The model on the previous page also describes the role of the variance management system: bridging the clinical pathway (as expressed through compliance variances) and continuous improvement (which usually focuses on outcomes)

This broadens the traditional variance management system role to include improving, as well as monitoring, clinical processes. The model for this role is based on thePlan - Do - Check - Act cycle of total quality management. We expand this model to include both the design phase of pathway development and the management phase of pathway usage. We call this the "double loop" clinical excellence cycle:

In the double loop model a pathway is developed, something for which variance and outcome data from other pathways is very helpful. Once a pathway is agreed upon it becomes the standard of care and the management cycle is initiated. The variance data (both compliance and effectiveness) are collected and analyzed. This analysis informs the ACT step: what - if anything - must we change? Is the problem - or opportunity if clinical practice is changing - in the pathway itself? Or, are changes in actual use or operational processes required?