Bottom-up perspectives on hospital-wide patient flow – A multi-site qualitative study of solutions to organizational paradoxes

Background : As healthcare demand outpaces capacity, improving hospital productivity is critical. Prior research suggests hospital-wide patient flow improvements can enhance efficiency but has largely neglected the insights of frontline healthcare professionals without managerial responsibilities. This study explores their perspectives on enabling efficient patient flow across hospitals. Methods: Semi-structured interviews were conducted with 15 nurses and 15 physicians at six Swedish tertiary and secondary care hospitals. A thematic analysis followed, based on inductive reasoning to identify meaningful subjects and themes. Results : Participants identified seven paradoxes hindering patient flow, linked to leadership, organizational design, routines, professional culture, and technology. These tensions intensify under operational stress and often lead to overtime or compromised care. Professionals emphasized the need for more aligned structures, clearer patient flow strategies, and performance metrics that support efficient transitions of patients. They advocated for more centralized coordination, better adherence to standardized routines, and investment in IT tools to improve decision-making. A critical finding is the gap between nurses’ understanding of patient flow and patient progression and their limited authority and mandates to progress patients, highlighting the need for stronger nurse-physician collaboration. Conclusions : Enhancing hospital-wide patient flow requires increased system-level coordination, better aligned hospital structures, and improved operational planning. The solutions proposed by frontline professionals also largely align with previously identified managerial strategies for improved hospital-wide patient flows, suggesting a shared understanding that could be leveraged to drive meaningful change.