New institutional setting, new organizational configurations: Redesigning the Danish emergency care system via a contingency approach

As a result of major administrative reform in 2007, the Danish emergency care system is undergoing the largest reorganization in decades (MHP, 2008; Vrangbaek, 2013). The number of acute hospitals has been reduced from more than 40 to 21 and new emergency departments (EDs) have been established (MHP, 2008; Wen et al., 2013, Mattsson, Mattsson & Jørsboe, 2014). The EDs are the cornerstones of the Danish National Health System (NHS), as up to 70% of all acute care patients are evaluated there; they can be treated and discharged, or admitted for further care (MHP, 2008; Wen et al., 2013). The EDs therefore play a crucial role in determining the design of the overall healthcare, being a critical pathway for acute care and addressing hospital crowding. The Danish emergency care system represents an organizational field (DiMaggio & Powell, 1983) in which highly specialized healthcare actors, such as primary care physicians (PCPs), systems of out-of-hours care clinics, ambulance systems, and hospitals, have to coordinate their actions with the ultimate objective of providing a timely and appropriate response toward the collective. On the other hand, following the general reform of 2007, the National Board of Health in Denmark (NBHD) has recommended the delivery of emergency care through fewer, larger, and more centralized EDs. This was done to concentrate specialties and provide a higher level of care with greater efficiency in a system in which the patients’ overall impression of hospitalization has traditionally been positive (MHP, 2008). Moreover, the overall reform generated (external) financial crunches for healthcare providers that predictably turned into internal pressures related to efficiency (e.g., Louis et al., 1999; Lega & DePietro, 2005; Reay & Hinings, 2005, 2009). The search for efficiency through the maximization of economies of scale, by concentrating specialized knowledge and equipment, is generating some symbiotic organizational effects. These can be studied at different levels of analysis (Hackman, 2003): a) at the macro level, through a general rationalization of public expense, in two ways: a.1) regions are in charge of the planning and delivery of healthcare, and new regional mechanisms for governance and funding, resulting in the diffusion of new performance appraisal approaches; a.2) positive operational spillovers are exploited amongst agents through coordination mechanisms based on healthcare networks, with several interdependent providers covering the various phases of emergency care; b) at the meso level, via the definition of structures, roles, and procedures of emergency care. In essence, each hospital designs its own ED, with different levels of managerial autonomy, human resource specialization, technological endowment, and design of internal processes. In short, the Danish emergency care system is trying to change toward a more cost-effective but also a more patient-oriented configuration; c) at the micro level, via the design of appropriate incentives for professionals. In Fearlie and Shortell’s (2001) terms, “A multilevel approach to change and the associated core properties can provide a framework for assessing progress on these and related issues over the next several years” (p. 307). This paper presents the preliminary results of a larger research project called DESIGN-EM, aimed at designing effective and efficient EDs. In a dynamic environment, in which each of the 21 Danish hospitals is still configuring its own ED, this research project aims to determine if differences in organization designs affect efficiency, effectiveness, the quality of patient care, and resource utilization. It reports on the part of the project attempting to investigate the meso level of analysis (hospitals/EDs), and focuses on the research gap related to the adoption of the multi-contingency approach (Burton & Obel, 1988, 2004) in the design of emergency care, with a specific focus on the EDs (Table 1). Thus, this research addresses the following research question: How can hospitals design their EDs to adapt to institutional, technological, and clinical dynamics?