Addressing variation in health services is one of the major challenges for clinicians and managers, both in New Zealand and internationally. Observing variation raises difficult questions about the equity, quality and consistency of care, and is an important starting point for quality improvement and service development. Better management of variation is one of the core elements of performance improvement identified by an Expert Advisory Group to the Ministry of Health in developing a new Integrated Performance and Incentive Framework (Expert Advisory Group 2014).
The Health Quality & Safety Commission’s Atlas of Healthcare Variation (the HQSC Atlas) is a starting point for analysing variation in a local area, and for developing service improvement activities to address variation. This guidance provides advice and examples, based on the HQSC Atlas, of analysing variation and working towards reducing variability and improving care.
The following questions form the basis for a systematic approach to analysing the causes and consequences of variation, and for making the decision about whether variation matters enough to engage in quality improvement activity:
- Are the data complete and accurate?
- Is there uncertainty or ambiguity in the clinical evidence?
- Are there quality issues?
- Is there inequity for patients?
- Is there inefficient use of resources?
- What environmental and population factors are relevant?
- How much variation should you expect?
If variation does matter, and there is an adverse impact which justifies working to improve care, there are generically five areas of activity which can contribute to managing variation and improving quality of care for the population:
- analysis
- patient expectations
- work with practitioners at the extremes of variation
- using and disseminating clinical information
- clinical consensus and service design.
Two examples of variation derived from the HQSC Atlas are examined with this generic framework, and supplementary analysis is provided. These illustrate different aspects of variation, and some of the various approaches which can be used to analyse information about variation, and to support improved practice.
Ultimately, managing variation is about the core functions of clinical governance. Both in New Zealand and internationally, there is increasing interest in using observations of variation as the starting point for identifying and prioritising quality improvement and clinical governance activities. The HQSC Atlas approach can support careful analysis, judicious use of clinical judgement, and challenging work with clinical professionals. Effectively utilised, there is enormous potential for positive effect in the form of improved health services for patients and communities.