Solving the perioperative path dilemma
By Patrice L. Spath, ART, BA
Consultant in Health Care Quality and
Resource Management
Forest Grove, OR
In the past two years, hospitals have begun to design clinical paths for the perioperative period. These paths start where unit-based patient care leaves off, detailing the surgical experience from induction of anesthesia to recovery in the post-anesthesia care unit. While not originally intended for use by perioperative caregivers, clinical paths can enhance surgical services by improving continuity of patient care and stabilizing perioperative procedures.
Many surgery department managers view the clinical path development process as an opportunity to discuss the cost of surgical care with all members of the perioperative care team. By sharing cost-saving ideas, the path that results from these discussions can reduce unnecessary expenses.
Paths should not be seen as the only action plan for achieving quality improvements and cost reductions in the operating room (OR). Many quick-fix strategies, such as pre-printed physician orders and standard physician preference cards, are easier to implement than clinical paths. Paths can be a powerful patient management tool, however, if they are designed by a multidisciplinary team that has spent some time reviewing data to identify improvement opportunities.
The goal of the team's activity should be to improve the process, not create the path. Once its analysis is complete, the team should determine whether a path is the right tool to "fix" the process or whether another action plan is more appropriate.
The process improvement project can help determine which course of action will achieve desirable results. The ideal steps of a perioperative process improvement project are listed below:
1. Get caregivers' attention with data.
Caregivers must first understand why the status quo needs changing. Provide caregivers with data showing the undesirable effects of process variation. Gather information that substantiates the need for improvements in perioperative care.
Surgeons' preference cards can be used as a data source for gathering physician practice variations. Make sure to answer the "so what" question, which demonstrates how physician variations in practice impact costs. (For an example of what could be included in a physician practice variation report, see the Impact of Physician Practice Variation on Financial Outcomes chart, p. 45.) Similar reports can be designed to illustrate the relationship between practice variation and clinical outcomes.
Patient feedback also can be useful outcomes data for the perioperative team to use for identifying improvement opportunities. Items rated unfavorably by patients should be included in the process improvement planning. (For examples of unfavorable experiences patients might report, see the Unfavorable Experiences Reported by Patients in Ambulatory Surgery Unit chart, p. 45.)
2. Benchmark with other providers.
Find out how other perioperative caregivers have streamlined services, reduced costs, and improved patient satisfaction. Organizations such as the University Hospital Consortium in Oak Brook, IL; The Sachs Group in Chicago; and the Institute for Healthcare Improvement in Boston sponsor formal benchmarking projects. Benchmarking also can be done less formally through professional groups or colleague networks.
3. Establish outcomes goals.
Once improvement opportunities have been identified, the multidisciplinary team should agree to the desired outcomes of their perioperative improvement project. It's important to be specific when articulating the expected benefits. The design of the action plan will vary according to the project goals. Examples of common perioperative improvement project goals include the following:
* reduce inefficiencies;
* improve communication;
* decrease incidence of side effects or complications;
* eliminate redundancy;
* reduce unnecessary variation in physician practice patterns;
* improve patient flow.
4. Define how the goal will be reached.
Select the action plan(s) necessary to accomplish the goal. A time-sequenced, multidisciplinary plan of care, such as a path, is a reasonable tactic if the goal is to reduce variation in processes and/or resource use. Other action plans, however, can also be considered, such as:
* automate certain tasks;
* decentralize services;
* cross-train staff to perform additional tasks;
* reduce the number of vendors and suppliers with whom you do business;
* involve suppliers as partners in meeting your requirements and improving processes.
A decision matrix can help the development team determine which action plan best meets its needs. First, list all possible action plans in a column to the left. Next, evaluate each plan using a series of questions with yes/no answers. Action plans with more "yes" answers are likely the best ones to pursue. (For a sample decision matrix, see the Action Planning Decision Matrix, above.)
Only after the perioperative team has carefully evaluated the OR processes and improvement goals, should a method be chosen to accomplish the goals. Sometimes the best tool will be a clinical path. At other times, a relatively isolated change that can start tomorrow is best. Some perioperative clinical paths seem prone to becoming a solution in search of a problem, rather than a tool that is selectively applied.
If a clinical path is chosen as the best solution, then proceed with the path development process. If not, implement the more desirable action plan. Paths should be viewed as one of many different action plans aimed at improving clinical processes -- not the only one. *
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