Table 2 Derivation of the Three Paradoxes
From: The three paradoxes of patient flow: an explanatory case study
Paradox 1 (Many Small Successes and One Big Failure) | ||
Thesis | Antithesis | |
Codes | Many valuable initiatives | Initiatives have low overall impact |
Incremental progress | Lack of progress | |
Success stories | “Band-Aid solutions” | |
Focus on sphere of control | Problems are outside our control | |
No bad initiatives (“everything works”) | Inadequate analysis of problem | |
Need for system redesign | ||
Theme | Localized initiatives (= successes) | Localized initiatives (= failure) |
Advocated by | Leaders of localized initiatives | Emergency stakeholders |
Sites active in flow efforts | Sites less active in flow efforts | |
Regional managers with major responsibility for current flow effort | Some program leaders of flow efforts | |
Regional managers without major responsibility for current flow effort | ||
Points of Convergence, Anomalies | Proponents of the antithesis themselves drew attention to the conjunction of localized improvements and stagnant system performance. Both sides noted the difficulty of working as a system, describing power struggles, unclear accountabilities and lack of integration. | |
Axis of Conflict | Focus on system parts vs. whole. | |
Synthesis | Initiatives have improved parts of the system but missed the greatest system problems/constraints. | |
Paradox 2 (Your Innovation Is My Aggravation) | ||
Thesis | Antithesis | |
Codes | Region stifles innovation | Site “innovations” undermine or duplicate program strategies |
Regional/program change processes are slow, cumbersome | ||
Sites’ efforts are hasty, unsystematic | ||
Sites should be allowed to find different ways to destination | ||
Site initiatives contradict each other (different destinations) | ||
Pan-regional consistency less important than flexibility | ||
Pan-regional consistency essential for efficiency, equity | ||
Region/program wants to control | ||
Sites want to be unique/special | ||
Theme | Site-led innovation (desirable) | Site-led innovation (undesirable) |
Advocated by | Site stakeholders | Leaders of most programs |
Most regional managers | ||
Points of Convergence, Anomalies | Participants on both sides advocated the spread of best practices through tailoring to local context; however, any examples provided were typically not flow-related. When participants described desirable/acceptable flow-related practice, sites’ definitions were broader than programs’. | |
Axis of Conflict | Decentralization vs. centralization | |
Synthesis | If sites and regional programs shared clear, specific goals (not merely general aspirations), either could lead change. | |
Paradox 3 (Your Order Is My Chaos) | ||
Thesis | Antithesis | |
Codes | Somebody else’s rules are the problem (inpatient, community programs; nursing homes, etc.) | Our rules are essential for safety and efficiency (inpatient, community programs) |
Programs’ criteria too restrictive, lead to stateless patients | Programs know whom they can and should serve | |
“Off-servicing” is necessary | Off-servicing is detrimental | |
Caring for all patients, irrespective of characteristics | Designing services for a defined population | |
Service consolidation across sites harms patients | Service consolidation across sites benefits patients | |
Theme | Gates (should be weakened) | Gates (must be maintained) |
Advocated by | Site stakeholders | Leaders of most other programs |
Emergency stakeholders | ||
Points of Convergence, Anomalies | Participants on both sides recognized that “gates” facilitate programs’ organization of care. | |
Several site and Emergency stakeholders advocated the thesis in relation to other parts of the system, and the antithesis in relation to their own. In contrast, non-Emergency program stakeholders who argued for the antithesis did so consistently. | ||
Axis of Conflict | Defining patients by location vs. by characteristics/needs | |
Synthesis | The phenomenon of stateless patients reflects haphazard system design. A well-designed system features appropriate (gated) services to meet the needs of each patient population. | |