h elective surgical ward and new bed management processes. The primary outcome measures were control chart changes in emergency department (ED) access block and overdue category 1 elective surgery waits over 3.5 years involving intervention hospitals and two control hospitals.

Results At one externally led redesign hospital, control charts indicated a decrease in ED access block outside control limits which coincided with the intervention, but this was not subsequently sustained. There were no special-cause variations seen in the other hospital. In contrast, at the internally led redesign hospital, there were two decreases in access block outside control limits during the intervention period, resulting in a decrease from a baseline average of 55% to a postintervention average of 22%. All hospitals showed declines in elective surgery waits with oscillations in data indicating the existence of special-cause factors other than redesign.

Conclusion Internally led compared with externally led redesign led to superior and sustained improvements in ED access block as a result of major structural reforms that were driven by committed clinicians and managers and cut across departmental boundaries.


  • Competing interests IAS acted as lead clinician for Internal Medicine in the Princess Alexandra Hospital clinical redesign programme; FB, MW and SB acted as leads in Mater Adult Hospital redesign programme.

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