Clinical Pathways: Use as Quality Improvement Tools

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Clinical PathwaysUse as Quality Improvement
Tools

• Larry Pennington MD

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Clinical Pathways

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

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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

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Clinical PathwaysTime Line

• Pre-admission
• Admission
• Procedure
• Post-op
• Discharge

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Clinical PathwaysCategories of Care

• Medical Interventions
• Assessment
• Tests
• Activities
• Medications/Treatments
• Nutrition/Fluids
• Teaching
• Discharge Planning
• Tubes/Monitoring
• Key outcomes (physician/nursing)

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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

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Clinical PathwaysVariance Record

• Look for common variances
• Improve pathway
• Improve compliance

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Clinical PathwaysReasons for Variance

• Patients clinical condition
• Patients social situation
• Associated diagnoses
• Changing technology or techniques
• Clinicians discretion
• Consultation and internal system services
• External issues primary care, home health care,
  etc

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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

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Clinical PathwaysSurgical Pathways
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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 patients 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

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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.

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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.

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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

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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?

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Clinical PathwaysThe Process