Removing artificial variability from a physiotherapy service helps to reduce length of stay in an orthopaedic enhanced recovery pathway.

Context This work was completed in the orthopaedic department of a district general hospital in the United Kingdom. The project involved patients having a hip or knee replacement operation. It was identified that patients who had operations on different days of the week experienced different standards of rehabilitation after their operation. There was unacceptable variation in patient experience and quality of care provided. Assessment of problem Analysis was completed using Dr Foster software. This illustrated differences to length of hospital stay depending on the day of operation. The analysis used case-mix adjustment methodology to control for natural differences in demographics. Staff then completed a root cause analysis to ascertain why this was happening. Intervention The physiotherapy service was changed to remove artificial variation in the provision of rehabilitation to patients who had operations on a different day. A business case was made and supported to change the physiotherapy service from a 5-day Monday to Friday service, to a 7-day a week service with extended working hours until 8pm from Monday to Friday. Standardised operating procedures were also introduced so that each patient received the same physiotherapy program and timings of physiotherapy interventions were recorded. Lessons learnt Effective pathways need to be supported by organisational structures and staffing arrangements which allow them to work. Pathways usually centre of clinical processes, but we have learnt that these must be accompanied by managerial changes in order to allow the clinical changes to be performed for every patient. Key Message High quality patient pathways should remove all possible sources of artificial variation. We have illustrated the improvement to quality possible by removing the variability in our physiotherapy service provision.