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 focus Medical 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 Pathways Critical Pathway Anticipated Recovery Path Managed care plans Care track Care 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 Development Prerequisites 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 improvements Remeasurement .

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 Format The format of the pathway include a task-time matrix spectrum of pathways of the medical record used as a simple checklist

Strategies continued Document and Analyze Variance The most important processes in the critical pathway Identification of factors the key features in process improvement Variance 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 advance For 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 outcomes Help improve and even reduce patient documentation Support training Optimize the management of resources Can 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 patients Help manage clinical risk Help improve communications between different care sectors

Benefits Disseminate accepted standards of care Provide a baseline for future initiatives Not prescriptive: don't override clinical judgment Expected to help reduce risk Expected 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 I mplementation 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 standards Component-based architecture implemented in Java 2 Supports the integration of systems using standard protocols such as HL7 , Edifact and XML Oracle 9i common data storage LDAP directory server to support user profiles and security Tibco 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

Clinical Pathways

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