Redesigning work processes in health care: lessons from the National Health Service.

Initiatives designed to improve the quality of health services and to make these services more responsive to patients have a long history. In the British National Health Service (NHS), these initiatives have recently included total quality management, business process reengineering, and quality collaboratives. Drawing on experience outside the health sector, where quality improvement methods of this kind typically originate, NHS policymakers have focused particularly on changing work processes in their quest to improve performance. In so doing they have had to confront not only the inevitable challenges of managing organizational change (Kotter 1996) but also some specific features of health care organizations that make change particularly problematic. This article analyzes and uses the NHS's experience to identify the lessons for future quality improvement initiatives. At the heart of this article is an account of one recent initiative, the national booked admissions program, which illustrates both the opportunities and the challenges in introducing and sustaining change. By comparing the different impacts of the national booked admissions program on a number of pilots and interviewing the program's participants to discover the reasons why some pilots were more successful than others, we identify those conditions that must be met in order to achieve quality improvements in health care organizations. We also examine the sustainability of the program and the factors that influence sustainability. In the United Kingdom, the national booked admissions program is important as the first of a series of quality improvement programs that were central to the Blair government's reform of the NHS. The government developed a ten-year plan for investment and reform (Secretary of State for Health 2000), whose rationale was that just doing more of the same was unlikely to resolve the problems confronting the NHS. Doing things differently was also essential to enable resources to be used more appropriately and to deliver services that were responsive to patients. The national booked admissions program thus was the forerunner of an ambitious policy to redesign health services around the patient, and the experience reported here is important in shedding light on the likely impact of the Blair government's reforms. This program is important internationally as an example of an initiative to use redesign methods to improve health care in order to overcome the quality shortcomings identified in the Institute of Medicine's report Crossing the Quality Chasm (Institute of Medicine 2001). As this report noted, safe, effective, and patient-centered health services require health care organizations based on sound design principles. Consistent with the NHS plan's approach, these principles mean working smarter and not just harder and applying methods developed outside health care to improve performance. The Institute for Healthcare Improvement (IHI) has been at the forefront of efforts in the United States and other countries to use these methods, and it has been prominently involved in much of the NHS's work since 1998. The IHI is a not-for-profit organization based in Boston that seeks to improve health by advancing the quality and value of health care.1 The evidence reported here therefore has implications for the future of the current quality improvement initiatives as well as for the impact of health care reform in the United Kingdom. At the end of this article we will discuss these implications.