The roundtable
What is unwarranted variation in care and what can be done about it was the theme of an HSJ roundtable, bringing together experts from a wide range of backgrounds to look for solutions.
Everyone in the NHS knows that care given to similar patients is very variable and not all of the differences can be justified. Sometimes their care is inappropriate, delayed and is ineffective or carries a higher risk of complications. Often this means the care is more expensive than it need be for the NHS – which is important for a cash-strapped system where demand is growing.
Roundtable participants
Alastair McLellan, editor HSJ– chair
Joe Harrison, chief executive, Milton Keynes Hospital Foundation Trust
Martin Sykes, finance director, Frimley Health Foundation Trust
Des Holden, medical director, Surrey and Sussex Healthcare Trust
Jim Easton, managing director, Care UK
Professor Tim Briggs, national director for clinical quality and efficiency and an orthopaedic surgeon
Candace Imison, policy director, Nuffield Trust
Rose Gallagher, head of standards knowledge and information team, RCN
Professor Jane Metcalf, consultant physician and deputy medical director, North Tees and Hartlepool Foundation Trust
Professor John Newton, chief knowledge officer, Public Health England
Lorraine Bewes, consultant and former finance director
Bryn Davies, European general manager, Syncera
Mike Kimmons, chief executive, British Orthopaedic Association
So why do these variations happen? Part of the answer the panel gave was around information: sometimes clinicians and the trusts which employ them are unaware that this is happening or that outcomes for patients are worse than in other areas.
Some variations may be due to clinical decisions by individual clinicians. This can be hard to address, although clinicians often respond well when presented with the data (once they have accepted its validity).
jim easton 6 june 2016 reducing variation
Care UK managing director Jim Easton
Jim Easton, managing director of Care UK, said independence of thought and action was important to doctors. This could lead to positions where, for example, there was good compliance with surgical checklists when they were voluntary but this dropped when they were imposed. It could be hard for doctors to reflect on unwarranted variation when this involved discussing harm to their patients.
But where good data exists it may not be accessed by everyone. Professor Jane Metcalf, deputy medical director at North Tees and Hartlepool Foundation Trust and the secondary care doctor on a CCG, said: ‘I only heard of the Atlas of Variation through my CCG work. My colleagues in the trust are not aware of it. If people are not aware of what variation is how can they compare themselves?’
However, Candace Imison, director of policy at the Nuffield Trust, pointed out it was ‘barking up the wrong tree’ to think it is just individual clinical decisions which contribute to variation – there are many systemic factors as well.
jane metcalf 6 June 2016
Jane Metcalfe: ‘If people are not aware of what variation is how can they compare themselves?’
Professor Tim Briggs, national director for clinical quality and efficiency, pointed out having ringfenced orthopaedic beds was associated with lower infection rates after surgery – but some trusts still did not have them, despite evidence there were significant savings from lower infection rates.
Des Holden, medical director of Surrey and Sussex Healthcare Trust, added: ‘Many of the things that are important in outcomes are not measured. It is only recently we started measuring how many patients with sepsis get antibiotics within an hour,’ he said.
So what would make things change? Many in the room felt there were encouraging signs with initiatives to highlight variation starting to have some effect. Professor Briggs’ work on a national review of elective orthopaedics is beginning to bring changes and greater engagement on the ground, and is now going to be replicated across 10 other specialties.
Leadership was identified by many as key to driving improvement and Joe Harrison, chief executive of Milton Keynes Hospital Foundation Trust, talked about how boards are making use of available data, especially around benchmarking.
Technology is also likely to have some effect. At the moment this is often adopted on a small scale but there are opportunities for this to spread and for new technologies to be adopted.
Syncera European general manager Bryn Davies said the reaction from inside the NHS was often that IT ‘did not work.’ ‘Even with technology that has been around for 10 or 15 years in other industries that can be a challenge,’ he said. That was true of things like GS1 standards for bar coding.
Many of the things that are important in outcomes are not measured
Some of the worst manifestations of variation are never events – incidents so potentially serious that they should never happen. He said technology to help prevent these was already available – scanning the boxes implants came in could highlight a mismatch between patient and implant, for example.
And Professor Briggs questioned whether it was realistic to ask the government for more funding for the NHS when there was so much variation in care. ‘We need to put our house in order first and then have a discussion about what we need to do,’ he said.
Video: roundtable conclusions
The key findings from our expert panel
Case study: How Medway Foundation Trust has cut variation
Variations in how people are cared for as they come through A&E and are admitted to hospital can mean poorer care for them and higher costs for the hospital.
In this video, we hear about how Medway Foundation Trust, strongly supported by a team from Guys and St Thomas’ Foundation Trust as part of a buddying arrangement, has transformed the care for patients admitted with acute medical problems.
This has led to shorter stays for patients and has allowed the trust to close some beds and deploy staff elsewhere.
Derby's four steps to consistent care
Never events and too much instrumentation are among the factors which contribute to variation. Surgeon and divisional medical director Arthur Stephen looks at four such factors and the steps his organisation has taken to overcome them
Derby Teaching Hospitals Foundation Trust completed 72,000 elective procedures in its 35 operating theatres and more than 1,500 hip and knee replacements in 2014.
Stakeholders at the trust have undertaken a partnership with Syncera, a strategic business unit of Smith & Nephew, to reduce unwarranted variation from the healthcare value equation, with the aim of aligning improved outcomes and reduced costs according to the healthcare value equation.
Fig 1. Value
Several areas of impact have been identified. Here, orthopaedic surgeon and divisional medical director Arthur Stephen provides insights from a clinical perspective on four of these.
Issue 1: Never events and near misses
“[Never events] are rare, but they do impact the patient significantly, and impact upon the trust because it triggers into action a series of obligatory events such as reporting to the clinical commissioning groups through a serious untoward incident and will normally generate a root cause analysis,” says Mr Stephen.
“In my experience, the main issue with a never event is rarely the fault of an individual person; it’s often system process.”
Solution: Reduce unwarranted variation in theatre
Reducing never events and near-misses rests on three key points: standardise practice, procedure and tools; educate consistently across teams using a range of multimedia tools; and harmonise by creating a supportive environment in which serious incidents are used as learning opportunities.
With Syncera Interactive, training results in standardisation according to each surgeon’s preference — so the theatre is set up the same way, every time, regardless of who’s scrubbing in. In addition, error-checker technology confirms the implant, patient and side, creating a further safety net for mitigating the risk of never events, which can also have steep financial costs. To wit: orthopaedic incidents cost £64m in litigation annually.
Issue 2: Efficient procedure flow
“When I walk into theatre I want to know that everybody there knows what we’re doing, knows on whom we are doing it and how we are going to do it. In my experience familiarity breeds consistency, not contempt.” says Mr Stephen.
“And that’s where efficient planning and preparation are key to ensure that the right instruments are there for that particular case.”
Solution: Optimise staff training to save theatre time
Syncera Interactive provides surgeon-specific procedural staff training for surgical technicians and nurses. With digital preference cards customised by surgeon and procedure, all members of the team have online access to pictures and videos of the patient prep and theatre set-up.
The virtual learning environment uses simple gaming theory to help techs learn the surgical instrument sequence, in a self-directed format. That way, when the surgeon walks into theatre, everything is prepared, in order and ready to go, saving valuable minutes. Add in streamlined instrument sets, and turnover times are reduced, thereby decreasing indirect surgical costs.
Syncera Interactive can result in up to five minutes of theatre time saved per procedure. It might not sound like a lot, but that few minutes’ breathing room is an opportunity to do that little bit extra that makes the patient feel well cared for, or to have a check-in with the theatre team that helps make everyone feel valued, confident and ready for the case at hand – or the cases to come. These value-added moments are critical to safety in theatre and should not be dismissed.
Issue 3: Too much unnecessary instrumentation
“Having fewer instruments is not necessarily a bad thing,” says Mr Stephen. “Yet the trays just seem to get bigger rather than smaller. Fewer instruments on the tray mean there’s less to count, less to account for, and lower sterilisation costs.
”Fewer instruments on a tray [also] basically makes the operation safer because there are fewer instruments to learn, fewer instruments to be familiar with, fewer bits of kit to construct and fewer instruments to lose.”
Solution: Optimise instrumentation
Using Syncera Interactive in collaboration with surgeons to streamline instrument sets and guide staff through theatre prep can help reduce the number of instruments in the operating theatres. Lost instruments can cost a 500-bed hospital over £100,000 per year, and operating theatre delays due to incorrectly assembled or unavailable instrument sets cost an average of £500 per hour.
£2.5m
Estimated annual spend on instrument processing
Streamlined sets also reduce reprocessing requirements. At an average of 67p per instrument sterilised in a tray of 51–60 instruments, if a hospital such as Derby processes 3.7 million instruments each year, that’s an estimated annual spend of nearly £2.5m. When you also consider the cost of reprocessing a single-wrapped instrument in a peel pouch is £1.06, and £7.44 for orthopaedic power tools, expenditures add up.
The goal of reducing orthopaedic instrumentation sterilisation by 60 per cent would result in significant savings.
Issue 4: Implant compatibility checks
“Where there are compatibility issues, the better prepared you are, the more you can feed technology to your own advantage,” says Mr Stephen. “So if you’re doing a left-sided operation and that is inputted into a system, and you scan an implant which comes up as a right, then you can immediately get a warning.”
Solution: Minimise implant-related wastage
In a US-based study, implant-related errors and wasted total knee arthroplasty (TKA) implants represent occur in 5.7 per cent of all TKA procedures. Seven orthopaedic surgeons implemented a computer based e-tracking and compatibility system that standardised implant labelling, confirmed correct size and side (and patient), and ensured compatibility within implant systems.
Using the system, they saved over £55,000 ($75,000) annually.
Syncera’s automated digital solution catches potential errors before the implant is opened or put into the patient, helping to potentially reduce implant-related waste by up to 85 per cent.
Sponsor's comment
The battle against variation can be seen as a series of opportunities, says Bryn Davies
There isn’t an issue more pressing for the NHS right now than getting maximum value out of the money hospitals are given, and unwarranted variation unquestionably drains value.
Bryn davies6th june 2016 hsj roundtable reducing variation034
Unwarranted variation is particularly prevalent in GP referrals, surgical outcomes, transitions to post-operative care, pricing (due to lack of transparency), pathways for referral and care, population health management, and IT infrastructure.
The healthcare leaders at this roundtable, who included finance directors, managing directors, chief executives, medical directors and researchers, discussed ways of eliminating unwarranted variation and explored integrated, cross-disciplinary solutions.
Variations lead to unmet needs
Variations lead to unmet needs and, therefore, potential approaches to solving unwarranted variation should be seen as opportunities to meet the needs of surgeons, nurses, staff, patients and communities, as well as the needs of the hospital, trust and NHS. A number of factors are key to this:
- Strong leadership must present a unified vision and promote a culture of openness throughout and between organisations, so that peer groups can leverage shared knowledge into change across the NHS.
- Data is an artefact of coding, which results directly from the quality of documentation. High-quality documentation allows for accurate root-cause analysis and is the bedrock of trustworthy data in terms of clinical outcomes and unwarranted variation.
- Better data also arises from refined definitions and standardised parameters for collection and examination. In turn, data that is relevant to practice will drive innovation and competition between individuals (eg surgeons) and systems of care to avoid being outliers.
- Peer-to-peer, clinically led review of services that is empowered by data leads to individual clinical change and innovation, particularly towards evidence-based performance management and practices.
- Care pathways and IT systems should be aligned for automated decision-making in a patient-centred way – not to make care rigidly inflexible, but to eliminate unwarranted variation in micro-decisions, thus leaving flexibility in decision making to the times where skilled judgement calls are needed.
Some variation in care will always be necessary, but should be reserved for times when expertise is truly needed. Targeting unwarranted variation means targeting areas of care that are most open to standardisation – while prioritising safety, low complication rates, optimised outcomes and the best value for the taxpayer.
Bryn Davies is the general manager, Europe, at Syncera by Smith & Nephew. Email bryn.davies@syncera.com
Syncera is a strategic business unit of Smith & Nephew. Our unique digital solutions are designed to help reduce unwarranted perioperative variation and optimise operating theatre efficiency. Optionally linked with clinically proven hip and knee implants to deliver further cost efficiencies.
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