Table 1 Identification, classification... | Emerald Publishing

Table 1

Identification, classification and management of variability

	Identification		Classification	Management
	Factors from the cause and effect diagram that the MDT identified as influencing current LOS	Detail of cause and description of variability	Type of variability	Change to care process to be introduced (all changes introduced from when the intervention commenced)	Evidence for success of change to care process (data and evidence source provided where appropriate)
Improvement aim 1 – to increase the number of patients with more than 14 days between pre-assessment and admission
(1)	Referral process from host board to GJNH	Different service level agreements (SLA), methods of referral and timing of referral	Artificial	Remove variability. Introduce a standardised SLA with all health boards and single waiting list management system	This was completed and implemented by July 2013
(2)	Clinic and theatre booking process	Patients not booked in order. Multiple booking systems	Artificial	Remove variability. Consolidate and introduce a single booking system for both clinic and theatre	This was completed and implemented by July 2013
(3)	Out-patient clinic capacity	Variable capacity depending on day and variable number of pre-assessment slots	Artificial	Remove variability. Change to increase clinic schedule and organisation of clinic capacity	This was achieved and the orthopaedic out-patient clinics were redesigned in June 2013
Improvement aim 2 – to decrease LOS by 2 days
(1)	Time between admission and operation	All patients were admitted the day before surgery	Artificial	Remove variability. Increase day of surgery admissions by completing anaesthetic review at the pre-assessment stage	Changes to increase anaesthetic cover in the pre-assessment started in May 2013, however the increased cover for clinics remained hard to fulfill due to staff shortages, until physicians associate were recruited in September 2013 to assist
(2)	Time to first mobilisation	Physiotherapy staffing levels varied throughout the week and meant that the day of operation and time of return from theatre would affect the time to first mobilisation. Limited weekend service	Artificial	Remove variability. Re-education of Caledonian technique to increase focus of early mobilisation and increase staffing levels by introducing a 7-day service	Training and education was provided by clinical leaders at the start of the intervention period in July–August 2013. The new 7-day therapy service was not introduced until January 2014 (the start of post-intervention period)
(3)	Patient expectation of LOS	Patients had different expectations of how long they would stay in hospital	Natural	Manage variability. Updated patient information resources and conducted staff training	A new discharge criteria booklet was produced by the clinical team, and created with the hospital communications department. This was piloted and launched in July 2013 at the start of the intervention period
(4)	Staff understanding of the Caledonian technique and ERAS	Expectations of patient pathway varied amongst staff	Natural	Manage variability Regular training sessions instigated and organised. Regular feedback on current LOS and outcomes introduced	Training and education was provided by clinical leaders at the start of the intervention period in July–August 2013. A mechanism for weekly data analysis and feedback was developed with the IT department and started in July 2013

	Identification		Classification	Management
	Factors from the cause and effect diagram that the MDT identified as influencing current LOS	Detail of cause and description of variability	Type of variability	Change to care process to be introduced (all changes introduced from when the intervention commenced)	Evidence for success of change to care process (data and evidence source provided where appropriate)
Improvement aim 1 – to increase the number of patients with more than 14 days between pre-assessment and admission
(1)	Referral process from host board to GJNH	Different service level agreements (SLA), methods of referral and timing of referral	Artificial	Remove variability. Introduce a standardised SLA with all health boards and single waiting list management system	This was completed and implemented by July 2013
(2)	Clinic and theatre booking process	Patients not booked in order. Multiple booking systems	Artificial	Remove variability. Consolidate and introduce a single booking system for both clinic and theatre	This was completed and implemented by July 2013
(3)	Out-patient clinic capacity	Variable capacity depending on day and variable number of pre-assessment slots	Artificial	Remove variability. Change to increase clinic schedule and organisation of clinic capacity	This was achieved and the orthopaedic out-patient clinics were redesigned in June 2013
Improvement aim 2 – to decrease LOS by 2 days
(1)	Time between admission and operation	All patients were admitted the day before surgery	Artificial	Remove variability. Increase day of surgery admissions by completing anaesthetic review at the pre-assessment stage	Changes to increase anaesthetic cover in the pre-assessment started in May 2013, however the increased cover for clinics remained hard to fulfill due to staff shortages, until physicians associate were recruited in September 2013 to assist
(2)	Time to first mobilisation	Physiotherapy staffing levels varied throughout the week and meant that the day of operation and time of return from theatre would affect the time to first mobilisation. Limited weekend service	Artificial	Remove variability. Re-education of Caledonian technique to increase focus of early mobilisation and increase staffing levels by introducing a 7-day service	Training and education was provided by clinical leaders at the start of the intervention period in July–August 2013. The new 7-day therapy service was not introduced until January 2014 (the start of post-intervention period)
(3)	Patient expectation of LOS	Patients had different expectations of how long they would stay in hospital	Natural	Manage variability. Updated patient information resources and conducted staff training	A new discharge criteria booklet was produced by the clinical team, and created with the hospital communications department. This was piloted and launched in July 2013 at the start of the intervention period
(4)	Staff understanding of the Caledonian technique and ERAS	Expectations of patient pathway varied amongst staff	Natural	Manage variabilityRegular training sessions instigated and organised. Regular feedback on current LOS and outcomes introduced	Training and education was provided by clinical leaders at the start of the intervention period in July–August 2013. A mechanism for weekly data analysis and feedback was developed with the IT department and started in July 2013