
Lisa Mueller
Associate Advisor
In January 2023, one in every seven NHS inpatient hospital beds was occupied by patients medically fit for discharge.¹ Delays in discharging patients not only impacts the availability of hospital beds for admitting new patients to the hospital, but patients whose discharge is delayed are also at higher risk of hospital-acquired infections and of losing independence.²
Discharging patients from a hospital is a complex process. It’s the product of collaboration between multiple interconnected actors and actions that are embedded within the organisational structure and culture within the NHS. The complexity of this system makes it challenging to improve the patient discharging process with a single nudge. Therefore, we decided to take a systems approach when we worked with the Homerton University Hospital NHS Foundation Trust to improve the efficiency of their discharge process. The systems approach – as outlined in BIT’s manifesto – is a way of examining an organisational culture challenge as a whole. Looking at the whole system allows us to identify more opportunities for change and understand the collective implications of heuristics – mental shortcuts that help people make quick, efficient decisions or solve problems. It also enables us to adjust specific features of the system to create wider changes and understand the longer-term impact of various policies on a system.
At Homerton Hospital, 80% of A&E patients are seen within four hours – more than the 70% average in England. However, like other NHS Trusts across the country, Homerton Hospital faces delays in hospital discharges which are caused by a multitude of factors. BIT was brought in to indentify the underlying human factors and biases contributing to delayed discharges, develop behaviourally informed solutions to address them, and address the wider implications of these solutions. Our work with Homerton Hospital initially focused on one ward with the option of scaling the intervention across the hospital at a later date.
In order to understand the patient discharge process on the ward, we observed handovers between shifts and different hospital staff, interviewed a wide range of stakeholders (e.g. nurses, junior and senior clinical staff), analysed hospital discharge data and ran workshops to map out the key tasks involved in the patient discharge process and how different parts of the system interact with each other.
To begin with, we needed to understand the different system actors involved in the discharge process (e.g. nurses, junior and senior medical staff), the steps in the discharge process and key bottleneck events (i.e. events that must take place before another event can happen). In order to do this we mapped out the discharge process and compared the ‘work as imagined’ vs the ‘work as done’ (theory vs practice).
Figure 1: Simplified discharge system process map highlighting key bottleneck events in red.
Whilst the process map gave us valuable insights into how the discharge process at the Homerton ward works, at this point, it wasn’t yet clear how the interactions between different groups of staff and their environment contributed to discharge efficiency.
This is why we created a behavioural systems map. The map highlights the relationships between the different actors, their interconnected behaviours, beliefs, and certain events within the system, which together form the system’s culture.
Figure 3: The simplified behavioural systems map outlining the key themes identified.
The map helped us to identify leverage points where small changes are likely to have a broader impact across the system. We categorised the leverage points based on whether they address events (e.g. low staffing), structures (e.g. perceived hierarchies within the team), systems goals (e.g. ensuring timely discharge) or paradigms (e.g. de-prioritising discharge-related tasks over clinical tasks). The key leverage points we found with the greatest influence across the discharge process were:
The behavioural systems map also allowed us to understand the wider impact of our proposed interventions. For instance, if a nurse gives feedback about a delayed discharge to the medical team, the map allows us to hypothesise how this might impact the other staff and the wider discharge process. The map also helps us identify why the nurse might not be giving regular feedback to the medical team and what needs to change in the system to allow them to follow a new protocol.
Given the complexity of the discharge process, we suggested a multi-modal intervention for the Homerton ward. Here are some examples of our recommendations that address the leverage points we identified:
Our proposed solutions are now being implemented as part of a hospital-wide action plan. The behavioural systems map acted as an additional output for Homerton Hospital which can be used as a basis for further interventions.
It can be challenging to make a difference in a complex system like a hospital discharge process. Multiple stakeholders with differing priorities and communication barriers can make coordination difficult. Hospitals operate within a network of interconnected systems (e.g. IT systems, patient management systems, external care services), and changes in one part of the system can have unforeseen impacts on others. There might also be cultural resistance towards change, for instance, because staff have established routines and a preference for the status quo. On top of that, compliance requirements and financial constraints might limit the extent of changes that can be made.
Behavioural systems mapping is a valuable tool to get an insight into these complex connected factors, identify opportunities for change and understand their wider implications on the system. But it is not a stand-alone solution for complex issues. At BIT, we embed behavioural systems mapping and systems thinking into our wider approach of evidence-based research and evaluation methods. This helps us set the right foundations for using systems mapping and draw meaningful conclusions from the rich information they provide.
If you are facing a behavioural challenge in your organisation and would like support with understanding the wider system it is embedded in, and to develop solutions with greater impact, get in touch.
³‘Deshrouding’ in a healthcare setting means making discharge process performance data accessible to all teams involved.
Associate Advisor
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Principal Policy Advisor