Transcript of "Clinical Pathways - Use as Quality Improvement Tools"
Use as Quality
Larry Pennington MD
• Clinical Pathways are structured,
multidisciplinary plans of care designed to
support the implementation of clinical guidelines
• Introduced in the 1990’s in the UK and USA
• Improve the continuity of care across
• Step wise sequencing of care.
• Categories of care or activities and their
• Intermediate and long term outcome
• Variance Record for documentation and
analysis of deviation
• Differ from practice guidelines,
protocols and algorithms
Categories of Care
• Medical Interventions
• Discharge Planning
• Key outcomes
• Look for common variances
• Improve pathway
• Improve compliance
Reasons for Variance
• Patient’s clinical condition
• Patient’s social situation
• Associated diagnoses
• Changing technology or techniques
• Clinician’s discretion
• Consultation and internal system
• External issues: primary care, home
health care, etc
• Facilitate introduction of guidelines to
improve the quality of care.
• Improve multidisciplinary
• Reach or exceed quality care
• Decrease unwanted practice variation
• Improve patient-clinician
communication and patient
• Identify research and development
Total Hip Coronary artery bypass
Total Knee Carotid enarterectomy
Femur Neck Fracture Cholecystectomy
Prostatectomy Hernia repair
Summary of Main Features
• Unitary, multidisciplinary plan for and record of care
• Details tasks, sequences, time-scale, and discipline.
Contains a checklist of all necessary action
• Includes patient’s expected condition over time
• Requires minimal free text
• Freely available to the patient
• Efficient and structured format for recording key data
• Variances are noted and analyzed
• Plan and practice adjusted following audit
• Facilitate the introduction of clinical practice goals and
methods based on research evidence.
• More complete and accessible date for audit and
change in practice
• Encourage multidisciplinary communication and care
• Promote patient focused care. Improve relationship
with patient, relieve anxiety, increase participation in
• Reduce paperwork
• Enable new staff to integrate quickly
• Facilitate incorporation of improvements in care.
• Waste of time
• Discourages appropriate clinical judgment
• Difficult with multiple pathologies and where
clinical management is variable
• May stifle innovation and progress
• Needs leadership, energy, good communication
and time and cooperation
• May be misused to reduce patient care costs
inappropriately and allow for one faction of health
care team to dominate.
Barriers to implementation
• Reluctance to change
• Lack of suitable guidelines and lack to resources to
develop them locally.
• Obstructive interpersonal politics
• Lack of credit given for improvements in quality of
• Cost driven goals dominate as opposed to quality
• The person responsible for coordinating any care
planning initiative must be sufficiently well informed
and of high enough standing within the organization
• Will it increase litigation?
• Will it cause a lack of individualized care
for each patient?
• Patients do not need or want that level of
• What about unusual or unpredictable
Select a topic
Identify key areas and set
Gather support Develop a pathway
Multidisciplinary study group Prepare documentation
Review current practice Pilot and then integrate
Involve local staff Regularly review variances
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