Published: 10/04/2003, Volume II3, No. 5850 Page 22 23

We would like to endorse and expand on the story 'Delays blamed on varied flows' (news, pages 10-11, 20 March).

The Institute for Healthcare Improvement, based in Boston, Massachusetts, is behind a number of initiatives, including 'Improving flow through acute care settings' - part of the Impact collaborative network (www. ihi. org).

Some of the fundamental principles of improving flow and ensuring 'every patient [has] timely access to appropriate care and [moves] efficiently through the system without unnecessary and unproductive delays' include not only variability but also batching, as alluded to in the example of x-ray reporting.

Where batching occurs throughout the hospital environment, there are inherent practices such as:

Ward rounds twice a week, ensuring that discharges only occur on these two days.

Pharmacy delivers take-home medicine to the wards twice a day, ensuring that discharges only occur after these two times.

Examples of a number of operating lists occurring at the same time, each with a patient requiring a bed in the intensive care unit post operatively, resulting in postponements, even though the elective demands on ICU for the rest of the week are much less.

The challenge is first to recognise the problem then to trial solutions to overcome them. IHI promotes the 'plan, do, study, act'approach.

Another feature of IHI philosophy is the concept of 'pull through' whereby downstream events are recognised and linked to an upstream one.

An example is linking the discharge of one patient to the admission of another by informing the admitting teams of the planned times of discharge from the wards.

A hospital developing a predictive capability - so enabling it to manage variability and resource allocation at the front line - has the potential to improve patient outcomes, increase staff morale and retention, reduce costs and improve quality of life for patients and care givers.

Our work with flow to date, albeit a short lived experience since mid-January, has shown that understanding flow is the key to achieving more.

Impact flow team East Lancashire health and social care community