Transcript to improve the quality of care.

Clinical Pathways:
Use as Quality
Improvement Tools
Larry Pennington MD
Clinical Pathways
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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.
Clinical Pathways
Main Components
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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
Clinical Pathways
Time Line
• Preadmission
• Admission
• Procedure
• Post-op
• Discharge
Clinical Pathways
Categories of Care
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Medical Interventions
Assessment
Tests
Activities
Medications/Treatments
Nutrition/Fluids
Teaching
Discharge Planning
Tubes/Monitoring
Key outcomes
(physician/nursing)
Clinical Pathways
Categories of Care (2)
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Assessment and Monitoring
Activity/Environmental
Consults
Diagnostics
Operative/Invasive
Procedures
Laboratory
Nutrition/I.V. Therapy
Medications
Therapies
Patient/Family Education
Expected Outcomes
Clinical Pathways
Variance Record
• Look for common variances
• Improve pathway
• Improve compliance
Clinical Pathways
Reasons for Variance
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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
Clinical Pathways
Aims
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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
Clinical Pathways
Surgical Pathways
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 Pathways
Summary of Main Features
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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
Clinical Pathways
Benefits
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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.
Clinical Pathways
Concerns
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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.
Clinical Pathways
Barriers to implementation
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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
Clinical Pathways
Common 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?
Clinical Pathways
The Process
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