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The three paradoxes of patient flow: an explanatory case study
BACKGROUND: Health 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. Focus...
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Formato: | Online Artículo Texto |
Lenguaje: | English |
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BioMed Central
2017
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Acceso en línea: | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5508770/ https://www.ncbi.nlm.nih.gov/pubmed/28701232 http://dx.doi.org/10.1186/s12913-017-2416-8 |
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author | Kreindler, Sara A. |
author_facet | Kreindler, Sara A. |
author_sort | Kreindler, Sara A. |
collection | PubMed |
description | BACKGROUND: Health 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. METHODS: This 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. RESULTS: Analysis 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. CONCLUSION: An 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. |
format | Online Article Text |
id | pubmed-5508770 |
institution | National Center for Biotechnology Information |
language | English |
publishDate | 2017 |
publisher | BioMed Central |
record_format | MEDLINE/PubMed |
spelling | pubmed-55087702017-07-17 The three paradoxes of patient flow: an explanatory case study Kreindler, Sara A. BMC Health Serv Res Research Article BACKGROUND: Health 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. METHODS: This 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. RESULTS: Analysis 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. CONCLUSION: An 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. BioMed Central 2017-07-12 /pmc/articles/PMC5508770/ /pubmed/28701232 http://dx.doi.org/10.1186/s12913-017-2416-8 Text en © The Author(s). 2017 Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. |
spellingShingle | Research Article Kreindler, Sara A. The three paradoxes of patient flow: an explanatory case study |
title | The three paradoxes of patient flow: an explanatory case study |
title_full | The three paradoxes of patient flow: an explanatory case study |
title_fullStr | The three paradoxes of patient flow: an explanatory case study |
title_full_unstemmed | The three paradoxes of patient flow: an explanatory case study |
title_short | The three paradoxes of patient flow: an explanatory case study |
title_sort | three paradoxes of patient flow: an explanatory case study |
topic | Research Article |
url | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5508770/ https://www.ncbi.nlm.nih.gov/pubmed/28701232 http://dx.doi.org/10.1186/s12913-017-2416-8 |
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