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Early access to senior decision makers and investigations has improved outcomes for many conditions. A surgical clinical decisions unit (CDU) was created to allow rapid assessment and investigation by on-call senior surgical team members to facilitate decision making and, if appropriate, discharge within a set time frame (less than four hours). The purpose of this paper is to compare outcomes for unscheduled general surgery admissions to the hospital before and after commissioning this unit.

Prospectively collected hospital episode statistics data were compared for all general surgical admissions for one year prior to (July 2010-June 2011) and two years after (July 2011-June 2013) the introduction of the CDU. Statistical analysis using the Mann Whitney U-test was performed.

More patients were discharged within 24 hours (12 per cent vs 20 per cent, p < 0.001) and total hospital stay decreased (4.6 days vs 3.2 days, p < 0.001) following introduction of CDU. Admission via A & E (273 vs 212, p < 0.01) was also decreased. Overall there was a 25.3 per cent reduction in emergency surgical admissions. No difference was noted in 30-day readmission rates (47 vs 49, p=0.29).

The introduction of a CDU in has increased early discharge rates and facilitated safe early discharge, reducing overall hospital stay for unscheduled general surgical admissions. This has decreased fixed bed costs and improved patient flow by decreasing surgical care episodes routed through the emergency department (ED). In all, 30-day readmission rates have not been influenced by shorter hospital stay. Service redesign involving early senior decision making and patient investigation increases efficiency and patient satisfaction within unscheduled general surgical care. Not original but significant in that the model has not been widely implemented and this is a useful addition to the literature.

The aim was to test the feasibility of using automated data, and evaluate the impact of an emergency cardiac decision unit (CDU) on the overall outcomes of patients seen for chest discomfort. We used a retrospective, quasi‐experimental design to identify patients who had cardiac enzymes measured and an electrocardiogram performed during an ED visit in two six‐month periods, pre‐CDU (1 January‐30 June 1995) and post‐CDU (1 January‐ 30 June 1996). A total of 4,336 patients had outcomes assessed. After opening, 14.8 per cent of all chest pain cases were treated in the CDU. Hospital admission rates were reduced from 81.1 per cent to 66.7 per cent. Length of stay, myocardial infarction rates, and mortality were unchanged. The 14‐day revisit rates increased from 5.3 per cent to 10.3 per cent. We conclude that cardiac decision units decrease hospital admissions but increase ED revisit rates as a consequence of this now frequently used care pathway.

The purpose of this paper is to consider the influence of the Emergency Department (ED) target wait time upon the discharge decision in ED, specifically for patients who have self-harmed. Pressures to discharge patients to avoid breaching the 4-h target wait time, potentially increase the risk of adverse responses from clinicians. For the patient who has self-harmed, such interactions may be experienced as invalidating and may result in adverse outcomes.

Secondary data analysis was applied to the retrospective referral data of a Mental Health Liaison Team (MHLT), collected over a period of 11 months from a single hospital in the North of England. In total, 734 episodes of care were referred to the team from ED, where the primary presentation was recorded as self-harm.

Over half of patients referred to the MHLT from ED having self-harmed were seen after already breaching the target and the potential for a more restrictive outcome reduced. Of those patients seen within 4 h, the potential for a more restrictive treatment option was increased.

Recommendations to improve the patient journey for those who have self-harmed include mental health triage and treatment in clinical areas outside of the target.

This study challenges the concept of the target as being realistic and attainable for patients who have self-harmed.

This exploratory study provides a starting point from which to explore the impact of the target time upon discharge decisions and clinical outcomes specifically for those who have self-harmed.

The purpose of this paper is to provide a quick overview of the current journal content.

A review of five papers.

The review section brings together the differing aspects of clinical governance discussed in the current journal.

The review section enables readers to prioritise articles with the most relevance for their needs or particular fields of healthcare.

In the last decade, greater attention has been paid to the role of management accounting and control (MAC) in making professional organizations more horizontal. The authors argue that earlier research has not shown how the interrelatedness between professional identities and MAC influences attempts to make organizations more horizontal. In this paper the authors respond to the call for more research on the relationship between horizontalization and accounting and control. The purpose of this paper is to contribute to the emerging literature on the relationship between accountability arrangements and professional identities.

Theoretically the authors have an actor-network theory (ANT) approach. Empirically, the authors followed two episodes where actors at top management levels in two Swedish health care organizations introduced horizontalization.

The two episodes support the view that the role of MAC when making professional organizations more horizontal is limited. Professionals dominate what happens at the operational level and they do not act on MAC rules and performance targets in opposition of their professional identity. However, in alliance with other interessement devices MAC may have a role in creating overflows, that is, pointing out imperfections in the existing frame. The authors noticed no signs that professionals developed hybrid identities as in previous research.

The authors apply ANT to move beyond the commonly used contingency and new institutional sociology perspectives.

The process of public sector reform in the United Kingdom continues to provoke debate. Even among advocates of the reform process there is a concern that improvements in public service provision have not been as marked as originally intended, and that the process has produced a variety of unintended consequences. The purpose of this paper is to explore possible explanations for these unintended consequences, and discuss possible practical solutions for policy makers and service commissioners.

In this conceptual paper focus is in particular upon attempting to explain managerial behaviour from insights offered by two well‐established managerial theories – stakeholder theory and resource dependency theory. Insights from these theories are used to explain the possible causes of the unintended consequences of the reform process. The discussion is illustrated and set in context by reference to a continuum of service delivery modes from monopoly provision through to full competition.

Theory suggests that managers inevitably prioritise the interests of what they identify as their key stakeholders, and particularly those providing critical resources. In the case of public services this means that the interests of government, as the commissioner and funder of services, are prioritised rather than the end‐users of services. Examples of how this distorts the objectives of government are highlighted. It is argued that understanding this aspect of managerial decision‐making and stakeholder prioritising opens up the potential to resolve the problem.

This is the first paper to address the question of managerial behaviour from these theoretical perspectives in the area of the public sector reform process.

The paper comprises an evaluation of the inclusion of art‐related education within a health promotion course for student nurses, which ran for four cohorts from 2001 to 2005, and a description of a project to introduce art into a clinical skills laboratory as part of the course.

The art‐related aspects of the course were evaluated by analysing qualitative comments from a questionnaire completed by a total of 83 students from the four cohorts. In addition, lecturers were invited to write their reflections. Only the 2003‐2004 cohort worked on the clinical skills laboratory art project in which students acted as a focus group, and later carried out interviews with patients.

The art‐related education was positively evaluated by most students, and appeared to have increased their awareness of health care environments. For some, it had promoted emotional awareness, empathy for patients and had been a therapeutic and enjoyable experience. A specification for art work to be introduced to the university's clinical skills laboratory was produced.

Using the arts in pre‐registration nurse education is relatively new in the UK, and this work provides an example of its potential to encourage empathy among student nurses for the experience of patients in health care settings. The paper provides an example of how art work could be introduced into health care settings.

One of the latest trends within public administration and healthcare organizations (HCOs) is process orientation, often in the shape of Lean management. The purpose of this study is to expand our understanding of process orientation of HCOs and the more specific aim is to investigate what measures are taken to re-frame the HCOs to include the process dimension.

This empirical study is based on 67 interviews and 20 meeting observations.

The main observation in this study is that introducing process-oriented management solutions is about disconnecting and cutting-off existing links. The authors see how attempts are made to cut-off links to the logic of functional specialization, the autonomy of the professional worker, equal treatment of patients and other objectives.

This study adds to and expands previous studies that have problematized the use of Lean-inspired ways of organizing in the public sector.