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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