Improving Patient Flow and Reducing Failure demand
Patient flow in the NHS refers to a patient’s progression through the various stages of care in the healthcare system. This journey starts with the initial contact with healthcare services, such as a GP appointment or visit to A&E, followed by diagnosis and treatment through to discharge or ongoing care and a package of support services. Efficient patient flow management improves standards of patient care, patient safety, and resource allocation whilst reducing waiting times and improving patient outcomes.
NHS organisations are at a critical moment. Following on from the COVID pandemic with a tired workforce and huge pressure to rebuild, deliver emergency care in a timely way, increase elective care and step-up outpatient work to reduce waiting lists and backlogs (as described in ‘Tackling the backlog of elective care’.)
Focusing on patient flow management offers a solution to this problem. Let’s begin by taking a high-level view of healthcare improvement for an organisation. Firstly, you have a population of patients who need our services; they form the demand for work. You also have a set of processes and capacity to meet that demand, to add value to the patient. Patient flow is the movement of your patients through that system, so they receive that value without delay, as shown in the diagram below.
Click on the image above to enlarge it
Demand, however, can be broken down into two types:
Value demand, the demand to do activities that add value to the patient, such as assessments, treatments, procedures, and rehabilitation.
There is also Failure demand; work that is caused by the failure to do something, or to do something right for the patient, in a timely way the first time.
Failure demand is created by the organisation not working properly. It is work created by not doing today’s work today. Ultimately, failure demand is caused by poor flow. Examples of this may include ambulance delays, lodged patients, delayed transfers of care, longer stays than necessary, cancelled appointments, cancelled operations, the requirement for waiting list management and bed management.
Failure demand is bad for our patient and results in harm. It is costly. It encourages variation, as staff creatively ‘workaround’ the blocked system. It is also bad for your workforce, as it adds a huge amount of burden and work, when they are already stretched trying to deliver the value demand. Staff burnout, frustration and poor morale can in part be attributed to overwhelming failure demand.
Flow is critical, and to improve patient flow, the organisation and its parts need to act in a different way for each type of demand. In the case of failure demand, identifying and removing the causes. At the individual level this might be by ensuring all of equipment needed is present to do a task in a timely manner and without delay. At the organisational level it might be understanding the demand for a service (e.g., Physio assessments, Active Recovery assessments) and relentlessly pursuing changes that ensure the system capability is reliably there in real time.
With value demand, by designing the patient flow system to meet the demand in the most efficient way it sets the organisation and teams up for success. If we design the system to do the ‘value work’ in real time and only the value work, costs will fall, variation will reduce, capacity will be released, and service will improve. In addition, the system is easier to work in, reducing burnout and frustration, improving morale, wellbeing, and intrinsic motivation. To do this involves a deep understanding of demand, capacity and the way work is organised.
To improve patient flow involves change but not all changes are improvements, and to understand the difference you need measures. Flow improvement requires measures of exactly what is going on in the work (the steps taken, how long they take, the reasons for delays) and for those measures to be put into the hands of the people who do the work. Change then becomes integral to the work, with an ethos on learning and improving in an adaptive and integral way. Making improvements and doing the job well is intrinsically motivating and supports organisations who aspire to the create a continuous improvement culture.