Reducing Unwarranted Variation in Clinical Services: A Practical Guide for NHS Teams

Why this topic matters

Unwarranted variation can manifest in numerous ways: differing rates of referral, investigation, treatment, or length of stay for similar patient cohorts across different departments, trusts, or geographical areas. While some variation is expected and appropriate (e.g., due to patient choice, individual needs, or local context), unwarranted variation signifies deviations from optimal, evidence-based care.

The consequences are significant:

• Patient Harm: Suboptimal care, delays, complications, or inequities in access.
• Inefficiency: Wasted resources, increased costs, and strain on staff and infrastructure.
• Loss of Trust: Perceived unfairness or inconsistency in service delivery.
• Missed Opportunities: Failure to adopt best practices and innovations consistently.

Initiatives like Getting It Right First Time (GIRFT) highlight the scale and impact of unwarranted variation, demonstrating substantial opportunities for improvement in both quality and efficiency across diverse clinical specialities.

Practical explanation: What is unwarranted variation?

Unwarranted variation can be categorised into two main types:

1. Clinical Variation

This refers to differences in clinical practice, treatment pathways, or outcomes that are not justified by clinical evidence, patient characteristics, or preferences. Examples include:

• Diagnostic pathways: Different approaches to investigating symptoms that lead to delays or missed diagnoses.
• Treatment choices: Prescribing different medications or procedures for the same condition, despite similar patient profiles.
• Surgical techniques: Variation in approach that affects recovery times or complication rates.
• Post-discharge care: Inconsistent follow-up or rehabilitation plans.

2. Operational Variation

This relates to inconsistencies in how services are organised, delivered, or accessed, often impacting efficiency and patient experience. Examples include:

• Referral processes: Disparate criteria or pathways for accessing specialist services.
• Waiting times: Significant differences in appointment or treatment waiting times for similar services.
• Pathway adherence: Inconsistent application of standardised pathways or protocols.
• Resource utilisation: Varying use of theatres, beds, or diagnostic equipment for similar activity levels.

It is essential to distinguish between unwarranted variation and appropriate variation. Appropriate variation acknowledges individual patient needs, preferences, comorbidities, or local resource constraints where a single 'best' approach might not exist. The focus must always be on identifying variation that deviates from optimal, evidence-based, or agreed-upon standards.

Common pitfalls in addressing variation

NHS teams often encounter challenges when trying to reduce unwarranted variation:

• Lack of robust data: Inadequate data collection or inability to benchmark effectively.
• Resistance to change: Clinical autonomy and established practices can make standardisation difficult.
• Blaming individuals: Focusing on individual clinician behaviour rather than systemic issues.
• 'One-size-fits-all' approach: Imposing solutions without considering local context or engaging frontline staff.
• Insufficient resources: Lack of dedicated time, staff, or funding for improvement initiatives.
• Poor communication: Inconsistent messaging about the 'why' and 'how' of change.
• Short-term focus: Failing to sustain improvements beyond the initial project phase.

A Step-by-Step Approach to Reducing Unwarranted Variation

Reducing unwarranted variation is a quality improvement (QI) endeavour. A structured approach is key:

Step 1: Identify and Prioritise Areas of Variation

• Data Analysis: Use existing data sources (e.g., GIRFT reports, national audits, local clinical audit data, trust performance metrics, electronic patient records) to identify areas where outcomes, costs, or processes vary significantly. Look for outliers.
• Stakeholder Engagement: Talk to frontline staff, patients, and carers. They often have invaluable insights into where variations exist and why.
• Benchmarking: Compare your service's performance against national averages, other trusts, or internal best performers. What are others doing differently?
• Prioritisation: Focus on areas with the greatest impact on patient safety, quality, resource use, or patient experience. A Pareto analysis can be useful here.

Step 2: Understand the Causes of Variation

Once an area is identified, delve deeper to understand why the variation exists. This is often the most critical step.

• Process Mapping: Map out the current state of a pathway or process. This reveals discrepancies in practice.
• Root Cause Analysis (RCA) techniques: Use tools like '5 Whys', Fishbone diagrams, or Driver Diagrams to explore contributing factors. These might include:
  • Lack of clear guidelines or protocols.
  • Inconsistent training or skill levels.
  • Differences in equipment or technology access.
  • Organisational culture or leadership styles.
  • Patient demographics or complexity (ensure this is not the sole cause).
  • Systemic issues in referrals, scheduling, or communication.
• Observation: Spend time observing processes in action across different settings.

Step 3: Develop and Implement Solutions

Solutions should be co-designed with those directly involved in the process.

• Evidence-based Guidelines: Implement or reinforce adherence to national guidelines (e.g., NICE, Royal College guidelines) or local protocols.
• Standardised Pathways: Develop and embed clear, consistent clinical pathways.
• Training and Education: Address knowledge or skill gaps through targeted training.
• Technology and Digital Solutions: Utilise digital tools for decision support, standardised documentation, or workflow management.
• Process Redesign: Streamline processes, reduce unnecessary steps, or improve communication handovers.
• Shared Learning: Facilitate multidisciplinary team meetings, peer review, and forums for sharing best practice.
• Leadership and Governance: Ensure strong leadership support and robust governance structures for monitoring and enforcing agreed standards.

Step 4: Monitor, Evaluate, and Sustain

Reducing variation is not a one-off event; it requires ongoing vigilance.

• Key Performance Indicators (KPIs): Define clear metrics to track the impact of your interventions (e.g., readmission rates, length of stay, complication rates, adherence to protocols).
• Regular Review: Establish a routine for reviewing data and performance against benchmarks.
• Feedback Loops: Create mechanisms for staff to provide feedback on the effectiveness of changes and identify new areas of variation.
• Culture of Continuous Improvement: Embed QI methodology into daily practice, fostering a culture where variation is regularly scrutinised and addressed.

Example in clinical practice: Optimising Fracture Neck of Femur Pathway

Consider a trust where the length of stay (LOS) for patients with a fractured neck of femur varies significantly between two orthopaedic wards. One ward consistently discharges patients quicker with similar or better outcomes.

• Identify: GIRFT data and local audit show high LOS variation for hip fractures between Ward A and Ward B.
• Understand: A multidisciplinary team (MDT) including orthopaedic surgeons, geriatricians, nurses, physiotherapists, and occupational therapists conducts process mapping and observes patient journeys on both wards. They find:
  • Ward A (lower LOS): Standardised pre-operative assessment, early morning theatre lists, immediate post-op mobilisation protocols, proactive discharge planning involving social services liaison, and daily MDT board rounds that include expected discharge dates.
  • Ward B (higher LOS): Inconsistent pre-op screening leading to theatre delays, physiotherapy sometimes starting later, discharge planning often initiated late in the patient's stay, and MDT rounds less focused on discharge.
• Develop & Implement: The trust implements a standardised 'Hip Fracture Pathway' across both wards, incorporating best practices from Ward A. This includes:
  • Mandatory use of a digital pre-assessment checklist.
  • Dedicated theatre slots for hip fractures.
  • Protocol for 'early supported discharge' with clear criteria.
  • Daily MDT board rounds with a focus on discharge barriers.
  • Targeted training for all ward staff on the new pathway.
• Monitor & Sustain: The QI team tracks average LOS, time to theatre, re-admission rates, and patient satisfaction using a dashboard. Regular pathway audits and staff feedback sessions ensure adherence and identify further improvements. The consultant geriatrician becomes the clinical lead for ongoing pathway optimisation.

How Lazomis can help

Lazomis provides a robust platform that can significantly support NHS teams in addressing unwarranted variation:

• Data Aggregation and Visualisation: Consolidate data from various sources (EPR, national audits, local systems) into intuitive dashboards, making it easier to identify variation at a glance and track KPIs over time.
• QI Project Management: Structure your variation reduction projects using built-in QI methodologies, from problem definition to impact measurement.
• Collaboration Tools: Facilitate multidisciplinary team work, shared document creation (e.g., standardised protocols), and communication across departments.
• Reporting and Benchmarking: Generate reports that compare performance against internal benchmarks or national averages, highlighting areas for improvement and demonstrating impact.
• Knowledge Repository: Store and share best practice guidelines, standardised pathways, and training materials, ensuring consistency across teams.

This resource supports, but does not replace, clinical judgement. Local policy, formulary and specialist advice should be followed.