University of Bohol
Graduate School & Professional Studies Department
Tagbilaran City, Bohol, Philippines
AS II - Nursing Services
Tools to Manage and Evaluation Care:
Clinical Pathway & Clinical Practice Guidelines
Mary Ann Tejano Adiong, RN, USRN - Masterand
At the end of this report, the student should be able to:
1. Discuss the definition of clinical pathway and clinical practice
2. Identify all involved staff common goals and helping them to
understand their roles in the entire care process.
3. Discuss the framework for collecting and analysing data on
the care process.
4. Explain how to improve patient satisfaction through
improved patient education e.g. better care giver-to-patient
communication on the plan of care.
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.
“Clinical Pathways (CP) is
multidisciplinary plans of best
clinical practice for specified
groups of patients with a
particular diagnosis that aid
the coordination and delivery
of high quality care. They are
both, a tool and a concept,
which embed guidelines,
protocols and locally agreed,
best practice, into
everyday use for the
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
Step wise sequencing of care.
To improve patient care
To maximize the efficient use of
To help identify and clarify the
To support clinical
effectiveness, clinical audit and
Facilitate introduction of guidelines
to improve the quality of care
Reach or exceed quality care
Decrease unwanted practice
communication and patient
Identify research and development
AS ACTIVE MANAGEMENT TOOLS:
Eliminate prolonged lengths of stay
arising from inefficiencies, allowing
better use of resources
Reduce mistakes, duplication of effort
Improve the quality of work for service
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
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
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
Categories of care or activities and
Intermediate and long-term outcome
CLINICAL PATHWAY DEVELOPMENT
Succeed when the decision to develop is taken on an organizational basis.
Senior management commitment and a strong medical and nursing lead
Pathway documentation is more likely to be used if it is simple, clear and
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.
Health and social care
GUIDELINES FOR THE DEVELOPMENT
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
Collect Clinical Pathway data and medical record reviews of
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
Multi-disciplinary, multi-agency, clinical and administrative
Structured Variance Tracking
Local and National standards
Evidence based, locally agreed, best practices
Tests, charts, diagrams, information leaflets, satisfaction
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
OPTIMUM DEVELOPMENT AND
SELECT A TOPIC
Topic of high-volume, high-cost diagnoses and procedures.
For example:- Critical pathway development for cardiovascular diseases and
SELECT A TEAM
Active physician participation and leadership is crucial
Representatives fromall groups
EVALUATE THE CURRENT PROCESS OF CARE
o Key to understanding current variation
o A careful review of medical records
o 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
The format of the pathway include a task-time
spectrum of pathways of the medical record
used as a simple checklist
DOCUMENT AND ANALYZE VARIANCE
o The most important processes in the critical
o Identification of factors the key features in
o 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.
o Team to concentrate on a few critical items
in the pathway that have been identified in
For example: length of stay in the intensive
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
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
Expected to help reduce risk; Expected to help reduce costs by shortening hospital
POTENTIAL PROBLEMS AND
BARRIERS TO CLINICAL PATHWAYS:
May appear to discourage personalized care
Risk increasing litigation
Don't respond well to unexpected changes in a
Suit standard conditions better than unusual or
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.
CPG’s are statement that include
recommendations intended to optimize patient
care that are informed by systematic review of
evidence and an assessment of the benefits and
harms of alternative care options.
Committee on Standards for Developing Trustworthy
THE PROCESS FOR CLINICAL PRACTICE
GUIDELINE CONTENT DEVELOPMENT