clinicalpathways

7/28/2019 clinicalpathways

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CLINICALPATHWAYS


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Introduction

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 thedelivery of healthcare. One such application of this

science to healthcare is Clinical Pathways.


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Critical Pathways

Interdisciplinary in focus

Medical and nursing plans

Physical therapy, Nutrition and MentalHealth


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History

1950s - Critical Path & Process Mapping

methodology in Engineering industry

1980s - Clinicians in Insurance industry, USA

Late 1980s - Prospective reimbursement systemat the New England Medical Center, UK

Early 1990s - Anticipated Recovery Pathwaysby

NHS in the U.K

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


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History

1994 - National Pathways User Group / NationalPathway 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 Projectsacross the U.K.


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Definition

Clinical Pathways (CP)is multidisciplinary

plans of best clinical practice for specified

groups of patients with a particular

diagnosis that aid the co-ordination anddelivery 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.


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Synonyms

Anticipatory recovery pathways (ARPs)

Integrated Care Pathways,

Multidisciplinary pathways of care ( MPCs),

Pathways of Care,

Care Maps,

Collaborative Care Pathways

Critical Pathway

Anticipated Recovery Path Managed care plans

Care track

Care Profiles


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WhyClinical 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


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As Active Management Tools

Eliminate prolonged lengths ofstay 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 andcorrect these promptly

Facilitate quality management and an outcomes

focus


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Distinguish Critical

Pathways From Clinical Protocols Protocols are treatment recommendations that are

often based onguidelines. Like the critical pathway,the goal of the clinical protocolmay be to decreasetreatment variation.

Protocols are mostoften focused on guidelinecompliance rather than the identificationof rate-limiting steps in the patient care process.

In contrast to critical pathways, protocols may ormay not include acontinuous monitoring and data-

evaluation component.


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Four Components of a Clinical

Pathway

A Timeline,

Categories of care or activities and their

interventions, Intermediate and long-term outcome

criteria,

Variance record


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Clinical Pathway DevelopmentPrerequisites

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 bywhom; since it promotes greater awareness of the

role of each professional involved in the care cycle


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Basis of Critical Pathway Technique

Define the processes

Timing of these processes,

Note target areas thatwere critical,

Measure variation, and make improvements

Remeasurement.


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Guidelines for the Development and

Implementation Educate and obtain support from physicians and

nurse, and establish a multidisciplinary team.

Identify potential obstacles to implementation.

Use Qualityimprovementmethods and tools.

Determine staff interest and select ClinicalPathways to develop.

Collect Clinical Pathway dataandmedical recordreviews of practice patterns.

Conduct literaturereviewof clinical practiceguidelines.

Develop variance analysis system and monitor thecompliance with documentation on ClinicalPathways.

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


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Constituents of Clinical Pathways

Multi-disciplinary, multi-agency, clinical andadministrative activities

Structured Variance Tracking

Local and National standards

Evidence based, locally agreed, best practices

Tests, charts, diagrams, information leaflets, satisfactionquestionnaires, etc.

Scales for measurement of clinical effectiveness

Outcomes

Freehand notes

Scalability to add activities to a standard CP forindividualized care for a particular patient

Problem, Plan, Goal and Notes or similar structuredfreehand area


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Optimum development and

implementation strategies

Select a Topic

Topic of high-volume, high-costdiagnoses andprocedures.

For example:- Critical pathway development forcardiovascular diseases and procedures

Select a Team

Active physician participation and leadershipiscrucial

Representatives fromall groups


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Strategies continued

Evaluate the Current Process of Care Key to understandingcurrent variation

A carefulreview of medical records

Identify the criticalintermediate outcomes, rate-limiting

steps, and high-cost areas

on which to focus.

Evaluate Medical Evidence and ExternalPractices

Evaluate the literature to identify evidence of bestpractices

In the absence of evidence, comparisonwith otherinstitutions, or "benchmarking," is the most reasonable

method to use.


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Determine the Critical Pathway Format

The format of the pathway includea task-time

matrix

spectrum of pathways of the medical record used

as a simplechecklist


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Document and Analyze Variance The most important processesin the critical

pathway

Identification of factors thekey features in process

improvement

Variance inclinical pathways is a result of the

omission of an action orthe performance of an

action at an inappropriate (often, a late) time

period.

Team to concentrateon a few critical items in the

pathway that have been identifiedin advance

For example: length of stay in the intensive care

unit


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Benefits

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


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Benefits

Help reduce variations in patient care (by

promoting standardization)

Help improve clinical outcomes

Help improve and even reduce patientdocumentation

Support training

Optimize the management of resources

Can help ensure quality of care and provide ameans of continuous quality improvement


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Benefits

Support the implementation of continuous clinical

audit in clinical practice

Support the use of guidelines in clinical practice

Help empower patients Help manage clinical risk

Help improve communications between different

care sectors


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Benefits

Disseminate accepted standards of care

Provide a baseline for future initiatives

Not prescriptive: don't override clinical judgment

Expected to help reduce risk

Expected to help reduce costs by shortening

hospital stays


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Are Clinical Practice Guidelines

and Clinical Pathways 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 bestevidence about prevention, diagnosis, prognosis,therapy, harm, and cost-effectiveness

Identify the range of potential decisions and provide

the physicians with the evidence which, whenadded to individual clinical judgment and patient'svalues and expectations, will help them their owndecisions in the best interest of the patient.


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Characteristics of Clinical practice guidelines

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 caneventually help to improve the clinical practice and

support the difficult decisions task for the clinicians

.


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Limitations of Clinical Pathways

Implementation of the care pathways has not been

testedin a scientific or controlled fashion.

No controlled studyhas shown a critical pathway to

reduce length of stay, decrease

resource use, orimprove patient satisfaction.

Most importantly,no controlled study has shown

improvements in patient outcome


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Potential Problems and Barriers to the

Introduction of Clinical Pathways

May appear to discourage personalized care Risk increasing litigation

Don't respond well to unexpected changes in apatient's condition

Suit standard conditions better than unusual orunpredictable ones

Require commitment from staff and establishment ofan adequate organizational structure

Problems of introduction ofnew technology

May take time to be accepted in the workplace Need to ensure variance and outcomes are properly

recorded, audited and acted upon.


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Challenges faced for

Implementation Difficulties 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 staffbecause

of their high turn-over, limited free time and heavy

clinical loads

Problems in finding a common meeting time acrossdisciplines, 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


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Technologies applied

J2EE open standards

Component-based architecture implemented in

Java 2

Supports the integration of systems using standardprotocols such as HL7, Edifact and XML

Oracle 9i common data storage

LDAP directory server to support user profiles and

security Tibco Active Enterprise(PAS module)


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Conclusion

A Clinical Pathway is thus a road map

for a patient as well as for the treatmentteam, which supports an Effective In-

patient Care.


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THANK YOU

Prepared by

Dr. S. Lakshmipradha

clinicalpathways

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