The NHS Institute for Innovation and Improvement website is now being administered by NHS Improving Quality - the Productive Series and other products are still being provided by Delivery Partners and supported by NHSIQ, and all material relating to the Productive Series is still accessible.

The NHS Institute closed on 31 March 2013. If an item you are looking for is not available here, you'll be able to see all publicly available content on The National Archives website:*/
This site uses cookies to help performance and allow us to improve your browsing experience. You can click here to view the cookies we use on this website along with information on how to restrict cookies using your browser settings. By clicking on the Continue button, you accept the terms of our privacy policy on our website.

| | |

Reducing Variation in Clinical Pathways to Reduce Delays

Back to previous page

Reducing Variation in Clinical Pathways to Reduce Delays

What is it and how can it help me?

The consistent use of a standardised pathway (protocol based care / integrated care pathways) will result in the patient's journey being quick, safe and as pleasant as possible.

This guidance describes an ideal patient pathway for patients who are admitted with gall bladder disease, however much of this practice could be applied to many clinical pathways.

Where possible, we have linked the description of the ideal pathway with tools and techniques that will help you make improvements in your current pathway. There is a lot of evidence to suggest that many cholecystectomy pathways across the NHS are ready for improvement. This would suggest that other pathways are also ripe for refinement.

The ideal pathway describes standardised procedures that you would expect the majority of patients to follow, say at least 80 percent of patients. The pathway also accommodates exceptions. It applies to all surgical patients, irrespective of whether they are a day case, 23 hour case or an inpatient.

When does it work best?

Redesigning the pathway will improve the patient experience, reduce waiting time and reduce costs by preventing avoidable readmissions. By putting standardised pre-assessment procedures in place, you are ensuring that the patient and carer are fully informed and prepared for admission, operation and discharge. Other benefits include reducing cancellations (see cancelled operations and DNAs). Emergency patients can also benefit from the pre-assessment process.

You will be able to:

  • Improve patient flow
  • Reduce variability in process
  • Increase activity
  • Make best use of capacity (frees up resources for inpatient operations and emergency care)
  • Treat patients faster with shorter waiting times

Reducing variation will also increase productivity and decrease waste e.g. less last minute cancellations, freeing up inpatient beds.

How to use it

There are many ways in which you can improve the experience for patients whilst ensuring value for money and speeding up the patient journey. As you implement some of these strategies, don't forget the importance of measuring success and monitoring progress.

Using data and information to enhance decision making:

  • Ensure that clinical coding is accurate by involving clinicians
  • Establish the baseline and set targets for improvement e.g. aim to achieve 90 per cent of elective laparoscopic cholecystectomies as day cases / 23 hour stay
  • Monitor and feedback on performance e.g. waiting list information, baseline and targets
  • Audit on a regular basis e.g. conversion rates, stay in rates and reasons for unplanned admission, infection, cancellations
  • Consider developing a rapid emergency surgical pathway (to enable surgery during the acute phase) reducing emergency admissions / readmissions

Referral process
You need to offer patients consistent information from all healthcare professionals throughout their pathway, beginning with the GP consultation. Check out the guidance on writing patient information.

  • Design a referral pathway to include pre-referral investigations and relevant patient details such as BMI, blood pressure and co-morbidity
  • Give patients a choice of dates and times for their outpatient appointment, pre-assessment and operation date
  • Aim for emergency patients to have early diagnosis
  • Develop an emergency care pathway with emergency, primary care and the surgical team, including fast track to a specialist outpatient clinic if appropriate

Pre-operative assessment

  • Provide dedicated facilities for pre-operative assessment with appropriate capacity to pre-assess all surgical patients
  • Allow nursing staff rapid access to diagnostics, anaesthetic opinions and other multidisciplinary consultations
  • Ensure pre-assessment staff give patients detailed information about admission, operation and discharge. This should be supported by written patient information see writing patient information 
  • Explore alternative methods for pre-assessment - telephone, face to face, group pre-assessment, primary care or other
  • Ensure that pre-assessment outcomes which may delay surgery are reported quickly (including waiting list office to avoid last minute changes)
  • Assess surgical inpatients prior to surgery to manage patient expectations and ensure standardisation of information

Simple amendments to admissions procedures include admitting patients on the same day as surgery and semi-blocking arrival times to keep the flow through the theatre. Where day case and 23 hour stay patients are on a mixed list, schedule day case patients early in the operating list so they can be discharged earlier.

Operative procedures

  • Develop all day operation lists (this may need alterations in consultant job plans)
  • Use dedicated lists for day surgery and short stay; avoid mixing with emergencies and inpatients if facilities allow
  • Ensure that day case anaesthetics allow early discharge

Post operative care, nurse led discharge and follow up

  • Base discharge criteria on patient recovery rather than minimum post-operative stay. This should be nurse led
  • Consider longer opening hours as part of your day case facility to support same day discharge
  • Standardise ward dispensed pre-packed  
  • Provide clear written patient information regarding discharge care with contact numbers: see writing information for patients
  • Offer 24 hour follow up advice and support e.g. a helpline
  • Arrange that the discharge summary is sent to GPs quickly
  • If all these procedures are put in place, there should be no need for routine outpatient follow up

Inpatient or day case and 23 hour stays (the cholecystectomy pathway)

You should be aiming for inpatient cases as the exception rather than the rule, but to achieve this, your organisation may need to change its mindset to expect more day cases and 23 hour stays.  

Surgical sub-specialisation reduces patient morbidity, increases productivity and reduces length of stay. Recent publications recommend a minimum number of 200 laparoscopic cholecystectomies per surgeon over a five year period (this equates to a minimum of 40 cases per year). Conversion rates should be less than five percent for elective laparoscopic cholecystectomy and less than ten per cent for emergencies.

It is worth noting that conversion rates for emergency laparoscopic cholecystectomies are halved (eight percent versus 16 percent) when operating in the acute phase of the disease, as opposed to allowing the acute episode to settle and operating at a later date. Emergency patients need fast access to diagnostic investigations (within 48 hours of presentation) to enable early operative intervention.


'It's everyone's job to get the list started on time. It requires a team effort for  operating lists to run smoothly,' consultant surgeon.

Variation in Clinical Pathways to Reduce Delays.jpg











What next?

You can use this guidance as both a reference point and check list in redesigning your clinical pathway: see protocol based care.

You can use this guidance as both a reference point and check list in redesigning your cholecystectomy pathway.

Understand what is happening in your pathway. You can develop a picture of your pathways by reviewing the last ten case files for patients who have been treated (ten emergency and ten electives), holding a patient pathway mapping session in a large or small group. This will give you a picture of the reality of what is going on at the moment in your pathway (especially in support function).

When you discuss improvement in your mapping session or in a meeting to share the results of the case file review, you can compare what is happening with the ideal pathway. Tools like the Edward de Bono's Six Thinking Hats may help you to focus discussion. A facilitator who is external to your team may be able to help.  

Additional resources

Protocol based care guidance will be useful for you, also you might want to review engaging clinicians.

British Association of Day Surgery, 2004 'Day Case Laparoscopic Chilecystectomy'

British Association of Day Surgery, 2002 'Ready to Go Home' (Discharge criteria: guidelines about the discharge process and the assessment of fitness for discharge)


The Delivering Quality and Value Team in the NHS Institute developed this pathway based on:

  • A literature review
  • Data analysis
  • Site visits in hospitals involving observing practice and formal interviews
  • Knowledge from these visits was then consolidated and the optimised pathway of care which is illustrated later in the document was identified

More information is available on the NHS Institutes Website.

Acknowledgements / sources

Delivering Quality and Value Priority Programme, NHS Institute for Innovation and Improvement

© Copyright NHS Institute for Innovation and Improvement 2008