To the Editor: The authors of the recent supplement on clinical process redesign have shown that improvement can occur in the efficiency and quality of hospital care.1 They acknowledged that this process was accompanied by an investment in external consultants and a boost to the system of 1800 beds. These interventions were necessary, and have been successful in the short term. However, these measures alone may not be sustainable for hospitals in the long term with the projected needs for the health care of an ageing population.2

The table in the appendix to the supplement showed most hospitals continuing to perform poorly in their response to increasing demands on emergency departments (EDs), with corresponding increases in admissions to hospital.3 It was interesting to note that, of all the hospitals listed, Campbelltown Hospital, with the largest increase in demand (27%), also had the lowest increase in admissions through its ED (6%). A similar phenomenon was noted at Bankstown Hospital, which had a 27% increase in demand and a 13% increase in admissions. Could these have been the result of the community and ambulatory redesign that occurred in these hospitals from 2000 to 2004?4 The common feature of these two hospitals is the linkages developed between ED community nurses and general practitioners, creating a situation whereby increasing demand does not have to rely entirely on hospital beds as a solution.5

The case of an older woman with diabetes, sepsis and heart failure described in one of the supplement articles6 implicates a failure in community chronic disease management, as well as hospital care. Older people will continue coming to EDs, and will continue to be admitted to hospital in increasing numbers. To avert future crises in health care, the success of hospital redesign needs to be matched by an equally well resourced redesign of primary health and community care.

To the Editor: The recent supplement to the Journal on clinical process redesign1 is a tepid attempt by NSW Health and their colleagues in South Australia to disguise their own shortcomings.

Astute readers need more than fancy jargon, acronyms and pretty diagrams to be convinced that reform of the sort suggested by NSW Health cuts the mustard. Indeed, some of the language (“The process will proceed with or without you”2) provides disturbing insight into the mindset of those at the helm. Also, the ideas exemplified in another section are at clear odds with what I experience daily as a senior clinician. To illustrate, McGrath and colleagues write of “engaging clinical leaders” and that “solutions need to be evidence-based”.3 Regrettably, the opposite is the reality. Senior medical clinicians are sidelined and the decision-making process becomes the domain of a few select individuals, thus making it sclerotic, remote from the clinical interface and, at times, autocratic. Further, some management decisions are implemented without any of the supposed evidence base that McGrath and colleagues3 refer to. Perhaps of greater concern is the notion of “stretch targets”.3 These are considered “essential to stimulate real innovation”, but, translated into plain English, sound like asking staff to work harder with no additional resources.

In the past 15–20 years I have witnessed several changes in senior hospital management, each bringing the “latest and greatest” ideas on public hospital reform. Sorry folks, we don’t need more of this nonsense. Rather than yet another futile cycle of reform per se, the community needs to have a debate on the level of health care that it wants, contrasted with how much of the “pie” should be consumed relative to other needs. Until that happens, we are merely pretending that “process redesign” is the answer to our problem.

To the Editor: In regard to your recent supplement dedicated to clinical process redesign in health care,1 we support the need to learn from other industries, but have concerns about an exclusive focus on process redesign to improve the quality and safety of health care for patients.

In industry, unlike in health care, outcomes surveillance is almost always feasible. Clinical practice reminds us of the fallibility of surrogate measures of benefit, which, like “processes”, require validation by “hard” outcomes.2 Industry knows when its services or products meet minimum quality standards and satisfy “customer” needs. By contrast, a “lean approach” in health care, while taking a patient-centred perspective of care processes, makes several assumptions.

• The first is that better flow processes relate directly to improved outcomes. Process redesign focuses on measuring targets such as access block and elective surgery waiting lists, which are subject to confounding and manipulation.3,4 The impact on health care outcomes remains unclear. Furthermore, the studies cited in these supplement articles had no concurrent controls.3,4

• The second assumption is the relative values of the process measures chosen. Is a relatively small reduction in time spent in the emergency department more important than use of an appropriate device for relieving pressure ulcers in an older woman with a fracture?5

• The third assumption is that there are cause and effect links between process redesign and outcomes, such as fewer episodes of litigation at Flinders Medical Centre.6 Such links cannot be substantiated without a control group, as concurrent changes, such as open disclosure and guideline implementation, may have similar effects.

Other literature pertaining to the benefits of lean thinking in process redesign emphasises opportunities to reallocate resources to implementing best practice as a result of the efficiencies and cost savings achieved.7 This assumes that process redesign occurs quickly, and that all cost savings are reallocated. These claims appeal to managers and directors constrained by external demands for meeting efficiency targets. The inevitable consequence is that organisations are likely to focus on simple “fixable” problems rather than more fundamental system-based problems requiring more resources and longer timeframes. Also, it can be argued that the process redesign examples are “micro-reforms” within a “macro-system” that remains unchanged. The hospital sector needs broader redesign wherein existing models and systems of care, and not just internal processes, are subject to critical review and improvement.

Process redesign should be viewed as a useful tool, but the primary starting point must continue to be the delivery of evidence-based care, which is known to give patients the best chance of optimal outcomes.

In reply: We agree with Wilson and Collins. Community-based or ambulatory alternatives to admission to an acute facility are essential adjuncts to the redesign and increased bed capacity referred to in our article.1 The capital costs alone will be prohibitive if our only strategy is adding bed capacity. We see a significant shift in capacity from the acute to community sector as eminently amenable to redesign methods: to map current constraints (as the issue is not just inadequate community services), engage clinicians in changing their referral and treatment patterns, improve awareness of alternatives, identify new processes to facilitate use of the community as a viable alternative, and embed these new behaviours through easily accessible redesigned pathways.

We chose the case study of the frail older patient deliberately, as it highlights how our current default option, hospitalisation, does not necessarily give these patients the best outcomes.

In response to Larcos, we are concerned that the frustrating complexity of our current system for patients and frontline staff alike has produced so many clinicians who, like him, are cynical about improvement. Good redesign activity does engage clinicians, and our best improvements arising from redesigned processes are those that have incorporated clinician and patient input. That is the practical everyday “evidence” on which good redesign is based.

Redesign does not ask staff to work harder. Significant leaps in performance can be achieved by redesigning to make an increased throughput easier to deliver. Good redesign eliminates the frustrating and wasteful steps in care that add no value to the staff or patient experience.

Finally, in response to Brand and colleagues, both delivery of evidence-based care and process redesign are required to improve access to services and, hence, equity, patient flow, and patient and staff experience, and to reduce wasted effort. There is mounting evidence that better flow processes are associated with better outcomes. An Australian study has shown that delayed progress through Australian emergency departments (EDs) is associated with increased mortality.2 Our own article illustrates a 30% reduction in statewide mortality in New South Wales EDs as flow improved, with a concomitant reduction in statewide hospital standardised mortality rate.1 When patient flow improves because constraints and disconnects are eliminated, then system efficiency improves; it is only when patients are processed with indecent haste that one might expect a deterioration in quality.

The improvements reported were not just measured in minutes from initial triage, but also in fewer hours spent in an ED before transfer to a ward, and in fewer days of waiting for tests and consultations as an inpatient before discharge.

The results provided in the supplement3 are for an entire state health system, the largest in Australia, illustrating a turnaround in state performance, and they therefore warrant serious consideration.