Planning without action and action without planning? Examining a regional health system's efforts to improve patient flow, 1998–2013

Abstract

Most health care organizations engage in formal and informal planning, yet their improvement initiatives may remain disjointed and reactive. Research on organizational decision-making has found that the "discovery" approach (seek and assess multiple options before selecting one) outperforms "idea imposition" (identify 1 option, then gather information to [dis]confirm it), yet is observed relatively infrequently. Might this imply that discovery frequently collapses before fruition? This qualitative study sought to better understand the planning-action disjunction, as observed in 1 organization, by comparing its planning processes against the discovery approach. It focused on a Canadian regional health system's recurrent, unsuccessful attempts to improve patient flow. Through extensive document review supplemented by interviews with 62 managers, it identified all relevant regional plans/reports produced during a 15-year period and followed each recommendation forward in time to discover its fate. Each report presented a lengthy, unprioritized list of disparate recommendations, few of which progressed to full implementation. It appeared that decision-makers repeatedly embarked on a discovery approach, but rapidly allowed it to splinter into multiple idea-imposition approaches; numerous options were generated, but never evaluated against each other. Thus, the product of each planning process was not a coherent strategy but a list of disconnected actions.

Despite Interventions, Emergency Flow Stagnates in Urban Western Canada

“…Calgary Zone participants reported that this approach initially yielded significant improvements in ED flow, but effects deteriorated after two to three years because such pressure could not be maintained indefinitely (Kreindler et al 2020). The most common regional strategy has centred on encouraging local players to develop their own initiatives, whether through Lean or ad hoc methods (Kinsman et al 2014;Kreindler 2018). As noted, such an approach succeeded in the two geographies of AHS South Zone, but other regions' attempts (which have, of course, varied widely in content and context) have not shown similar results.…”

The stipulation‐stimulation spiral: A model of system change

“…Study 2 chronicled a Canadian regional health system's strenuous, unsuccessful efforts to reduce emergency department wait times and improve patient flow. (Research methods, which included review of approximately 700 documents; in‐depth interviews with 62 senior, middle, and departmental managers; and quantitative analysis of flow indicators, have been described elsewhere …”

“…(Research methods, which included review of approximately 700 documents; in-depth interviews with 62 senior, middle, and departmental managers; and quantitative analysis of flow indicators, have been described elsewhere. 53 ) Initially, leaders sought to gain greater control over system outcomes (need for precision) by promoting pan-regional consistency, which curtailed hospitals' freedom to innovate (weakening stim). (It should be noted that the region's strategy did not include high-precision stip strategies, such as redesign of services based on rigorous analysis of the flow problem, or introduction of powerful mechanisms to hold hospitals accountable for performance.)…”

“…Two studies in which attempts at large-system change produced disappointing or mixed results were conducted as part of the development of these concepts; their findings have previously been reported without reference to stip and stim [51][52][53] and are now interpreted through this new theoretical lens. The pattern that emerged from both was the inverse of the stip-stim spiral: When confronted with a need for precision or resonance, decision-makers responded not by strengthening the corresponding approach but by weakening its opposite.…”

When Coproduction Is Unproductive Comment on "Experience of Health Leadership in Partnering with University-Based Researchers in Canada: A Call to ‘Re-Imagine’ Research"

“…5 Tight decision-making timelines are sometimes characterized as a good reason why decision-makers cannot wait for research findings, although this characterization seems open to question: In one documented case, a health system made repeated, unsuccessful efforts, spanning more than a decade, to solve one particular problem; each effort was marked by a flurry of panicked activity and an insistence that there was no time for further information-gathering or deliberation. 6 On this note, there are many bad reasons – some mentioned in this article, others elsewhere. For example, decision-makers may request evidence on a decision so highly politicized, or under the control of individuals with such rigid opinions, that the “voice” of research is sure to be silenced.…”