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This chapter examines why managed clinical networks are an appropriate approach to sustainable healthcare, and discusses the conditions for the effectiveness of these multi-stakeholder, clinician-led modes of organizing. It describes the development of a national clinical network to achieve system-wide improvement in the provision of publicly funded cardiac surgery services in New Zealand, and the subsequent evolution of a broader network encompassing the whole cardiac care patient pathway.

The case study of the two cardiac clinical networks focuses on the emergence and evolution of the networks over a four-year period from 2009. Data were collected from interviews with key stakeholders of both networks and from internal and published documentary evidence. Analysis of the case study is informed by network theory and prior studies of managed clinical networks.

Progress made towards the achievement of the goals of the initial cardiac surgery network encouraged a broadening of focus to the entire cardiac care pathway and the establishment of the national cardiac network. An important benefit has been the learning and increase in understanding among the different stakeholders involved. Both clinical networks have demonstrated the value of clinician engagement and leadership in improving the delivery of health services, and serve as a best practice model for the development of further clinical networks for health services that require a national population base.

The case study analysis of the two cardiac clinical networks identifies five mutually reinforcing themes that underpin network effectiveness: network structure, management and governance, and internal and external legitimation. These themes encompass a number of factors suggestive of successful managed clinical networks, and offer insights into the use of such networks in organizing for sustainable healthcare.

This study aims to examine how health-care managers in acute care and post-acute care facilities support and plan to improve transitional care for cardiac patients and their family caregivers, to better manage care in the home.

A qualitative descriptive approach, guided by appreciative inquiry was used in this study. A purposive sample of 16 participants were engaged in the study. Participants completed a demographic questionnaire, the caregiver policy lens questionnaire and participated in one of four focus group interviews. The semi-structured focus group interviews were audio-recorded and analyzed using thematic analysis.

Using Donabedian’s framework, six major themes contributed to how health-care managers can improve transitional care: structure included supporting personnel and continuing education; process included enacting approaches of care, coordinating care among the health-care team and calling to work upstream; and outcomes included needing to clarify expectations of home care services and witnessing the impact of the caregiver role.

These findings demonstrate the importance of Donabedian’s core dimensions of structure and processes in influencing caregiver outcomes. These results emphasize the central role of the manager in influencing system change to improve transitional care.

Palliative care concentrates on reducing the severity of disease symptoms, rather than providing a cure. The goal is to prevent and relieve suffering and to improve the quality of life for people facing serious, complex illness. It is therefore critical in the palliative environment that caregivers are able to make recommendations to patients and families based on reasonable assessments of amount of suffering and quality of life. This research uses statistical methods of evaluation and prediction as well as simulation to create a multiple criteria model of survival rates, survival likelihoods, and quality of life assessments. The results have been reviewed by caregivers and are seen to provide a solid analytical base for patient recommendations.

The purpose of this paper is to investigate the impact of a “Do Not Attempt Resuscitation” (DNAR) order on subsequent decision making relating to the clinical care of the patient.

The approach taken was a questionnaire based on a hypothetical clinical case, completed by medical and nursing staff of all grades in general medical, surgical, and orthopaedic wards.

There is a reduction in the urgency attached to reviewing a deteriorating patient following institution of a DNAR order. Many doctors and nurses will not perform a range of interventions in the patient with a DNAR order in place. Confusion exists regarding whether an apnoeic, peri‐arrest patient should be ventilated when a DNAR order is in place.

This was a single‐centre study, looking at a hypothetical situation. Further studies at more centres, and investigating different designs of DNAR form, would clarify the best format for these to take.

A DNAR statement may often be interpreted as limiting other forms of care. This is more likely amongst more junior doctors and nursing staff, who are frequently the first line of assessment of these patients. More explicit DNAR forms may be advisable to confirm what treatments are to be continued.

This paper demonstrates that DNAR decisions are taken as a surrogate marker for limiting other forms of care, and that this extends to medical and nursing staff at all grades.

This case study, written by the manager of an intensive/coronary care unit of an Ontario hospital, demonstrates the difficulties faced by health care managers in controlling costs and dealing with complexity in the current health care and hospital environment. The case describes actions taken to reduce staffing expenditures in an intensive care unit through a rearrangement of nursing duties and the introduction of a different level of nursing staff to take over some of the nursing duties previously carried out by registered nurses. Although the actions were unsuccessful, the careful documentation and analysis of the results of the actions brings to the fore the multi‐faceted nature of the problems faced by hospitals in managing their costs and at the same time meeting their medical mandate. Concludes by pointing to the ongoing nature of the cost problem as nursing professionals are caught in the squeeze between providing the service they are trained for, and their need for appropriate compensation under conditions of increasing work pressure.

The high variability in cardiac surgery length – is one of the main challenges for staff managing productivity. This study aims to evaluate the impact of six interventions on open‐heart surgery operating theatre productivity.

A discrete operating theatre event simulation model with empirical operation time input data from 2,603 patients is used to evaluate the effect that these process interventions have on the surgery output and overtime work. A linear regression model was used to get operation time forecasts for surgery scheduling while it also could be used to explain operation time.

A forecasting model based on the linear regression of variables available before the surgery explains 46 per cent operating time variance. The main factors influencing operation length were type of operation, redoing the operation and the head surgeon. Reduction of changeover time between surgeries by inducing anaesthesia outside an operating theatre and by reducing slack time at the end of day after a second surgery have the strongest effects on surgery output and productivity. A more accurate operation time forecast did not have any effect on output, although improved operation time forecast did decrease overtime work.

A reduction in the operation time itself is not studied in this article. However, the forecasting model can also be applied to discover which factors are most significant in explaining variation in the length of open‐heart surgery.

The challenge in scheduling two open‐heart surgeries in one day can be partly resolved by increasing the length of the day, decreasing the time between two surgeries or by improving patient scheduling procedures so that two short surgeries can be paired.

A linear regression model is created in the paper to increase the accuracy of operation time forecasting and to identify factors that have the most influence on operation time. A simulation model is used to analyse the impact of improved surgical length forecasting and five selected process interventions on productivity in cardiac surgery.

Bundled payments for care are an efficient mechanism to align payer, provider, and patient incentives in the provision of health care services for an episode of care. In this chapter, we use agency theory to examine the evolution of bundled payment programs in private and public payer arrangements, and postulate future directions for bundled payment development as a key component in the provision and payment of health care services.

Cardiovascular diseases are the leading cause of death worldwide. In Italy, acute myocardial infarction (AMI) is a major cause of hospitalization and healthcare costs. AMI is a myocardial necrosis event caused by an unstable ischemic syndrome. The Italian government has defined an indicator called “AMI: 30-day mortality” to assess the quality of the overall care pathway of the heart attacked patient. In order to guarantee high standards, all hospitals had to implement techniques to increase the quality of care pathway. The aim of the paper is to identify the root cause and understand the mortality rate for AMI and redesign the patient management process in order to improve it.

A Lean Six Sigma (LSS) approach was used in this study to analyze the patient flow in order to reduce 30-days mortality rate from AMI registered by Complex Operative Unit (COU) of Cardiology of an Italian hospital. Value stream mapping (VSM) and Ishikawa diagrams were implemented as tools of analysis.

Process improvement using LSS methodology made it possible to reduce the overall times from 115 minutes to 75 minutes, with a reduction of 35%. In addition, the corrective actions such as the activation of a post-discharge outpatient clinic and telephone contacts allowed the 30-day mortality rate to be lowered from 16% before the project to 8% after the project. In this way, the limit value set by the Italian government was reached.

The limitation of the study is that it is single-centered and was applied to a facility with a limited number of cases.

The LSS approach has brought significant benefits to the process of managing patients with AMI. Corrective actions such as the activation of an effective shared protocol or telephone interview with checklist can become the gold standard in reducing mortality. The limitation of the study is that it is single-centered and was applied to a facility with a limited number of cases.

LSS, applied for the first time to the management of cardiovascular diseases in Italy, is a methodology which has proved to be strategic for the improvement of healthcare process. The simple solutions implemented could serve as a guide for other hospitals to pursue the national AMI mortality target.

Hospitals and health‐care facilities are among the most complex, costly, and challenging buildings to design, construct and manage. To become a health facilities manager of a hospital or other medical centre in the USA, one requires knowledge not only of how to manage people, but also of how to deal with government agencies and all kinds of regulations and inspections. The hospital facility must cope with the idea of being open 25 hours a day, and having staff to control 365 days a year.