1. Care Pathways The how and why of clinical management Pieter Degeling

2. Policy agenda of health reform  Search for efficiency - 1980’s  Funding  New management structures  Information technology +  Emerging Clinical Performance Agenda – 1995  Clinical audit  Clinical effectiveness  Service integration  Safety/quality  Evidence based  Risk management  Quality improvement  Value for money

3. Policies are aimed to encourage structured multidisciplinary conversations about questions such as: Are we doing the right things?  In light of assessed health needs and existing resource constraints, are we delivering value for money?  On a condition-by-condition basis, how appropriate and effective are the services we offer? Are we doing things right?  On a condition by condition basis, how systematized are our care processes?  How are we performing on risk, safety, quality, patient evaluation and clinical outcomes? Do we have the capacity to get better?  On a condition-by-condition basis, what strategies are in place for service and professional development?  What are we doing about clinical mentoring, leadership development, staff appraisal and review?

4. Some questions about implementing this approach  At what organizational level should these conversations occur?  Who should be involved?  Who should generate and facilitate these conversations?  What structural and resource supports will these people require?  What methods might they use?

5. Answers  Org level  Involvement  Responsibility  Structural support  Method Clinical unit/team Multidisciplinary team Clinician managers Authorisation via CG Clinical pathways (H/V)

6. Conventional Hospital Organisation

7. “Clinical Product Line” Model Final Products Intermediate Products

8. Final Products Intermediate Products

9. What was missing was a method

10. Quality Indicators Outcome Indicators Routine Review of Variance Prospectively Costed Integrated Care Pathways Characteristics of Integrated Care Pathways

11.  Systematically developed and evidenced based written statements,  About the agreed sequence of diagnostic and therapeutic events in primary, acute and/or community care  Whose occurrence or non occurrence, for high volume case types, will significantly affect, quality, outcomes and cost.

12. Why high volume case types? High volume case types are those for which :  we can get the biggest ‘bang for the buck’ as we attempt to improve:  Efficiency  Effectiveness  Patient Experience  Quality  We can generate reliable data for statistical analysis

13. High volume case types – major teaching hospital 40 HRGs (out of 547) account for 46% of all emergency episodes and these HRGs account for 37% of all emergency generated bed days 19 of these HRGs reference conditions that have a high risk of readmission that account for 27% of A&E admissions and 15% of A&E generated bed days 40 HRGs account for 46% of all elective admissions and these account for 28% of all elective bed days. 40 HRGs account for 79% of elective day cases 10 HRGs account for 96% of maternity (&birth) admissions and 91% of maternity bed days

14. High volume case types- DGH (4 ) Emergency admissions account for 53% of all care episodes and 82.9% of all bed days consumed within the Trusts 30 HRGs (out of 547) account for 46% of all emergency episodes and these HRGs account for 39% of all emergency generated bed days within the Trusts. 18 of these HRGs reference conditions (usually chronic) with a high risk of repeated emergency admission. These patients tend to account for 32.8% of all emergency patient episodes and 17.6% of all bed days. Non day elective episodes account for 17% of all bed days with the Trusts 54 HRGs account for 67.9% of all nonday elective episodes. These HRGs account for 63% of elective non day bed days used within the Trusts. 30 HRGs account for 75% of all day only elective episodes.

15. High Volume Emergency Admissions – Repeated Adm HRGHRG label% Adm% B Days D20Chron Obstruct Pulmonary Dis/Bronch37.2239.16 S16Poison Toxic Effects /Overdoses18.2517.62 P06Minor Infections (incl Immune Disord)5.417.73 E36Chest Pain <70 w/o cc7.477.81 D21Asthma >49 or w cc1.441.41 F47Gen Abdom Disord <70 w/o cc4.847.85 E33Angina >69 or w cc18.1118.73 H42Sprains Strains /Minr Open Wounds <70 w/o cc1.431.11 L09Kidney/Urin Tract Infections >69 or wcc3.772.92 D99Comp Eld w a Respiratory Sys PDx6.545.81 E18Heart Fail/Shock >69 or wcc6.675.38 E29Arrhythmia/Conduction Disord >69 or wcc4.683.37 P13Other Gastro/Metabol Disord9.1615.09 E31Syncope/Collapse >69 or wcc2.873.31 F46Gen Abdom Disord >69 or wcc5.784.44 E12Acute Myocardial Infarction w/o cc0.660.37 P03Upper Respiratory Tract Disord5.739.07 E35Chest Pain >69 or w cc7.266.99 P15Accidental Injury1.681.38 P04Lower Respiratory Tract Disord11.3721.33 E34Angina <70 w/o cc13.6517.11 F17Stom/Duod Disord >69 or wcc2.222.17 A22Non-Transient Stroke/CVA >69 or wcc0.100.12 D13Lobar Atyp/Viral Pneumon >69 or wcc2.132.33

16. High Volume Elective Cases HRGHRG labelElec AdmDay CaseTot% ElecCum % Day N12Other Maternity Events87822276231545.38 96.21 L21Bladder Minor Endo Px w/o cc147514221156963.659.0390.60 F98Chemo w a Digestive Sys PDx53578852142093.3012.3362.30 B02Phako Cataract Extract w Lens Implant32788604118822.7615.0972.41 F06Oesophagus - Diagnostic Pxs9019313102142.3717.4691.18 S01Haematol Disord w Minor Px19518236101872.3719.8380.85 J37Minor Skin Pxs - Cat 1 w/o cc1233871099432.3122.1487.60 A07Intermediate Pain Pxs1317818795042.2124.3486.14 M06Upper Genital Tract Inter Pxs3327584591722.1326.4763.73 M10Surg Termination of Pregnancy594737779711.8528.3392.55 S22Planned Pxs Not Carried Out4797312379201.8430.1739.43 C24Mouth/Throat Pxs - Cat 3708937074591.7331.904.96 E14Cardiac Catheterisation w/o Complicat2147516073071.7033.6070.62 J98Chemo w a Skin Breast/Burn PDx3413337567881.5835.1749.72 F35Large Intestine - Endo/Inter Pxs762566664281.4936.6788.15 F16Stom/Duod - Diagnos Pxs476550959851.3938.0692.05 S98Chemo w a Haem Inf Dis Poison /Non-spec PDx1611407456851.3240.7471.66 E15Percutan Translum Coronary Angioplasty (PTCA)5168951771.2041.940.17 H26Inf Spne Joint/Conn Tiss Disrd <70 or w/o cc877420850851.1843.1282.75 M98Chemo w a Fem Reprod Sys PDx3478124047181.1044.2226.28 B05Other Ophthalmic Pxs - Cat 2379403744161.0345.2491.42 E04Coronary Bypass37990 0.8846.130.00 D17Cystic Fibrosis355323437870.8847.016.18 M07Upper Genital Tract Maj Pxs352218437060.8647.874.96

17. High Volume Elective Cases – % Day Cases HRGHRG labelDC %Nat DC %Risk N12Other Maternity Events44.5742945.57 L21Bladder Minor Endo Px w/o cc89.1542887.56Hgh Sig F98Chemo w a Digestive Sys PDx61.7768283.86Low Sig B02Phako Cataract Extract w Lens Implant71.9277785.13Low Sig F06Oesophagus - Diagnostic Pxs88.8475595.13Low Sig S01Haematol Disord w Minor Px78.0663586.21Low Sig J37Minor Skin Pxs - Cat 1 w/o cc81.0006582.57Low Sig A07Intermediate Pain Pxs85.7187793.62Low Sig M06Upper Genital Tract Inter Pxs62.6004174.63Low Sig M10Surg Termination of Pregnancy91.5374190.71Hgh Sig S22Planned Pxs Not Carried Out37.477553.3Low Sig C24Mouth/Throat Pxs - Cat 34.76313126.32Low Sig E14Cardiac Catheterisation w/o Complicat57.2951463.08Low Sig J98Chemo w a Skin Breast/Burn PDx49.3276890.84Low Sig F35Large Intestine - Endo/Inter Pxs85.8484893.91Low Sig F16Stom/Duod - Diagnos Pxs90.1194296.08Low Sig S98Chemo w a Haem Inf Dis Poison /Non-spec PDx67.7757479.73Low Sig E15Percutan Translum Coronary Angioplasty (PTCA)0.1476861.97Low Sig H26Inf Spne Joint/Conn Tiss Disrd <70 or w/o cc74.8887733.11Hgh Sig M98Chemo w a Fem Reprod Sys PDx25.6145472.07Low Sig B05Other Ophthalmic Pxs - Cat 287.2676290.41Low Sig E04Coronary Bypass00.17Low Sig D17Cystic Fibrosis4.54987422.67Low Sig M07Upper Genital Tract Maj Pxs4.3365541.62Hgh Sig

18. A number of important provisos  ICPs are not immutable documents setting out inviolable treatment regimens.  The existence of a pathway does not obviate clinicians’ responsibility to make clinical judgements and to tailor care according to their assessment of the clinical needs of individual patients.  Thus clinical variation remains a ‘to be expected’ (in the sense of an often required) feature of clinical practice.  The matter at issue is what a clinical team can learn from these variations and how they can systematize this learning.  Accordingly, when the care process varies from that described in the pathway, the reasons for the variance are recorded and become the focus of structured across-profession conversations described above.

19. Benefits of Pathways Pathways central to:  Clinical work systemisation - improved quality, patient experience and efficiency  Across sector/profession communication  Across time and location benchmarking  Moving clinical governance from issues management to a clinical improvement  Integrating the reform agenda

20. Clinical systematisation – does it work? -60 -40 -20 0 20 40 60 -8-6-4-20246 STRINGENT BUDGET MANAGEMENT ORIENTATION SOME PROPENSITY TO WORK PROCESS CONTROL FORGIVING BUDGET MANAGEMENT ORIENTATION MINIMAL PROPENSITY TO WORK PROCESS CONTROL Good quality Variable to poor quality 5 6 1 2 11 3 12 8 4 7 910 Degeling et al 2000

21. Across profession communication

22. Cultural orientations of professions SYSTEMATISED CONCEPTS OF CLINICAL WORK INDIVIDUALISTIC CONCEPTS OF CLINICAL WORK Clinical Purism and Opaque Accountability Financial realism and transparent accountability

23. The across country (across time) resilience of professional sub-cultures SYSTEMATISED CONCEPTS OF CLINICAL WORK INDIVIDUALISTIC CONCEPTS OF CLINICAL WORK Clinical purism and opaque accountability Financial Realism and transparent accountability

24. Pathways as mediums for enacting culture change Clinical/Resource interconnections Clinical work systemisation Shared multidisciplinary power Transparent Accountability CLINICAL PATHWAY BASED MANAGEMENT SYSTEMS

25. Across sector communication

26. Acute Care TrustsPCTsGeneral Practice 1Financial viability Quality 2 Equal access 3 Organisational stability 4ProductivityQualityStaff welfare 5Equal accessStaff welfareFinancial viability 6Service innovation Productivity 7Staff welfareProductivityService innovation 8Teaching and research Organisational goals ranked across Sectors

27. Professional Subcultures Acute MCMMGMNMNCAHMAHC Clinical/ Resource interconnections-++++/-+- Transparent accountability-+/-++ +- Work systematisation--+/- - Multidisciplinary teams--+/-+++- PCT LeadGMNMNCGPPNPM Clinical/Resource interconnections+/-++ - - Transparent accountability+/-+++-- Work systematisation+/-+++- Multidisciplinary teams+/- ++--

28. Cultural stances of Professions in hospital and primary care settings Financial realism and transparent accountability Emphasis on clinical purism and opaque accountability Individualistic concepts of clinical work Systematised concepts of clinical work

29. Consequences of absence of method for across sector communication

30. High Volume Emergency Admissions – Repeated Adm HRGHRG label% Adm% B Days D20Chron Obstruct Pulmonary Dis/Bronch37.2239.16 S16Poison Toxic Effects /Overdoses18.2517.62 P06Minor Infections (incl Immune Disord)5.417.73 E36Chest Pain <70 w/o cc7.477.81 D21Asthma >49 or w cc1.441.41 F47Gen Abdom Disord <70 w/o cc4.847.85 E33Angina >69 or w cc18.1118.73 H42Sprains Strains /Minr Open Wounds <70 w/o cc1.431.11 L09Kidney/Urin Tract Infections >69 or wcc3.772.92 D99Comp Eld w a Respiratory Sys PDx6.545.81 E18Heart Fail/Shock >69 or wcc6.675.38 E29Arrhythmia/Conduction Disord >69 or wcc4.683.37 P13Other Gastro/Metabol Disord9.1615.09 E31Syncope/Collapse >69 or wcc2.873.31 F46Gen Abdom Disord >69 or wcc5.784.44 E12Acute Myocardial Infarction w/o cc0.660.37 P03Upper Respiratory Tract Disord5.739.07 E35Chest Pain >69 or w cc7.266.99 P15Accidental Injury1.681.38 P04Lower Respiratory Tract Disord11.3721.33 E34Angina <70 w/o cc13.6517.11 F17Stom/Duod Disord >69 or wcc2.222.17 A22Non-Transient Stroke/CVA >69 or wcc0.100.12 D13Lobar Atyp/Viral Pneumon >69 or wcc2.132.33

31. GP Practice Variation – Percentage of Additional Patients with COPD and Asthma by Angina within each Practice

32. Some thoughts on chronic disease Application ‘year of care’ concept to long- term conditions

33. Chronic Disease Progression Time Wellness Stage 1: Self Management Stage 2: Care Management Stage 3: Case Management 0

34. Issues  Can we affect the rate of disease progression? Yes  Who is best placed to do this? Primary Care  What do we require to bring it off? ‘Year of care pathway’

35. Requires … Year of care pathways that, for each stage of disease progression (stage 1,2, 3 …),  describe the composite of ‘care activities’  That will be undertaken by both patients and service providers  in the period of a year

36. Year of care pathways are: Written statements that,  for nominated conditions and specified stage of progression within a condition  describes the sequence of diagnostic and therapeutic events  that will be performed by patients and care providers (often in different service settings)  whose occurrence or non occurrence will significantly affect, quality, outcomes and cost For example year of care pathways for patients with: Stage 1 Diabetes or Stage 3 COPD or Stage 2 CHD.

37. Components of a ‘Year of Care’  Clinical management  Diagnostic/Monitoring  Drugs  Therapy  Patient self-management  Empowered patient  Patients as co-producer  Patient as choice maker  Support Component

38. Co-producing Patients… Are patients who take responsibility for managing their condition with respect to:  Knowledge of their disease  Self monitoring  Therapeutic interventions  Diet  Exercise  Smoking Paradoxically: this requires structured support from service providers

39. A ‘Year of Care Model’ for COPD Tests & Drugs type 1 Patient as Co-ProducerSupport Self Management Tests & Drugs type 2 Patient as Co-producer Support Care Management Tests & Drugs Type 3 Patient as Co-Producer Support Case Management

40. Potential percentage bed day savings for HRGs with significant repeated admission rates

41. Clinical government benefits of pathways From issues to clinical performance management

42. Conventional model of clinical governance Risk management Clinical Audit Clinical EffectivenessQuality Assurance Research Development Clinical Governance Committee TRUST Staff

43. Clinical Production Focused Model – Acute settings Each condition/treatment specific report includes data on evidence, cost outcomes, clinical effectiveness, quality, safety, adverse events, variance, complaints/claims TRUST/MANAGEMENT BOARD/CEO ORTHOPAEDICS UNIT Hip Replacement Type 1 Facture Type 1Fracture Type 2 Knee Replacement Type 1 Hip Replacement Type 2 Clinical Governance Council

44. Clinical Production Focused Structure – PCT settings Each condition/treatment specific report includes data on evidence, cost outcomes, clinical effectiveness, quality, safety, adverse events, variance, complaints/claims TRUST/MANAGEMENT BOARD CLINICAL GOVERNANCE COUNCIL (PEC GROUP) Year of care for Diabetes Year of care for COPD Year of care for CHD Year of care for Self harm patients Year of care for Asthma

45. Pathways as mediums for integrating the modernisation agenda

46. Instead of silos… CHOICECHOICE COMMISSIONCOMMISSION CLINGOVCLINGOV INFOTECHINFOTECH PERFORMANCEPERFORMANCE CAP RENEWALCAP RENEWAL INTEGRATIONINTEGRATION WORKFORCEDEVTWORKFORCEDEVT

47. An Integrated Agenda Patient Choice Service Integration Workforce Developme nt Clinical Pathway Focused Management Systems Capital Renewal Commissionin g Clinical Governance & Performance Management Information Technology

48. So what are we waiting for?