The last mile of care – digitising hospital operations

By Vicky Morley, Senior Clinical Advisor, Systematic. The article was originally published in the online media Health Estate Journal.

As hospitals continue to digitise clinical processes, the promise of faster, safer care increasingly depends on how well digital tools align with day-to-day operations. Vicky Morley, Senior Clinical Advisor at Systematic, explores how fragmented operational systems create hidden friction in hospitals, and how better alignment between digital platforms and frontline operations can streamline care delivery and improve patient flow.

When digital decisions meet physical reality

A clinical decision can be made in minutes. A doctor reviews results, confirms treatment, and agrees that a patient is ready to transfer or discharge. In digital terms, the system works: the decision is recorded in the electronic patient record (EPR), orders are placed, documentation is complete.

But recording a decision is not the same as delivering it.

What follows depends not only on clinical software but on operational infrastructure.

For a patient ready to move, capacity must exist elsewhere in the system. A bed space must be identified and prepared. The room must be cleaned and made safe. The patient must be transported. Equipment must be located and verified as fit for use. Information must move between teams who do not share the same systems, screens or priorities.

These actions determine whether the clinical decision translates into timely care — or into delay.

So why does operational flow still break down inside digitally enabled hospitals?

Frontline operational teams play a critical role in designing effective digital workflows.

The issue is not a lack of technology. Most hospitals operate multiple digital systems across operational domains. Bed management platforms, portering and task management tools, maintenance and medical device management systems and asset registers all perform defined functions. The challenge is that they are rarely configured around end-to-end workflow. Instead, they reflect functional ownership rather than the realities of day-to-day operations.

Hospitals therefore rely on informal mechanisms to bridge the gaps: phone calls to confirm bed availability, whiteboards updated in parallel with digital systems, radio calls to reprioritise tasks, local knowledge of where equipment is usually located. These workarounds are not signs of poor practice; they are adaptive strategies developed to maintain flow in complex, high-pressure environments.

The result is a loss of operational coherence between digital intent and physical delivery.

This is the “last mile” of care: the point at which a system's promise meets the reality of delivering it.

If the NHS is to realise the full value of its digital investment, attention must shift to this operational layer. Digitising documentation is only part of the journey. The next step is ensuring that digital decisions translate into care delivered without delay.

Where operational flow breaks down

Coordination challenges tend to arise at the boundaries between systems and teams. Across acute hospitals, three recurring patterns are visible.

Three patterns where flow breaks down:

Digital status lags conditions on the ground
People become the integration layer between systems
Reactive reprioritisation under pressure expands coordination effort

Digital status does not always reflect conditions on the ground

Clinical and operational systems depend on timely status updates. In practice, the pace of clinical work means these updates often lag behind real-world conditions.

A patient may be clinically discharged, but if discharge is not entered promptly in the EPR, the bed remains digitally occupied. This prevents cleaning tasks from being triggered, obscures real-time availability for bed managers and ultimately delays admissions.

Similarly, portering or cleaning tasks may remain open in task management systems even after work has been completed on the ward, leaving operational dashboards out of step with the physical state of the environment.

Healthcare professional talking on the phone at a workstation with multiple clinical software screens in a hospital setting. — When digital status does not reflect conditions on the ground, operational dashboards become unreliable and decision making slows.

Asset visibility can present similar challenges. An infusion pump may appear available in an asset register while physically located elsewhere in the hospital. A device may be due for planned preventative maintenance (PPM) yet still be circulating in clinical areas because its status is not visible at the point of use.

When digital records cannot be relied upon as a source of truth, situational awareness is compromised. Decision-making slows, task alignment becomes less predictable, and compliance oversight becomes more difficult to maintain.

People become the integration layer

Where systems do not communicate seamlessly, staff perform the work of integration themselves.

Portering teams may receive digital task requests but reprioritise work through radio communication. Bed managers reconcile occupancy across multiple screens. Domestic supervisors maintain parallel lists to ensure spaces are cleaned in the correct order. Clinical engineering teams rely on ward-level updates to confirm device movement before updating records.

These activities sit outside formal reporting structures, yet they consume significant operational time. They also introduce fragility: coordination depends on individuals rather than shared infrastructure.

Reactive reprioritisation under pressure

Two hospital staff members transporting empty beds along a bright hospital corridor. — Delivering care requires coordination across staff, space and equipment beyond the clinical record.

Hospital operations are inherently dynamic, yet digital systems tend to assume linear progression: task created, task completed, status updated.

In practice, operational work rarely follows that pattern. Priorities shift and activities are paused, interrupted, escalated or reprioritised as conditions change across the hospital.

When digital tools do not reflect this fluidity, coordination effort expands. Time is lost between decision and action — not because of clinical uncertainty, but because operational sequencing is unclear.

The effects of these three patterns accumulate. Small delays compound across the day. Discrepancies emerge between what systems record and what is physically true. Planned activity is displaced by reactive intervention, and data quality weakens because systems do not align with lived workflow.

“Systems that fail to incorporate temporal, spatial and resource realities will inevitably be supplemented — or selectively bypassed — by informal coordination mechanisms.”

Vicky Morley

Senior Clinical Advisor

Systematic

The operational cost of fragmentation

This fragmentation has a price. A hospital may be extensively digitised and still lose significant capacity every day to operational friction it cannot easily see or measure.

Operational impact:

Delays in operational coordination reduce effective capacity even where physical space and equipment exist. A bed may be cleaned but not released in the system, a transfer task may not be prioritised at the right moment, or equipment may be unavailable because its location cannot be verified. In each case, patient flow slows and pressure escalates. Across a busy acute site, minutes lost in these handovers accumulate into significant operational strain.

For bed managers and patient flow teams, incomplete visibility of discharge status and room turnaround creates additional uncertainty. Without reliable signals that a bed has been released for use, forecasting availability becomes an exercise in estimation rather than coordination.

In theatre environments, uncertainty around equipment readiness or tray availability can delay list starts or require last-minute substitutions, reducing utilisation of valuable clinical time and disrupting carefully planned schedules.

For estates, facilities and clinical engineering teams, limited asset visibility often pushes work away from planned preventative maintenance toward reactive response. Equipment utilisation falls when location and servicing status cannot be verified with confidence.

The result is a hospital environment that operates with far less predictability than its digital systems might suggest.

Healthcare professional reviewing clinical data on multiple screens at a hospital workstation. — Reliance on desktop workflows introduces delays between clinical decisions and operational action.

Workforce impact:

Senior professionals are drawn into validation and coordination tasks rather than technical delivery. Informal knowledge becomes essential: knowing where equipment is likely to be found, which dashboard reflects the most current status, or who to contact to confirm readiness.

Over time, this increases cognitive load and embeds dependency on individuals rather than systems.

Financial impact:

Extended length of stay constrains elective activity. Theatre downtime reduces productivity. Poor asset visibility contributes to short-term equipment hire or duplicate procurement. Reactive maintenance increases lifecycle expenditure compared to planned intervention.

Individually, these pressures appear marginal. Collectively, they shape capacity, compliance and cost across the organisation.

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Why digitisation efforts in operational environments falter

Given the availability of digital tools, why does this gap persist?

The challenge is not simply technical integration. It lies in the nature of operational work itself.

Operational workflows are shaped by three structural constraints:

Temporal coordination - tasks must occur in the right order and at the right time.
Spatial coordination - work depends on the physical readiness of space and assets.
Resource dependency - people, equipment and capacity must align simultaneously.

For example, a discharge decision may be recorded digitally (temporal coordination), but if the bed space has not yet been cleaned (spatial readiness) and transport staff are unavailable to move the patient (resource dependency), the workflow stalls despite the system recording progress.

Operational workflows depend on temporal, spatial, and resource coordination aligning simultaneously.

Digital platforms are frequently implemented using process maps that assume predictable progression and stable conditions. System configuration therefore reflects how work is expected to occur rather than how it adapts under pressure.

In reality, operational routines represent a form of institutional muscle memory. Over years of managing fluctuating demand, spatial constraint and safety risk, teams develop tacit sequencing rules that allow work to continue even when conditions change.

When systems are configured according to expected process rather than lived workflow, friction emerges. If discharge documentation triggers immediate bed reallocation before a space is physically ready, clinical teams may delay updating the system to retain control of sequencing. If equipment tracking relies on scanning protocols that do not reflect real movement pathways, compliance deteriorates during peak demand.

“

“The last mile of care is not a clinical problem. It is an infrastructure and coordination challenge.”

Vicky Morley

Senior Clinical Advisor

Systematic Healthcare

These responses are not resistance to digitisation; they are adaptive safeguards that allow staff to maintain operational continuity.

Systems that fail to incorporate temporal, spatial and resource realities will inevitably be supplemented — or selectively bypassed — by informal coordination mechanisms.

Mapping real workflows before procurement and implementation is therefore essential. Understanding how tasks progress across time, how priorities shift and how information flows between teams provides the foundation for infrastructure that supports delivery rather than constrains it.

Automation as an enabler — when grounded in workflow

Automation, when grounded in operational reality, becomes a structural enabler of flow rather than another layer of operational complexity.

Event-triggered processes can materially reduce manual intervention and strengthen operational visibility. For example, discharge documentation can automatically initiate cleaning tasks, while completion of cleaning can release a bed in real time.

Similarly, tracking the movement of medical devices, theatre trays and other clinical assets can update availability across wards and departments without manual reconciliation.

When workflow has been properly mapped and behavioural incentives support timely status updates, automation reinforces coordination rather than undermines it. It reduces duplication of data entry, shortens the interval between decision and action and limits reliance on informal escalation.

Fragmented operational systems require staff to bridge coordination gaps manually, while integrated workflows automate routine task transitions

The difference this makes in practice is visible at the ward level. A recent implementation at a large Scottish hospital operating at high occupancy, for example, shows how reducing friction at the point of request can accelerate the entire discharge-to-clean sequence. Nursing staff previously had to walk to a workstation, log in and navigate multiple screens to request a discharge clean — an estimated five minutes per request. By replacing that process with a single mobile interaction at the point of care, the time between discharge and cleaning task initiation reduced significantly. Even modest reductions in that interval compound across the day. Internal modelling suggests that optimising task flows could free up to 12 inpatient beds per day.

“

“Recording a decision is not the same as delivering it.”

Vicky Morley

Senior Clinical Advisor

Systematic Healthcare

The distinction is not between automation and manual practice. It is between automation that reflects operational dependencies and automation that ignores them.

Digitising the last mile of care therefore requires more than connecting systems. It requires designing digital infrastructure around how work actually unfolds so that technology strengthens operational coherence across the hospital.

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What successful implementation looks like

If automation must be grounded in lived workflow, what does that look like in practice?

Hospitals that have improved operational coordination tend to follow a disciplined approach. The common factor is not the specific technology selected, but the discipline with which it is embedded into day-to-day operations.

Observation before configuration
Frontline operational staff are engaged early in system design. Workflow observation is conducted before technology decisions are finalised. Informal workarounds are treated as valuable insight into the coordination gaps that formal systems currently fail to address.
In practice, this means spending time with the teams who manage the daily movement of patients, equipment and tasks across the hospital. Walking in their footsteps and listening to their challenges often reveals the small sequencing decisions and local adaptations that allow patient flow to continue under pressure.
Mapping workflow reality
Observed workflows are then translated into structured process maps. The goal is not simply to connect digital platforms but to ensure that system configuration reflects how tasks move across teams and spaces.
This stage often surfaces dependencies that are not captured in formal procedures — such as the order in which rooms are prioritised for cleaning or the informal escalation pathways used when equipment cannot be located quickly. Encoding these relationships into digital workflows allows systems to support operational coordination rather than disrupt it.
Operational performance metrics
Success measures extend beyond system deployment. Metrics such as bed turnaround intervals, on-time task completion, equipment utilisation, theatre start-time reliability and reductions in manual reconciliation provide tangible indicators of improvement.
Monitoring these measures over time allows organisations to assess whether digital tools are genuinely improving coordination or simply shifting workload elsewhere in the system.
Targeted automation
Automation is introduced selectively. Event-triggered processes — such as discharge documentation initiating cleaning tasks or equipment movement updating availability in real time — reduce manual coordination and improve visibility across teams.
When implemented carefully, these automations remove routine coordination work from frontline staff while preserving flexibility for teams to adapt when operational priorities change.

Engaging infrastructure leaders earlier

A recurring challenge in hospital digitisation programmes is timing. Clinical systems are often prioritised, with operational infrastructure addressed later once architectural decisions have been made and workflow assumptions embedded.

Estates, facilities and clinical engineering teams manage the physical and asset environment that enables care. Their insight into spatial constraints, compliance obligations, asset lifecycles and operational dependencies is critical to system design.

Excluding these perspectives from early procurement decisions risks embedding fragmentation into the digital environment itself.

Reframing the last mile

Digitisation has transformed how clinical decisions are recorded and communicated. The next phase of transformation must ensure those decisions can be delivered reliably within the physical hospital environment.

When digital systems align with real-world workflow, the impact extends beyond efficiency. Hospitals gain clearer operational visibility. They reduce hidden coordination labour. They strengthen compliance and improve flow. Most importantly, they build resilience into the system rather than relying on individual adaptation to hold it together.

Operational infrastructure is not a secondary consideration in hospital digitisation. It determines whether digital investment translates into measurable value.

Addressing this challenge requires earlier and deeper engagement of estates, facilities and clinical engineering leaders in digital strategy. It means designing automation around temporal, spatial and resource realities — and recognising that transformation remains incomplete while digital intent and physical delivery remain misaligned.

The last mile of care is not a clinical problem. It is an infrastructure and coordination challenge — and the operational teams who manage it are not peripheral to hospital digitisation. They are central to its success.

Vicky Morley

Senior Clinical Advisor at Systematic

Drawing on 15 years’ experience across healthcare, from intensive care nursing to clinical operations and digital transformation, she brings a frontline clinical perspective to the challenge of digitisation. At Systematic, she works with NHS organisations to close the gap between digital systems and frontline reality — improving patient flow, reducing operational friction and supporting the teams who deliver care under pressure.

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