- 1. University of BoholGraduate School & Professional
Studies DepartmentTagbilaran City, Bohol, PhilippinesAS II -
Nursing ServicesAdministration PracticeTools to Manage and
Evaluation Care:Clinical Pathway & Clinical Practice
GuidelinesMary Ann Tejano Adiong, RN, USRN - Masterand
2. OBJECTIVES:At the end of this report, the student should be
able to:1. Discuss the definition of clinical pathway and clinical
practiceguidelines.2. Identify all involved staff common goals and
helping them tounderstand their roles in the entire care process.3.
Discuss the framework for collecting and analysing data onthe care
process.4. Explain how to improve patient satisfaction
throughimproved patient education e.g. better care
giver-to-patientcommunication on the plan of care. 3.
INTRODUCTION:The application of computers togenerate, validate,
secure and integratehealthcare data to support the decisionmaking
activities of clinical andadministrative professional has added
anentirely new dimension to thefunctioning of healthcare
industry.Techniques of Quality Management Scienceare among the
newer approaches tomanaging the delivery of healthcare. Onesuch
application of this science tohealthcare is Clinical Pathways. 4.
Clinical Pathways (CP) ismultidisciplinary plans of bestclinical
practice for specifiedgroups of patients with aparticular diagnosis
that aidthe coordination and deliveryof high quality care. They
areboth, a tool and a concept,which embed guidelines,protocols and
locally agreed,evidence-based, patient-centered,best practice,
intoeveryday use for theindividual patient. 5. Clinical Pathways
are structured,multidisciplinary plans of care designed tosupport
the implementation of clinicalguidelines and protocols. Introduced
in the 1990s in the UK and USA Improve the continuity of care
acrossdisciplines Step wise sequencing of care. 6. To improve
patient careTo maximize the efficient use ofresourcesTo help
identify and clarify theclinical processesTo support
clinicaleffectiveness, clinical audit andrisk management 7.
Facilitate introduction of guidelinesto improve the quality of care
Improve multidisciplinarycommunication Reach or exceed quality
carestandards Decrease unwanted practicevariation Improve
patient-cliniciancommunication and patientsatisfaction. Identify
research and developmentquestions 8. AS ACTIVE MANAGEMENT TOOLS:
Eliminate prolonged lengths of stayarising from inefficiencies,
allowingbetter use of resources Reduce mistakes, duplication of
effortand omission Improve the quality of work for serviceproviders
Improve communication with patients asto their expected course of
treatment Identify problems at the earliestopportunity and correct
these promptly Facilitate quality management and anoutcomes focus
9. DISTINGUISH CRITICALPATHWAYS FROM CLINICAL PROTOCOLS Protocols
are treatment recommendationsthat are often based on guidelines.
Like thecritical pathway, the goal of the clinicalprotocol may be
to decrease treatmentvariation. Protocols are most often focused
onguideline compliance rather than theidentification of
rate-limiting steps in thepatient care process. In contrast to
critical pathways, protocolsmay or may not include a
continuousmonitoring and data-evaluation component. 10. FOUR
COMPONENTS OF A CLINICALPATHWAY: A Timeline, Categories of care or
activities andtheir interventions, Intermediate and long-term
outcomecriteria, Variance record 11. CLINICAL PATHWAY
DEVELOPMENTPREREQUISITES: Succeed when the decision to develop is
taken on an organizational basis. Senior management commitment and
a strong medical and nursing leadare essential. Pathway
documentation is more likely to be used if it is simple, clear
anduser friendly. The process of pathway development considers why
tasks andinterventions are performed, and by whom; since it
promotes greaterawareness of the role of each professional involved
in the care cycle. 12. BASIS OF CRITICALPATHWAY TECHNIQUE: 13.
VARIATION:Systems variationsHealth and social careprofessional
variationsPatient variations 14. GUIDELINES FOR THE DEVELOPMENTAND
IMPLEMENTATION: Educate and obtain support from physicians and
nurse, andestablish a multidisciplinary team. Identify potential
obstacles to implementation. Use Quality improvement methods and
tools. Determine staff interest and select Clinical Pathways
todevelop. Collect Clinical Pathway data and medical record reviews
ofpractice patterns. Conduct literature review of clinical practice
guidelines. Develop variance analysis system and monitor
thecompliance with documentation on Clinical Pathways. Use a pilot
Clinical Pathway for 3 to 6 months; revise asneeded. 15.
Multi-disciplinary, multi-agency, clinical and
administrativeactivitiesStructured Variance TrackingLocal and
National standardsEvidence based, locally agreed, best
practicesTests, charts, diagrams, information leaflets,
satisfactionquestionnaires, etc.Scales for measurement of clinical
effectivenessOutcomesFreehand notesScalability to add activities to
a standard CP forindividualized care for a particular
patientProblem, Plan, Goal and Notes or similar structuredfreehand
area 16. OPTIMUM DEVELOPMENT ANDIMPLEMENTATION STRATEGIES:SELECT A
TOPIC Topic of high-volume, high-cost diagnoses and procedures.For
example:- Critical pathway development for cardiovascular diseases
andproceduresSELECT A TEAM Active physician participation and
leadership is crucial Representatives fromall groupsEVALUATE THE
CURRENT PROCESS OF CAREo Key to understanding current variationo A
careful review of medical recordso Identify the critical
intermediate outcomes, rate-limiting steps, and high-costareas on
which to focus.EVALUATE MEDICAL EVIDENCE AND EXTERNAL PRACTICES
Evaluate the literature to identify evidence of best practices In
the absence of evidence, comparison with other institutions,
or"benchmarking," is the most reasonable method to use. 17.
DETERMINE THE CRITICAL PATHWAYFORMAT The format of the pathway
include a task-timematrix spectrum of pathways of the medical
recordused as a simple checklistDOCUMENT AND ANALYZE VARIANCEo The
most important processes in the criticalpathwayo Identification of
factors the key features inprocess improvemento Variance in
clinical pathways is a result ofthe omission of an action or
theperformance of an action at aninappropriate (often, a late) time
period.o Team to concentrate on a few critical itemsin the pathway
that have been identified inadvanceFor example: length of stay in
the intensivecare unit 18. Support the introduction of
evidence-based medicine and use of clinical guidelines Support
clinical effectiveness, risk management and clinical audit Improve
multidisciplinary communication, teamwork and care planning Can
support continuity and co-ordination of care across different
clinical disciplines andsectors; Provide explicit and well-defined
standards for care Help reduce variations in patient care (by
promoting standardization) Help improve clinical outcomes; Help
improve and even reduce patient documentation Support training
Optimize the management of resources Can help ensure quality of
care and provide a means of continuous quality improvement Support
the implementation of continuous clinical audit in clinical
practice Support the use of guidelines in clinical practice Help
empower patients; Help manage clinical risk Help improve
communications between different care sectors Disseminate accepted
standards of care Provide a baseline for future initiatives
Expected to help reduce risk; Expected to help reduce costs by
shortening hospitalstays 19. POTENTIAL PROBLEMS ANDBARRIERS TO
CLINICAL PATHWAYS:May appear to discourage personalized careRisk
increasing litigationDon't respond well to unexpected changes in
apatient's conditionSuit standard conditions better than unusual
orunpredictable onesRequire commitment from staff and establishment
ofan adequate organizational structureProblems of introduction of
new technologyMay take time to be accepted in the workplaceNeed to
ensure variance and outcomes are properlyrecorded, audited and
acted upon. 20. CPGs are statement that includerecommendations
intended to optimize patientcare that are informed by systematic
review ofevidence and an assessment of the benefits andharms of
alternative care options.Committee on Standards for Developing
TrustworthyCPGs (IOM-AHRQ) 21. THE PROCESS FOR CLINICAL
PRACTICEGUIDELINE CONTENT DEVELOPMENT