Want to improve clinical path implementation?
Hospital relies on patient care coordinators
Achieving buy-in from team members for implementing clinical paths is always a challenge. But through a collaborative effort between nursing and quality/resource management at a Georgia hospital, acceptance of clinical paths has been improved by making patient care coordinators responsible for implementing them, thus making them feel they have "frontline ownership" of the process.
Phyllis Cobb, RNC, nursing informatics specialist at Columbia Doctors Hospital in Columbus, GA, says that in the past, when a clinical path was implemented, it would be placed on the patient’s chart temporarily.
"It wasn’t a permanent part of the patient’s chart," says Cobb. "So some [documentation] got done and some didn’t. It was viewed only as a guideline, and no one took ownership of it."
For example, in 1995, when evaluating transurethral resection of the prostate (TURP) paths, Cobb says "We couldn’t locate on the medical record whether patients had even been placed on a clinical path."
"We couldn’t determine what percentage of patients having TURP done had been put on a path," she notes.
At that time, utilization management and discharge planning roles already had been merged into a case management position in quality management. Clinical paths were being developed by a case management steering committee, says Holly McGucken, RN, BSW, director of quality and resource management. A clinical care path design team was part of the steering committee, and the team’s job was DRG selection, team development, and path design. The case managers were the "gatekeepers" of the system, says McGucken, but that process wasn’t as effective as it could have been.
"That didn’t work because case managers weren’t here 24 hours a day," she explains. "The case manager wouldn’t see some admissions until 12 hours or more later, so patients weren’t being put on the paths. There was no coordination on the units. That’s when we decided to [designate] the frontline nurse as the patient care coordinator."
Coordinators took over paths
After receiving training from steering committee members, the patient care coordinators then took on clinical paths and made sure all appropriate patients were placed on them. The day-to-day implementation of clinical paths by the patient care coordinators include the following, says McGucken:
• direct care of patients on paths, or delegating it to other nurses;
• path implementation at admission;
• documentation by exception;
• patient, family, staff, and physician education;
• clinical care path advocacy for their units;
• development and coordination of patient care teams or patients on paths;
• identifying, analyzing, and follow-up on exceptions or variances that have been detected as part of the path;
• assisting with development of new paths;
• collecting, analyzing, and evaluating clinical outcomes for quality improvement purposes.
The new approach is working. McGucken says that the latest analysis of the TURP path indicated that 85% of patients had been placed on it. (See sample TURP path, p. 15 and above.) In addition, length of stay (LOS) for TURP patients is down from 4.4 days in 1994 to 2.4 days in late 1996.
"It’s continuing to go down," says McGucken. "[LOS] is about 1.8 days or 1.9 days now."
Overall average costs for TURP are down by $1,500 as well, she adds.
The hospital recently acquired a new software system for systemwide data collection that contains some path templates. But Cobb says those paths don’t always reflect the aspects of clinical paths specific to the hospital, so a performance improvement project is planned for this year to make them more individual and adaptable.
"We’ve felt it was very important from the beginning that we develop our own clinical paths based on our own history and area and practice guidelines,"says Cobb.
McGucken says the next goal is eventually to have patient care coordinators become fully responsible for patients on clinical care paths.
"Our plan is for 80% of patients who are appropriate for care paths on every unit to be placed on them," she notes.
The remaining 20% of patients will be followed by case managers. Much of the case managers’ work will be following patients outside of the hospital. High-risk patients with a history of readmissions, multiple admissions, or high-risk diagnoses will receive coordinated home health care visits, and follow-up to improve compliance with physician appointments or medication.
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