Avoid these pathway project stumbling blocks
Physician-driven involvement stays on track
As if researching, winning approval for, and developing a critical pathway isn't enough work, keeping the momentum going during the final development phases can be as difficult as those first steps.
Case managers who've experienced problems in the past offer some real-world advice on how case managers can avoid potential stumbling blocks when implementing paths:
* Make pathway projects physician-driven.
"I have seen many pathways come out of the department of nursing, and that's always a negative. Physicians generally don't want a nurse in charge of that, so it's best that a physician be the team leader," says Toni Cesta, PhD, RN, director of case management at Long Island College Hospital in Brooklyn, NY.
For many case managers, this question arises: How do you get the physicians involved, much less be a champion for your pathway? "It becomes a matter of organizational change, so that it becomes a part of how the organization operates and is not just a splinter group of physicians or nurses driving the process. It becomes an expectation of the organization that physicians and other disciplines participate in these teams," Cesta says.
In fact, Cesta's organization requires physician participation in reviewing and approving paths as part of the physician credentialing process. "Every time we come out with a new guideline, it is distributed to the physician staff, and they are expected, within a certain amount of time, to review and respond to it. If they don't, then it could affect their credentialing."
William Beaumont Hospital in Royal Oak, MI, also focuses its pathway development efforts on physician involvement. At the root of this new emphasis is a commitment that the hospital's medical administration made to pathway development, explains Beverly Hydo, RN, clinical nurse specialist of medical nursing.
"We now have teams, each headed by a physician, that include people from all different disciplines involved in the patient's care. Physician involvement is absolutely essential," Hydo adds.
* Use a continuous quality improvement (CQI) methodology.
A steering committee or quality council looks at organizational data and targets clinical areas for paths at Long Island. After a decision is made, a pathway team is developed. The team is always led by a physician and facilitated by a nurse. Other disciplines are represented as needed on the team, Cesta says.
"The team's responsibility is to look at the data and then decide what tools it wants to use to correct the problem, and usually that involves a map or guideline and system changes. The team's recommendations are brought back to the quality council again for approval, and the changes are put into place," Cesta explains.
* Focus on outcomes measurement.
Outcomes management in relation to pathways is becoming more important, but it also has been a piece that's neglected, says Cesta. "We've been using pathways for 10 years, and people are just starting to realize how important outcomes management is. Conceptually people are struggling with this. They are focusing on the financial outcomes and not on the clinical outcomes."
Cesta's facility identifies intermediate outcomes on pathways, which are expected outcomes while the patient is still in the hospital. Pathway teams also identify discharge outcomes, which are goals patients must achieve for a safe discharge.
"Not only can we track these [outcomes] concurrently, we can also do variance analysis on them. This is going to be one of the future ways of measuring quality," Cesta predicts.
* Include references on paths.
Cesta also advises including references on your pathways to convey that the documents are well-researched, state-of-the art guidelines. This strategy is a "big selling point to the physicians," she says, adding that it gives the guidelines credence that the information is the most up-to-date.
The pathway team documents all references on the pathway itself so that "we can say, 'Alright, this isn't six people who dreamed this up,' which is the way we used to do paths," Cesta notes. She adds that the references make the pathways much more of an objective, as opposed to a subjective, scientific tool.
* Add disclaimers to ease liability concerns.
While liability issues continue to concern physicians more than case managers, it is an area that should be addressed during implementation. "I've been keeping close tabs on the legal literature surrounding guidelines. For a while, I was seeing a lot of negative material, but now I'm seeing articles that are giving both sides of the story, and the jury isn't back yet [on the liability issues] because there hasn't been a lot of litigation involving guidelines yet," says Cesta.
Long Island does not tell physicians there is no legal liability with the use of pathways, Cesta says. But Long Island is clear, however, regarding the purpose of pathways. Each path has a disclaimer statement that states the pathways are guidelines only, Cesta notes. *
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