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  1. 1. University of Bohol Graduate School & Professional Studies Department Tagbilaran City, Bohol, Philippines AS II - Nursing Services Administration Practice Tools to Manage and Evaluation Care: Clinical Pathway & Clinical Practice Guidelines Mary Ann Tejano Adiong, RN, USRN - Masterand
  2. 2. OBJECTIVES: At the end of this report, the student should be able to: 1. Discuss the definition of clinical pathway and clinical practice guidelines. 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.
  3. 3. 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.
  4. 4. “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, evidence-based, patient-centered, best practice, into everyday use for the individual patient”.
  5. 5.  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.
  6. 6. 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
  7. 7.  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
  8. 8. AS ACTIVE MANAGEMENT TOOLS:  Eliminate prolonged lengths of stay arising from inefficiencies, allowing better use of resources  Reduce mistakes, duplication of effort and omission  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
  9. 9. 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.
  10. 10. FOUR COMPONENTS OF A CLINICAL PATHWAY:  A Timeline,  Categories of care or activities and their interventions,  Intermediate and long-term outcome criteria,  Variance record
  11. 11. 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.
  13. 13. VARIATION: Systems variations Health and social care professional variations Patient variations
  14. 14. 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.
  15. 15. 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
  16. 16. 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 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.
  17. 17. 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 o The most important processes in the critical pathway o Identification of factors the key features in process improvement 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 advance For example: length of stay in the intensive care unit
  18. 18.  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  Support training  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 stays
  19. 19. 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 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.
  20. 20. 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 CPG’s (IOM-AHRQ)