Successful pathways need physician input
Study existing protocols, modify for your practice
The No. 1 rule to follow when developing critical pathways for your practice is to involve your physicians every step of the way, experts say.
"For the process to work, it has to be led by a physician practitioner. The success depends on physicians having buy-in. If they feel they have been left out of the process, they may not follow it," says Mike Boguszewski, manager at Hamilton HMC, a health care consulting firm in Minneapolis.
Although nurses, clinical specialists, and nurse practitioners should get involved helping identify alternative treatments or courses of action, the success of a critical pathway depends on physician buy-in.
Pathway development works best if the physicians who treat patients with each particular condition lead the process. For instance, when Sandhills Physicians Inc., a physician organization in Fayetteville, NC, began developing critical pathways for its new community-based health plan, Doctors Direct Healthcare, 40 physicians were on the committees, which developed 60 pathways.
A representative of each of the three urology groups in the physician network worked on development of the pathways for urological conditions, according to Rita Graves, administrator of the 250-physician organization. They tailored the pathway to the specific needs of their community.
"We’re known as the kidney stone belt of the United States. That is a significant issue here. Our physicians understand the dietary patterns of our population that come into play in trying to treat kidney stones," Graves says.
The critical pathway committee dealt with some of the issues that may arise between primary care physicians and specialists. Each pathway designates what testing specialists want done in primary care. So far, 42 out of about 60 proposed critical pathways are complete. Each physician has received a copy of each protocol, whether or not it’s specific to his or her practice.
"The protocols are designed for Doctors Direct, but all patients get the benefit of them. You can’t discriminate against patients based on what type of insurance they have. You have to select the best clinical guidelines to create the best outcome for that patient," she says.
If your practice is considering developing critical pathways, Boguszewski advises taking these steps:
- Compile a list of the top disease groups in your community. You may want to work with a local employer coalition to determine the key disease management areas, such as low back pain, asthma, diabetes, and depression.
- Decide what areas would benefit from pathways. Look at your internal data to determine what areas have the opportunity for cost reduction through standardization.
For instance, if there are widely varying costs for hip replacement surgery, you might select this as your initial pathway. Examine the cost of prosthetic devices and why there is a wide variation in costs.
Determine if there is a link to the patient’s age or lifestyle and the choice of prosthetic device, or if there is a difference in functionality among patients who receive the less-expensive device. If not, you might consider standardizing through development of a pathway.
Your practice may choose not to have a pathway for every single patient you treat. "For low-volume types of conditions or where the cost isn’t very high, it might not be worth the effort to have a formalized process," he says.
Instead you may choose to start with the largest volume or high-cost procedures or conditions and attack those first. Then you can make sure their process works and they show some success before tackling other areas.
- Collect pathways from other physician practices, professional associations, organizations concerned with specific diseases and conditions, or the federal Agency for Healthcare Research and Policy. Review the pathways as a group, and get an idea of the structure and whether you’d like to modify one or build your own. The committee should write out each step in how they currently treat those patients and compare that to pathways from other groups as a benchmark.
In addition, the committee should examine the best performers in the practice. "If a practice has 12 people doing one procedure and one is ahead in cost per treatment but nothing says clinical care is compromised, it should look at what this physician does and see if it could incorporate that into a standardized pathway," Boguszewski says.
- Design your pathways with all the physicians in your practice. "If physicians feel restricted or feel they have been left out, or if the pathway doesn’t allow them enough flexibility to make the best decisions for their patients, they won’t follow it," he says.
- Once you have created a standard pathway, add in secondary characteristics, such as age, life expectancy, and comorbidities. Those characteristics can be addressed by splits or branches on the pathway. It doesn’t have to be one way for all people, Boguszewski says.
- Monitor compliance with the pathways. This doesn’t just mean tracking variances from the pathway. There should be a peer review team that looks at pathway compliance and why variances occur.
- Monitor the outcomes. It’s not enough to monitor compliance. You need to determine whether you are actually getting benefits from the pathways.
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