CLINICAL PATHWAYS

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 the delivery of healthcare. One such application of this science to healthcare is Clinical Pathways.

Critical Pathways

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

Health

History

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

History

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.

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 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”.

Synonyms

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

Why 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 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 promptly

Facilitate quality management and an outcomes focus

Distinguish Critical Pathways From Clinical Protocols

Protocols 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 Pathway

A Timeline, Categories of care or activities and

their interventions,Intermediate and long-term outcome

criteria, Variance record

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 by whom; since it promotes greater awareness of the role of each professional involved in the care cycle

Basis of Critical Pathway Technique

Define the processes

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

improvementsRemeasurement.

Variation

Systems variations Health and social care professional

variations Patient variations

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 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 Pathways

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 implementation strategies

Select 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 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 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 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

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

Benefits

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

Benefits

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

Benefits

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

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 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 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 can eventually help to improve the clinical practice and support the difficult decisions task for the clinicians .

Limitations of Clinical Pathways

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 the Introduction of Clinical 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 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 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 applied

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)

Conclusion

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 YOU

Prepared by

Dr. S. Lakshmipradha