Reorganisation of emergency departments: From policy to practice

Resumé

Background: In 2007, a national policy of emergency department reorganisation was announced in Denmark. To obtain the expected benefits of the policy, the policy must be put into practice. The aim of this study is to assess the relation between policy and practice after this policy announcement.

Methods: The study was designed as a cross-sectional study and we conducted a survey across all Danish emergency departments (n=21), to assess the policy implementation from 2007-2017. The questionnaire was answered by executive staff at the EDs (100% response rate). We applied the multi-contingency theory as an analytical framework to classify policy recommendations (specialised equipment, centralisation, multidisciplinary teams, triage, flow coordinator, senior physician, qualification upgrade) according to key organisational design dimensions (strategy, structure, coordination, staff, incentive structure) known to affect patient outcome. The framework further guides our analysis and expectations of the policy implementation process and ED impact.

Results: The implementation rate varied across organisational dimensions: Coordination (multidisciplinary teams, triage, flow coordinator) was first implemented and terminated at the highest rates from 86-100%, whereas the implementation of structure (specialised equipment and centralisation) and staff (senior physicians and qualification upgrade) were more sluggish with implementations rates from 10-76% and 33-90%, respectively. The policy did not adhere to the multi-contingency theory and strategy and incentive structure were identified as missing organisational design dimensions of the policy.

Conclusion: We found hesitant and heterogeneous translation from policy to practice, probably due to cooperation and recruitment challenges. According to our analytical framework, these issues might be caused by a lack of linkage between policy and theory. However, most of the Danish EDs developed new coordination strategies to resolve these issues. Since the policy did not suggest a complete design plan, it is not surprising, that the EDs have tried to develop independent solutions. It also shows that if only a partial design is specified with no time limits, the implementation may take different routes.