Bob Luttman, Robert Luttman & Associates
(Briefly) Revisiting VMS Design Issues
Gateway Variance System
Gateway Documentation - Normal Days
Gateway Documentation - Insert Days
Gateway Variance Management System
OK, so what can we do about all of these problems?
Focus on the So What issues. Look back upstream at your process through the lens of you planned outcomes. What are the major milestones in the process? The points where the patient will significantly deviate from the pathway. The bullet points in rounds.
These are the gateways in the process, the forks in the road of the care process where some patients may take the road less traveled.
How did the idea arise? Easy, while I was busy in a back office spinning numbers in a statistical program the case managers were on the floors asking questions about the patients. Dumb me. I forgot the first rule of statistical thinking: process thinking. I didn't listen to the process only the numbers.
The case manager was in the ICU asking why patients were still there when the pathway said they were supposed to be in the step-down unit. She recorded the answers in her own database. Out came the answers we needed. Out went my database.
In came the idea of gateways.
This picture shows a care process with two gateways, say ICU transfer and discharge.
At the end of the planned ICU stay a decision is made about transfer. If all is well the patient moves on. If not, two alternatives are possible, the patient is held in the ICU for an extra day or two (using insert days which we will cover soon), or - if the patient develops severe complications or comorbidities - the pathway is discontinued. The same is true at discharge.
These gateways are like canaries in a coal mine. They tell you when you have a problem; right now for an individual patient, continuously for a patient population.
Gateways are not always time oriented. You could use intermediate outcomes such as extubation, or administration of thrombolytics in the ED, or patient at X level of health status at first follow-up clinic visit.
With this in mind we can develop a gateway oriented variance model.
