Operational versus strategic

Patient A versus patients like Patient A

It often feels as if we only ever address patient flow at an operational level. Our focus is on the hospital front door. Our attention is devoted to moving individual patients more quickly. Our actions are intended to speed up—rather than change—existing processes.

But patient flow can only really be fixed if it is addressed at the strategic level. Less emphasis on what we do about Patient A and more emphasis on how we change the processes in place for dealing with all of the patients like Patient A.

A lot of operational activity that takes place in relation to patient flow is rightly focused on individual patients' lengths of stay. For example, some patients who are already earmarked for discharge later today can—through operational intervention—get discharged three or four hours earlier than they would've. Patients who are scheduled to go home tomorrow might be able to get home today instead. These operational interventions are all good and necessary but it can all be a bit too ad hoc and usually there's not enough of such operational activity to make a serious impact on patient flow.

If length of stay is to be tackled so that it has a tangible, permanent and ongoing impact on patient flow, then teams of clinicians—and individual clinicians within those teams—need to look more strategically at why their average length of stay is what it currently is, and what it ought to be, and what actions can be taken to reduce it from the 'what is' level to the 'what ought to be' level.

The teams of clinicians we are talking about here are teams that are usually 'distant' from the hospital front door (where the patient flow problem manifests itself most 'visibly') so if one definition of 'strategic' is that it's to do with things that are 'not immediately visible' (whereas operational things are), then this makes the issue strategic. Also, it's a 'chain reaction' thing, so there has to be an understanding of what the ought-to-be numbers are and how those ought-to-be numbers will impact on the staging posts upstream. This kind of knowledge also belongs in the box labelled 'strategic'.

The trouble is, we keep on addressing patient flow as if it were an operational problem. It's as if—day after day—we're making a category error. Somehow we need to persuade NHS managers out of their operational mindsets and into strategic mindsets. This is not going to be easy. But we'll only achieve it if we can find ways of demonstrating that what appear at first sight to be operational problems are actually strategic problems that require data-driven solutions.

[23 December 2022]

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