2 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.
3 Why pathways? 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.
4 Why does JCI recognize pathways Pathways reflect care that is –PlannedStandardizedOrganizedDocumented
5 Why pathways?Pathways can improve team communication and coordination of care, thus preventing medical errors.
6 Why pathways?Pathways can improve team communication and coordination of care, thus preventing medical errors.
7 How is a TMC pathway developed Pathway topics are chosen from Medical City’s high-volume, high-risk or problem-prone cases.MQIO forms a multidisciplinary pathway team.The team defines population of patients to be covered by the pathway.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
8 How is a TMC pathway developed 5. The team presents the pathway to the concerned departments and units for approval6. The team pilot tests the pathway to ensure ease of use7. MQIO monitors and evaluates pathway use byMeasuring and analyzing variancesMaking appropriate modifications to the clinical contentAddressing process improvement
9 What pathways are implemented in TMC? Acute asthmatic attackAcute abdominal pain (non-traumatic)Chest painPneumonia (in adults and children)Normal birthAcute appendicitisAcute diarrhea (in adults and children)Coronary artery bypass graft procedureSepsis alert
10 Parts of a Clinical Pathway Pathway titleInclusion and exclusion criteriaPatient’s informationPhysician’s NotesS: subjective complaints/symptomsO: objective physical and laboratory findingsA: assessment/ working diagnosis/ clinical impressionP: plan of care (diagnostic, therapeutic, rehabilitative, others)
11 Parts of a clinical pathway 5. OrdersAssessment 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)
12 Parts of a Clinical Pathway 5. OrdersActivity/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)
13 Parts of a Clinical Pathway Orders or interventions may be mandatory or optionalMandatory interventions – marked by bullets (•) and applicable to 100% of the populationMust be carried out once a pathway is activatedDon’t need a checkmark to be carried outIf deemed not applicable to the patient, may be crossed out and initialed by APOptional interventions – marked by tick boxes () and may not apply to 100% of the populationOption box () should be marked with a check () if the intervention meets the needs of the patientIf box is left empty, intervention need not be done
14 Parts of a Clinical Pathway 6. Pathway activation- by the attending physician or resident-in-charge7. Pathway acknowledgement- by the nurse-in-charge8. Variance column9. Signature column
15 Parts of a clinical pathway 1. Pathway title2. Eligibility & exclusion criteria3. Patient’s data
16 Parts of a clinical pathway 4. Physician’s notes (SOAP)5. Orders
17 Parts of a clinical pathway Bulleted interventions are mandatory interventionsInterventions with tick boxes are optional interventions
18 Parts of a clinical pathway 6. Pathway activation7. Pathway acknowledgment
19 Parts of a clinical pathway 8. Variance column9. Signature column
20 How are clinical pathways used? General guidelines in using pathwaysThe 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.
21 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 bottomOnce activated, the pathway shall serve as a pre-printed doctor’s order setThe 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.
22 The role of the MD in using pathways The AP / resident-in-chargeSees to it that all mandatory interventions are applicable to the patientCancels any mandatory intervention NOT applicable to the patient. REMEMBER: you must initial any canceled intervention.Ticks the optional interventions you think the patient needs
23 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 bottomCarries out all mandatory intervention that are not cancelled and optional interventions that are checkedwrites his / her initials and the time the order was done on the Sign column
24 All the other members of the care team have active roles in using pathways Accomplishing interventionsTherapists, 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
25 The pathway is a great tool for communicating to your co-workers: Use the pathway duringNursing shift endorsementAP roundsRounds by referred doctorsChart roundsInterdepartmental conferences
26 Variances A variance is any mandatory or checked optional intervention that was not done.an abnormal findingAn unmet outcome within the time frameVariances may be noted by any care team member.Whenever a variance is noted, the variance code and initials is written in the variance column.
27 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 theinterns’ or resident’s progress notes, if a MD noted the variancenurses’ 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.
28 Documenting variances The Variance column: where care team members write the Variance code
29 VARIANCE CODESA. Patient/family 1. Patient’s medical condition2. Patient/family decision3. Patient/family availability4. No funds5. Other reasonsB. Physician Medical order2. Provider(s) decision3. Provider(s) response time4. Other reasonsC. TMC System Results/Data availability2. Supplies/Equipment related3. Appointment Availability4. Weekend/HolidayD. Outside TMC Transportation availability2. Home Care availability3. Other reasonsFor example, if a mandatory test is not done because the patient has no money yet, the cause of that variance is encoded as “A4”.
30 How to analyze pathway variances Identify critical pathway orders. These are the orders which, if not carried, will significantly put the patient at risk for harm.Using the variance monitoring form, count the number of variances that occurred in the critical pathway orders.Perform RCA to determine causes of variances.Pilot test countermeasures.Monitor variance counts and note if they decrease over time..
31 OutcomesThe 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.
32 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.
33 Reviewing outcomes: nurse-in-charge’s role Reviews patient’s progress daily against intermediate and discharge outcomesReview 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.
34 Reviewing outcomesA met outcome – should be initialed; no other documentation necessaryAn unmet outcome – consider as varianceOutcome not met within time frame - may require adjusting the interventionVariance due to unmet outcome – describe in progress notes in SOAP formatOutcome met earlier than expected – a positive variance; document/initial on the date it was met
35 Discontinuing the pathway The pathway will be discontinued whenever:The patient’s primary diagnosis changesThe patient’s condition significantly worsensThe patient fails to meet clinical outcomes for 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.
36 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.
37 Are you a pathway warrior? A pathway isA time-bound clinical algorithmA standard treatment protocol with pre-specified outcomesA pre-printed order setAll of the aboveAnswer: DA pathway is completely activated byThe nurse in chargeThe attending physicianThe emergency room physicianAnswer: D. Complete activation requires approval by the managing physician and acknowledgment by the nurse in charge.
38 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 aboveAnswer: 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 aboveAnswer: B
39 Are you a pathway warrior? 5. Who reviews the pathway daily?a. Nurse In Chargeb. Resident In Chargec. Intern In Charged. All of the aboveAnswer: D6. A variance is recorded as a variance code in the variance column whena. 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 interval
40 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 aboveAnswer: 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 anymoreAnswer: 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
41 Are you a pathway warrior? 8 out of 8 – your patients are cared for in an evidence-based, standardized fashion6 or 7 out of 8 – your patients are nearly at par with those in other JCI accredited hospitals4 or 5 out of 8 – some of your patients are not being cared for according to world class levels of quality2 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.
42 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 Acuin President and CEO Director, Medical Quality Improvement