Participant demographics
Out of the 48 participants invited, 17 did not respond after three reminders, and eight dropped out due to workload issues and scheduling conflicts, resulting in 23 final participants. We conducted four focus groups: three with HCWs and one with patients (Table 2). Despite diverse staff representations, participants consistently highlighted similar concerns, indicating data richness and adequate sample size. Among the participants, 52.2% (12/23) were male, and 47.8% (11/23) were female. Most HCWs (53%) were aged 30–45 years, and most patients (60%) were aged ≥ 45 years. Among HCWs, 70.6% had bachelor’s or master’s degrees, and 76.5% had clinical backgrounds. The most common job duration was 5–10 years (35.3%). Most patients (67%) had a bachelor’s degree.
Main categories and subcategories of patient flow focus group discussions
The process of open coding produced 378 coded extracts. The analysis revealed three main categories and several subcategories (Table 3).
Patient flow dynamics and scope
Participants confirmed the importance of patient flow and highlighted persistent challenges. The scope of patient flow was viewed broadly, encompassing all aspects of care from home to hospital and back to the community. Patient satisfaction varied, and while interventions showed potential, challenges persisted (Table 1, Supplementary Material 3).
“… So to me, patient flow is the movement of our patients into and out of our facilities and our healthcare service in general …” (F2P8)
“We actually are gradually drifting down on the standards that we are prepared to accept, and we’re doing it for the right reasons, but we’re not acknowledging the impact this has on people, and the care we wanna give versus the care we’re allowed to give in the system we have.” (F1P2)
Patient flow challenges
The challenges in the population (patients and providers) category included community-based care obstacles, staffing issues, and inequities in accessing quality care (Table 2, Supplementary Material 3).
Challenges of population (patients and providers)
The population (patients and providers) challenges included the subcategories “community-based care,” “staffing,” and “inequities in access to high-quality care services” (Table 2).
Challenges of community-based care
The participants highlighted challenges in community-based care (Table 3, Supplementary Material 3), including peak demand during weekends and winter, inappropriate emergency service use due to low health literacy, and discharge delays in regional areas due to limited social services, blocking emergency department beds.
“So we need, so there’s so much criteria on discharge that sometimes we keep them in just another day, cause we can’t access a physio, we can’t access, you know, a dietitian… holds up a bed day for us, and as a consequence, we have they’re blocked down in the ED.” (F3P16)
Virtual assessments were ineffective, and financial barriers limited access to home care, leading to ED overuse. Vulnerable individuals faced care coordination challenges, including hospitals not returning permanent residents to aged care facilities.
“Hospitals not returning permanent residents back following an ED presentation even as a Public run RACF and there is limited pathways to Post-Acute Care Service (PACS)/ Hospital in the Home (HITH) or trust that the RACF staff can provide the care within the facility.” (F2P12)
Underdeveloped community paramedicine, inconsistent GP care, and limited bulk-billing options further strained the system. Elderly care access was also problematic, with patients often waiting for crises before receiving resources.
“I think people’s access to primary care GPs… it’s becoming to find bulk billing GP’s and so that part of the system then flows into the public system and creates greater pressure.” (C3)
“I think people’s access to primary care GPs, is, you know, like it’s becoming more difficult to find bulk billing GP’s and so that part of the system then flows into the public system and creates greater pressure.”
Challenges of staffing
Participants described staffing challenges in healthcare, including burnout, recruitment and retention issues, salary disparities, and inadequate support systems. Burnout is common due to the long hours and heavy patient loads. Salary gaps and recruitment struggles are particularly notable in remote areas. A declining interest in emergency medicine careers post-COVID-19 worsened the shortage of qualified professionals. Inadequate patient flow training compounds these challenges, as inadequate support systems fail to address frontline workers’ needs, diminishing patient care quality and overall system performance (Table 4, Supplementary Material 3).
“And particularly post COVID suddenly that fact where you went to work and you had a higher than zero chance of dying on a daily basis kind of made people go… And plus it’s become an increasingly stressful environment since then. So fewer people are going into training.” (F1P2)
“There’s no… it’s all just a bunch of people going to work trying to do the right thing, but the system itself not necessarily supporting them to do that … and that is to work those long hours and also maintain a level of equanimity and emotional stability.” (C4)
Challenges of inequities in access to high-quality care services
Participants highlighted challenges in accessing high-quality care, mainly due to financial barriers, with many resorting to emergency departments due to affordability issues (Table 5, Supplementary Material 3).
“GPs offer a fantastic value for money …, but I think that they’re perhaps have been gradually underfunded. And access and availability of GPs is certainly something that patients use as a factor for why they’re seeking care in emergency department.” (F3P17)
“…lack of bulk billing availability is putting enormous burden on the ED departments” (C2)
Participants recounted cultural and gender biases, disability accessibility issues, and language barriers that complicated their access to appropriate care.
“My barrier is the language, not able to describe the symptoms precisely due to the language barrier.” (C5)
Challenges of capacity category
Challenges within the capacity category highlighted two subcategories: “inefficient resource allocation and resource constraints” and “patient volume growth” (Table 2).
Challenges of inefficient resource allocation and resource constraints
The participants described significant challenges due to inefficient resource allocation and constraints (Table 6, Supplementary Material 3). Financial limitations hinder healthcare service expansion, preventing the construction of more hospitals despite increasing demands. Limited inpatient bed availability and morning bed shortages are critical issues exacerbated by aging infrastructure.
“I’m going to say inpatient bed availability. So I know our hospital in … is probably 30 plus years old and we have not had an increase in bed stock in that time.” (F1P5)
There is also a noticeable shortage of medical staff, including junior doctors, GPs, and nursing staff, with increased sick leave further constraining resources. Resource allocation challenges lead to frequent reallocations of staff from emergency departments, impacting patient care. Staffing constraints during overtime and weekends are prevalent, with patient transport services often unavailable, resulting in care delays.
“Sometimes on a busy night shift just because simply that that return home job is very low, low priority and we often don’t have patient transport officers working overnight time or over the weekend” (F1P3)
Challenges of patient volume growth
The participants highlighted a growing challenge in managing patient volume growth. Changing demographics and increasing demands in emergency departments exacerbate this issue. The high demand for aged care beds results in many elderly patients remaining in hospitals for extended periods (Table 7, Supplementary Material 3).
“… And then all of the hoops that they’ve got to jump through to be able to access an aged care bed. So those, once they reach ED, they are then in that hospital for quite a period of time.” (F1P5)
Participants reported that there was a rise in patients seeking care from GPs, overwhelming the system. Challenges in inpatient bed allocation for specialty patients with complex care needs result in discharge delays and prolonged hospital stays. The overuse of emergency services for nonemergency visits and frequent patient readmissions disrupt hospital operations and efficiency.
“I’d also add. Readmissions, I think, is a is a real challenge.” (F1P1)
Challenges in the process category
The process category encompasses various subcategories (Tables 8 and 9, Supplementary Material 3):
Bed management challenges
Participants identified significant issues in managing patient flow despite adding new beds. Mere bed increases provide temporary relief without addressing underlying issues. Tasks related to bed allocation consume valuable time, diverting resources from patient care.
“We know that if you open up beds, you fill them up, you don’t necessarily change anything, you get an artificial improvement for a period of time.” (F2P6)
Challenges in modernizing the healthcare system
Participants identified significant challenges in modernizing healthcare, citing inefficiencies in handling patient flow data and resistance to change. The traditional five-day healthcare model is outdated, hindering efforts toward long-term sustainability.
“We’re stuck with ways that relate to historical processes. But in a world that has changed around us. We’ve traditionally had the situation by which ED has done a lot of things for the hospital as a whole and sucked up a lot of problems.” (F1P2)
Challenges in the private hospital system
Participants highlighted a disconnect between the public and private healthcare systems, particularly concerning day procedures. Private hospitals lacking financial incentives for urgent care complicate referrals, leading to patients being redirected elsewhere. This results in additional ambulance transfers, worsening patient flow challenges.
“…, it’s frustrating as hell for us when the crews turn up and the patient’s like, I wanted to go to … (one private hospital), and they said no. And there’s no comeback on them. trying to get the patient to them is an absolute nightmare that will then involve another QAS transfer, which I think you guys clock in about two and a half grand per transfer.” (F1P2)
Fundamental structural problems in the funding model of the healthcare system
Participants highlighted a fundamental structural problem in the healthcare system’s funding model, especially regarding the fee-for-service model for GPs. This model incentivizes treatment over prevention, as funding is based on patient presentations rather than avoiding admissions. Hospital funding mechanisms, driven by activity-based funding (ABF), create disconnects between medical and surgical admissions, leading to flow inefficiencies. Additionally, there is a lack of incentives for preventive care, exacerbated by outdated models prioritizing acute care over chronic disease management.
“Which is like … was describing before we’ve got these outdated and anachronistic health system models and funding models that are set up for acute care, not for complex chronic disease care, which is what we have. That is the reality that we deal with now.” (F1P1)
Gaps in sharing information about the patients
Gaps in sharing patient information present significant challenges in healthcare, leading to unnecessary tests and burdens on both patients and the system.
“an example might actually be more like, additional tests that have just been done in the Community or at one part of the Community practice that we don’t know about… they’re done in the hospital outpatient department, and then they’re done again in the general practice, you know.” (F1P1)
Participants highlighted significant issues in patient information sharing, such as unnecessary tests, challenges in coordinating between public and private providers, and difficulties with health passports due to complexity and low engagement. Data sharing restrictions hinder access across care levels, leading to inadequate information for QAS staff and GPs’ real-time access. Limitations of My Health Records and privacy concerns in healthcare information sharing further impact patient care.
“I had an appointment with the cardiologist and she goes, ‘Ohh, so you’ve got an overactive thyroid, has your GP been in touch?’. So, what had happened was the tests hadn’t, the results of the test hadn’t gone to my GP, and it wasn’t in the discharge letter.” (C3)
Lack of effective systemic coordination
The lack of systemic coordination in healthcare poses significant challenges. Blurred lines of care coordination between GPs and EDs in satellite hospital centres create fragmented patient pathways. Challenges in maintaining multidisciplinary rounds exacerbate coordination issues, affecting patient outcomes. Communication challenges among stakeholders hinder seamless care transitions. Fragmented coordination and communication highlighted systemic inefficiencies. The role and efficacy of satellite hospitals are questioned due to cost misalignments. Varying levels of understanding of patient flow within the organization highlight the need to foster interdepartmental communication.
“Varying levels of understanding of patient flow within the organization highlight the need for fostering interdepartmental communication.” (F2P10)
Transition challenges
Participants described various challenges within the patient care transition phase. Access block with admitted patient boarding emerged as a significant issue, causing delays in care due to limited bed availability. Patient selection for ambulance transport complicated flow and efficiency, while referring patients to other providers, particularly for specialized care, presented obstacles. Timely medical rounds and consultation assessments were hindered, leading to discharge delays and prolonged stays. Inadequate planning and operation of transit lounges exacerbated these challenges, causing bottlenecks. Interhospital transfers added complexities in managing care transitions and coordinating care, further straining the healthcare system’s capacity for seamless patient transitions and continuity of care.
“So for example, if the medical consultants do their rounds, they might do outpatients in the morning and they come up to the wards and do their rounds in the afternoon. So those discharges aren’t happening until later in the afternoon, so therefore the patients are in ED all day waiting for that.” (F2P8)
Participants noted delays in hospital admissions, compounded by ambulance delays, direct ward admission challenges, increased ambulance staff workload, knowledge gaps about hospital capabilities, and delays in ambulance calls. The study also highlighted delayed triage and handovers due to busy nursing staff.
“I guess the other barrier to patient flow would be there’s often lengthy delays with handover. So a nursing staff are very busy and it wouldn’t be unusual to wait 10–20 minutes for a nurse to free up for hand over.” (F2P9)
Delays in discharging patients from inpatient wards present challenges such as ensuring follow-up services to prevent readmissions, transitioning patients from acute care, managing prolonged decision-making due to factors such as medical coverage and workload, patient retention, transport delays, and prolonged wait times for discharge scripts and allied health services.
“Whatever issue presenting issue immediately, there isn’t that follow up to then plug me into or make sure that I have support once I leave the emergency department. If I’m not being admitted to the ward, which sometimes I am, sometimes I’m not.” (C3)
“I guess we’re the back end of patient flow at the moment being RACFs and in that space we do experience a lot of challenges getting people into our RACFs, which then has a direct impact, I guess on the maintenance patients within the hospital.” (F1P5)
Challenges in healthcare management and patient communication
Participants identified significant challenges in healthcare management and patient communication, particularly in emergency care for patients with multiple health conditions. These included delayed identification of medication side effects and treatment, lack of fast-tracking for lifelong patients, and communication issues with overworked physicians. There were challenges in timely access to clinical tests, all of which contributed to poor patient outcomes.
“if you’ve got a complex problem that the registrar’s really don’t know about it, and they can’t know everything. So that’s understandable, but there is no fast tracking of people who are patients for life or who have these rare conditions that, you know, in general aren’t known about.” (C4)
“They did an ultrasound on his knee and once again he slipped through the cracks and after that I think it was four hours. That time I went to the window and said ‘what’s happening with my husband?’ and they said ‘Oh hasn’t he been discharged?’ I said ‘no, we’re still waiting here” (C1)
Patient flow improvement solutions
In the main category of patient flow improvement solutions, three critical categories were identified: “human factors”, “infrastructure”, and “management-organization-policy” (Table 10, Supplementary Material 3).
Human factors solution
The participants emphasized the impact of team leaders and nurse navigators in managing hospital patient flow challenges and stressed the importance of utilizing experienced doctors during emergencies to alleviate emergency room overload. Integrating GPs into emergency departments was noted to broaden the medical care focus and enhance the overall quality of emergency care. Public health education on appropriate healthcare and ambulance service utilization has emerged as a critical factor. Participants also discussed the vital roles of nursing staff in patient flow programs, underscoring the importance of trusting triage nurses for effective patient care guidance. Executive buy-in was emphasized as essential, highlighting the significance of top-level support for program success. Education and workforce development for nurses, prehospital staff, and paramedics were deemed crucial for informed patient selection, transport decisions, and safe field discharge across diverse healthcare settings.
“I guess my main point is really look after your staff, because they’re the ones looking after us” (C3)
“… that’s education is always the first thing to go in our hospitals, especially for nursing. And I think what we need to do is reinvest in education and get. Because we know that the universities just aren’t turning out the nurses at the quality that they were.” (F3P16)
Infrastructure solution
Participants emphasized infrastructure solutions for enhancing patient flow, stressing the need to balance bed expansion with workforce shortages (Table 12, Supplementary Material 3). They highlighted that solely increasing bed capacity without addressing staffing deficiencies would not resolve efficiency issues. Optimal hospital operations rely on effective resource utilization, encompassing both beds and staff. Resource redistribution and initiatives such as transit care hubs were suggested to mitigate risks and enhance patient flow. Moreover, expanding ramps to streamline patient movement within the healthcare system were discussed.
“we don’t need the additional beds and all of that sort of stuff. We are operating well… it’s how we pull it all together and have the right people with the right skills to be able to provide that in a in a format that is informative as opposed to in summative.” (F2P6)
Management-organization-policy solution
This category encompasses strategies for enhancing healthcare management and organizational policies (Tables 10 and 13, Supplementary Material 3):
Diverse patient needs
Participants emphasized accommodating diverse patient needs via primary care and community health initiatives. They proposed utilizing Medicare for extended GP hours and enhancing care for older adults (integrated geriatric care, real-time fall response teams). The involvement of private insurers in preventive healthcare was suggested, as was the exploration of community-based alternatives such as local tertiary services, home care, and community paramedicine. Prioritizing patient-centric care was deemed vital for enhancing outcomes and satisfaction.
“So it’s the community supports and the early identification and the access to the services that these people require to I guess, bypass the emergency department and give them the care and the support that they need within that Community environment, and then access at the point of time that they need to access an RACF rather than reaching that crisis point.” (F1P5)
Communication and collaboration
Effective communication and collaboration throughout the healthcare system emerged as a consistent topic throughout the discussions, highlighting the need to integrate healthcare services for continuity of care and meeting patient expectations. Participants stressed a cultural shift towards collaborative management and seamless information flow from executives to frontline staff. Improving collaboration between medical specialties, implementing a mental health first responder model, and enhancing the collaboration of ambulance services with Retrieval Services Queensland (RSQ) were noted as vital for optimizing patient flow and outcomes. Promoting patient-centric care in healthcare was emphasized as essential.
“And it’s just trying to support them to do better in a way that we always have patients at the centre of all our decision making.” (F2P10)
Directing patients for appropriate care
The participants highlighted the significance of improving ambulance services to reduce hospital transports, along with utilizing clinical hubs, telehealth services, and digital health to enhance prehospital care. The implementation of patient navigation programs and a primary health coreponder model to divert ED visits were discussed as solutions. Facilitating timely treatment for triage categories ‘fours and fives’ in an interim admission center to reduce waiting room occupancy was also described.
“So we’re really just trying to capture those patients before, because often a lot of people, we find that a calling in, that they’re not really sure how to navigate the health system and they’re just wanting some advice and some health literacy. So it’s really trying to just redirect those patients the best we can, whether it even be.” (F1P4)
Health system and process improvement
Participants described the importance of quick access to patient information and addressing privacy challenges for timely follow-up care. Streamlined action planning and accountability in private healthcare were seen as crucial for enhanced patient care. The participants also highlighted the importance of adopting an appreciative approach rather than blaming to foster collaboration within the health care environment. Empowering patient independence and safety through initiatives such as grab rails and home modifications was advocated. Enhancing patient flow through coordinated decision-making and data-driven solutions was emphasized. Adopting holistic approaches to bed block management and changing the approach to system-level operations, along with testing new strategies, was deemed essential. Strategies to mitigate political influences on healthcare decision-making and optimize hospital operations for predictable patterns were emphasized. Prioritizing tasks and transitioning to a seven-day healthcare service model were suggested for organizational efficiency. The development of patient-centric tools such as a real-time ER triage app was recommended to improve the patient experience during emergency visits and meet urgent care expectations.
“And when my discharge summaries are promptly provided to my GP, I feel better supported and safer that when I leave I will be well cared for.” (C3)
“… Without trialling new models of care and strategies, we won’t know how well they work. We need to test them in practice.” (F2P11)
“So and there are examples from across, probably in the United States where they’ve moved to a seven day model and have actually realised a lot of benefits and saved hundreds of millions of dollars in preventing another hospital being built so, but I guess that it’s a complex conversation because we’ve never had it ever.” (F2P10)
Transition to seven-day health care service
Participants suggested using offload paramedics in hospitals to improve patient flow. They could help with tasks such as blood draws and patient movement, speeding up procedures and transitions in the emergency department. Early identification and streamlined placement for patients needing RACF beds are vital for resource efficiency. Intermediate care solutions for swift transitions to maintenance care were also emphasized. Streamlining direct admissions to hospital wards and early senior ED physician reviews for stable patients were effective strategies to reduce bottlenecks. Using predeparture checklists in the ED was proposed for better service coordination.
“Identification early of patients that are potentially going to need referral to an RACF bed.” (F1P5)
“So and for us in particular, it was the direct admission process. So moving from a push model to a pull model.” (F1P2)
Mapping qualitative findings to the UR
Comparative mapping tables were utilized to present this integration, enhancing comprehension (Supplementary Material 4, Tables 1-7). The comparison of our qualitative study and the UR highlights the complex challenges facing Queensland’s healthcare system. Both sources identify issues such as peak demand, staff burnout, and financial barriers, emphasizing the need for systemic improvements in infrastructure, communication, and collaboration.
FGDs identified new patient flow challenges not mentioned in the UR, such as limitations in virtual patient assessments, the implementation of community paramedicine roles, and decreased interest in emergency medicine post-COVID-19. Specific Australian healthcare staffing issues, such as GP sustainability and recruitment, were also highlighted. FGDs noted healthcare access disparities related to cultural inclusivity, gender, and disability. Inefficiencies in bed management, the integration of modern healthcare practices, structural funding problems, and a lack of incentives for preventive care were discussed. In the private hospital system, the disconnect with public services and financial disincentives for emergent care were emphasized. Challenges in sharing patient information and real-time access for GPs were also noted.
FGDs identified several new solutions for improving patient flow not mentioned in the UR. These include leveraging experienced doctors in emergencies, public health education on proper ED use, increasing bed availability, launching transit care hubs, providing free primary care for the uninsured, comprehensive geriatric assessments, integrated care models for better team coordination, data-driven management to optimize patient flow, streamlined discharge processes, and direct hospital admissions to bypass ED consultations.
Additionally, new insights reveal diverse patient needs and structural problems in the funding model, such as issues with GP payment systems and private hospital dynamics. Privacy concerns and limitations in information sharing also emerge as important considerations.
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