Do not let your clinical path efforts fall flat
Keys to effective implementation
By Patrice Spath, ART
Consultant in Health Care Quality and Resource Management
Forest Grove, OR
Although clinical paths have been started at many hospitals, they sometimes have not been successfully integrated into their patient management process. Listed below are some of the common problems that create ineffectual clinical path strategies:
• Failure to identify goals/objectives for the path-based patient care strategy before beginning the process.
• Negligence in integrating clinical path development and path-based patient care with other patient care strategies (i.e. case management, quality improvement, work redesign, and utilization review).
• Insufficient education (on the part of the direct patient caregivers) to understand the concept of path-based patient care and how paths will help the organization achieve their managed care objectives.
• Failure to substantiate the benefits of clinical paths.
Before paths are designed, the leaders must identify opportunities for process improvements and unexplainable variations in care and share this information with caregivers.
• Attempting to design paths for as many patient groups as possible in a short period of time.
In hindsight, institutions that have attempted to hurry their path development efforts, are now saying, "300 paths is 280 too many."
• Making clinical path use mandatory for all physicians.
It may be better to provide skeptical physicians with objective information about how paths have benefited other physicians’ patient care activities. Use valid and reliable data to win them over not coercion.
• Collecting path variance data that will not be useful for improving the clinical processes of care.
History suggests that only significant path detours need to be tallied and analyzed.
Institutions are finding there is no right way to implement path-based patient care. The goals set for their strategy have a significant influence on path design and deployment decisions. There are, however, some critical factors that increase the likelihood of success in each stage of path implementation: planning, path design, and process improvement.
Planning success factors
Prior to implementing paths, the administrative and medical staff leaders of the organization must be educated in how clinical paths are used in managing patient care. If these leaders are not personally committed to path-based patient care, it is likely to fail. Other issues important during the path planning phases include:
• A leadership group is involved in setting the path design and implementation strategies for the organization.
• Quality improvement, not cost control, is the primary goal of path-based patient care.
• All goals and objectives are clearly defined in measurable terms.
• A mechanism for measuring goal attainment is defined and integrated with the deployment strategies.
• The goals and objectives are communicated to all caregivers, and they understand how path-based patient care will improve quality and reduce costs.
• Plans are made to integrate clinical paths into the organization’s quality, utilization, and case management program activities.
• Adequate resources are provided to initiate the path-based patient care strategies of the organization. This should include substantial human and financial resources earmarked for physician and staff education.
Physicians, nurses, and other health professionals caring for patients should be personally involved in the initial design of the paths that will affect them. Not all caregivers will be on the path design team, but they should be provided an opportunity to react to the draft version prior to implementation. A survey form can be used to solicit caregivers’ input. (See clinical path survey, p. 168.) Other issues to consider when designing clinical paths:
• The time progression for clinical paths is clinically relevant to the patients’ management course.
• The clinical path incorporates current knowledge about optimal medical practices and effective treatment approaches.
• The clinical path includes elements of patient management and expected outcomes during a specified period of patient care.
• The clinical path represents optimal quality, not necessarily lowest costs for a specific provider.
• Where possible, the clinical paths do not compel physicians, nurses, and other caregivers to document the same information in more than one place.
• Physician standing orders, flow sheets, check lists, and other discipline-friendly reminder tools are used to deploy the path recommendations.
• Clinical paths are readily accessible to all caregivers throughout the patient’s episode of care.
• Caregivers are asked to respond concurrently only to significant path variances.
• Caregivers are asked to report only significant path variances.
• Preliminary plans are initiated to design an information system which will support automated "point-of-care" data entry.
Process improvement success factors
Information gained from path variance reporting and other data collection activities should be reviewed by a multidisciplinary team representing physicians, nurses, and other clinicians caring for patients. When evaluating path-based performance measures, this team should look for:
• system breakdowns requiring correction;
• validation of the clinical care hypothesis of the path that is, maximum quality at minimum cost;
• the impact of variances on patient outcomes.
An important element of process improvement includes the analysis of patient outcome data that covers an entire episode of care and includes information obtained from patients about their function and quality of life following treatment. This type of data can help caregivers evaluate the long-term impact of path-based patient care.
Physicians, nurses, and other clinicians who are expected to use the clinical path to manage patients should be regularly provided with the results of variance analysis and patient outcome studies. Information such as that shown in the patient intra-muscular medication/education chart can help caregivers make better patient care decisions. (See intramuscular pain medication and education chart, p. 169.)
Institutions cannot afford to spend staff and financial resources on any strategy that will not help them achieve their managed care objectives. If paths are a part of your organization’s clinical process improvement initiative, then it’s important to incorporate as many success factors as possible into your path implementation strategy.
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