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 .
Interdisciplinary in focus
Medical and nursing plans
Physical therapy, Nutrition and Mental Health
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
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.
“ 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”.
Anticipatory recovery pathways (ARPs)
Integrated Care Pathways,
Multidisciplinary pathways of care ( MPCs),
Pathways of Care,
Collaborative Care Pathways
Anticipated Recovery Path
Managed care plans
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
Categories of care or activities and their interventions,
Intermediate and long-term outcome criteria,
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
Health and social care professional 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
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
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.
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
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
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
Help reduce variations in patient care (by promoting standardization)
Help improve clinical outcomes
Help improve and even reduce patient documentation
Optimize the management of resources
Can help ensure quality of care and provide a means of continuous quality improvement
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
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
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)
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 .