Getting into the Flow:
Operational Efficiency in ED

Authors: Adam Dalby / Editor: Jasmine Medhora / Codes:  / Published: 10/01/2023

This blog is based on an Executive MBA dissertation, submitted in January 2022 to the University of Hull.

Improved flow is the current golden bullet, the saviour of ED, in the NHS – the key to unlocking the issues with the health service in its current state of crisis. But how is flow achieved? Are there other aspects of care delivery, based on systems thinking methodologies that can provide further insights into improving the quality, safety, and experience of care for NHS patients? This blog aims to define operational effectiveness in ED, the aspects of management that impact on it, and what can be done to enhance care on a national, regional, and local basis following the application of such an approach to an NHS District General Hospital.

Operational Effectiveness

Operational effectiveness is defined in vague terms and is concerned with the delivery of safe and effective care, of an acceptable quality, in an appropriate environment. The mantra of right care, right place, right time, is at the heart of operational effectiveness.

Operational effectiveness, for the purposes of this blog, is impacted upon by three key elements: effectiveness of triage, generic operational factors (e.g., flow times), and the nature of staffing in ED. These are defined in Figure 1.

Fig.1: Factors Impacting on Operational Effectiveness in Emergency Departments

Improvement of the factors outlined in Figure 1 has traditionally been undertaken through the utilisation and adoption of traditional operations management. Such methods, however, rooted in Taylorism (so-called scientific management), are often inappropriate as they are transcribed, without modification, from a manufacturing-based industry to a service-based industry. We are not creating widgets; were providing care. Scientific approaches to healthcare improvement have failed, and to misquote Einstein, we cannot continue to use the approaches which have failed in the past and expect different results.

Systems Thinking in Healthcare

Healthcare in the UK is delivered within a complex system, and so the adoption of systems-thinking methodologies particularly the Vanguard Method (Figure 2) is appropriate to consider the wider context in which healthcare is delivered. The Vanguard Method isderived from the same seminal research as the IHI Model for Improvement used in quality improvement work within healthcare, and systems-based approaches are already utilised in the sector. Looking beyond the ED itself with such an approach, provides a much broader perspective on potential areas for change limited only by imagination and the influence of the individuals attempting to improve care processes and outcomes.

Fig.2: The Vanguard Method of Systems-Based Change

The Vanguard Method takes a much wider perspective than traditional operational management. It looks at how to move the system from what it is currently achieving (which isnt necessarily what it was originally intended to achieve) to focus on what the system should be achieving to meet the needs of patients. The stepwise process provides a framework for improvement in many service-based industries but is a particularly powerful tool for use in healthcare due to the integrated nature of healthcare delivery and the complexity of the system.

Application in the NHS

When the methodology was applied to an NHS Emergency Department in a District General Hospital, thirteen processes were analysed (Figure 3), within which thirteen value-adding tasks were identified along with thirty-two tasks classified as waste-work within those processes.

The system was found to work to achieve timeliness of care over and above everything else as its current purpose, regardless of the relevance of such a metric to the patient and their care. Legislative boundaries were recognised as key elements within the system conditions, with management considering the political reputation of the organisation in terms of the timeliness of care above all else.

Fig.3: Processes Identified in the Application of The Vanguard Method to an ED in a DGH

Patient-centred, safe, and effective care was defined as what the system should be achieving, and recommendations in Plan were developed in line with achieving this purpose. Recommended improvements were divided into local, regional, and national changes.

Local changes involved transferring work which did not add value out of the ED or eliminating such work from processes where possible. Other improvements included managing the expectations of patients, clarifying protocols for the movement of patients to alternative services within and outside of the hospital, utilising senior clinicians earlier in the patient journey, and consideration of flow through an assessment of ward occupancy for different specialties and increasing the efficiency of the utilisation of bed space. On a regional level, Integrated Care Systems may provide opportunities to introduce surplus capacity to provide for system adaptability during times of excess demand, as well as improve the integration of social and healthcare within the two separate systems. Nationally, incentivisation of collaborative working throughout the system (intra-system) and between systems i.e. social care ( inter-system) is an area of interest for improving the delivery of care.

A New Approach?

Whilst not a perfect approach, the utilisation of systems thinking is a key tool in managing the increasingly complex system of healthcare delivery in the UK. Such an approach lends itself to the adoption of appropriate changes to a specific service-based setting, such as healthcare. Considering the bigger picture of the system provides the facilities for wider change which, whilst more challenging to implement, provide the biggest potential for achieving long-term improvements in the delivery of care. Given the increasing demand, demographic change, and increasing complexity of care delivery it is time that systems-thinking was applied on a greater scale, and replaced the use of traditional, manufacturing-orientated methodologies, which consistently fail to deliver, yet continue to be adopted.

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