Pathways can improve perioperative process
Generic pathways help achieve integration of care
By Patrice Spath, ART
Brown-Spath & Associates
Forest Grove, OR
Horizontal and vertical integration of health care activities should be a vital component of any health care organization's case management strategy. All case managers are facing three distinct coordinative tasks in the delivery of patient care:
· coordination of clinical care, across specialty and professional lines;
· coordination of clinical support and ancillary services;
· coordination of the various, sometimes specialized, tasks of the direct caregivers.
To meet these challenges, both macro and micro care-coordination initiatives must take place. On a macro level, chronic disease management and other initiatives can be used to systematize clinical care as patients move between provider settings. On a micro level, intrafacility front-line care coordination tools such as clinical paths, patient-centered care, and team treatment planning can be used to improve communication and collaboration among caregivers and reduce costs.
Because clinical paths originated as care coordination tools for unit-based nurses, the perioperative component of the patient care continuum usually was not detailed on surgical paths. With the need to coordinate care and reduce costs wherever patients receive services, paths are now being jointly developed and used by all members of the health care team. For years, perioperative staff have used tools such as physician preference cards and the perioperative nursing record to enhance coordination and communication within their service and with pre- and postoperative caregivers. With today's emphasis on horizontal and vertical integration of patient care services and the new initiatives prompted by these challenges, caregivers in the operating theater (surgeons, anesthesiologists, nurses, technicians) are considering other methods for managing the perioperative period. One tool that is being developed by these caregivers is a clinical path.
Common characteristics of peri-op paths
Caregivers have only recently begun to develop paths for the perioperative episode of care. These initiatives are occurring as an independent surgical services strategy or as a component of a larger surgical pathway initiative that covers an episode of hospital care. Perioperative paths are being developed for a facility's high-volume surgical procedures. (See example of vascular surgery peri-op path on p. 92.) Some organizations design generic perioperative paths, e.g., one path covering all orthopedic procedures, another covering all vascular procedures, another covering all endoscopy procedures, etc. [See p. 93 for an example of a generic ambulatory surgery path that starts in the post-anesthesia care unit (PACU).] All patients can be put on this path. There is some differentiation built into the path depending upon the type of anesthesia the patient had. Generic paths like this one are especially useful for those organizations wishing to use the path for documentation purposes. The same form can be used to document patient care activities for all patients, regardless of the type of surgery they had performed. If procedure- specific paths are used for documentation purposes, a large number of different paths must be developed.
Perioperative paths usually focus on the nature, amount, timing, sequence, or duration of patient care activities. They can include patient care problems, interventions, and expected outcomes. However, the content of perioperative paths is, for the most part, related to the specific goals the caregivers are trying to achieve, rather than a "traditional" model. The 1997 Clinical Path Work Group of the Association for Operating Room Nurses (AORN) suggested that perioperative paths include the following time periods: Immediate Pre-op, Intraoperative, and Immediate Post-op. Like the content of paths, the time lines, format, degree of specificity, and how the path is used by perioperative caregivers varies significantly from organization to organization.
Define goals in specific terms
Perioperative pathway development starts with the identification of improvement goals. There are no "right" goals. What's most important is that administrative and physician leaders in surgical services agree on the importance of achieving the goals. Be sure to describe the goals in measurable terms. Well-defined goal statements are specific. Specific means detailed, particular, or focused. A goal is specific when everyone knows exactly what is to be achieved. Being specific means spelling out the details of the goal. For example:
· "Improve patient outcomes" is too general for a goal statement because it does not provide any specific information about what is to be accomplished.
· "Decrease the incidence of postoperative complications" is more specific because it narrows the scope of the desired outcome.
But to be the most specific, a goal statement should say something like:
· "Decrease the incidence of prolonged (more than 24 hours) postoperative nausea/vomiting by 20% within the next 6 months."
If there is no agreement that perioperative care needs to be improved, any attempt to stabilize processes is likely to fail, whether packaged as a clinical path or something else. You've got to get their attention. Why should caregivers want to change the status quo? It's important to collect and share data with the perioperative team to substantiate the existence of undesirable variation. For example, data showing unexplained differences among surgeons (see chart, top of p. 94) can be used to support the need for reducing physician practice variations. Data illustrating breakdowns in perioperative processes, such as instrument packs missing needed equipment (see chart, bottom of p. 94) can motivate staff to make changes in their procedures. If delayed or cancelled cases are causing costly disruptions of surgical services, then show caregivers how often they are the source of such disruptions (see chart, middle of p. 94).
Should path stand alone?
Once the perioperative pathway goals are established and the team realizes the need for change, it's time to design the path. Several questions must be answered during this step. First, will the perioperative path be a stand-alone document, or will it be incorporated as one or two columns into the facility's existing surgical path? The standardized path format adopted by the facility for use in the patient care units may be too restrictive for the perioperative caregivers. By creating a separate path, peri-op staff can define intervention categories that are unique to their services. Likewise, they have more space in which to indicate all the activities that are performed in the operating room and/or PACU.
Integrating the perioperative path with the hospitalwide format can enhance communication between the unit caregivers and perioperative services. With both the unit nurses and perioperative nurses working from the same document, communication can be strengthened. However, if perioperative caregivers wish to use their path for patient care documentation, it is likely they'll need more than one small column on a much larger pathway.
The next step is to bring together all relevant caregivers to participate in the design of the perioperative path. This group should meet to discuss the goals of path-based patient care and strategize its development approach. While there is no right way to design the perioperative component of a path, listed below are usual development strategies.
· Identify the specific patient care outcomes to be achieved (both interval and end-point). Working backwards from the outcomes, identify the patient care interventions that must be completed in a particular sequence in order to achieve these outcomes.
· Review patient records, nursing practice standards, clinical guidelines, existing perioperative protocols, physician preference cards and standing orders, intraoperative checklists, etc. to identify the common elements of care. Organize these care elements into clinically relevant perioperative time frames, based on when they are expected to occur in order to achieve desired outcomes. Uncommon interventions should not be listed on the path. Controversial interventions can either be omitted from the path or be debated and settled.
Peri-op caregivers participate in development
The process used to develop perioperative pathways at Leigh Valley Hospital, Allentown, PA is shown below. When the hospital develops a pathway for surgical patients, the perioperative caregivers participate in the housewide development process. The final perioperative path, however, is displayed separately (see path, p. 92).
1. The Hospital's Clinical Team Leader notifies the OR specialist and specialty coordinator that a surgical clinical path is being developed.
2. The OR specialist and specialty coordinator attend Collaborative Practice Team meetings to give input on the episode of care and the perioperative experience.
3. The OR specialist and specialty coordinator work with the relevant perioperative caregivers to develop the perioperative clinical path.
4. Cost data reviewed by the perioperative caregivers include aggregate OR cost data and physician-specific data.
5. The OR specialist does an analysis of OR supplies (physicians' "Pick List") in collaboration with the specialty coordinator.
6. The OR specialist and specialty coordinator identify potential areas for operations improvement and share their findings with the physicians.
7. Estimates of planned savings in equipment/ supplies is established with physician input.
8. The OR specialist/specialty coordinator adds approved changes to the physicians' Pick List and reviews changes with staff.
9. The path and Pick List changes are implemented on a predetermined date.
10. Following implementation, quarterly evaluations are prepared by care management staff and sent to the appropriate Division Chief and Chairmen. These data include baseline cost information prior to changes, target cost savings, and actual costs per case following the changes.
Use variance data to make improvements
Path variances are used both concurrently (during the episode of care) and retrospectively (after the episode of care is done). Concurrently, someone has to observe what's happening with the patient right now and determine if there are significant variances that need to be addressed and rectified. Aggregate data about critical variances from the perioperative path are used retrospectively to identify opportunities for improvement. Your perioperative path implementation strategy must include a process for reporting these variances.
How variances are used concurrently and how they are reported for retrospective analysis will vary from facility to facility. When implementing perioperative clinical paths, the questions that must be answered relative to variances include:
· Who will be responsible for monitoring adherence to the path during the perioperative episode (e.g., circulating nurse, anesthesiologist, PACU nurse, etc.)?
· What action, if any, will be expected if the patient varies from the path (e.g., no concurrent action, alert surgeon, anesthesiologist, or other caregivers, etc.)?
· How will you capture variance events for later analysis (e.g., on the clinical path form itself, or on a separate form that is not part of the patient's record)?
· What additional data might be necessary for retrospective variance analysis (e.g., minutes of delay caused by the variance, clinical outcome data, cost data, etc.)?
Organizations that have implemented perioperative paths are reporting both cost reductions and improved teamwork. These paths have been shown to reduce surgical costs by improving the efficiency of perioperative services as well as decreasing physician practice variations. Perioperative clinical paths may be a worthwhile tool if existing performance improvement and cost reduction initiatives are not achieving your goals. At the very least, perioperative staff should be involved in the development of surgical paths being designed for use by unit-based caregivers. Even if your surgical paths do not address the perioperative phase of care, OR and PACU staff can verbalize their needs to the unit nurses to ensure patients arrive in the OR with all preoperative prerequisites completed. Ideally, these same OR staff can begin to work on perioperative paths as well, asking the unit nurses what the PACU nurses must do prior to returning the patient to the care unit.
Additional Resources
· AORN Clinical Path Template (1997)
Developed by the Clinical Path Task Force of the Association for Operating Room Nurses (AORN)
Cost: $12 ($10 for AORN members)
To order, call (800) 755-2676 and ask for Item #MAN-214 or visit the AORN bookstore on their Web site: http://www.aorn.org
· Mastering Path-Based Patient Care (1995)
By Patrice Spath
Cost: $50
Published by Brown-Spath & Associates, Forest Grove, OR
To order, call (503) 357-9185 or visit their Web site: http://www.brownspath.com
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