Care and Flow: Using Soft Systems Methodology to understand tensions in the patient discharge process

Abstract

Many hospitals face a daily struggle to manage capacity, especially where wards contain patients with a combination of health and social care needs. In this study, Soft Systems Methodology was used to understand the process of discharging patients from an acute hospital and to answer the question ‘Why do patients with complex needs often spend longer on the wards than is necessary?’. Through a series of twenty structured interviews, several problems with the discharge planning process were identified. Problems included ineffective communication, slow processing of paperwork, limited forward planning, no clear ownership of the process and delays in finding care in the community. The persistence of these problems despite longstanding guidance on discharge planning can be understood by recognising the tension between two different philosophies in hospitals – a traditional ‘Care’ mindset focusing on the immediate needs of patients on the wards, and a planning-focused ‘Flow’ mentality, where the hospital’s responsibility to the wider community dominates. Soft Systems Methodology was found to be an effective approach for discussing discharge planning and highlighting this tension. Based on the insights gained from the interviews, three practical initiatives have now been implemented to reconcile the tension and thereby reduce delays in the hospital.

Keywords:

• patient discharge process
• Soft Systems Methodology
• complex needs

Acknowledgements

The authors are grateful for the time given by the interviewees at the hospital. This project was undertaken as part of a lean green belt initiative supported by Patients First (a major transformation programme established in May 2008 to use tools such as lean and Six Sigma to deliver improved patient care). At the time of the project, one of the authors (S. Smith) was working in the Adult Social Care team at Surrey County Council, Kingston Upon Thames, UK.

Notes

1 The Health Needs Assessment (HNA) is a document produced to summarise a patient’s health care needs at a point in time. This pulls together inputs from several different practitioners and has been used by local government as a first step in determining the source of funding for a patient’s continuing healthcare.

2 When talking about patients with complex needs, practitioners often use the term medically stable to refer to those complex needs patients who no longer need to be kept in hospital on medical grounds. This may mean that they have returned to a baseline of health following an acute illness or injury, or that whilst they are still recovering they do not need to be in a hospital environment. It may also include palliative patients for whom hospital treatments will no longer be effective.