" Six ways not to improve patient flow" from a research article & a seventh one from me &

The research article from BMJ "Six ways not to improve patient flow: a qualitative study" by Dr Sara Adi Kreindler, sets out the unintended consequences of practices that we see often in initiatives to improve the flow of patients out of hospital: https://qualitysafety.bmj.com/content/26/5/388.

The "six ways" are:

1. ‘Just add another form’ (neither population, capacity, nor process)

2. Improve efficiency—in the wrong part of the process (process without capacity)

3. Create a ‘parking lot’ (process with capacity that does not match the duration of population needs)

4. Design services for a poorly defined population (capacity without population)

5. Add capacity that is poorly targeted to its intended population (capacity without process)

6. When the bottleneck moves, do not follow it (population, capacity and process must be defined anew)

I would add another one:

7. Build capacity without agency: Very often, we train people in flow improvement techniques and redesign processes but what we don't do is support them to build their agency - the sense that they have the power and the permission to take action to improve things in their own services. Over the years, I have seen that lack of agency is a far bigger issue when it comes to failure of change, than lack of methodological skills or lack of resources for change. An example from the NHS trusts who took part in the Virginia Mason/NHS partnership is the Andon Cord. This is based on a principle from Toyota Production Systems where If someone on the production line (or in the patient process) finds a fault, defect, malfunction, shortage, tool issue, or safety problem, they pull the cord and stop the process. People have the power to stop things and put them right before they become big problems. Often when we as leaders focus in on a particular problem, like patient discharge, we end up micromanaging and we unintentionally take people's  agency away when we need them to use it most. more on the Andon Cord: https://psychsafety.co.uk/psychological-safety-79-the-andon-cord/