HLTH 4100 Week 2 Open Systems Analysis Paper Example

The Emergency Admission Process as an Open System: Inputs, Throughputs, Outputs, Feedback and the Boundary Where the Hospital Stops Controlling the Flow

Student Name

Walden University

HLTH 4100: Healthcare Organization Theory and Behavior

Instructor Name

Month Day, Year

The Emergency Admission Process as an Open System: Inputs, Throughputs, Outputs, Feedback and the Boundary Where the Hospital Stops Controlling the Flow

Why an Open Systems View

In open systems theory, an organization draws resources from outside, converts them through connected internal parts, sends results back out and corrects itself using what it learns from those results (Katz & Kahn, 1978). The language is easy to recite: inputs, throughputs, outputs, feedback, boundary. It is harder to apply to a real service in a way that explains anything. This paper applies it to one process at the 240-bed community hospital where I work in the quality department: the movement of a patient from the decision to admit in the emergency department to arrival in an inpatient bed. At our hospital, that process takes a median of about five hours, more than twice as long as at a similar hospital in our system. The aim is to see whether the systems view explains the delay better than the usual complaint that there are not enough beds.

Inputs

The process has four main inputs. The first is patients: on an average weekday, about 38 emergency department patients are admitted, arriving unevenly, with a peak between 2:00 and 8:00 p.m. The second is beds: about 225 staffed inpatient beds, of which, on a typical afternoon, fewer than ten are empty and clean. The third is staff: nurses on each unit, the hospitalist physicians who accept admissions, transport aides and environmental services staff who clean rooms. The fourth is information: the admission order, the bed request, the patient's condition and the unit's current workload. Inputs from the environment that the hospital does not control include the number of patients arriving at the emergency department and the number of patients other facilities are willing to accept on discharge.

Throughputs

The throughput is the series of steps that turn an admission decision into a patient in a bed. Six steps were traced from the record and from interviews: the emergency physician decides to admit; a hospitalist accepts and writes orders; the emergency department enters a bed request; a unit charge nurse decides whether and when to accept the patient; environmental services cleans the room if needed; and transport moves the patient. At our hospital, the longest step is the fourth. The charge nurse's acceptance, which involves a phone call between the emergency department nurse and the unit, took a median of 95 minutes in a sample of 40 admissions last month, longer than all the other steps combined except waiting for a clean room.

Outputs

The intended output is an admitted patient in an appropriate bed, with treatment continuing without interruption. Unintended outputs include patients boarding in the emergency department for hours, emergency department rooms unavailable for new arrivals, ambulance diversion on the busiest evenings and frustration among staff in both departments. Research on emergency department crowding has linked boarding to delays in care and worse patient experience, and has identified inpatient capacity and hospital flow, not emergency department processes alone, as the main drivers (Asplin et al., 2003).

Feedback

Feedback is how the system learns from its outputs. At our hospital, feedback on the admission process is weak in two ways. First, the emergency department tracks boarding time, but the inpatient units do not see it; their own dashboards show discharges and length of stay, not how long admitted patients waited downstairs. Second, feedback is delayed. Boarding times are reported monthly in a quality committee meeting that charge nurses do not attend. The units that control the bottleneck therefore receive no direct feedback about it. In open systems terms, the loop that should connect outputs to the part of the system that could change them is broken.

How the System Responds to Pressure

Open systems tend to respond to pressure in ways that protect their core work. On the busiest evenings, the inpatient units protect their core, safe care for current patients, by slowing acceptance of new ones. The emergency department, under the same pressure, protects its core, treating new arrivals, by boarding admitted patients in hallways and asking for ambulance diversion. Each response is rational for the part of the system that makes it. Together, they move the pressure onto patients who have already been admitted but have nowhere to go.

A systems view also predicts what happens when one part improves alone. When our emergency department shortened its own treatment times last year, boarding grew, because patients reached the admission decision faster and then waited longer for beds. Improving one part of a system without changing the connection between parts can make the whole perform worse.

The Boundary

Every system has a boundary where its control ends. For the admission process, the boundary is not the hospital's outer wall but the line between the emergency department and the inpatient units. Each side optimizes for what it controls: the emergency department for moving patients out, the inpatient units for managing their current patients safely. Nobody owns the handoff between them. A second boundary sits at discharge: the hospital cannot control how quickly nursing homes and rehabilitation facilities accept patients, which affects how many beds open each day. The systems view makes clear that the first boundary is internal and could be redrawn, while the second is external and must be managed through relationships.

What the Systems View Adds

The common explanation, not enough beds, focuses on a single input. The systems view shows that inputs are similar to the comparison hospital's, and that the difference lies in the throughput, the charge nurse acceptance step, and in feedback, the units never see boarding times. It suggests two changes that a bed-shortage explanation would never suggest: give inpatient units direct, daily feedback on how long their admitted patients waited, and redraw the internal boundary by giving one role authority over the handoff, as the comparison hospital does with its bed manager. Organization theory describes open systems as able to adapt when feedback reaches the parts that can act on it (Scott & Davis, 2007). At our hospital, the problem is that the parts that can act are the ones that never hear.

References

Asplin, B. R., Magid, D. J., Rhodes, K. V., Solberg, L. I., Lurie, N., & Camargo, C. A., Jr. (2003). A conceptual model of emergency department crowding. Annals of Emergency Medicine, 42(2), 173-180. https://doi.org/10.1067/mem.2003.302

Katz, D., & Kahn, R. L. (1978). The social psychology of organizations (2nd ed.). Wiley.

Scott, W. R., & Davis, G. F. (2007). Organizations and organizing: Rational, natural, and open system perspectives. Pearson Prentice Hall.