The three paradoxes of patient flow: an explanatory case study

Abstract

BackgroundHealth systems in many jurisdictions struggle to reduce Emergency Department congestion and improve patient flow across the continuum of care. Flow is often described as a systemic issue requiring a “system approach”; however, the implications of this idea remain poorly understood. Focusing on a Canadian regional health system whose flow problems have been particularly intractable, this study sought to determine what system-level flaws impede healthcare organizations from improving flow.MethodsThis study drew primarily on qualitative data from in-depth interviews with 62 senior, middle and departmental managers representing the Region, its programs and sites; quantitative analysis of key flow indicators (1999–2012) and review of ~700 documents furnished important context. Examination of the interview data revealed that the most striking feature of the dataset was contradiction; accordingly, a technique of dialectical analysis was developed to examine observed contradictions at successively deeper levels.ResultsAnalysis uncovered three paradoxes: “Many Small Successes and One Big Failure” (initiatives improve parts of the system but fail to fix underlying system constraints); “Your Innovation Is My Aggravation” (local innovation clashes with regional integration); and most critically, “Your Order Is My Chaos” (rules that improve service organization for my patients create obstacles for yours). This last emerges when some entities (sites/hospitals) define their patients in terms of their location in the system, while others (regional programs) define them in terms of their needs/characteristics. As accountability for improving flow was distributed among groups that thus variously defined their patients, local efforts achieved little for the overall system, and often clashed with each other. These paradoxes are indicative of a fundamental antagonism between the system’s parts and the whole.ConclusionAn accretion of flow initiatives in all parts of the system will never add up to a system approach, and may indeed perpetuate the paradoxes. What is needed is a coherent strategy of defining patient populations by needs, analyzing their entire trajectories of care, and developing consistent processes to better meet those needs.

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

“…The cross‐sectional phase of the case study sought to discover why performance had stagnated, examining the issue at both the micro (initiative‐by‐initiative) and macro (system) levels. As reported elsewhere, analysis revealed 3 paradoxes: “Many Small Successes and One Big Failure” (past initiatives had succeeded at improving parts of the system but failed to address the most important constraints to flow); “Your Innovation Is My Aggravation” (local innovation clashed with regional integration); and “Your Order Is My Chaos” (rules that improved the organization of care for 1 group of patients often created obstacles for another). A fourth paradox was also observed: When managers described past efforts to improve flow, they reported both action without planning (frenetic, unfocused activity; “jumping to solutions”) and planning without action (protracted high‐level discussions that became mired at the conceptual level).…”

“…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.…”

“…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? …”

Temporal pacing of outcomes for improving patient flow: Design science research in a National Health Service hospital

“…However, their transfer into practice has been varied (Boyer, Gardner, & Schweikhart, 2012;Boyer & Pronovost, 2010;Kreindler, 2017). However, their transfer into practice has been varied (Boyer, Gardner, & Schweikhart, 2012;Boyer & Pronovost, 2010;Kreindler, 2017).…”

“…Hence, managing bed capacity and LoS are imperatives to improving patient flow, which is, in turn, linked to the delivery of high quality, safe, and patient care (Kreindler, 2017). Delays can therefore be caused by a lack of integration with external service providers, impacting still further on bed capacity.…”