Six cardinal errors in improving patient flow

In the past, I have discussed the issue of the management of the flow of patients in Ireland and possible solutions. This is not an Irish problem per se, as worldwide there is ongoing attempts to try match demand for healthcare with a finite supply of resources. The problem is that we have not really understood what demand is or how to effectively supply inpatient healthcare, writes Dr. Peter Lachman.

Dr. Peter Lachman
Dr. Peter Lachman

In its latest Trolley/Ward Watch analysis, the Irish Nurses and Midwives Organisation (INMO) has recorded 6,136 patients on trolleys in August 2016 awaiting admission for in-patient treatment. This is a 6% reduction as compared to August 2015. (https://www.inmo.ie6).

Should we say there has been an improvement in the way the system manages patients or is this just normal variation and the possibly effect of the weather? If one plots the variation on a Statistical Control Chart (SPC) one would indeed see normal variation; the coming months will see if there is real improvement.

In Ireland there have been many initiatives on flow and much has been spent in time and money, often with little to show for it. Each initiative claims it will be the “holy grail” and solve the problem. As each new vendor of a new method comes along to sell their unique solution, (often something that has been tried and tested in a different context), the claims are made that the cure of this flow problem has arrived. And then there are those who say it is all about resources, i.e. just give us more doctors, nurses and beds and all will be fine.

The message is clear – improve flow by linking patients with process and capacity and understand the complexity of their relationship.

A recent article from Canada should be essential reading for all who plan or commission or deliver initiatives to improve flow. Kreindkar studied initiatives in one health district and comes up with a number of key lessons. The key is to link population with process and then with capacity. However she found six cardinal errors that are repeated over and over and have no sustainable impact.

  • ‘Just add another form’ (neither population, capacity, nor process)
    This is a common approach viz., let’s count more in the hope things will get better; or fill out some sort of ongoing audit that will give us more information. Just as the proverb that you do not fatten a cow by continually weighing it, this approach is simply not productive.
  • Improve efficiency—in the wrong part of the process (process without capacity)
    A lot of the interventions aim to have become leaner – but no matter how efficient one is one does need to recognise capacity issues too.
  • Create a ‘parking lot’ (process with capacity that does not match the duration of population needs)
    This is a favourite solution i.e move the “bed blockers to the discharge lounge or those on trolleys to an admissions holding ward. These are ways to deflect attention from unsolved problems of process and capacity.
  • Design services for a poorly defined population (capacity without population)
    Another mistake is not to understand the population even if one increases the capacity
  • Add capacity that is poorly targeted to its intended population (capacity without process)
    Often increased capacity does not solve the problem, especially if the wrong patients fill the new capacity due to failure to sort out the process.
  • When the bottleneck moves, do not follow it (population, capacity and process must be defined anew)
    The final issue is about the theory of constraints how bottlenecks which just move on as one sorts it, if the capacity and process are not understood.

The message is clear – improve flow by linking patients with process and capacity and understand the complexity of their relationship.

Reference (on open access)

Kreindler SA. Six ways not to improve patient flow: a qualitative study. BMJ Qual Saf 2016;0:1–7