1. Clinical Pathways: Use as Quality Improvement Tools Larry Pennington MD

2. Clinical Pathways Clinical Pathways are structured, multidisciplinary plans of care designed to support the implementation of clinical guidelines and protocols. Introduced in the 1990’s in the UK and USA Improve the continuity of care across disciplines Step wise sequencing of care.

3. Clinical Pathways Main Components Timeline Categories of care or activities and their interventions Intermediate and long term outcome criteria Variance Record for documentation and analysis of deviation Differ from practice guidelines, protocols and algorithms

4. Clinical Pathways Time Line Pre- admission Admission Procedure Post-op Discharge

5. Clinical Pathways Categories of Care Medical Interventions Assessment Tests Activities Medications/Treatments Nutrition/Fluids Teaching Discharge Planning Tubes/Monitoring Key outcomes (physician/nursing)

6. Clinical Pathways Categories of Care (2) Assessment and Monitoring Activity/Environmental Consults Diagnostics Operative/Invasive Procedures Laboratory Nutrition/I.V. Therapy Medications Therapies Patient/Family Education Expected Outcomes

7. Clinical Pathways Variance Record Look for common variances Improve pathway Improve compliance

8. Clinical Pathways Reasons for Variance Patient’s clinical condition Patient’s social situation Associated diagnoses Changing technology or techniques Clinician’s discretion Consultation and internal system services External issues: primary care, home health care, etc

9. Clinical Pathways Aims Facilitate introduction of guidelines to improve the quality of care. Improve multidisciplinary communication Reach or exceed quality care standards Decrease unwanted practice variation Improve patient-clinician communication and patient satisfaction. Identify research and development questions

10. Clinical Pathways Surgical Pathways Abdominal Hysterectomy Aortic/mitral valve Total HipCoronary artery bypass Total KneeCarotid enarterectomy Femur Neck FractureCholecystectomy LaminectomyMastectomy ProstatectomyHernia repair TURP

11. Clinical Pathways Summary of Main Features Unitary, multidisciplinary plan for and record of care Details tasks, sequences, time-scale, and discipline. Contains a checklist of all necessary action Includes patient’s expected condition over time Requires minimal free text Freely available to the patient Efficient and structured format for recording key data Variances are noted and analyzed Plan and practice adjusted following audit

12. Clinical Pathways Benefits Facilitate the introduction of clinical practice goals and methods based on research evidence. More complete and accessible date for audit and change in practice Encourage multidisciplinary communication and care planning Promote patient focused care. Improve relationship with patient, relieve anxiety, increase participation in care. Reduce paperwork Enable new staff to integrate quickly Facilitate incorporation of improvements in care.

13. Waste of time Discourages appropriate clinical judgment Difficult with multiple pathologies and where clinical management is variable May stifle innovation and progress Needs leadership, energy, good communication and time and cooperation May be misused to reduce patient care costs inappropriately and allow for one faction of health care team to dominate. Clinical Pathways Concerns

14. Clinical Pathways Barriers to implementation Reluctance to change Lack of suitable guidelines and lack to resources to develop them locally. Obstructive interpersonal politics Lack of credit given for improvements in quality of care Cost driven goals dominate as opposed to quality based goals The person responsible for coordinating any care planning initiative must be sufficiently well informed and of high enough standing within the organization

15. Clinical Pathways Common Questions Will it increase litigation? Will it cause a lack of individualized care for each patient? Patients do not need or want that level of information. What about unusual or unpredictable cases?

16. Clinical Pathways The Process Select a topic Identify key areas and set goals Gather supportDevelop a pathway Multidisciplinary study groupPrepare documentation Identify established guidelines Educate staff Review current practicePilot and then integrate Involve local staffRegularly review variances