Each of the components is designed, linked, and implemented together. While we will explore the operational details of the system in future weeks (and in more detail in the Next Generation Quality workshop), some initial points to ponder are:

• The clinical pathway and the variance management system are the basis of patient documentation. Almost all care is documented on the clinical pathway, as is variance data. No additional variance paperwork is required.
• Progress notes are incorporated into the documentation and are a key tool for bedside variance elimination, the first step in the continuous improvement process.
• The team that created the pathway (please use a team to create them!) is also the team that oversees the implementation and use of the pathway. This includes variance issues.
• Nobody washes a rented car. Care providers can only change what they own. The continuous improvement process must convey problems and data up the organization if they persist or are global. This also allows senior leadership to use their quality management skills.
• The system is scaleable, a fancy IS term for ability to grow and adapt to your needs over time. This can start as a manual system, it was designed that way. It is also easy to automate as Information Systems gets done fixing all those millennium bugs.

While the system can meet almost all of your clinical process needs, the following caveats apply:

• The system must fit into your organization's processes, information systems, and culture.
• It is conceptually different than traditional clinical pathways and continuous improvement methodologies. Though many people are moving in this direction, resistance is possible from more conservative departments.
• It is more work over the short term. Continuous improvement requires continuous effort. This is not something a handful of people do at a quarterly or monthly meeting; it is something everybody must focus on everyday.