Kreindler Sara A
Department of Community Health Sciences and Health Systems Performance Platform, George & Fay Yee Centre for Healthcare Innovation, University of Manitoba, 451-753 McDermot Ave, Winnipeg, MB, R3E 0T6, Canada.
BMC Health Serv Res. 2017 Jul 12;17(1):481. doi: 10.1186/s12913-017-2416-8.
Health systems in many jurisdictions struggle to reduce Emergency Department congestion and improve patient flow across the continuum of care. Flow is often described as a systemic issue requiring a "system approach"; however, the implications of this idea remain poorly understood. Focusing on a Canadian regional health system whose flow problems have been particularly intractable, this study sought to determine what system-level flaws impede healthcare organizations from improving flow.
This study drew primarily on qualitative data from in-depth interviews with 62 senior, middle and departmental managers representing the Region, its programs and sites; quantitative analysis of key flow indicators (1999-2012) and review of ~700 documents furnished important context. Examination of the interview data revealed that the most striking feature of the dataset was contradiction; accordingly, a technique of dialectical analysis was developed to examine observed contradictions at successively deeper levels.
Analysis uncovered three paradoxes: "Many Small Successes and One Big Failure" (initiatives improve parts of the system but fail to fix underlying system constraints); "Your Innovation Is My Aggravation" (local innovation clashes with regional integration); and most critically, "Your Order Is My Chaos" (rules that improve service organization for my patients create obstacles for yours). This last emerges when some entities (sites/hospitals) define their patients in terms of their location in the system, while others (regional programs) define them in terms of their needs/characteristics. As accountability for improving flow was distributed among groups that thus variously defined their patients, local efforts achieved little for the overall system, and often clashed with each other. These paradoxes are indicative of a fundamental antagonism between the system's parts and the whole.
An accretion of flow initiatives in all parts of the system will never add up to a system approach, and may indeed perpetuate the paradoxes. What is needed is a coherent strategy of defining patient populations by needs, analyzing their entire trajectories of care, and developing consistent processes to better meet those needs.
许多辖区的卫生系统都在努力减少急诊科拥堵，并改善整个连续护理过程中的患者流程。流程通常被描述为一个需要“系统方法”的系统性问题；然而，这一观点的影响仍未得到充分理解。本研究聚焦于一个加拿大地区卫生系统，其流程问题尤为棘手，旨在确定哪些系统层面的缺陷阻碍了医疗机构改善流程。
本研究主要利用对代表该地区、其项目和场所的62名高级、中级和部门经理进行深入访谈所获得的定性数据；对关键流程指标（1999 - 2012年）的定量分析以及对约700份文件的审查提供了重要背景信息。对访谈数据的分析表明，数据集中最显著的特征是矛盾；因此，开发了一种辩证分析技术，以在更深层次上审视观察到的矛盾。
分析发现了三个悖论：“诸多小成功与一个大失败”（举措改善了系统的部分，但未能解决潜在的系统约束）；“你的创新是我的困扰”（局部创新与区域整合相冲突）；最关键的是，“你的秩序是我的混乱”（改善我的患者服务组织的规则给你的患者造成了障碍）。当一些实体（场所/医院）根据其在系统中的位置定义患者，而其他实体（区域项目）根据其需求/特征定义患者时，就会出现最后一个悖论。由于改善流程的责任在以不同方式定义患者的群体之间分配，地方层面的努力对整个系统收效甚微，且常常相互冲突。这些悖论表明系统的部分与整体之间存在根本的对立。
系统各部分的流程举措的累加永远无法构成一种系统方法，实际上可能会使这些悖论长期存在。需要的是一种连贯的策略，即根据需求定义患者群体，分析他们的整个护理轨迹，并制定一致的流程以更好地满足这些需求。
