Clinical Pathways: Use as Quality Improvement Tools

1. Clinical Pathways:Use as Quality Improvement Tools • Larry Pennington MD

2. Clinical Pathways • Clinical Pathways are structured, multidisciplinary plans of care designed to support the implementation of clinical guidelines and protocols. • Introduced in the 1990’s in the UK and USA • Improve the continuity of care across disciplines • Step wise sequencing of care.

3. Clinical PathwaysMain Components • Timeline • Categories of care or activities and their interventions • Intermediate and long term outcome criteria • Variance Record for documentation and analysis of deviation • Differ from practice guidelines, protocols and algorithms

4. Clinical PathwaysTime Line • Pre-admission • Admission • Procedure • Post-op • Discharge

5. Clinical PathwaysCategories of Care • Medical Interventions • Assessment • Tests • Activities • Medications/Treatments • Nutrition/Fluids • Teaching • Discharge Planning • Tubes/Monitoring • Key outcomes (physician/nursing)

6. Clinical PathwaysCategories of Care (2) • Assessment and Monitoring • Activity/Environmental • Consults • Diagnostics • Operative/Invasive Procedures • Laboratory • Nutrition/I.V. Therapy • Medications • Therapies • Patient/Family Education • Expected Outcomes

7. Clinical PathwaysVariance Record • Look for common variances • Improve pathway • Improve compliance

8. Clinical PathwaysReasons for Variance • Patient’s clinical condition • Patient’s social situation • Associated diagnoses • Changing technology or techniques • Clinician’s discretion • Consultation and internal system services • External issues: primary care, home health care, etc

9. Clinical PathwaysAims • Facilitate introduction of guidelines to improve the quality of care. • Improve multidisciplinary communication • Reach or exceed quality care standards • Decrease unwanted practice variation • Improve patient-clinician communication and patient satisfaction. • Identify research and development questions

10. Abdominal Hysterectomy Aortic/mitral valve Total Hip Coronary artery bypass Total Knee Carotid enarterectomy Femur Neck Fracture Cholecystectomy Laminectomy Mastectomy Prostatectomy Hernia repair TURP Clinical PathwaysSurgical Pathways

11. Clinical PathwaysSummary of Main Features • Unitary, multidisciplinary plan for and record of care • Details tasks, sequences, time-scale, and discipline. Contains a checklist of all necessary action • Includes patient’s expected condition over time • Requires minimal free text • Freely available to the patient • Efficient and structured format for recording key data • Variances are noted and analyzed • Plan and practice adjusted following audit

12. Clinical PathwaysBenefits • Facilitate the introduction of clinical practice goals and methods based on research evidence. • More complete and accessible date for audit and change in practice • Encourage multidisciplinary communication and care planning • Promote patient focused care. Improve relationship with patient, relieve anxiety, increase participation in care. • Reduce paperwork • Enable new staff to integrate quickly • Facilitate incorporation of improvements in care.

13. Clinical Pathways Concerns • Waste of time • Discourages appropriate clinical judgment • Difficult with multiple pathologies and where clinical management is variable • May stifle innovation and progress • Needs leadership, energy, good communication and time and cooperation • May be misused to reduce patient care costs inappropriately and allow for one faction of health care team to dominate.

14. Clinical PathwaysBarriers to implementation • Reluctance to change • Lack of suitable guidelines and lack to resources to develop them locally. • Obstructive interpersonal politics • Lack of credit given for improvements in quality of care • Cost driven goals dominate as opposed to quality based goals • The person responsible for coordinating any care planning initiative must be sufficiently well informed and of high enough standing within the organization

15. Clinical PathwaysCommon Questions • Will it increase litigation? • Will it cause a lack of individualized care for each patient? • Patients do not need or want that level of information. • What about unusual or unpredictable cases?

16. Select a topic Identify key areas and set goals Gather support Develop a pathway Multidisciplinary study group Prepare documentation Identify established guidelines Educate staff Review current practice Pilot and then integrate Involve local staff Regularly review variances Clinical PathwaysThe Process