Clinical Pathways and Variance Analysis

What is a clinical pathway? A multidisciplinary proactive plan of care for a

specific diagnosis or procedure. It is a timeline of patient care activities which

is used by all disciplines for planning, anticipating, implementing, and evaluating care.

Enhances interdisciplinary collaboration Helps to reduce unnecessary variations in patient

care and outcomes. Supports development of care partnerships and

empowers patients and their careers. A tool to incorporate local and national guidelines

into everyday practice, Manages clinical risk and meets the requirements

of clinical governance.

Why pathways?

Why does JCI recognize pathways

Pathways reflect care that is –

• Planned

• Standardized

• Organized

• Documented

Pathways can improve team communication and coordination of care, thus preventing medical errors.

Why pathways?

Why pathways?

Pathways can improve team communication and coordination of care, thus preventing medical errors.

How is a TMC pathway developed

1. Pathway topics are chosen from Medical City’s high-volume, high-risk or problem-prone cases.

2. MQIO forms a multidisciplinary pathway team.3. The team defines population of patients to be covered by

the pathway.4. The team drafts the pathway according to available

evidence, including existing pathways and evidence-based Clinical Practice Guidelines. The draft pathway specified (a) Time intervals, (b) Interventions per element of care and (c) patient outcomes prior to discharge

5. The team presents the pathway to the concerned departments and units for approval

6. The team pilot tests the pathway to ensure ease of use

7. MQIO monitors and evaluates pathway use bya. Measuring and analyzing variancesb. Making appropriate modifications to the clinical

contentc. Addressing process improvement

How is a TMC pathway developed

What pathways are implemented in TMC?

• Acute asthmatic attack• Acute abdominal pain (non-traumatic)• Chest pain• Pneumonia (in adults and children)• Normal birth• Acute appendicitis• Acute diarrhea (in adults and children)• Coronary artery bypass graft procedure• Sepsis alert

Parts of a Clinical Pathway

1. Pathway title

2. Inclusion and exclusion criteria

3. Patient’s information

4. Physician’s Notes

a. S: subjective complaints/symptoms

b. O: objective physical and laboratory findings

c. A: assessment/ working diagnosis/ clinical impression

d. P: plan of care (diagnostic, therapeutic, rehabilitative, others)

Parts of a clinical pathway

5. Orders Assessment and Monitoring (vital signs, hemodynamic

monitoring, weights, etc) Laboratory tests/Tests/Procedures (Routine diagnostic

tests) Treatments (medical and nursing orders, dressing

changes) Medications/IVS (IV fluids, blood orders, routine

medications) Nutrition (Enteral and parenteral feedings, diet and fluid

restrictions, supplemental feedings)

5. Orders Activity/Safety (Activity orders and/or limitations (ex. turn

q 2 hours, PT or OT consult/orders) Consults (referrals) Psychosocial (assurance that illness is self-limiting,

assuring a mother that she can breastfeed, assuring family that patient’s usual activity may be resumed in 3-7 days)

Patient/Family Education (hand hygiene, breastfeeding education, possible sources of infection)

Discharge Planning (assessment of patient outcomes, referrals to home or post-operative care)


Orders or interventions may be mandatory or optional• Mandatory interventions – marked by bullets (•) and applicable

to 100% of the population– Must be carried out once a pathway is activated– Don’t need a checkmark to be carried out– If deemed not applicable to the patient, may be crossed out and

initialed by AP• Optional interventions – marked by tick boxes () and may not

apply to 100% of the population– Option box () should be marked with a check () if the

intervention meets the needs of the patient– If box is left empty, intervention need not be done


6. Pathway activation - by the attending physician or resident-in-

charge7. Pathway acknowledgement - by the nurse-in-charge8. Variance column9. Signature column


1. Pathway title

2. Eligibility & exclusion criteria

3. Patient’s data

Parts of a clinical pathwayPHYSICIAN’S ADMITTING ORDER SHEET

For Clinical Pathway ___________________________________________ Inclusion criteria: Exclusion criteria: PATIENT’S NAME LAST NAME FIRST NAME MIDDLE NAME

BIRTHDATE PIN

ORDERS Var Sign

Admit to ________ under the service of _________ Vital Signs Monitoring:

Diagnostics/ Procedures

Medication/IVF

Diet/ Nutrition Order

Activity/safety order

Consults order

Provide for psychosocial needs

Provide patient/ family education

PHYSICIAN’S NOTES S – Subjective Complaints / Symptoms O – Objective Physical / Lab Findings A – Assessment / Working Impression / Clinical Diagnosis 1. 2 3 4 P – Plan of Care Diagnostic, Therapeutic, Rehabilitative, Others

Discharge planning orders

Activated by : Acknowledged by: ___________________________ ____/____ ___________________________ ____/____ Signature Over Printed Name Nurse-in-Charge ATTENDING PHYSICIAN /RESIDENT

Parts of a clinical pathwayPHYSICIAN’S ADMITTING ORDER SHEET

For Clinical Pathway ___________________________________________ Inclusion criteria: Exclusion criteria: PATIENT’S NAME LAST NAME FIRST NAME MIDDLE NAME

BIRTHDATE PIN

ORDERS Var Sign



Medication/IVF



Consults order






4. Physician’s notes (SOAP)

5. Orders

Bulleted interventions are mandatory interventions

Interventions with tick boxes are optional interventions

PHYSICIAN’S NOTES ORDERS Var Sign

Vital Signs Monitoring: Watch out for signs of respiratory failure Watch out for complications such as effusion,

pneumothorax, etc

Do the following lab tests/ procedures: CBC Pulse oximeter reading Chest PA, Lateral TACS ABG Pleural Fluid Analysis Blood C/S Sputum C/S

Please give Oxygen inhalation at ________ l / min Bronchodilator: _______________________________ Steroid: Zinc

S – Subjective complaints / Symptoms Previous antibiotic intake? Yes. Details_____________________________ No.

Start IV fluids Diet orders NPO Aspiration precautions Regular diet

O – Objective physical Please start oral amoxicillin (for PCAP A / B): Penicillin G Sodium (for PCAP C) IV Ampicillin (PCAP C): Other antibiotics:_________________________



PHYSICIAN’S ADMITTING ORDER SHEET For Clinical Pathway ___________________________________________

Inclusion criteria: Exclusion criteria: PATIENT’S NAME LAST NAME FIRST NAME MIDDLE NAME

BIRTHDATE PIN

ORDERS Var Sign



Medication/IVF



Consults order






6. Pathway activation

7. Pathway acknowledgment


8. Variance column

9. Signature column

PHYSICIAN’S ADMITTING ORDER SHEET For Clinical Pathway ___________________________________________

Inclusion criteria: Exclusion criteria: PATIENT’S NAME LAST NAME FIRST NAME MIDDLE NAME

BIRTHDATE PIN

ORDERS Var Sign



Medication/IVF



Consults order






How are clinical pathways used?General guidelines in using pathways The pathway is a permanent part of the patient’s

medical record. The Pathway may be used in lieu of the Care Plan,

Orders and Notes Sheet accomplished by the medical staff.

The Nurse in Charge and Attending Physician will select the appropriate pathway on admission OR when the interval of care begins.

The care delivered and patient outcomes will be managed against the pathway.

The role of the MD in using pathways

The MD activates the pathway. The AP / resident-in-charge activates the pathway

by signing at the bottom Once activated, the pathway shall serve as a pre-

printed doctor’s order set The AP’s / resident’s signature signifies approval of

the orders for the time interval. Any additional orders which do not appear on the

pre-printed pathway (e.g., medications, IV fluids, parenteral nutrition, etc) must be written on the traditional order sheet.

The AP / resident-in-charge Sees to it that all mandatory interventions are

applicable to the patient Cancels any mandatory intervention NOT

applicable to the patient. REMEMBER: you must initial any canceled intervention.

Ticks the optional interventions you think the patient needs

The role of the MD in using pathways

The Nurse’s role in using pathways:

The nurse-in-charge assists the AP in selecting the appropriate pathway.

Acknowledges activation of the pathway by signing at the bottom

Carries out all mandatory intervention that are not cancelled and optional interventions that are checked

writes his / her initials and the time the order was done on the Sign column

All the other members of the care team have active roles in using pathways

Accomplishing interventions Therapists, nutritionists, residents, interns, and

clerks do all mandatory observations pertaining to them that are not cancelled and all optional interventions that are checked.

Whenever an intervention is accomplished, the care team member writes his / her initials and the time the order was done on the Sign column

The pathway is a great tool for communicating to your co-workers:

Use the pathway during Nursing shift endorsement AP rounds Rounds by referred doctors Chart rounds Interdepartmental conferences

Variances

A variance is • any mandatory or checked optional intervention that

was not done.

• an abnormal finding

• An unmet outcome within the time frame

• Variances may be noted by any care team member.

• Whenever a variance is noted, the variance code and initials is written in the variance column.

Documenting variances

Whoever noted the variance must make a note to describe the nature and cause of the variance and any actions taken.

Variance notes may be written in the interns’ or resident’s progress notes, if a MD

noted the variance nurses’ notes, if nurse-in-charge noted the

varianceA variance monitoring form, documenting all variances

in the pathway, is filled out by the nurse supervisor after every pathway patient is discharged.

Documenting variances The Variance column: where care team members write the Variance code

ER Order Sheet / INPATIENT ADMITTING ORDER SHEET For Pediatric Patients With Community-Acquired Pneumonia

Inclusion criteria: Patients 3 months to 5 years with cough, tachypnea and / or chest indrawing; Exclusion criteria: chronic lung disease, chronic heart disease, malnutrition, neurological disorders, malignancy, immuno-suppressed conditions, asthma, transferred and/or admitted from another hospital PATIENT’S NAME LAST NAME FIRST NAME MIDDLE NAME

ATTENDING PHYSICIAN DEPARTMENT

PHYSICIAN’S NOTES ORDERS Var Sign

Vital Signs Monitoring: Watch out for signs of respiratory failure Watch out for complications such as effusion,

pneumothorax, etc

Do the following lab tests/ procedures: CBC Pulse oximeter reading Chest PA, Lateral TACS ABG Pleural Fluid Analysis Blood C/S Sputum C/S

Please give Oxygen inhalation at ________ l / min Bronchodilator: _______________________________ Steroid: Zinc

S – Subjective complaints / Symptoms Previous antibiotic intake? Yes. Details_____________________________ No.

Start IV fluids Diet orders NPO Aspiration precautions Regular diet

VARIANCE CODES

A. Patient/family 1. Patient’s medical condition 2. Patient/family decision 3. Patient/family availability 4. No funds 5. Other reasons B. Physician 1. Medical order 2. Provider(s) decision 3. Provider(s) response time 4. Other reasonsC. TMC System 1. Results/Data availability 2. Supplies/Equipment related 3. Appointment Availability 4. Weekend/Holiday 5. Other reasons D. Outside TMC 1. Transportation availability 2. Home Care availability 3. Other reasons

For example, if a mandatory test is not done because the patient has no money yet, the cause of that variance is encoded as “A4”.

How to analyze pathway variances

1. Identify critical pathway orders. These are the orders which, if not carried, will significantly put the patient at risk for harm.

2. Using the variance monitoring form, count the number of variances that occurred in the critical pathway orders.

3. Perform RCA to determine causes of variances.4. Pilot test countermeasures.5. Monitor variance counts and note if they

decrease over time..

Outcomes

• The measurable outcomes that a patient is expected to experience is specified in the pathway for every time interval (e.g., daily, per shift).

• Because outcomes are pre-determined, the pathway can prompt any member of the care team to call the attention of the AP if the expected outcomes are not achieved within the time interval. Thus, interventions can be modified, added, discontinued in a timely way.

Reviewing outcomes: MD’s role

All care team members must review the problem list, variances and outcomes daily. Pathways ensure that the members of the care team are looking at the same plan of care.

AP and all referred MDs are accountable for reviewing the patient’s progress against intermediate and discharge outcomes on a daily basis.

And for revising the plan of care based on the review of patient’s outcomes.

Reviewing outcomes: nurse-in-charge’s role

Reviews patient’s progress daily against intermediate and discharge outcomes

Review variances daily and report them to the AP and the rest of the care team.

Ensures that all variances result in re-evaluation of plan of care by appropriate disciplines.

Reviewing outcomes A met outcome – should be initialed; no other

documentation necessary An unmet outcome – consider as variance Outcome not met within time frame - may require

adjusting the intervention Variance due to unmet outcome – describe in

progress notes in SOAP format Outcome met earlier than expected – a positive

variance; document/initial on the date it was met

Discontinuing the pathwayThe pathway will be discontinued whenever: The patient’s primary diagnosis changes The patient’s condition significantly worsens The patient fails to meet clinical outcomes for 24-48

hoursTo discontinue the pathway, a progress note (SOAP) is

written by the MD outlining the patient’s new plan of care and new orders. A new nursing plan of care is also written. The pathway is then filed in the patient record.

Keys to pathway success

Make pathways part of your quality program. Ensure strong collaboration between all relevant disciplines,

with a strong medical lead. Select appropriate medical conditions in making pathways. Base the pathway orders on best available evidence / best

practice. Collect and analyze variances and involve the staff in

interventions to decrease variances. Incorporate adherence to pathway policies in performance

appraisal of all staff members.

Are you a pathway warrior?

1. A pathway is a. A time-bound clinical algorithmb. A standard treatment protocol with pre-specified outcomesc. A pre-printed order setd. All of the above Answer: D

2. A pathway is completely activated bya. The nurse in chargeb. The attending physicianc. The emergency room physiciand. All of the aboveAnswer: D. Complete activation requires approval by the managing

physician and acknowledgment by the nurse in charge.

Are you a pathway warrior?3. The following personnel must write his/her initial and time done next

to each pathway order after it has been done:a. Resident in charge or on dutyb. Nurse in chargec. Intern in charge or on dutyd. All of the above

Answer: D. 4. If an additional order not on the pathway is desired, such an order must

be writtena. On the pathwayb. On the standard Order Sheetc. On the Progress Notesd. Any of the above

Answer: B

Are you a pathway warrior?5. Who reviews the pathway daily?

a. Nurse In Chargeb. Resident In Chargec. Intern In Charged. All of the above

Answer: D6. A variance is recorded as a variance code in the variance column when

a. A lab test is not done during the care intervalb. An outcome is not met during the care intervalc. A treatment is not done during the care intervald. All of the above

Answer: D

Are you a pathway warrior?7. Which of the following pathway/s is/are implemented in TMC?

a. Coronary artery bypass graftb. Pneumonia in childrenc. Normal birthd. All of the above

Answer: D8. If the admitting staff fails to activate a pathway in a patient whose

condition is covered by a TMC pathway, what should be done on the succeeding hospital days? a. continue writing orders on the standard Order Sheetb. look for the admitting staff member so that a pathway can be activated in retrospectc. activate the pathway on the succeeding daysd. do not activate the pathway anymore

Answer: C. Even if the pathway has not been activated upon admission, the patient can still be managed according to pathway orders on succeeding days provided he meets the inclusion criteria

Are you a pathway warrior?

8 out of 8 – your patients are cared for in an evidence-based, standardized fashion

6 or 7 out of 8 – your patients are nearly at par with those in other JCI accredited hospitals

4 or 5 out of 8 – some of your patients are not being cared for according to world class levels of quality

2 or 3 out of 8 – you can improve the quality of your patients’ care!*

0 or 1 out of 8 – let us try again** Please go over the slides again.

This SIM Card certifies that

______(please overwrite with your name, thank you)__, MD

has successfully completed the

Self Instructional Module on Clinical Pathways.

(Sgd) Dr Alfredo Bengzon (Sgd) Dr Jose AcuinPresident and CEO Director, Medical Quality Improvement

Clinical Pathways and Variance Analysis

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