Physicians embrace path development when data spotlight performances
When and how data are presented is critical to buy-in
If you’re having difficulty getting physicians involved in clinical pathway development, you’re not alone. When clinical pathways were introduced in the early 1990s as a way to improve patient care and control costs, many physicians balked. Why should they be involved in one more process that scrutinized their practices and required them to change?
"We’ve been through the school of hard knocks in coming to the place where we are now," says Karen Elder, RN, MSN, coordinator of case management practices at Vanderbilt University Medical Center in Nashville, TN. "When we first started out, many physicians viewed pathways as cookbook medicine, and they didn’t like it. [Pathways] were seen as a nursing function only.
"But we felt that physicians along with the entire health care team needed to understand why we had to change," she adds. "We had to establish a need for reform in their minds. The way we did that was through using data."
She explains that by obtaining data from their own hospital as well as from groups such as the Health Care Financing Administration and the University Hospital Consortiums (UHC) in Chicago, the clinical pathway team was able to compare average charges/costs by DRG.
"UHC data allowed us to compare our practice with other academic medical centers, which is comparing apples to apples," says Elder. "More importantly, data from HCFA allowed us to see how competitive we were in the Nashville market."
At the same time, the state of Tennessee had developed its own Medicaid program, called Tenn Care, and the Clinton administration was proposing national health care reform measures.
"The chemistry was right because there was a lot of uncertainty and change happening," Elder says. "There was no doubt that we were going to have to be cost-effective. We used what was going on in the national and local media along with this data to establish the need for reform in our own institution."
Cardiologists were among the first physicians to show interest in pathway development. Elder, in conjunction with Vanderbilt Medical Center’s CEO and clinical chief for cardiology, attended a cardiology clinical faculty meeting and gave an in-depth presentation on how Vanderbilt was performing compared to other hospitals for diagnoses such as acute myocardial infarction, unstable angina, and chest pain. She also included the physicians’ own statistics via an anonymous code.
"They could look at how the division was doing for a DRG, they could look at individual cardiologists, and most importantly, they could compare their numbers with others," Elder says.
Data were broken down by length of stay (LOS) and charges for different departments. In addition, Elder says she included data from other competing hospitals in the Nashville area.
"That really got their attention," she says. "We were trying to [expand] our cardiology program, and we made the point loud and clear that we can’t grow a program and get these [managed care] contracts unless we are competitive in terms of LOS, charges, quality, and patient satisfaction."
Next, Elder says the pathway team simply "threw out all the old pathways," which were viewed as nursing tools, and started over. She sat down with four cardiologists and devised a pilot program for pathways on ischemic heart disease, using available research and national guidelines.
"What was different the second time around was that all the physicians came to the table," she notes. "That was really the greatest experience, because it wasn’t just one token physician saying, This is how I practice.’ It was all of the physicians giving their input, and challenging and learning from one another."
Keep meetings by the clock
Another important aspect of developing pathways with physicians is to respect their time, says Katy Daubenmire, RN, BSN, inpatient manager at Hocking Valley Community Hospital in Logan, OH. Nurses have successfully worked with chief of staff James Hayward, DO, for several years. In particular, they have trimmed down the hospital’s first clinical pathway on congestive heart failure with Hayward and three other physicians to improve physicians’ standing orders, which were "too bulky" at first, she says, and patient education, which needed to be more in-depth.
Daubenmire says meetings must be concise, and they must follow a set format to save time.
"I can’t emphasize [enough] starting and stopping on time," she says. "We present [topics], have discussion, take action, and then make an assignment. All our meetings take on that structure subject, discussion, action, and assignment. When we meet again, we start where we left off at the last meeting. It keeps things more structured, and that has helped a lot in dealing with the physicians. They feel we’re respecting their time, and they’re respecting ours."
Another way to streamline pathway development with physicians is to present pathways to them via their departments to gain their input all along the process. At Divine Providence Hospital, which is part of the Susquehanna Health System in Williamsport, PA, cardiopulmonary case manager Judy Niklaus, RN, says pathway development goes through several levels, and physicians are encouraged to make changes every step of the way.
After changes are proposed during regular collaborative practice group meetings, Niklaus sends a rough draft of the pathway to department physicians and asks them to make change suggestions. Pathways used to be sent through the medical care executive committee, but sending them through individual departments makes physicians more likely to feel a part of the process and buy into it.
"Next, it goes to a the physician continuous quality improvement committee," Niklaus notes. "They give final approval to the path."
Alyssa Pickles, RN, BSN, care management coordinator at John D. Archbold Memorial Hospital in Thomasville, GA, says 19 pathways have been developed there since 1994. She says she’s seen an increase from about 10% to 60% in physician participation in pathways since that time. She attributes much of that success to continually feeding back data to physicians on clinical outcomes.
"They can only take financial data to a certain extent," Pickles says. "I’m following clinical data such as how many sputum [samples] are obtained now as opposed to prior to the [pneumonia] pathway, and how many grow out cultures. I’m following how many patients are changed to PO antibiotics on the appropriate date. The doctors can see that we’re truly trying to help the patient here, not just saving the hospital money." (See story about comparative data, above.)
Pickles says when physicians seem reluctant to get involved with pathway development, she asks them to become part of the process.
"I’ll ask them to help us out on the steering committee to see where our true goals lie," she says. "They can see that we’re not just trying to control their practices."
Having a "physician champion" is absolutely necessary to the process, agrees Elder, as is providing physicians with meaningful data.
"Otherwise, this won’t work," she says. "Keep presenting data until you get a group of physicians who will engage with you in this process. Get the numbers for your hospital and for others. Learn about DRGs and reimbursement. Look at things like profit-loss, and what your payer mix is. You’ve got to make [physicians] feel they’re part of the process before they’ll start owning it."
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