Problem-Solving: The first step to better patient flow

By Spencer Humphrys, Managing Director - Nexus Consulting

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Good problem-solving skills are the key to leading and delivering safer, faster, and better care.

In healthcare, there is always a lot of discussion and focus on 'best practice' processes. Spreading best practices has undoubtedly improved care; just look at the improvements in stroke outcomes and the reduction in central line infections. However, in other areas, it has made things worse. The pressure to deliver change at pace often leads people to seek easy wins, which usually involves trying to 'lift and shift' the newest best practice process being discussed.

But it's not the process that should be copied, but rather the principles behind why the process works, and importantly, the specific problem being addressed and the local circumstances in which it had to work.

The usual challenge

It's 08:00 on a Monday morning. You walk to the hospital entrance and see four ambulances parked outside the hospital. The emergency department is already full, with most treatment spaces taken by patients waiting for a bed on a ward, and the waiting room is filled with anxious and upset people who have spent hours waiting to be seen. The picture on the wards is no different. Every bed and every escalation space are full. By 10:00, the wards have only identified a handful of patients who might be able to go home today. There's no update on community capacity, the emergency department is unsafe, and the most senior medic for the night has just called in sick. 

There's no doubt everyone is working hard, but the system is stuck. Patients are waiting too long, staff are frustrated and burned out, the pressure is mounting, and patient safety is suffering. 

So, what do you do?

The usual organisational response is to try to solve these problems by going a mile wide and an inch deep and hoping something works. Do programme boards, workstreams, tens of related projects, and lots of 'good ideas' from the highest-paid person sound familiar? 

But if we ran a survey, I'd bet that most would say the previous actions never actually solved the real problem or made things significantly better. Maybe there isn't an answer? I disagree with that. There is an answer to every problem; we just need to find it.

The real problem is that people don't work on the actual problem

It's rare to find an organisation that has taken the time to truly investigate and understand the actual problem that needs to be solved. This is always easy to spot because if there are more than two or three priorities, the real root cause is unlikely to have been found.

In every process, no matter how big, complicated, or complex, there is always a single biggest problem. This is the Theory of Constraints (ToC) mindset. Most people have heard of the ToC, although you may have heard of it phrased differently. A team is only as good as its weakest player; a chain is only as strong as its weakest link, etc. It's all the same. There's always one key problem, but it's rarely the easy issue or the problem people want to address.

Taking time to understand the core of the problem is always time well spent and is the cornerstone of our consulting and problem-solving approach.

A quote often attributed to Einstein is about what he would do if he had an hour to solve a problem that his life depended on. His answer?

"I would spend 55 minutes understanding the problem, then take 5 minutes to solve it". 

A real-life example: Basingstoke A&E performance

Like most organisations, Basingstoke have brilliant people working hard to make things better for patients. And just like most places, these great people are frustrated with buildings that need replacing, staff challenges and shortages, increasing patient demand, a massive urgent care change programme, and performance that wasn't shifting. 

We spent six weeks working with the team to get to the root causes of their challenges. That's right, six weeks of pure focus. We looked at millions of data items and spent over 100 hours observing people and processes in the A&E.

The project results? 

• The Urgent Care Programme scope reduced by 86%

• Patient time in the department is down 14% and performance is up 12%

Basingstoke A&E all type weekly four-hour performance

Six weeks is a long time, and most people don't have that luxury. But taking as much time as possible at the start is invaluable, and I promise it will save you hundreds of hours of wasted effort down the line. 

Our problem-solving framework

There are numerous problem-solving and improvement approaches. Like most effective improvement teams, we use various models in our approach. But in general, we combine the Lean Six Sigma DMAIC approach with the Theory of Constraints. Here's how:

1. D: Define the problem

   1. Speak to as many people as possible, in a structured way, to understand what the big (most common) problem is, and how people describe it. Tip: They will usually explain the symptoms, not the problem itself. And even this will be shaped by their internal biases. But it will give you some insight. Pull the themes of what people are saying into a single sentence problem statement (which you will refine and change as you go, e.g. "How can we improve X?")

   2. Using a straightforward process, such as the five-whys (here's an explainer if you need it: How To Perform A 5 Whys Analysis: Step-by-Step Guide) is helpful at this point. It can help you move from symptom to problem and also deepen your understanding of the issue that people want you to solve. 

2. M: Measure the problem

   1. Now you have an idea of what the actual problem is, you need to measure it. And whatever you think or feel, everything is measurable. If you have data available, use it. When you find gaps, poor-quality data, or even a complete lack of data, don't just pull more data extracts or send out questionnaires. Go to where the work happens, where the problem is visible, and spend time observing, measuring, and speaking directly with the people affected to understand the issue in detail.

   2. At this point, go back and bulk up your problem statement with some data. Turn the question from a narrative ("How can we improve X?") to a quantified problem ("X is currently taking Y, how can we improve this by Z%?").

3. A: Analyse

   1. By now, you will have a problem statement and some information. But what does the data show you? Are there patterns? Is it different depending on the day of the week or time of the day? Is the problem consistent? Have you found any new issues that mean you need to revise your problem statement? If so, do you need to revisit and measure the issue again? Then update your problem statement again to make it even more precise and actionable (e.g. "X is currently taking three times as long on Monday, how can we improve this by Z% to match the average of the rest of the week?")

4. T: Test

   1. This is a crucial step in problem-solving, and one that is often overlooked. Even after you've done all your work, written a brilliant problem statement, and measured and analysed the problem, at this stage, it's still just a (well-informed) guess. What works in theory rarely works the same in practice. So go and test your ideas. Part of problem-solving is getting real-world feedback to understand how the problem responds. Tip: You'll learn more from this stage than you think you will; do it poorly or too quickly at your peril. When you run your tests, use a simple method such as the Plan, Do, Check, Act (PDCA or PDSA in some places) to help you test more quickly and learn more effectively. This learning may send you all the way back to step 2 ('Measure'). If it does, that's a win. It's not a failure. You've learnt more about the problem. Because at the end of the day, problem-solving is all about learning. 

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I hope you've found this blog interesting and valuable. Problem-solving is a skill, and it's hard. You need to practise it as much as you can and practise it with conscious attention. What didn't work? What did you learn about yourself? What assumptions did you make that tripped you up, or made things more complicated for you? Taking the time to consider these questions will help you become a more effective learner and problem solver in the future. 

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If you're struggling with patient flow or performance improvement, or you'd like to learn more about what we helped Basingstoke achieve, please get in touch with us using the button below for a no-pressure discussion.

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