Modelling the emergency care system in Denmark: Reacting to institutional changes via a contingency approach

In consequence of a 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 the 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), since up to 70% of all acute care patients are evaluated there, where 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 health assistance, being a critical pathway for acute care and for hospital crowding. The Danish emergency care system represents an organizational field (DiMaggio & Powell, 1983; Scott, 1995; Wotten & Hoffman, 2008) in which highly specialized healthcare actors such as Primary Care Physicians (PCPs), systems of off-hours care clinics, ambulance systems and hospitals have to coordinate their actions with the ultimate objective to be timely and appropriately responsive towards the collectivity. On the other hand, following the general reform of 2007, the National Board of Health in Denmark (NBHD) has recommended that the delivery of emergency care through fewer, larger, and more centralized EDs. That in order to concentrate specialists and provide a higher level of care in a more efficient way, in a system in which the patient overall impression of the hospitalization has traditionally been positive (MHP, 2008). Moreover, the overall reform generated (external) financial crunches towards healthcare providers that predictably turned into internal pressures towards efficiency (e.g. Louis et al., 1999; Lega & DePietro, 2005; Reay & Hinings, 2005, 2009). The search for efficiency via the maximization of economies of scale, by concentrating specialized knowledge and equipment, is generating three symbiotic organizational effects, that can be studied at different level of analysis (Hackman, 2003): a) at a macro-level, via a general rationalization of the public expense, in two ways: a1) since the regions are in charge the planning and delivery of health care, new regional mechanisms for governance and funding, the diffusion of new performance appraisal approaches; a2) via the exploitation of operational positive spillovers among agents, through coordination mechanisms based on healthcare networks (Lomi et al., 2014) with several interdependent providers covering the various phases of emergency care ; b) at a meso-level, via the definition of structures, roles and procedures of emergency care: in fact, each hospital is designing its own ED, with different level of managerial autonomy, human resource specialization, technological endowment, design of internal processes. In short, the Danish emergency care system is trying to change towards more cost-effective but also more patient-oriented configurations; c) at a micro-level, via the design of appropriate incentives for professionals. To say with Fearlie and Shortell “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” (2001: 307). The paper presents the preliminary results of a larger research project called DESIGN-EM aiming at designing effective and efficient EDs. In a dynamic environment, in which each of the 21 Danish hospitals is still configuring its own ED , the research project aims at understanding if differences in organization designs affect efficiency, effectiveness, quality of patient care, and resource utilization