Back in the manufacturing world, the distinction between “push” and “pull” is often much more obvious than it is in healthcare. Push production occurs when products are built based on the forecast were something other than actual customer needs. In the Lean approach, pull systems are the ideal to prevent overproduction, to reduce inventory costs, and to make sure the customer gets what they need when they need.
In healthcare, pull systems can be very effective for the replenishment of supplies and medications. But the conversation often gets muddled when we are talking about patients. It “pull” or “push” better for patient flow? Is that even the right question?
I was recently at a conference where a team presented about emergency patient flow (or the lack thereof) at their hospital. They described the old condition as one where the ED “pushed” admitted patients to the floor, making a call to say “hey, we need a bed.” The problem was that the inpatient unit was often not ready to take the patient or they didn't have the space available – so the patient wasn't moved.
This describes poor patient flow, not having the resources available or not being able to move the patient when it's medically necessary. This handoff of patients from emergency to the inpatient unit needs to be a two way agreement. I agree it would be bad to push a patient to a floor if they are going to just sit in the hallway without the proper service or medical attention.
In the presentation, they talked about moving to a pull system that “has roots in the lean thinking methodology and is far more effective than a push system.”
They described a pull system as one where the inpatient floor triggered the movement of a patient's by informing emergency department that they are ready to receive a patient.
If the patient is waiting until the unit is ready, is that really improving patient flow? Is it just an academic quibble to call that a pull instead of a push? Is it really “far more effective” to wait until the unit “pulls” the patient? Either way, in the push or pull approaches, it seems like the patient didn't move until the inpatient unit was ready – so what's the difference then?? It might be less frustrating to the inpatient unit team, but is that really the primary goal?
I'd argue that the true “pull” that's necessary is a patient “pulling” upon the resources that are needed and having those resources made available or delivered immediately based on that demand. If a patient needs a room, that patient should, in effect, “pull” the room. The language around this is a bit silly because were not physically pulling the room to the patient, we are moving the patient up to the room.
So again, who cares about push or pull? Are rooms available when they are needed, for the sake of the patient and for the sake of the emergency department not getting overcrowded? Do we have the right capacity available, when and where it's needed? I think those are the right questions to be asking so we can actually improve patient flow.
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