Optimising Healthcare Pathways: Strategies for Reducing Duplication

Why this topic matters

Duplication in healthcare pathways often stems from well-intentioned but uncoordinated efforts, leading to suboptimal outcomes. For instance, a patient might undergo similar diagnostic tests at different points in their journey, or encounter multiple clinicians requesting the same basic information. This not only wastes NHS resources, including staff time, consumables, and equipment capacity, but can also cause patient frustration, delays in diagnosis, and potentially impact clinical outcomes.

Reducing duplication is a key lever for improving productivity and efficiency within the NHS. It aligns with national priorities such as those highlighted by NHS England's "Getting It Right First Time" (GIRFT) programme, which consistently identifies unwarranted variation and duplication as areas for significant improvement. By tackling duplication, organisations can create capacity, enhance staff morale by removing frustrating redundancies, and ultimately deliver a smoother, safer patient journey.

Practical explanation

Duplication can arise from several factors:

• Lack of interoperability: Poor communication between IT systems means information is not easily shared, leading to re-entry of data or repeated investigations.
• Siloed working: Departments and specialities operating independently may not be aware of work undertaken elsewhere in the patient's pathway.
• Variance in clinical practice: Different clinicians or teams may follow slightly different diagnostic or management algorithms for the same condition, resulting in repeated steps.
• Inadequate information sharing: Incomplete handovers or patient summaries necessitate re-gathering information.
• Risk aversion: Performing additional tests or assessments "just in case" without clear clinical justification, especially true when patients transfer between care settings.
• Patient factors: Patients presenting in different settings for the same or related issues without a unified care record.

Effective reduction of duplication requires a systematic approach that looks across the entire patient journey rather than just single departmental processes. It often involves mapping pathways, analysing data, and fostering inter-departmental collaboration.

Common pitfalls

Addressing duplication isn't straightforward, and several pitfalls can hinder progress:

• Focussing on symptoms, not causes: Simply stopping a duplicated test without understanding why it was being done in the first place can lead to new problems or transfer the duplication elsewhere.
• Lack of stakeholder engagement: Without buy-in from all relevant clinical and administrative teams, changes may be resisted or undermined.
• Underestimating the benefits: The cumulative benefits of small reductions in duplication across many pathways can be enormous but may not be immediately obvious, making it hard to maintain momentum.
• Over-reliance on technology alone: While IT solutions are vital, they must be accompanied by changes in practice and culture. A new system won't fix poor communication if people aren't trained or incentivised to use it effectively.
• Ignoring patient perspective: Patients often experience duplication most acutely. Their insights are invaluable in identifying bottlenecks and redundant steps, yet they are sometimes overlooked in process improvement efforts.
• Lack of measurement: Without clear metrics to track improvements, it's difficult to demonstrate success or quantify capacity released.

Step-by-step approach to reducing duplication

This framework uses a structured approach to identify and eliminate duplication.

Step 1: Define the Scope and Pathway

Choose a specific patient pathway or service where duplication is suspected. Start with a high-impact, frequently used pathway. Clearly define the start and end points of the pathway to be analysed.

Step 2: Map the Current State Pathway

Working with all key stakeholders (clinicians, nurses, allied health professionals, administrative staff, and ideally patient representatives), map out every step in the current 'as-is' pathway. Use process mapping tools to visualise:

• Every action taken
• Every decision point
• Every hand-off
• Every information exchange
• Resources used (staff, equipment, time)

Look for areas where the same information is collected multiple times, the same tests are run repeatedly, or patients are asked similar questions by different staff members.

Step 3: Identify Duplication Hotspots

Once the pathway is mapped, review it critically to pinpoint areas of duplication. Ask:

• Where is information being re-recorded or re-requested?
• Are tests or assessments being repeated without new clinical indications?
• Are patients navigating similar bureaucratic steps at different points?
• Where do delays occur that might lead to re-work?
• Are different teams performing similar functions without coordination?

Categorise the identified duplications by type (e.g., data entry, diagnostic tests, clinical assessment).

Step 4: Analyse Root Causes

For each identified duplication, delve deeper to understand why it exists. Use techniques like the '5 Whys' or fishbone diagrams. Common root causes include:

• Lack of access to previous results (IT system issues).
• Unclear ownership or responsibility for a task.
• Historical practice no longer fit for purpose.
• Training deficiencies.
• Absence of a standardised protocol.
• Defensive medicine practices.

Step 5: Design the Future State Pathway

Work collaboratively to redesign the pathway, eliminating or significantly reducing identified duplications. Brainstorm solutions for each root cause. Consider:

• Standardisation: Developing clear, agreed-upon protocols for investigations and assessments.
• Information Sharing: Implementing or optimising electronic health record (EHR) use, shared databases, and improved handover processes.
• Role Redesign: Empowering staff to complete tasks or access information previously requiring multiple steps.
• Lean Principles: Applying lean methodologies to reduce waste and streamline flow.
• Technology Solutions: Exploring new digital tools or better utilisation of existing ones.
• Patient Education: Informing patients about the pathway and seeking their input to prevent unnecessary re-presentations.

Step 6: Implement and Monitor

Implement the redesigned pathway, often starting with a pilot phase. Crucially, establish clear metrics to monitor the impact of the changes. This could include:

• Number of repeated tests per patient.
• Average patient journey time.
• Staff time saved.
• Patient satisfaction scores.
• Cost savings (e.g., fewer consumables, reduced clinic slots for re-assessments).

Continuously monitor, gather feedback, and be prepared to iterate and refine the pathway. This supports a culture of continuous improvement.

Example in clinical practice

Consider an elderly patient repeatedly admitted to hospital with heart failure exacerbations. Historically, each admission involved full blood count, renal function, liver function tests, and a chest X-ray on arrival, simply because previous results were not immediately accessible or trusted by the admitting team.

Applying the steps above:

1. Scope: The pathway for 'Acute Heart Failure Admission' was chosen.
2. Map Current State: Mapping revealed that basic bloods and X-rays were frequently repeated if more than 24 hours old, even if available electronically but not easily visible in the admitting system.
3. Identify Hotspots: The repetition of routine investigations was a major hotspot.
4. Analyse Root Causes: Root causes included: limited integration between ED and ward systems, perceived medico-legal risk of acting on 'old' results, and lack of a trust-wide protocol for accepting recent investigations on re-admission.
5. Design Future State: Solutions included:
   • Developing a clear trust-wide protocol on the acceptable age of routine investigations for re-admitting heart failure patients.
   • Improving the front-page visibility of recent key investigations within the electronic patient record (EPR) for admitting clinicians.
   • Integrating results viewing from ED and ward systems where possible.
   • Briefing clinical teams on the updated protocol and system enhancements.
6. Implement and Monitor: The new protocol and system visibility were piloted. Monitoring tracked the number of 'unnecessary' repeat investigations and noted a 30% reduction in the initial 3 months, freeing up biochemistry and radiology capacity, and reducing patient waiting times in ED.

This example illustrates how targeted intervention, supported by cross-functional collaboration and clear guidelines, can significantly reduce duplication and improve patient care.

How Lazomis can help

Lazomis provides a suite of tools designed to support your efforts in identifying and reducing duplication in healthcare pathways:

• Process Mapping Tool: Our intuitive digital process mapping tool allows teams to collaboratively visualise existing pathways ('as-is') and design streamlined 'to-be' processes. This helps identify bottlenecks and duplication hotspots.
• Data Dashboards: Integrate data from various sources to track key metrics related to duplication, such as repeat investigation rates, patient journey times, and resource utilisation. These dashboards provide real-time insights into the impact of your improvement initiatives.
• Project Management Templates: Structured templates guide your team through the entire quality improvement (QI) cycle, from problem definition and root cause analysis to implementation and monitoring of changes, ensuring a systematic approach to tackling duplication.
• Collaboration Features: Facilitate seamless communication and document sharing among multidisciplinary teams, breaking down silos that often contribute to duplication.

Lazomis helps NHS teams to systematically approach complex challenges like duplication, supporting data-driven decision-making and collaborative improvement efforts. This resource supports, but does not replace, clinical judgement. Local policy, formulary and specialist advice should be followed.

Key takeaways