Organic versus mechanistic approaches to system-wide improvement: Reducing delays to critical care

Abstract

Increasing pressure towards value-based care has increased focus on patient safety and operational improvement initiatives in healthcare delivery. While improvement efforts have increased since the beginning of the patient safety movement, dissemination of these improvements across the complex health system continues to be a challenge. Senior leaders often want improvements to spread fast and wide throughout the organization. We propose that an organic process of developing localized clarity of objectives and collaborative problem solving between units provides a more effective foundation for extending improvements across the system. We follow a large-scale patient safety effort to reduce the time from admission in the Emergency Department (ED) to arrival in the Intensive Care Unit (ICU) to show how the approach taken by leadership impacts successful extension of improvements across an organization.

Keywords:

• Sociotechnical systems
• process improvement
• care transitions
• patient flow
• healthcare management

Appendix

ICU Patient Flow Interview Guide

Background Information

1. How many years have you worked in your current position?

2. How many years have you worked for the organization?

3. What is your current job title/job classification?

4. What specific goals and metrics does your unit track regarding patient safety?

5. How do you know if you are successful?

ICU Patient Movement–Process

1. What is the process to move ICU patients to or from your unit? Is this process documented anywhere?

2. Is this process similar across shifts and personnel?

3. What is the process for ICU patient placement if all the ICUs are full?

ICU Patient Movement–Communication

1. What type of communication occurs with the following areas during an ICU patient move? (Exclude respondent’s own unit):

2. Emergency Department; SICU; MICU; MAT; CTICU; Surgical Floor; Medical Floor; PACU; ENIT; Bed Coordination

1. Is communication between units clear, concise, and accurate? If not, can you give me an example?

2. What are the barriers to effective and efficient communication between these various units?

Problem Identification and Resolution

1. Can you give examples of common problems your unit encounters when trying to move patients?

2. What is the process for problem resolution between units? For example, if a patient waited in the ED (or ICU for floor respondents) for three hours while there was an open bed, how does your unit respond?

3. Can you sense when patient safety is more vulnerable? If so, what do you do to adjust the current situation to minimize risk to the patient?

4. Do you believe that ICU patient moves are a priority within the organization?

5. What do you think is the hospital biggest barrier to being able to move patients to or from the ICU in a timely fashion?

6. Do you believe ICU patient delays are attributable to one particular source, or is it a broader, systems problem?