A Toolkit for Redesign in Health Care: Final Report

Appendix A. Review of the Literature

Quality of Health Care

Agency for Healthcare Research and Quality. Executive Summary. In: National Healthcare Quality Report. Rockville, MD: Agency for Healthcare Research and Quality. 2003;1-8.

American Organization of Nurse Executives. Patient Care Redesign: Lessons From the Field. Weaver D (Ed.). Chicago: AHA Press. 1999.

Benedetto AR. Adapting manufacturing-based Six Sigma methodology to the service environment of a radiology film library.  American College of Healthcare Executives. Fellowship case reports. Accessed 8 October 2004. Available at: http://www.ache.org/mbership/AdvtoFellow/CASERPTS/benedetto01.cfm.

Berwick DM. Escape Fire: Designs for the Future of Health Care, Collected Speeches, 1992-2002. San Francisco: Jossey-Bass (A Wiley Imprint). 2004.

Berwick D, James B, Coye MJ. Connections between quality measurement and improvement. Medical Care 2003;41(1 Suppl):I30-I38.

Chassin MR. Is health care ready for Six Sigma quality? The Milbank Quarterly 1998;76(4):565-91, 510.

Chassin MR, Galvin RW. The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality. Journal of the American Medical Association 1998;280(11):1000-5.

Clarke A, Rao M. Developing quality indicators to assess quality of care. Quality and Safety in Health Care 2004;13(4):248-9.

Cleary PD. A hospitalization from hell: a patient's perspective on quality. Annals of Internal Medicine 2003;138(1):33-39.

Epping-Jordan JE, Pruitt SD, Bengoa R,et al. Improving the quality of care for chronic conditions. Quality and Safety in Health Care 2004;13(4):299-305.

Epstein AM, Weissman JS, Schneider EC, et al. Race and gender disparities in rates of cardiac revascularization: do they reflect appropriate use of procedure or problems in quality of care? Medical Care 2003;41(11):1240-55.

Ettinger W, Van Kooy M. The art and science of winning physician support for Six Sigma change. The Physician Executive 2003 September-October;29(5):34-38.

First Consulting Group. Advanced Technologies to Lower Heath Care Costs and Improve Quality Massachusetts Technology Collaborative Innovation Outlook Series  2003. Available at: http://www.masstech.org/institute/health/STATFinal9_24.pdf

Forrester NE. Accelerating patient-care improvement in the ED. Healthcare Financial Management 2003 August;57(8):38-43

Goldstein SM. Empirical support for the Baldrige award framework in U.S. hospitals. Health Care Management Review 2002;27(1):62-75.

Griffith JR. Championship management for healthcare organizations. Journal of Healthcare Management 2000;45(1):17-30.

Health Grades, Inc. HealthGrades Quality Study Patient Safety in American Hospitals. Golden, CO: Health Grades, Inc. 2004.

Hibbard JH. Engaging health care consumers to improve the quality of care. Medical Care 2003;41(1):I61-I70.

Isaacs LS, Knickman JR (Eds.). To Improve Health and Health Care. Volume VI: The Robert Wood Johnson Foundation Anthology. San Francisco: Jossey-Bass. 2003.

James B. Information System Concepts for Quality Measurement. Medical Care 2003;41(1):I71-I79.

Johnstone PA, Hendrickson JA, Dernbach AJ, et al. Ancillary services in the health care industry: is Six Sigma reasonable? Quality Management in Health Care 2003;12(1):53-63.

Kirk SA, Campbell SM, Kennell-Webb S, et al. Assessing the quality of care of multiple conditions in general practice: practical and methodological problems. Quality and Safety in Health Care 2003;12(6):421-7.

Kizer KW. The "new VA": a national laboratory for health care quality management. American Journal of Medical Quality 1999;14(1):3-20.

Leape LL. Reporting of adverse events. New England Journal of Medicine 2002;347(20):1633-8.

Leatherman ST, Hibbard JH, McGlynn EA. A research agenda to advance quality measurement and improvement. Medical Care 2003;41(1 Suppl):I80-I86.

McGlynn EA. An evidence-based national quality measurement and reporting system. Medical Care 2003;41(1 Suppl):I8-I15.

McGlynn EA. Introduction and overview of the conceptual framework for a national quality measurement and reporting system. Medical Care 2003;41(1 Suppl):I1-I7.

McGlynn EA. Selecting common measures of quality and system performance. Medical Care 2003;41(1 Suppl):I39-I47.

McGlynn EA, Cassel CK, Leatherman ST, et al. Establishing national goals for quality improvement. Medical Care 2003;41(1 Suppl):I16-I29.

Monitoring reduces hospital-acquired infections by 19%. Performance Improvement Advisor. 2003;7(8). Atlanta: National Health Information.

Nelson EC, Batalden PB, Huber TP, et al. Microsystems in health care: part 1. Learning from high-performing front-line clinical units. The Joint Commission Journal on Quality Improvement 2002;28(9):472-493.

Nelson EC, Batalden PB, Homa K, et al. Microsystems in Health Care: part 2. Creating a rich information environment. The Joint Commission Journal on Quality and Safety 2003;29(1):5-15.

Ohldin A, Taylor R, Stein A., et al. Enhancing VHA's mission to improve veteran health: synopsis of VHA's Malcolm Baldrige award application. Quality Management in Health Care 2002;10(4):29-37.

Patterson R (Ed.). Changing Patient Behavior: Improving Outcomes in Health and Disease Management. San Francisco: Jossey-Bass. 2001.

Rakich JS. Quality, CQI and reengineering in health services organizations. Journal of Health & Social Policy 2001; 13:41-58.

Sandrick K. Tops in quality. Trustee 2003 September;56(8):12-16, 1.

Scalise D. Six Sigma in action: case studies in quality put theory into practice. Hospitals & Health Networks 2003;77(5):57-62, 2.

Schyve PM. The evolution of external quality evaluation: observations from the Joint Commission on Accreditation of Healthcare Organizations. International Journal for Quality in Health Care 2000;12(3):255-8.

Scott T, et al. The quantitative measurement of organizational culture in health care: a review of the available instruments. Health Services Research 2003 June;38(3):923-45.

Shine KI. 2001 Robert H. Ebert Memorial Lecture. Health Care Quality and How to Achieve It. New York: Milbank Memorial Fund. Available at: http://www.milbank.org/reports/020130Ebert/020130Ebert.html.

Sirio C, Segel KT, Keyser DJ, et al. Pittsburgh regional healthcare initiative: a systems approach for achieving perfect patient care. Health Affairs (Millwood) 2003;22(5):157-65.

Stryer D, Clancy C. Boosting performance measure for measure. British Medical Journal 2003; 326(7402):1278-9.

Thomson American Health Consultants. Make these changes to cut delays, diversion hours. ED Management 2003;15:64-5.

Patient Safety

Bagian JP. Commentary. Promoting patient safety at VA: learning from close calls. Forum 2001 October;1-2, 8.

Battles JB, Lilford RJ. Organizing patient safety research to identify risks and hazards. Quality and Safety in Health Care 2003;12 Suppl 2:ii2-ii7.

Behm D. A blueprint for patient safety. Planned layout of new facility near West Bend hailed as revolutionary. JSOnline: Milwaukee Journal Sentinel 19 July 2003.

Center for the Study of Healthcare Management. Designing a Safe Hospital. University of Minnesota: Carlson School of Management Publication Series 1. Available at: http://www.csom.umn.edu/Assets/4220.pdf

Chassin MR, Becher EC. The wrong patient. Annals of Internal Medicine 2002;136(11):826-33.

Cook AF, Hoas H, Guttmannova K, et al. An error by any other name. American Journal of Nursing 2004;104(6):32-43, quiz 44.

Croskerry P, Shapiro M, Campbell S, et al. Profiles in patient safety: medication errors in the emergency department. Academic Emergency Medicine 2004;11(3):289-99.

Feinstein KW. We can't reward what we can't perform: the primacy of learning to change systems. Health Affairs (Millwood) 2002 July-December; Suppl Web Exclusives:W118-119.

Fiesta J. Liability for falls. Nursing Management 1998;29:24-26.

Fried MW. Human investigations: Answering to an ever higher authority. Gastroenterology 2002;123(6):1761.

Gabbard GO. The illusion of safety. American Journal of Psychiatry 2004;161(3):427-8.

Henneman EA, Gawlinski A. "Near-miss" model for describing the nurse's role in the recovery of medical errors. Journal of Professional Nursing 2004;20(3):196-201.

Hobgood C, Hevia A, Hinchey P. Profiles in patient safety: when an error occurs. Academic Emergency Medicine 2004;11(7):766-70.

Kerzman H, Chetrit A, Brin L, et al. Characteristics of falls in hospitalized patients. Journal of Advanced Nursing 2004;47(2):223-9.

Kjellberg K, Lagerstrom M, Hagberg M. Patient safety and comfort during transfers in relation to nurses work technique. Journal of Advanced Nursing 2004;47(3):251-9.

Kostpopoulou O, Wildman M. Sources of variability in uncertain medical decisions in the ICU: a process tracing study. Quality and Safety in Health Care 2004;13(4):272-80.

Krohn R. In search of the ROI from CPOE. Journal of Healthcare Information Management 2003;17(4):6-9. Available at: http://www.himss.org/content/files/jhim/17-4/krohn.pdf

Lanham B, Maxson-Cooper P.Is Six Sigma the answer for nursing to reduce medical errors and enhance patient safety? Nursing Economics 2003;21(1):39-41, 38.

Larson L. Connectivity: getting staff to use patient safety tools. Trustee 2004;57(4):6-10.

Leape L, Epstein AM, Hamel MB. A series on patient safety. The New England Journal of Medicine  2002;347(16):1272-4.

Malone B. Pursuing patient safety. Quality and Safety in Health Care 2004;13(2):86-87.

Mawji Z, Stillman P, Laskowski R., et al. First do no harm: integrating patient safety and quality improvement. Joint Commission Journal on Quality Improvement 2002;28(7):373-86.

Mello MM, Hemenway D. Medical malpractice as an epidemiological problem. Social Science and Medicine 2004;59(1):39-46.

Murff H.J, Gosbee JW, Bates DW. Chapter 41. Human Factors and Medical Devices. In: Making Health Care Safer. A Critical Analysis of Patient Safety Practices. (Prepared by the  University of California San Francisco-Stanford University Evidence-based Practice Center under Contract No. 290-97-0013.) Rockville, MD: Agency for Healthcare Research and Quality. 2001. AHRQ Pub. No. 01-E058. 

O'Neill KA, Shinn D, Starr KT, et al. Patient misidentification in a pediatric emergency department: patient safety and legal perspectives. Pediatric Emergency Care 2004;20(7):487-92.

Ostrosky-Zeichner L. Medical order formatting in the era of patient safety. Critical Care Medicine2004;32(3):882-3.

Plews-Ogan ML, Nadkarni MM, Forren S, et al. Patient safety in the ambulatory setting. Journal of General Internal Medicine 2004;19(7):719-25.

Revere L, Black K. Integrating Six Sigma with total quality management: a case example for measuring medication errors.  Journal of Healthcare Management 2003;48(6):377-9; discussion 392.

Rubin G, George A, Chinn DJ, et al. Errors in general practice: development of an error classification and pilot study of a method for detecting errors. Quality and Safety in Health Care 2003;12(6):443-47.

Scalise D. Six Sigma in action: case studies in quality put theory into practice. Hospitals & Health Networks 2003;77(5):57-62, 2.

Segel K, Feinstein K. What patient safety is teaching us. Grantmakers in Health 24 September 2001:1-2.

Shojania KG, Duncan BW, McDonald KM, et al. Safe but sound: patient safety meets evidence-based medicine. Journal of the American Medical Association 2002;288(4):508-13.

Stryer D. Patient safety, research and evidence: getting to improved systems. Journal of General Internal Medicine 2004;19(7):808-9.

Stump LS. Re-engineering the medication error-reporting process: removing the blame and improving the system.  American Journal of Health System Pharmacy  2000;57 Suppl 4:S10-S17.

Thomas EJ, Petersen LA. Measuring errors and adverse events in health care. Journal of General Internal Medicine  2003;18(1):61-67.

Vincent C, Moorthy K, Sarker SK, et al. Systems approaches to surgical quality and safety: from conception to measurement. Annals of Surgery 2004; 239(4):475-82.

Wachter RM, Shojania KG. The Patient safety movement will help, not harm, quality. Annals of Internal Medicine 2004;141(4):326-7.

Wachter RM, Shojania KG. Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes. New York: Rugged Land. 2004.

Youngberg BJ, Hatlie MJ. The Patient Safety Handbook. Sudbury, MA: Jones and Bartlett. 2004.


Amberg M. The Benefits of Business Process Modeling for Specifying Workflow-Oriented Application Systems. Business Information Systems. Bamberg, Germany: University of Bamberg. 1996 April:1-6.

Barry-Walker J. The impact of systems redesign on staff, patient, and financial outcomes. Journal of Nursing Administration 2000;30:77-89.

Bremner B, Dawson C.Can anything stop Toyota? BusinessWeek 17 November 2003; 3858:114-20, 122.

Burns LR, Wharton School Colleagues. The Health Care Value Chain: Producers, Purchasers and Providers. San Francisco: Jossey-Bass. 2002.

Farhoomand AF, Ng P. FedEx Corp.: Structural Transformation Through e-Business. University of Hong Kong. 2000.

Chyna JT. Reengineering your medical staff organization: care, efficiency and relationships. Healthcare Executive 2001 July/August;16(4):20-25.

Dickstein Shapiro Morin & Oshinsky, LLP. Think, think again. Harvard Business Review 1996 September-October:150-8.

Drescher NI. Redesign of medication and supply distribution in a day surgery center. AORN Journal 2000;72:854-61.

Fraser SW. The Patient's Journey: Mapping, Analyzing and Improving Healthcare Processes. United Kingdom: MPG Books. 2002.

Gaucher EJ, Coffey RJ. Breakthrough Performance: Accelerating the Transformation of Health Care Organizations. San Francisco: Jossey-Bass. 2000.

General Accounting Office. Hospital Emergency Departments:  Crowded Conditions Vary among Hospitals and Communities. Report to the Ranking Minority Member, Committee on Finance, U.S. Senate. GAO-03-460. Washington, DC: U.S. General Accounting Office. 2003 March. Available at: http://www.gao.gov/new.items/d03460.pdf

Ghorra S, Reinert SE, Cioffi W, et al. analysis of the effect of conversion from open to closed surgical intensive care unit. Annals of Surgery 1999;229(2):163-171.

Guarisco S, Oddone E, Simel D. Time analysis of a general medicine service. Journal of General Internal Medicine 1994;9:272-277.

Institute for Healthcare Improvement. Improving Patient Flow: The Esther Project in Sweden. Available at:  http://www.ihi.org/IHI/Topics/Flow/PatientFlow/ImprovementStories/Improv....

Institute for Healthcare Improvement. Optimizing Patient Flow: Moving Patients Smoothly through Acute Care Settings [Innovation Series white paper]. Boston: Institute for Healthcare Improvement. 2003.

Kelly K, Mass M. SONA 7: Health Care Work Redesign. Thousand Oaks, CA: SAGE Publications. 1995.

Kenagy JW. Delivering on the Promise: An Adaptive Approach to Information Technology in Healthcare. Cambridge, MA: Kenagy & Associates. 2004.

Lillrank P, Kujala J, et al. Patient in process—a new approach to managing patient processes in healthcare. 3rd International Conference on the Management of Healthcare and Medical Technology. 7-9 September 2003. Warwick, United Kingdom.

Litvak E, Long MC, Cooper AB, et al. Emergency department diversion: causes and solutions. Academic Emergency Medicine 2001;8(11):1108-10.

Long JC. Healthcare Lean. Michigan Health and Hospitals 2003;39(4):54-55.

Mangum S, Cutler K. Increased efficiency through OR redesign and process simplification. AORN Journal 2002;76(6):1041-46.

Martin LL, Gertsen F, Johansen J. Applying Lean thinking in hospitals—exploring implementation difficulties. 3rd International Conference on the Management of Healthcare and Medical Technology. 7-9 September 2003. Warwick, United Kingdom.

Minichiello TM, Auerback AD, Wachter RM. Caregiver perceptions of the reasons for delayed hospital discharge. Effective Clinical Practice 2001;4(6):250-255.

Nussbaum B. The power of DESI. Business Week 2004 May 17:86-94.

P&G continues restructuring and streamlines its workforce. Chemical Market Reporter 14 June 1999;255(24).

Panchak P. Lean health care? It works! Industry Week 1 November 2003:1-5.

Quintero JR. Achieve cost benefits with innovative care management. Nursing Management 2002;33(4):35-42.

Reid W. Developing and implementing organisational practice that delivers better, safer care. Quality and Safety in Health Care  2004;13(4):247-8.

Rozich JD, Resar RK. Using a unit assessment tool to optimize patient flow and staffing in a community hospital. Joint Commission Journal on Quality Improvement 2002;28(1):31-41.

Russell LB, Gold MR, Siegel JE, et al. The role of cost-effectiveness analysis in health and medicine. Journal of the American Medical Association 1996;276(14):1172-77.

Siegel E, Reiner B. Work flow redesign: the key to success when using PACS. American Journal of Roentgenology 2002 March:178:563-66.

Spaite D, Bartholomeaux F, Guisto J, et al. Rapid process redesign in a university-based emergency department:  decreasing waiting tine intervals and improving patient satisfaction. Annals of Emergency Medicine. 2002;39(2):168-77.

Steckler A, Linnan L. Process Evaluation for Public Health Interventions and Research San Francisco: Jossey-Bass. 2002.

Walley P. Cellular operation design in healthcare. 3rd International Conference on the Management of Healthcare and Medical Technology. 7-9 September, 2003. Warwick, United Kingdom.

Ying A, Mercury MD Inc. Impact of Hospital Computer Systems on Resident Work Hours. Boston: Medical Records Institute.

Customer Service

Alderson PO. Noninterpretive skills for radiology residents: customer service and satisfaction in radiology. American Journal of Roentgenology 2000;175:319-23.

Baird K. Customer Service in Health Care: A Grassroots Approach to Creating a Culture of Service Excellence. San Francisco: Jossey-Bass. 2000.

Burns JP. Performance improvement with patient service partners. Journal of Nursing Administration 1998;28(1):31-37.

Colwell CB, Pons PT, Pi R. Complaints against an EMS system. Journal of Emergency Medicine 2003;25(4):403-8.

Conner JM, Nelson EC. Neonatal intensive care: satisfaction measured from a parent's perspective. Pediatrics 1999;103(1):336-49.

Dologite KA, Willner KC, Klepeiss DJ, et al. Sharpen customer service skills with PCRAFT Pursuit. Journal for Nurses in Staff Development 2003;19(1):47-51.

Frampton SB, Gilpin L, Charmel PA. Putting Patients First: Designing and Practicing Patient-Centered Care. San Francisco: Jossey-Bass. 2003.

Godfrey MM, Nelson EC, Wasson JH, et al. Microsystems in health care: part 3. Planning patient-centered services. The Joint Commission Journal on Quality and Safety 2003;29(4):159-70.

Goonan KJ, Stoltz PK. leadership and management principles for outcomes-oriented organizations. Medical Care 2004;42(4 Suppl):III31-III38.

Harrison A. The war on waiting. Health Care UK 2000 Winter:52-60.

Hoff RA, Rosenheck RA, Meterko M, et al. Mental illness as a predictor of satisfaction with inpatient care at veterans affairs hospitals. Psychiatric Services 1999;50(5):680-5.

Kipp, K.M. Implementing nursing caring standards in the emergency department. Journal of Nursing Administration 2001;31(2):85-90.

Kuisma M, Maatta T, Hakala T, et al. Customer satisfaction measurement in emergency medical services. Academic Emergency Medicine 2003;10(7):812-15.

Laing A. Meeting patient expectations: healthcare professionals and service re-engineering. Health Services Management Research 2002;15:165-72.

Landon BE, Zaslavsky AM, Beaulieu ND, et al. Health plan characteristics and consumers' assessments of quality. Health Affairs (Millwood) 2001;20(2):274-86.

Lewis B. Children's hospital designed for needs, comfort of anxious families. The Tennessean [online version], 4 December 2003.

McInnes KG. I CARE: An organization-wide customer service education program. Journal for Nurses in Staff Development 2003;19(4):195-202.

Miller MA, Kinsel K. Patient focused care and its implications for nutrition practice. Journal of the American Dietetic Association 1998;98(2):177-81.

Moore M, Ahmed T, Glazer A. Using an automated knowledge agent for reference and customer service. Journal of the Medical Library Association 2004;92(2):271-3.

Richins SM. Customer service for step-down patients. Journal of Nursing Administration 2002;32(11):558-60.

Schwab RA. Emergency department customer satisfaction: the point of view paradox. Annals of Emergency Medicine 2000;35(5):499-501.

Seago JA. Evaluation of a hospital work redesign: patient focused care. Journal of Nursing Administration 1999;29(11):31-38.

Trotter G. Against customer service. Journal of Emergency Medicine 1998;16(2):227-34.

Turhal NS, Efe B, Gumus M, et al. Patient satisfaction in the outpatients' chemotherapy unit of Marmara University, Istanbul, Turkey: a staff survey. BMC Cancer 2002;2:30. Epub 2002 Nov 20.

Verdessi BD, Jara G, Fuentes R, et al. The role of discriminant analysis in the refinement of customer satisfaction assessment.  Revista de Saude Publica 2000;34(6):623-30.

Wasson JH, Godfrey MM, Nelson EC, et al. Microsystems in health care: part 4. Planning patient-centered care. The Joint Commission Journal on Quality and Safety 2003;29(5):227-37.

Worthington K. Customer satisfaction in the emergency department. Emergency Medicine Clinics of North America 2004;22(1):87-102.

Young WB, Minnick AF, Marcantonio R. How wide is the gap in defining quality care? Comparison of patient and nurse perceptions of important aspects of patient care. Journal of Nursing Administration 1996;26(5):15-20.

Workforce Development

Abrass CK, Ballweg R, Gilshannon M, et al. A process for reducing workload and enhancing resident's education at an academic medical center. Academic Medicine 2001;76(8):798-805.

American Organization of Nurse Executives. Patient Care Redesign: Lessons From the Field. Weaver D (Ed.). Chicago: AHA Press. 1999.

Baker C, Beglinger J, King S, et al. Transforming negative work cultures: a practical strategy. Journal of Nursing Administration 2000;30(7-8):357-63.

Beck N, Kieser A. The complexity of rule systems, experience and organizational learning. Organization Studies 2003(24(5):703-814.

Boex, J.R. and Leahy, P.J. Understanding Resident's Work: Moving Beyond Counting Hours to Assessing Educational Value. Academic Medicine 2003;78(9):939-44.

Breslin PT, Gale SO, Weitzner WM. Operational and design strategies for a reduced workforce: address staff shortages by investigating operational model and facility design that encourage efficiency and productivity. Healthcare Financial Management 2003 March;57(3):62-65.

Burke RJ, Greenglass ER. Hospital restructuring and nursing staff well-being: the role of personal resources. Journal of Health and Human Services Administration 2001 Summer;24(1):3-26.

Carnevale AP, Fry RA. The Economic and Demographic Roots of Education and Training. [Paper commissioned by The Manufacturing Institute]. Washington, DC: National Association of Manufacturers. 27 November 2001.

Carzoli RP, Martinez-Cruz M, Cuevas LL, et al. Comparison of neonatal nurse practitioners, physician assistants, and residents in the neonatal intensive care unit. Archives of  Pediatric & Adolescent Medicine 1994;148(12):1271-6.

The Manufacturing Institute, Center for Workforce Success. Results of workforce development survey of NAM Associations Council. National Association of Manufacturers Web site. Accessed 9 June 2004.

Hecht WA, Landstrom G, Nisbet MM, et al. Meeting the nursing shortage head on. A round table discussion. Healthcare Financial Management 2003 March;57(3):52-58, 60.

Ettinger W, Van Kooy M. The art and science of winning physician support for Six Sigma change. The Physician Executive 2003 September-October 2003;29(5):34-39.

Galvin RS, McGlynn EA. Using performance measurement to drive improvement: a road map for change. Medical Care 2003;41(1 Suppl):I48-I60.

Gasiorek-Nelson S. DAU opens its doors in Hunstville, Ala.: taking education directly to the workforce. Program Manger 2002 March-April:18-21.

Gonzalez-Torre PL, Adenso-Diaz B, Sanchez-Molero O. Capacity planning in hospital nursing: a model for minimum staff calculation. Nursing Economics 2002;20(1):28-36.

Green BA, Johnson T. Replacing residents with midlevel practitioners: a New York City-area analysis. Health Affairs (Millwood) 1995 Summer;14(2):192-8.

Hofer T, Hayward RA, Greenfield S, et al. The unreliability of individual physician "report cards" for assessing the costs and quality of care of a chronic disease. Journal of the American Medical Association 1999;281(22):2098-105.

Howie JN, Erickson M. Acute care nurse practitioners: creating and implementing a model of care for an inpatient general medical service. American Journal of Critical Care 2002 September;11:448-58.

Ingersoll GL, Fisher M, Ross B, et al. Employee response to major organizational redesign. Applied Nursing Research 2001 February;14:18-28.

Ingersoll GL, Kirsch JC, Merk SE, et al. Relationship of organizational culture and readiness for change to employee commitment to the organization. Journal of Nursing Administration 2000 January;30:11-20.

Izzo JB, Withers P. Winning employee retention strategies for today's healthcare organizations. Healthcare Financial Management 2002 June;56(6):52-57.

Janz BD. Cooperative learning and cycle time reduction. Cycle Time Research 1996;2(1):29-40.

Jones KR, Redman RW. Organizational culture and work redesign: experiences in three organizations. Journal of Nursing Administration 2000;30(12):604-10.

Jones KR, Redman RW, VandenBosch TM, et al. Evaluation of the multifunctional worker role: a stakeholder analysis. Outcomes Management for Nursing Practice 1999;3(3):128-35.

Kelly K, Mass M. SONA 7: Health Care Work Redesign. Thousand Oaks, CA: SAGE Publications. 1995.

Kotter JP. Leading Change. Boston: Harvard Business School Press. 1996.

Landon BE, Normand SL, Blumenthal D, et al. Physician clinical performance assessment: prospects and barriers. Journal of the American Medical Association 2003;290(9):1183-9.

Moore SS, Nettleman MD, Beyer S, et al. How residents spend their nights on call. Academic Medicine 2000;75(10):1021-4.

Neuman K. Understanding organizational reengineering in health care: strategies for social work's survival. Social Work in Health Care. 2000;31(1):19-33.

Pillar B, Jarjoura, D. Assessing the impact of reengineering on nursing. Journal of Nursing Administration 1999;29(5):57-64.

Reason J. Human error: models and management. British Medical Journal 2000;320:768-70.

Reason J. Human factors aspects of safety management systems. Presented at the 15th Annual FAA/TC/CAA Maintenance Human Factors Symposium, March 27-29, 2001. London, England.

Riportella-Muller R, Libby D, Kindig D. The substitution of physician assistants and nurse practitioners for physician residents in teaching hospitals. Health Affairs (Millwood) 1995 Summer;14(2):181-91.

Russell JC, Kaplowe J, Heinrich J. One hospital's successful 20-year experience with physician assistants in graduate medical education. Academic Medicine 1999 June;74(6):641-45.

Schulman M, Lucchese KR, Sullivan AC. Transition from housestaff to nonphysicians as neonatal intensive care providers: cost, impact on revenue, and quality of care. American Journal of Perinatology 1995;12(6):442-6.

Snell RS. The learning organization, sense-giving and psychological contracts: a Hong Kong case. Organization Studies 2002 July-August;23(4):549-69.

Thrall TH. Work redesign. Hospitals & Health Networks 2003 March;77(3):34-38, 40, 2.

Trisolini MG. Applying business management models in health care. International Journal of Health Planning and Management 2002;17(4):295-314.

Workforce Innovation Networks. Theory of change for workforce innovation networks (WINs). 2002. Available at: http://www.jff.org/jff/PDFDocuments/TheoryChangeWINs.pdf

Young J, Urden LD, Wellman DS, et al. Management curriculum redesign: integrating customer expectations for new leaders. Nurse Educator 2004;29(1):41-44.

Zarbo RJ, Nakhleh RE, Walsh M, et al. Customer satisfaction in anatomic pathology. A College of American Pathologists Q-probes study of 3065 physician surveys from 94 laboratories. Archives of Pathology and Laboratory Medicine 2003 January;127(1):23-29.


Alvarez L. Where the healing touch starts with the hospital design. New York Times 7 September 2004:F-5.

Beale C, Brideau L, Caldwell K, et al. Trends in critical care planning and design. Panel discussion. Health Facilities Management 2004 January;17(1):24-37.

Center for the Study of Healthcare Management. Designing a Safe Hospital. University of Minnesota: Carlson School of Management Publication Series 1. Available at: http://www.csom.umn.edu/Assets/4220.pdf

Fong DB. Illuminating thoughts: Devising lighting strategies for clinical spaces. Health Facilities Management 2003 July;16(7):24-29.

Greene J. Building smarter EDs. Hospitals & Health Networks 2002;76(12):32-36, 1.

Hamilton K, Kunkle J, Levine J, et al. The future of the facility. Executive dialog series. Health Facilities Management 2003;16(1):23-37.

Hamilton DK. Before breaking ground, take stock. Spending millions on a new hospital won't fix a dysfunctional organization. Modern Healthcare 2003 October;33(40):19.

Haugh R. Administrative. In: Scalise D, Thrall TH, Haugh R, et al. The patient room. Hospitals & Health Networks 2004 May;78(5):34-38, 40, 49-51.

Hendrich AL, Fay J, Sorrells AK. Effects of acuity-adaptable rooms on flow of patients and delivery of care. American Journal of Critical Care 2004;13(1):35-45.

Institute of Medicine, Board on Health Care Services. Work and workspace design to prevent and mitigate errors. In: Page A (Ed.). Keeping Patients Safe: Transforming the Work Environment of Nurses. (226-285). Washington, DC: National Academies Press. 2004.

Martell LK. Postpartum women's perceptions of the hospital environment. Journal of Obstetric, Gynecologic, and Neonatal Nursing 2003;32(4):478-85.

Martineck T. Facility profile. Design makes most of mountain location. Health Facilities Management 2003;16(6):14-15.

Martineck T. Facility profile. Emory hospital provides oasis in midtown Atlanta. Health Facilities Management 2004;17(3):10-11.

McLaughlin S. Sneak peek: A look at JCAHO's reorganized Environment of Care chapter. Health Facilities Management 2003 September;169):33-36.

Pangrazio JR. Room with a view: looking at the future of patient room design. Health Facilities Management 2003 December;16(12):30-32.

Rich M. Healthy hospital designs: improving d cor and layout can have impact on care; fewer fractures and infections. The Wall Street Journal 27 November 2002:B-1, B-4.

Romano M. Turning green. Healthcare works to catch up with other industries in environmentally sensitive design and construction. Modern Healthcare 2004 Mar 29;34(13):29-31.

Rostenberg B. The architecture of reform. How design of imaging facilities can be template for a new health system. Modern Healthcare 2003 Dec 1;2003;33(48):20.

Runy LA. Universal rooms. In: Scalise D, Thrall TH, Haugh R, et al. The patient room. Hospitals & Health Networks 2004 May;78(5):34-38, 40, 49-51.

Sandrick K. A higher goal. Evidence-based design raises the bar for new construction. Health Facilities Management 2003 September;16(9):16-21.

Scalise D. Bedside technology. In: Scalise D, Thrall TH, Haugh R, et al. The patient room. Hospitals & Health Networks 2004 May;78(5):34-38, 40, 49-51.

Simmons M. Facility profile. Cityscape theme supports caregiving. Goryeb Children's Center, Morristown, N.J. Health Facilities Management 2003 April;16(4):12-13.

Tools for Redesign

General Conceptual Framework for Health Care Redesign

Bergey J, Smith D, Tilley S, et al. Why Reengineering Projects Fail [technical report]. Pittsburgh: Carnegie Mellon University Software Engineering Institute. 1999.

Carter T. Hospitals and reengineering. Journal of Hospital Marketing & Public Relations 2002;14(1):59-78

Cole DA. Creating outcomes with redesign efforts. AORN Journal 1999;70(3):406-13.

Hansten R, Washburn M. Toolbook for Health Care Redesign. Gaithersburg, MD: Aspen Publishers. 1997.

Harrison MI. Diagnosing Organizations: Methods, Models and Processes. Thousand Oaks, CA: SAGE Publications. 2005.

Lee SY, Alexander JA. Managing hospitals in turbulent times: do organizational changes improve hospital survival? Health Services Research 1999 October;34(4):923-46.

Locock L. Healthcare redesign: meaning, origins and application. Quality and Safety in Health Care 2003 February;12(1):53-57.

Malhotra Y. Business process redesign: an overview. IEEE Engineering Management Review 1998 Fall;26(3):27-31.

Porter ME, Teisberg EO. Redefining competition in health care. Harvard Business Review. 2004 June;82(6):64-76.

Tarantino DP. Process redesign. Part 1: process selection. The Physician Executive 2003 November-December;29(6):71-73.

Teng JTC, Jeong SR, Grover V. Profiling successful reengineering projects. Communications of the ACM 1998;41(6):96-102.

Walston SL. Reengineering hospitals: evidence from the field. Hospital and Health Services Administration 1997 Summer;42(2):143-63.

Walston SL, Burns LR, Kimberly JR. Does reengineering really work? An examination of the context and outcomes of hospital reengineering initiatives. Health Services Research 2000 February;34(6):1363-88.

Walston SL, Kimberly JR, Burns LR. Institutional and economic influences on the adoption and extensiveness of managerial innovation in hospitals: the case of reengineering. Medical Care Research and Review 2001 June;58(2):194-228.

Walston SL, Urden LD, Sullivan P. Hospital Reengineering: An Evolving Management Innovation: History, Current Status and Future Direction. Journal of Health and Human Services Administration 2001;23(4):388-415.

Operations Research as a Tool

Brinckloe WD. Managerial Operations Research. New York: McGraw-Hill. 1969.

Duckworth WE, Gear AE, Lockett AG. A Guide to Operational Research, 3rd ed. London; New York: Chapman & Hall/Halsted Press. 1977.

Mitchell G. The Practice of Operational Research. Chichester, England; New York: John Wiley & Sons Ltd. 1993.

Application of Lean as a Tool

Koenigsaecker G. A manager's guide to implementing Lean. Manufacturing and Technology News 16 May 2001;8(9):6-11.

Lean Concepts LLC. Case studies. Available at: www.leanconcepts.com. Accessed 13 February 2004.

Liker JK. The Toyota Way: 14 Management Principles from the World's Greatest Manufacturer. New York: McGraw-Hill. 2004.

Thompson DN, Wolf GA, Spear SJ. Driving improvement in patient care: lessons from Toyota. Journal of Nursing Administration 2003 November;33(11):585-95.

Womack JP, Jones DT. Beyond Toyota: how to root out waste and pursue perfection. Harvard Business Review 1996 September-October;74(5)140-58.

Womack JP, Jones DT. Lean Thinking: Banish Waste and Create Wealth in Your Corporation. New York: Free Press. 2003.

Institute for Healthcare Improvement Toolkit

Nelson E, Nolan K, Nolan T, et al. IHI's health system measures kit: version 1.0. Pursuing Perfection & IMPACT Network. Institute for Healthcare Improvement.2004.

Application of Six Sigma as a Tool

Benneyan JC, Lloyd RC, Plsek PE. Statistical process control as a tool for research and healthcare improvement. Quality and Safety in Health Care 2003 December;12(6):458-64.

Bertels T, Williams M, Dershin H. Six Sigma: a powerful strategy for healthcare providers. Aon Healthcare Alliance Health Line Special Edition 2001;1-5.

Dusharme D. Quality conversation with Mikel Harry. The foremost expert on Six Sigma talks about its past, present and future [online article]. Quality Digest 2004 February;24(2).

Rozgus A. Using the sixth sense: by implementing the Six Sigma approach, companies can move ahead of the pack. The Concrete Producer 2003 August;1.

Scalise D. Six Sigma: the quest for quality. Hospitals & Health Networks 2001;75(12):41-46, 2.

Seecof  D. Applying the Six Sigma approach to patient care. [online article]. Healthcare Solutions Insights 2000 May 1:2(5). GE Medical Systems Healthcare Solutions. 2000.

Baldrige Criteria

Baldrige National Quality Program. 2004 Health Care Criteria for Performance Excellence. Gaithersburg, MD: National Institute for Standards and Technology. 2004.

Dunn P, Santamour B. How health care won its first Baldrige. Hospitals & Health Networks 2003;77(9):67-74, 2.

Clinical Microsystems

Batalden PB, Nelson EC, Edwards WH, et al. Microsystems in health care: part 9. Developing small clinical units to attain peak performance. The Joint Commission Journal on Quality and Safety 203;29(11):575-85.

Batalden PB, Nelson EC, Mohr JJ, et al. Microsystems in health care: part 5. How leaders are leading. The Joint Commission Journal on Quality and Safety 2003;29(6):297-308.

Buckingham M, Coffman C. First, Break all the Rules: What the Worlds Greatest Managers Do Differently New York: Simon & Schuster. 1999.

Godfrey MM, Nelson EC, Wasson JH, et al. Microsystems in health care: part 3. Planning patient-centered services. The Joint Commission Journal on Quality and Safety 2003;29(4):159-70.

Huber TP, Godfrey MM, Nelson EC, et al. Microsystems in health care: part 8. Developing people and improving work life: what front-line staff told us. The Joint Commission Journal on Quality and Safety 2003;2910):512-22.

Kosnik LK, Espinosa JA. Microsystems in health care: part 7. The microsystem as a platform for merging strategic planning and operations. The Joint Commission Journal on Quality and Safety 2003;29(9):452-9.

Mohr JJ, Barach P, Cravero JP, et al. Microsystems in health care: part 6. Designing patient safety into the microsystem. The Joint Commission Journal on Quality and Safety 2003;29(8):401-8.

Mohr JJ, Batalden PB. Improving safety on the front lines: the role of clinical microsystems. Quality & Safety in Health Care 2002 March;11(1):45-50.

Nelson EC, Batalden PB, Huber TP, et al. Microsystems in health care: part 1. Learning from high-performing front-line clinical units. The Joint Commission Journal on Quality Improvement 2002;28(9):472-493.

Nelson EC, Splaine ME, Plume SK, et al. Good measurement for good improvement work. Quality Management in Health Care 2004;13(1):1-16.

Wasson JH, Godfrey MM, Nelson EC, et al. Microsystems in health care: part 4. Planning patient-centered care. The Joint Commission Journal on Quality and Safety 2003; 29(5):227-37.

Page last reviewed August 2016
Internet Citation: Appendix A. Review of the Literature. Content last reviewed August 2016. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/toolkit/tkappa.html