This document discusses standardizing patient care through the use of critical pathways and clinical decision support tools to improve outcomes. Standardizing care can improve patient outcomes and satisfaction, increase financial performance, and decrease costs by reducing unnecessary testing, treatment costs, length of stay, and admission rates. The document proposes a project to standardize care in emergency departments for specific illnesses through developing critical pathways informed by evidence-based research and integrating clinical decision support tools. Implementation would require approval from leadership councils and addressing regulatory requirements, clinician concerns about standardized care, and continually evaluating data on compliance and outcomes.
Presentation from NHS Improvement endoscopy workshop held at Ambassadors Hotel, London on 29 January 2013
http://www.improvement.nhs.uk/diagnostics/EndoscopyImprovement/Events.aspx
Improving endoscopy admin systems - a trial of direct booking
Wendy Mitchell
James Paget University Hospitals NHS Foundation Trust
Presentation from NHS Improvement endoscopy workshop held at Ambassadors Hotel, London on 29 January 2013
http://www.improvement.nhs.uk/diagnostics/EndoscopyImprovement/Events.aspx
Improving endoscopy admin systems - a trial of direct booking
Wendy Mitchell
James Paget University Hospitals NHS Foundation Trust
A presentation, describes basics of Clinical Governance
What do we have in common
as Medical Doctors/Medical
Practitioners?
1. We are technical experts in our fields
2. We are leaders
3. We are managers
4. We are accountable for the patient care and health services
5. We are change agents
6. We are respected highly in the community
7. We are responsive
8. We are good communicators and negotiators
9. We are kind and empathic
10. We are decent and disciplined
Clinical Governance is a strategic framework for the development of high quality healthcare
"A framework through which organizations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish" – NHS, UK
“clinical governance is a way of making sure that everyone who passes through health system is well cared for”
or
System that enable staff to work in the best possible way
+
Staff performing to the highest possible standards
Seven pillars of Clinical Governance
Patient and public involvement (PPI)
Risk management
Staffing and staff management
Education and training
Clinical effectiveness & Research
Using clinical information & IT
Clinical audit
Patient and public involvement
Ensuring services meet the need of the patients
Patient and public feedback is used to improve services
Patients and the public are involved in the development of services and the monitoring of treatment outcomes
Risk management
Complying with protocols
Learning from mistakes and near-misses
Reporting adverse events
Assessing the risks – probability of occurrence, impact
Promoting blame free culture
Staffing and staff management
Appropriate recruitment and management of staff
Ensuring that underperformance is identified and addressed
Encouraging staff retention by motivating and developing staff
Providing good working conditions
Education and Training
Providing appropriate support available to enable staff to be competent in doing their jobs and to develop their skills so that they are up to date
Professional development needs to continue through lifelong learning
Clinical effectiveness & Research
Clinical effectiveness implies ensuring that everything we do is designed to provide the best outcomes for patients
Clinical audit
Clinical audit is a quality improvement cycle that involves measurement of the effectiveness of healthcare against agreed and proven standards for high quality, and taking action to bring practice in line with these standards so as to improve the quality of care and health outcomes
Clinical audit is a systematic process of looking at your practice and asking:
What should we be doing?
Are we doing it?
If not, how can we improve?
Training need assessment of sri lankan nurses: New innovative methodVENODEN DHARMARAJAN
In-service training needs of the nurses of Sri Lanka weren't assessed prior to conduct training sessions resulted in a mismatch of demand and provision. A new method was training need assessment was tested that found to effective
Standard of care / Standard of Practice / Clinical Guideline/ Clinical Pathway Naz Usmani
A very brief presentation to differentiate between clinical process improvement practice , guideline and pathway .
I have reflected on the basic differences between them .
Standard of care / Standard of Practice / Clinical Guideline/ Clinical Pathway Naz Usmani
A very brief presentation about the clinical process improvements including practices, standards of care , guideline and pathway . I have reflected upon the basic differences between them . Hope it is useful
Director of Strategy and Development, Australian Commission on Safety and Quality in Healthcare.
Presentation given at "Health Literacy Network: Crossing Disciplines, Bridging Gaps", November 26, 2013. The University of Sydney.
A presentation, describes basics of Clinical Governance
What do we have in common
as Medical Doctors/Medical
Practitioners?
1. We are technical experts in our fields
2. We are leaders
3. We are managers
4. We are accountable for the patient care and health services
5. We are change agents
6. We are respected highly in the community
7. We are responsive
8. We are good communicators and negotiators
9. We are kind and empathic
10. We are decent and disciplined
Clinical Governance is a strategic framework for the development of high quality healthcare
"A framework through which organizations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish" – NHS, UK
“clinical governance is a way of making sure that everyone who passes through health system is well cared for”
or
System that enable staff to work in the best possible way
+
Staff performing to the highest possible standards
Seven pillars of Clinical Governance
Patient and public involvement (PPI)
Risk management
Staffing and staff management
Education and training
Clinical effectiveness & Research
Using clinical information & IT
Clinical audit
Patient and public involvement
Ensuring services meet the need of the patients
Patient and public feedback is used to improve services
Patients and the public are involved in the development of services and the monitoring of treatment outcomes
Risk management
Complying with protocols
Learning from mistakes and near-misses
Reporting adverse events
Assessing the risks – probability of occurrence, impact
Promoting blame free culture
Staffing and staff management
Appropriate recruitment and management of staff
Ensuring that underperformance is identified and addressed
Encouraging staff retention by motivating and developing staff
Providing good working conditions
Education and Training
Providing appropriate support available to enable staff to be competent in doing their jobs and to develop their skills so that they are up to date
Professional development needs to continue through lifelong learning
Clinical effectiveness & Research
Clinical effectiveness implies ensuring that everything we do is designed to provide the best outcomes for patients
Clinical audit
Clinical audit is a quality improvement cycle that involves measurement of the effectiveness of healthcare against agreed and proven standards for high quality, and taking action to bring practice in line with these standards so as to improve the quality of care and health outcomes
Clinical audit is a systematic process of looking at your practice and asking:
What should we be doing?
Are we doing it?
If not, how can we improve?
Training need assessment of sri lankan nurses: New innovative methodVENODEN DHARMARAJAN
In-service training needs of the nurses of Sri Lanka weren't assessed prior to conduct training sessions resulted in a mismatch of demand and provision. A new method was training need assessment was tested that found to effective
Standard of care / Standard of Practice / Clinical Guideline/ Clinical Pathway Naz Usmani
A very brief presentation to differentiate between clinical process improvement practice , guideline and pathway .
I have reflected on the basic differences between them .
Standard of care / Standard of Practice / Clinical Guideline/ Clinical Pathway Naz Usmani
A very brief presentation about the clinical process improvements including practices, standards of care , guideline and pathway . I have reflected upon the basic differences between them . Hope it is useful
Director of Strategy and Development, Australian Commission on Safety and Quality in Healthcare.
Presentation given at "Health Literacy Network: Crossing Disciplines, Bridging Gaps", November 26, 2013. The University of Sydney.
Estrategias para Implementación de las Guías de Práctica ClínicaGuíaSalud
"Estrategias para Implementación de las Guías de Práctica Clínica" presentación realizada por Andrew D. Oxman, investigador del Norwegian Institute of Public Health en las Jornadas Científicas de GuíaSalud (Madrid, 4 abril 2016)
Sills MR. Overview of the SAFTINet Program. Presented to the Emergency Department Research Committee, Department of Pediatrics, University of Colorado School of Medicine. 6 January 2015.
This presentation by the Bureau of Health Information to the Royal Australasian College of Physicians looks at using clinical outcome data to improve patient care.
It examines:
Why measure and report on performance?
- Accountability and quality improvement
What is performance really?
- It is not a measure of what the system is, it is a measure of how well the system does
Whose performance is it anyway?
- Attributing results to providers, units or sectors requires a careful assessment
3. Summary of Relevant Literature
• Patients follow a critical path
• Improvement in patient outcomes
• Improve patient satisfaction
• Improvement in health care reform
4. Summary of Relevant Literature
• Reduces medical errors
• Reduces length of stay
• Reduces financial burden
• Evidence Based Research
• Integration of Clinical Decision Support (CDS) tools
• Electronic Health Record
6. Project Continued
Implementation
• Meet with Stakeholders
• Develop Critical Pathways
• Use of Evidence-based research
• Integrate Clinical Decision Support
Tools
7. Standardization Resolution
• Medical Executive Council
• Clinical Leadership Council
• Legal and regulatory requirements
• Integration of critical care pathways
• Integration of CDS
9. Standardization Resolution
• Health promotion model
• Lewin’s change theory
• Exception to the rule
• Clinician push back
• Cookie cutter medicine
• Fair and equal treatment
10. Standardization Implementation
• Implemented Critical Pathways
• Data reports for compliance
• Follow up with outliers
• Continued leadership support
• Implementation of new critical pathways
13. References
Button, P. (2012). Collaboration strategies for CDS success. Health Management Technology, 33(7), 13-13.
Petiprin, A. (2015). Health promotion model . Retrieved from Nursing Theory : http://www.nursing-
theory.org/theories-and-models/pender-health-promotion-model.php
Rocco, G., Affonso, D., Mayberry, L., Sasso, L., Stievano, A., & Alvaro, R. (2015). Center of excellence to build
nursing scholarship and improve health care in Italy. Journal of Nursing Scholarship, 47(2), 170-177.
doi:10.1111/jnu.12125
Yang, H., Li, W., Lui, K., & Zhang, J. (2012). Knowledge-based clinical pathway for medical quality
improvement. Information Systems Fronteirs, 14(1), 105-117. doi:10.1007/s10796-011-9307-z
Editor's Notes
In the world of health care reform organization and providers are being asked to improve patient care, improve outcomes, and make it less expensive to be treated. After all the education and experience, providers tend to get into a groove on how to treat a patient. Is always the best medicine? Is all the treatment the same? The fast answer is no. Each provider, organization, or hospital has their own way of doing things. Sometimes, this is not the most efficient or productive. Standardizing patient care, by way or critical pathways is a way to provide the patient with excellent medical care at a lower cost. Standardization will improve outcomes, patient satisfaction, organization financial performance, clinician workflows, and patient safety. Standardization will also decrease unnecessary diagnostic testing, cost of treatments, length of stay, and admission rates for observation. To make best use of clinician time and organizational resources, treatment standards need to be examined. “A priority is efforts to leverage assets and resources that will increase the chances for success in developing new nursing roles and expanding the scope of practice” (Rocco, et al., 2015, p. 172)
“A clinical pathway is a standardized treatment pattern to manage medical activities in order to improve the quality of service and optimize the use of resources” (Yang, Li, Lui, & Zhang, 2012, p. 106). The research and literature, that the author has examined, is showing a great improvement in patient outcomes when standardized clinical care pathways or critical care pathways are utilized. Standardization is becoming more popular due to the healthcare reform act and the increasing need to prevent future illness due to previous care. “The message is clear: In order to comply with the myriad of reform requirements, hospitals, must find a way to avoid the variations in care that drive up costs and result in negative outcomes” (Button, 2012, p. 12). By using evidence-based research and developing a standardized critical pathway system, clinicians can improve outcomes, improve patient safety and satisfaction, as well as improving practice for nurses and physicians.
Support from literature suggest that standardizing care through the use of clinical care pathways does improve patient outcomes, reduce errors, and ensures that each patient is provided the same care throughout the disease process. Although, each patient may present differently and take a different path through the disease, having a guideline to follow allows clinicians to gage the disease process and act accordingly. All patients and clinicians can improve through the use of clinical pathways and standardization. It is still a clinician’s expertise and wisdom that will further improve the process so clinical pathways should not be used as the only source of treatment. Overall, literature and evidence does support the continued use and research of standardization of care in the hospital setting. It also supports the improvement of outcomes, financial gains, and satisfaction with medical care both in the patient environment and in the clinician environment.
The emergency department will see a plethora of illnesses and diseases. Treating each patient with care and to the best of our abilities takes coordination and practice. Part of this practice needs to be standardizing the care these individuals receive. Research has shown that patients with specific illnesses or diseases follow a critical path such as, syncope or sepsis. The emergency department (ED) is where a lot of these patients will present. That was the basis for the author’s project implementation.
Yang, Li, Lui, and Zhang, (2012), examine the use of knowledge-based clinical pathways to improve overall patient outcomes, reduce medical errors, and improve workflows. They did find evidence that supports the use of clinical pathways however, they also found that the pathways are not always used either by choice or by mistake. Clinical care pathways are only as good as the user who implements them and follows them. Meeting with stakeholders and leadership will help ensure the compliance and utilization of the critical pathways. Clinical pathways are evidence-based and also use clinical expertise in development.
The Medical Executive Council (MEC) and the Clinic Leadership Council (CLC), at the author’s organization, is where this proposal for clinical care pathways was introduced. Standardizing care has to be a collaborative effort between the physicians, legal, and regulatory departments. Every aspect must be examined to ensure that all parties are united and fulfilling their obligation to each aspect of their role. Physicians must agree on a pathway of treatment. All physicians have their own way of treating a disease or illness. It will be them who decide what that pathway will look like, with the use of evidence-based research. After the decision making process was over, the team was able to design and implement specific care pathways in the ED.
Implemented in the clinical or critical care pathway are groups of orders sets, diagnostic tests, and interventions found by meeting and discussing the outcomes and using evidence-based research to determine the best path for these patients. Evidence-based research is the basis for the change because evidence shows that patients are better treated when a clinical pathway is used.
“Health promotion is directed at increasing a patient's level of well-being. The health promotion model describes the multidimensional nature of persons as they interact within their environment to pursue health” (Petiprin, 2015, p. 1). . Each patient has their own path that they could take on the disease track but nursing intervention can move the path into a better, more positive direction, if caught early. Knowing what those next intervention will be depends on the evidence from previous cases and the research discovered after the fact. Diseases usually have a known direction, factor in the patients individual symptoms, nursing knowledge, and evidence-based practice and you have a critical care pathway in the making. “Health promotion is directed at increasing a patient's level of well-being. The health promotion model describes the multidimensional nature of persons as they interact within their environment to pursue health” (Petiprin, 2015, p. 1).
Knowing how others will react to change is an obstacle that can be overcome if one knows how to handle the situation. Lewin’s, (1951), theory refers to three stages of change unfreezing, moving, and refreezing. “Unfreezing involves motivating individuals by getting them ready for change, moving involves encouraging individuals to adopt a new perspective that enables them to perceive that the current situation can be improved, and refreezing involves reinforcing new patterns of behavior”.
Not all patients will follow the critical path. These patients will be the exception to the rule. This is when education, experience, and wisdom will take more precedence than a critical path. Critical pathways will not take the place of experience and education. They are only an asset to help improve the system already in place.
No matter what the treatment, pathway or individual, the patient will always receive fair and equal treatment according to their signs and symptoms. Nothing can replace the wisdom that providers gain from years of experience. We will always need that but if providers can enhance the way they think and treat patients, everybody wins.
The new electronic documentation systems allow leadership and managers to run data reports to gage the way that end users are using the system. The team developed a data report that would see how many times a clinical pathway was used, how many times diagnostic testing was or was not ordered, if a patient was admitted, who used the care pathway, and how long the patient stayed in the emergency room. It took the involvement of mangers and leadership to keep engaged with the implementation and hold end users accountable for using the pathways. Weekly data reports were ran and any outliers were contacted immediately while the case was still fresh in their minds. Mangers would ask why they strayed from the pathway, why they did not use it, or what other circumstances played a part in their decision. Once the staff knew that they were being held accountable and this wasn’t a new fad, they were more confident and responsible for pulling the care pathway and utilizing it correctly.
This slide shows data reports in a score card format for easier review. It shows how the percentage of usage gradually went up as more and more involvement was apparent by leadership.
To keep the integration of clinical pathways running smoothly it is imperative that leadership stay engaged and follow up with the staff in the department. Clinical pathways are a part of evidence-based practice by utilizing them and keeping them useful to the improvement of patient outcomes. In this project the author enlisted the emergency department managers, physicians, nurses, physician scribes, chief nursing officer, chief medical officer, and many others in leadership to gain support and educate them on the research of standardized treatment. Once all parties were engaged, they formed a committee that would oversee the project and keep it on track.
Nursing informatics (NI) is the specialty the author choose to follow for her master’s degree in nursing. Informatics is all about bringing together nursing science, information science, and technology science into a smooth integrated body. The use of care pathways, embedded in the electronic health record and supported by evidence-based nursing research brings together all three sciences. Presenting the finding of this project to push other new projects can be done by presenting the finding of this project and the practicum project to leadership and stakeholder of other emergency department organizations or hospitals. NI never forgets the foundations of nursing so they are always willing to integrate new evidence into nursing practice as long as it improves or increases the overall outcomes of patient care.
Button, P. (2012). Collaboration strategies for CDS success. Health Management Technology, 33(7), 13-13.
Petiprin, A. (2015). Health promotion model . Retrieved from Nursing Theory : http://www.nursing-theory.org/theories-and-models/pender-health-promotion-model.php
Rocco, G., Affonso, D., Mayberry, L., Sasso, L., Stievano, A., & Alvaro, R. (2015). Center of excellence to build nursing scholarship and improve health care in Italy. Journal of Nursing Scholarship, 47(2), 170-177. doi:10.1111/jnu.12125
Yang, H., Li, W., Lui, K., & Zhang, J. (2012). Knowledge-based clinical pathway for medical quality improvement. Information Systems Fronteirs, 14(1), 105-117. doi:10.1007/s10796-011-9307-z
