These are some of the most commons questions about variance management systems. To ask your own question, or get our help in solving your variance problems, use our OnLine Consulting page.
What is a variance?
Technically, any deviation from the pathway is a variance. At RLA we distinguish between compliance variances (where an activity was not performed or an outcome not achieved as planned) and effectiveness variances (where the desired outcomes and performance measures - such as planned LOS - were not attained).
That is too much data, isn't there and easier way to collect and analyze variance data?
Yes. Two methods for reducing variance data woes are possible. One, is to identify key, or critical, variances; those activities or outcomes deemed essential to the patient population's care. Another method, our Gateway method, identifies key milestones - "gateways" - in the care process and collects data on why patients are delayed passing through the gateway. The following model illustrates a two gateway model, such as a post-op stay with an ICU phase and a stepdown unit phase.
At each gateway the patient can take one of three pathways: continue as planned, delay their progress for at least a day, or fall-off the pathway. Those delayed at the gateway continue their pathway using an insert - or add on - day document which duplicates the pathway document with the addition of a box to collect the reason for the delay. This is the gateway variance which, for this pathway, reduces the data collection to two data points. Add some critical variances and a powerful database is created with little effort. The detail variances, all those activities and outcomes on the pathway, have their variances recorded in the documentation, where it is available for process improvement efforts.
It is the insert day that provides the increased robustness of the Gateway system's documentation. The care team no longer must switch from 'regular' to pathway documentation as the patient's progress changes.
How do Gateway variances relate to other variances?
Gateway variances tell the care team where in the process problems are occurring and what is driving those problems. This points the way to more focused and controlled follow-up studies and evaluations. Other variances data is necessary to effectively analyze and address Gateway variances. Some are vital to quality patient care in their own right (critical variances), others provides documentation on the care provided to patients. Recording these variances for future analysis is critical.
Our Variance Pyramid shows the relationship between these variance types and to variance reporting and analysis.
How can I use variance data to improve outcomes?
We believe that variances from expected or planned outcomes are also variances; whether financial, clinical, patient satisfaction, or quality. Including these effectiveness variances in variance analysis is possible through the Gateway system, critical variances, and balanced scorecards. The following matrix provides a model for process improvements based on both compliance and effectiveness variances.
- Good Compliance / Good Effectiveness - Your pathway is working well and the care team is providing effective care using the pathway. While you can congratulate yourself and the care team for its success future competitive changes, practice changes, and other vagaries may require a change. You might also proactively improve the pathway to create competitive advantage. Take a look at patients with better than expected outcomes for opportunities to further improve care.
- Good Compliance / Bad Effectiveness - The care team is following the pathway, yet outcomes are poor. This implies that the pathway itself is bad or being improperly applied to segment of the patient population. A review of the pathway is suggested.
- Poor Compliance / Good Effectiveness - The care team is providing good care despite the pathway, not because of it. Reviewing the pathway and actual practice is recommended in order to align pathway and practice.
- Poor Compliance / Poor Effectiveness - The care team is not providing good care and are not using the pathway. A thorough review of current practice is recommended; when effective care processes are in place then - and only then - can you design a reliable and useful pathway.
How do variance management systems fit into an overall process improvement strategy?
Clinical pathways define a care process for a patient population. Processes are the essence of any improvement strategy. So is data, which pathways - through the variance management system - can provide in abundance.
As we discuss in our Clinical Pathways Short Takes, an effective pathways system enables a 'double loop' improvement process. At the heart of this improvement model is variance management system: providing the essential data for the decisions made in the ACT step. Do we modify the clinical and operational processes? Do we modify the pathway? What do we change" Where are our problems?
Two loops, two opportunities to improve care. Both driven by the variance management system.
Robert Luttman & Associates offers many other clinical pathways services. We have published, presented, taught, and lectured on clinical pathways, variance management systems, and continuous improvement around the world. Some of the services you will find on this site are:
OnLine Consulting
We offer you the opportunity to connect with us from the convenience of your desktop, on any topic, at no charge. Simply visit our OnLine Consulting page to choose the most convenient way for you to contact us. We will answer any and all questions related to healthcare performance improvement. If Online Consulting is not for you then call us at: (508) 359-9630.
OnLine Workshops
We offer online versions of our workshops, two of which center around clinical pathways. The first is Variance Management Systems which focuses on the multitude of issues (legal, statistical, and operational) affecting pathways, the various strategies - including our Gateway system - for addressing these issues, how to analyze variance data using quality management tools and techniques, and integrating variance data into an overall organizational performance measurement system. Second, is Next Generation Quality which looks at the overall clinical pathways system and its relationship to an organizational performance excellence program. The workshop addresses such issues as how pathways fit into an organizational improvement strategy, cost accounting and pathways, variance management systems, and creating balanced scorecards from clinical pathways and variance data.
OnSite Consulting and Workshops
We offer extensive consulting and training services. We can help your organization develop and implement a clinical pathways program or its components; integrate your pathways program into a Next Generation Quality program; design and implement a process improvement program; and train your staff in the tools and techniques they need to succeed.
Gateway Variance Management System
Our Gateway Variance Management System is in development. We will make a FREE beta version for Macintosh and Windows computers available on February 15th. A Palm pilot version will follow in May 2000. For information on a customized web based version, or custom versions of any other version, contact us today.
Publications
We can honestly say that we wrote the book on clinical pathways variance analysis. Our variance book, How to Design Clinical Pathways Variance Systems for Continuous Improvement, is available from the Center for Case Management, (508) 651-2600.
We have scoured the Internet for clinical pathways materials. At our Bookstore you will find an assortment of books available for on-line ordering. The Center for Case Management also carries a wide assortment of materials on pathways and case management, especially our variance book: How to Design Clinical Pathways Variance Systems for Continuous Improvement. You can contact the Center at (508) 651-2600. Brown-Spath Associates also has materials on clinical pathways, process improvement, and case management. Call Patrice Spath at (503) 357-9185.
The New Economy of virtual worldwide organizations is also the model of Robert Luttman & Associates. Our connections span the globe and include the finest consultants in the healthcare field. Our clinical pathways partners, in particular, offer tremendous services and products.
Center for Case Management
In the mid-1980's a group of dedicated and visionary nurses and other healthcare professionals invented the clinical pathway. Since then they have gone on to create theCenter for Case Management, the best clinical pathways and case management organization in the world. We are proud that the Center and RLA have forges a partnership that combines our respective strengths. The Center's knowledge, experience, publications, conferences, and client network are breathtaking. They provide the tools, techniques, and thinking necessary for navigating the turbulent waters of managed care, clinical integration, clinical pathways, and performance improvement.
Southern Medical Association
Based in Birmingham, AL, the Souther Medical Association provides financial, management, and continuing education services to physicians and their practices from Texas to Delaware. We offer many of our workshops and consulting services to SMA members at a significant discount. For more information contact: Ed Waldron at (800) 423-4992, x-269.