Plan-do-check-act’ develops clinical paths
Process integrates disciplines, patient outcomes
A Kaiser Permanente hospital has implemented the "plan-do-check-act" (PDCA) approach to developing clinical paths, which has helped simplify the process and improved patient outcomes.
Joy Mendoza Grande, RN, MS, CCRN, managed care coordinator at Kaiser Permanente Hospital in Sacramento, CA, says the PDCA process was begun in 1993 based on traditional total quality management principles. Pathway development included identifying target diagnoses, forming a multidisciplinary task force, and monitoring outcomes. (See chart, p. 187.) It also includes evaluating and revising the program based on outcome analysis.
"First, we identify the diagnoses we’re going to work on based on the diagnoses that are high-risk, high-volume, and demonstrate suboptimal utilization patterns," says Grande.
A multidisciplinary group of physicians, nurses, educators, discharge planners, and ancillary care providers in the hospital, clinical, home health, and skilled nursing facilities develop the paths, she says.
"Because Kaiser is an integrated health maintenance organization, it is easy to develop the pathway focusing on the care of the patient across the full continuum of care, including ambulatory, inpatient, and post-discharge," Grande explains.
Research provides some answers
The first part of the process involves a literature search for scientific studies and clinical practice guidelines related to specific diagnoses. Chart review and baseline assessment are done, as well as patient satisfaction surveys.
"We look at best practices and benchmarks inside and outside of Kaiser to see what they’re doing well," says Grande. "Having all this information, we sit down and analyze our care of that patient population, look at gaps in care, missing links, and challenge unfounded traditional ways. When we develop a best practice clinical path, we ask the team if they were going to take care of that patient, what would be the best way they could do that? Then we ask them to design that care."
So far, 13 clinical pathways have been developed at the facility, as follows:
• total hip replacement;
• total knee replacement;
• rule-out myocardial infarction;
• adult pneumonia;
• laminectomy;
• normal delivery/normal newborn;
• outpatient chest pain;
• colectomy;
• amputation;
• chronic obstructive pulmonary disease;
• pediatric asthma;
• radical prostatectomy;
• cesarean section.
Improvement has been noted in many of the diagnoses, says Grande. With total knee replacement, for example, hospital length of stay was reduced from eight to three days, with patients being discharged to home. The path also includes a preoperative class and improved collaboration between the patient and his or her providers, especially between the hospital and home health.
In the rule-out myocardial infarction pathway, length of stay was reduced from 1.8 days to 0.8 days, with no 48-hour readmissions, says Grande. Stress test scheduling was identified as one of the systems’ problems during pathway development because physicians often were doing their own scheduling for the procedure. She notes that using a physician’s time was found not to be the most efficient way to schedule stress tests.
"So now, when a patient is placed on the pathway, stress testing is automatically [ordered] by the unit clerk."
Clinical and utilization measurements as well as patient satisfaction surveys indicate how well improvements are working.
"Those outcomes are reported back to the multidisciplinary team on a quarterly basis," says Grande. "They assess and analyze the results. Based on those analyses, we do revisions to the program."
Baby care education emphasized
She explains that on the normal delivery pathway, the team identified that patient education on baby care was needed, especially now that shorter lengths of stay for those patients have become the norm. A baby care video was provided to patients in the clinic at 28 weeks of pregnancy, and pamphlets were developed to accompany teaching that occurred in the hospital. But follow-up surveys indicated patients needed more education.
"So in response to that, we’ve now started a 36-week prenatal class on baby care," Grande says. "You really have to look at the care of the patient beyond the hospital. You have to look at it before and after the hospital stay so the care you provide will truly address the needs of the patient."
Some patient populations will require home health care as part of their recovery, such as those undergoing total hip replacement, she notes.
"We made an arrangement that these patients are seen the next day after discharge in their homes," says Grande. "There’s communication within 24 hours of discharge with home health staff."
Grande says that some of the challenges in pathway development include finding resources to put the right systems into place, time for the multidisciplinary team members, and obtaining buy-in from all the people impacted by the pathway.
"That includes not only physicians, but everyone including the unit clerks who make up the patient charts or the laboratory technician processing a blood test," she notes.
"You have to analyze your current system and [see] how you’re caring for that patient," Grande concludes. "You have to look at the loopholes and clinical practice gaps. You try to eliminate practices that you do just because that’s how it’s always been. In this process, you don’t just look at patient care, you also look at systems."
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