How not to manage flow (or no more forms please) #WILTW

This is the 116th #WILTW

While those working in Emergency Medicine spend their lives trying to create, fix, or wanting to cry at the ‘flow‘ in their departments everyone experiences its importance.

For example, standing in the queue of a fast food restaurant your hunger and irritation grow as you realise the rate of people arriving is clearly greater than the amount of people leaving with food.  Whats more you notice the obvious variation in the way the queues are moving; and are convinced your ‘one starred’ server is definitely slower than than ‘five starred’ server in the row you should have joined.

The BMJ’s Quality and Safety Journal recently published a paper entitled: Six ways not to improve patient flow. It is a qualitative study (exploratory research measuring the quality of something descriptively rather than numerically) trying to work out why initiatives at improving patient flow through Emergency Departments often fail. The authors interviewed senior staff and analysed documents in a region in Canada and then drew a number of conclusions as to why interventions to improve flow often failed.

Click on box to bring up full size diagram

I’ll be honest that the diagrammatic representation initially confused me and I didn’t quite understand what they were trying to represent. One of the problems is that they are using ‘capacity‘ to describe the needs of patients rather than in its traditional medical sense of how much spare resource there is to respond to a particular need. However what did strike a cord was the 6 reasons they highlighted which caused initiatives to fail.

I have attempted to describe these below. It is important to read the original paper to get a proper understanding but I think the “Just add another form” route to failure will be familiar to many health care professionals (and probably those outside of health care as well!)


The authors noted some common themes from interviewees when exploring the absence of consideration of population, capacity or process:

Among the favourite targets of criticism were ‘bed meetings’ that, although intended to produce action on barriers to flow, allegedly produced only talk.

But while there is obvious face validity to the six issues does this help us  or just tell us what we already knew? Thinking that an initiative which works in one location can be easily taken somewhere else should certainly be challenged. And before starting any new project it would seem sensible to make sure everyone understands the population they are dealing with and what that population actually needs.

Sadly on a practical note I am not sure it will help you get your burger any faster though…

What have you learn this week? #WILTW

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