CLINICALCLINICAL PATHWAYSPATHWAYS

IntroductionIntroduction

The application of computers to generate, validate, secure and integrate healthcare data to support the decision making activities of clinical and administrative professional has added an entirely new dimension to the functioning of healthcare industry.

Techniques of Quality Management Science are among the newer approaches to managing the delivery of healthcare. One such application of this science to healthcare is Clinical Pathways.

Critical Pathways Critical Pathways

Interdisciplinary in focusMedical and nursing plans Physical therapy, Nutrition and Mental

Health

HistoryHistory

1950s - Critical Path & Process Mapping methodology in Engineering industry

1980s - Clinicians in Insurance industry, USA Late 1980s - Prospective reimbursement

system at the New England Medical Center, UK

Early 1990’s - ‘Anticipated Recovery Pathways’ by NHS in the U.K

1991-92 - 12 pilot sites for Pathways were set up in Northwest London

HistoryHistory

1994 - National Pathways User Group / National Pathway Association was set up.

Integrated Care Pathway (ICP) in the U.K. evolved.

2002 - NeLH Pathways Database was launched.

Free sharing of ICPs and ICP Projects across the U.K.

DefinitionDefinition

“Clinical Pathways (CP) is multidisciplinary plans of best clinical practice for specified groups of patients with a particular diagnosis that aid the co-ordination and delivery of high quality care. They are both, a tool and a concept, which embed guidelines, protocols and locally agreed, evidence-based, patient-centered, best practice, into everyday use for the individual patient”.

SynonymsSynonyms

Anticipatory recovery pathways (ARPs) Integrated Care Pathways, Multidisciplinary pathways of care ( MPCs), Pathways of Care,Care Maps, Collaborative Care PathwaysCritical PathwayAnticipated Recovery PathManaged care plansCare trackCare Profiles

WhyWhy Clinical Pathways?Clinical Pathways?

To improve patient care To maximize the efficient use of

resources To help identify and clarify the clinical

processes To support clinical effectiveness,

clinical audit and risk management

As Active Management ToolsAs Active Management Tools

Eliminate prolonged lengths of stay arising from inefficiencies, allowing better use of resources

Reduce mistakes, duplication of effort and omissions

Improve the quality of work for service providers Improve communication with patients as to their

expected course of treatment Identify problems at the earliest opportunity and

correct these promptlyFacilitate quality management and an outcomes

focus

Distinguish Critical Distinguish Critical Pathways From Clinical Pathways From Clinical ProtocolsProtocolsProtocols are treatment recommendations

that are often based on guidelines. Like the critical pathway, the goal of the clinical protocol may be to decrease treatment variation.

Protocols are most often focused on guideline compliance rather than the identification of rate-limiting steps in the patient care process.

In contrast to critical pathways, protocols may or may not include a continuous monitoring and data-evaluation component.

Four Components of a Clinical Four Components of a Clinical Pathway Pathway

A Timeline, Categories of care or activities and

their interventions,Intermediate and long-term outcome

criteria, Variance record

Clinical Pathway DevelopmentClinical Pathway DevelopmentPrerequisitesPrerequisites

Succeed when the decision to develop is taken on an organizational basis.

Senior management commitment and a strong medical and nursing lead are essential

Pathway documentation is more likely to be used if it is simple, clear and user friendly

The process of pathway development considers why tasks and interventions are performed, and by whom; since it promotes greater awareness of the role of each professional involved in the care cycle

Basis of Critical Pathway Basis of Critical Pathway TechniqueTechnique

Define the processes

Timing of these processes, Note target areas that were critical, Measure variation, and make

improvementsRemeasurement.

VariationVariation

Systems variations Health and social care professional

variations Patient variations

Guidelines for the Development Guidelines for the Development and Implementation and Implementation Educate and obtain support from physicians and

nurse, and establish a multidisciplinary team. Identify potential obstacles to implementation.Use Quality improvement methods and tools.Determine staff interest and select Clinical

Pathways to develop.Collect Clinical Pathway data and medical

record reviews of practice patterns.Conduct literature review of clinical practice

guidelines.Develop variance analysis system and monitor

the compliance with documentation on Clinical Pathways.

Use a pilot Clinical Pathway for 3 to 6 months; revise as needed.

Constituents of Clinical Constituents of Clinical PathwaysPathways Multi-disciplinary, multi-agency, clinical and

administrative activities Structured Variance Tracking Local and National standards Evidence based, locally agreed, best practices Tests, charts, diagrams, information leaflets,

satisfaction questionnaires, etc. Scales for measurement of clinical effectiveness Outcomes Freehand notes Scalability to add activities to a standard CP for

individualized care for a particular patient Problem, Plan, Goal and Notes or similar

structured freehand area

Optimum development and Optimum development and implementation strategiesimplementation strategiesSelect a Topic Topic of high-volume, high-cost diagnoses

and procedures. For example:- Critical pathway development

for cardiovascular diseases and procedures

Select a Team Active physician participation and

leadership is crucial Representatives from all groups

Strategies continuedStrategies continued

Evaluate the Current Process of Care Key to understanding current variation A careful review of medical records Identify the critical intermediate outcomes, rate-

limiting steps, and high-cost areas on which to focus.

Evaluate Medical Evidence and External Practices

Evaluate the literature to identify evidence of best practices

In the absence of evidence, comparison with other institutions, or "benchmarking," is the most reasonable method to use.

Strategies continuedStrategies continued

Determine the Critical Pathway FormatThe format of the pathway include a task-

time matrixspectrum of pathways of the medical record

used as a simple checklist

Strategies continuedStrategies continued

Document and Analyze VarianceThe most important processes in the critical

pathway Identification of factors the key features in

process improvementVariance in clinical pathways is a result of the

omission of an action or the performance of an action at an inappropriate (often, a late) time

period.Team to concentrate on a few critical items in the

pathway that have been identified in advanceFor example: length of stay in the intensive care

unit

BenefitsBenefits

Support the introduction of evidence-based medicine and use of clinical guidelines

Support clinical effectiveness, risk management and clinical audit

Improve multidisciplinary communication, teamwork and care planning

Can support continuity and co-ordination of care across different clinical disciplines and sectors;

Provide explicit and well-defined standards for care

BenefitsBenefits

Help reduce variations in patient care (by promoting standardization)

Help improve clinical outcomesHelp improve and even reduce patient

documentation Support trainingOptimize the management of resourcesCan help ensure quality of care and provide

a means of continuous quality improvement

BenefitsBenefits

Support the implementation of continuous clinical audit in clinical practice

Support the use of guidelines in clinical practice

Help empower patientsHelp manage clinical riskHelp improve communications between

different care sectors

BenefitsBenefits

Disseminate accepted standards of careProvide a baseline for future initiativesNot prescriptive: don't override clinical

judgmentExpected to help reduce riskExpected to help reduce costs by shortening

hospital stays

AreAre Clinical Practice Clinical Practice Guidelines Guidelines and and Clinical Clinical Pathways Pathways related? related?

Characteristics of Clinical practice guidelines Attempt to define practice questions and

explicitly identify all their decision options and outcomes

Explicitly identify, appraise and summarize the best evidence about prevention, diagnosis, prognosis, therapy, harm, and cost-effectiveness

Identify the range of potential decisions and provide the physicians with the evidence which, when added to individual clinical judgment and patient's values and expectations, will help them their own decisions in the best interest of the patient.

Characteristics of Clinical practice Characteristics of Clinical practice guidelinesguidelines

Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. This is the source for the clinical practice guidelines.

This shows that clinical pathways, when used in combination with clinical practice guidelines, will assist in reinforcing a clinical workflow, which can eventually help to improve the clinical practice and support the difficult decisions task for the clinicians .

Limitations Limitations of Clinical of Clinical PathwaysPathways

Implementation of the care pathways has not been tested in a scientific or controlled fashion.

No controlled study has shown a critical pathway to reduce length of stay, decrease

resource use, or improve patient satisfaction.

Most importantly, no controlled study has shown improvements in patient outcome

Potential Problems and Barriers to Potential Problems and Barriers to thethe Introduction of Clinical Introduction of Clinical Pathways Pathways

May appear to discourage personalized care Risk increasing litigation Don't respond well to unexpected changes in

a patient's condition Suit standard conditions better than unusual

or unpredictable ones Require commitment from staff and

establishment of an adequate organizational structure

Problems of introduction of new technology May take time to be accepted in the

workplace Need to ensure variance and outcomes are

properly recorded, audited and acted upon.

Challenges faced for Challenges faced for IImplementationmplementationDifficulties in engaging senior clinicians and

persuading them to participate in the procedure of designing and implementation of the clinical pathways (e.g. engaging a cardiologist or neurologist in the process)

Difficulties in engaging junior medical staff because of their high turn-over, limited free time and heavy clinical loads

Problems in finding a common meeting time across disciplines, and getting the multidisciplinary staff involved in the use of the clinical pathways for the training for their effective use and learning their importance in the clinical practice

Technologies Technologies appliedapplied

J2EE open standardsComponent-based architecture implemented in

Java 2Supports the integration of systems using

standard protocols such as HL7, Edifact and XMLOracle 9i common data storageLDAP directory server to support user profiles and

securityTibco Active Enterprise(PAS module)

ConclusionConclusion

A Clinical Pathway is thus a road map for a patient as well as for the treatment team, which supports an Effective In-patient Care.

THANK YOUTHANK YOU

Prepared by

Dr. S. Lakshmipradha