Six ways not to improve patient flow: a qualitative study

Abstract

Background Although well-established principles exist for improving the timeliness and efficiency of care, many organisations struggle to achieve more than small-scale, localised gains. Where care processes are complex and include segments under different groups' control, the elegant solutions promised by improvement methodologies remain elusive. This study sought to identify common design flaws that limit the impact of flow initiatives. Methods This qualitative study was conducted within an explanatory case study of a Canadian regional health system in which multitudinous flow initiatives had yielded no overall improvement in system performance. Interviews with 62 senior, middle and departmental managers, supplemented by ∼700 documents on flow initiatives, were analysed using the constant comparative method. Results Findings suggested that smooth flow depends on linking a defined population to appropriate capacity by means of an efficient process ; flawed initiatives reflected failure to consider one or more of these essential elements. Many initiatives focused narrowly on process, failing to consider that the intended population was poorly defined or the needed capacity inaccessible; some introduced capacity for an intended population, but offered no process to link the two. Moreover, interveners were unable to respond effectively when a bottleneck moved to another part of the system. Errors of population, capacity and process, in different combinations, generated six ‘formulae for failure’. Conclusions Typically, flawed initiatives focused on too small a segment of the patient journey to properly address the impediments to flow. The proliferation of narrowly focused initiatives, in turn, reflected a decentralised system in which responsibility for flow improvement was fragmented. Thus, initiatives' specific design flaws may have their roots in a deeper problem: the lack of a coherent system-level strategy.

The three paradoxes of patient flow: an explanatory case study

“…The study’s quantitative component, which confirmed the lack of regional flow improvement and the negligible impact of most interventions, is reported as a supplement to the companion article [10]. This paper focuses on the study’s qualitative component; in-depth individual and small-group interviews (early 2013) with a purposive sample of 62 senior, middle and departmental managers constituted the primary method, supplemented by review of all available documents describing the nature, implementation, and/or impacts of flow initiatives.…”

Planning without action and action without planning? Examining a regional health system's efforts to improve patient flow, 1998–2013

“…Minor treatment areas were established in 4 EDs by 2008; as of early 2013, the other 2 sites nominally possessed them but were not using them. Nor did full implementation guarantee substantial impact on flow: some initiatives tackled too small a part of the problem to yield large effects; some demonstrated no effects at all …”

“…The overall case study's mixed‐methods design incorporated quantitative analysis of flow indicators 1999 to 2012; in‐depth interviews with 62 senior, middle, and departmental managers; review of ~700 documents solicited from managers throughout the organization; and participant observation of regional flow meetings/events in 2007 to 2009 and 2012 to 2014 . The present extension draws to a small extent on the interviews (the methods of which have been described in detail in the 2 prior articles) and observation, but most heavily on documentary sources.…”

“…Sources consulted during this phase included regional and provincial press releases, annual reports, internal and external presentations, project‐management documents (project charters, progress reports, closure reports), meeting minutes, program‐level quality plans (which often included progress updates), documentation produced during Lean initiatives (“A3s”), and reports of evaluation findings (formal or informal). One product of this investigation was an inventory of existing and past flow initiatives, covering their content, scope, timing, and impacts; this was published along with the findings of the cross‐sectional component, and is not repeated here. The present article focuses on providing a narrative of the Region's engagement with the problem of patient flow, extending from the first flow‐related report on record (1998) to the end of 2013.…”

“…Moreover, it examined a process with a successful outcome, whereas explication of the planning‐action disjunction demands an analysis of failure. Accordingly, the present study chronicles a regional health system's management of an intractable issue over a 15‐year period; it extends an explanatory case study concerning this system's strenuous, yet ultimately unsuccessful, efforts to improve patient flow . This study addresses the following research questions: Through what processes did decision‐makers identify initiatives to improve flow? To what extent did these processes conform to a discovery approach, and at what point(s) did they diverge? What initiatives were generated, and what was their fate? …”