Nine major forces are involved:

Changing patient populations and their needs
Higher patient expectations
Recognition that many types of care can be better delivered in community settings
Evidence suggesting that high quality care requires high volume centres and the emergence of stand-alone single specialty centres
Advances in clinical knowledge and technology
Impact of digital technologies on health care delivery
Difficulties in attracting and retaining a sufficiently skilled workforce
Financial and funding challenges
Requirements to measure quality
Although their relative importance differs from country to country, these forces are at play worldwide. To investigate how hospitals are responding, we identified global best practices through interviews with healthcare experts in conjunction with an extensive literature search.

Our findings show that contemporary healthcare providers around the world face several urgent imperatives: to strengthen clinical quality; to increase the delivery of personalised, patient-centred care; to improve the patient experience; and to improve their efficiency and productivity. As a result, providers are introducing innovations in care delivery, often to achieve several objectives. These innovations include adopting lean and standardised processes to improve quality and optimise productivity, increasing the use of automation and non-medical staff to change the way their clinical staff are deployed, using new technologies to deliver better quality care at lower cost, involving patients more closely in the delivery of care and harnessing patient-generated data to personalise treatments. In our experience, the most successful providers have paid as much attention to change management as to the changes themselves. By addressing the mindsets and cultures of clinical and non-clinical staff, these providers have increased the agility of their organisations and achieved sustained success.

Many providers are also making a variety of strategic and structural changes to their hospitals, sometimes in response to incentives or payment reforms. Major healthcare delivery systems are pursuing three types of strategy as they strive to balance quality, access and cost.

Many large "regional centre" hospitals seek to increase volumes of specialised services to provide high quality care at an affordable price.
Smaller hospitals (sometimes called local or community hospitals) form networks to invest in infrastructure, share administrative costs and attract and retain staff who wish to undertake a range of clinical work. In some countries, such networks are also formed by larger hospitals, again with the aim of sharing the gains from economies of scale and volume.
Vertical integration is increasing between regional hubs, small local hospitals, community care and, in some cases, payers. This latter trend makes it easier for delivery systems to coordinate the full range of care and provide care closer to home.
Which of these strategies is best for a given health care provider depends both on the provider's starting point and on local market conditions: e.g., regulations, cultural beliefs, funding sources, competitive conditions.

Some countries may not yet feel the full force of the external factors reshaping their hospitals. We believe, however, that it is a case of "not yet" rather than "never". Today, all hospitals must make choices about how to change the way they deliver care. If they are to improve efficiency, meet the expectations and demands of patients (and often payers) and attract and retain the best staff, providers must continue to innovate.