Clinical Practice Guidelines / Pathways as a Strategy / Tool for Hospital Quality Service Improvement

Clinical Practice Guidelines

as a Strategy / Tool for Hospital Quality

Service /Improvement

Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg Short Course on Total Quality Management

June 23 - 27, 2014 UP Manila College of Public Health

Clinical Practice Guidelines / Pathways





Clinical Pathways as a Strategy / Tool for Hospital Quality







Outline of Contents of Talk:• Definition of Terms• Why the Strategy• How to Go About It (The Tool)





Practice Guidelines as a Strategy / Tool for Hospital

Quality Service ImprovementDefinition of Terms:• Clinical Practice Guidelines / Evidence-based

Clinical Practice Guidelines• Clinical Pathways / Care Pathways• Clinical Practice Protocols• Policies and Procedures • Standard Operating Procedures• Citizen’s Charter

Column Headings:

• Services Offered• Steps /

Procedures• Requirements /

Forms• Duration• Fees / Charges• Persons

Responsible• Location

Practice Guidelines as a Strategy and Tool for Hospital

Quality Service Improvement

Citizen’s Charter• Document setting out standards of service • Non-medical and medical services• Government institutions• Manuals and posters• Publicized to clients and staff leading to knowledgeable

clients and staff

QUALITY SERVICE / IMPROVEMENT

Clinical Practice Guidelines as a Strategy for Hospital Quality

Service Improvement Citizen’s Charter

It aimed to improve public services in the UK by:• Making administration accountable and citizen friendly.• Ensuring transparency and the right to information.• Taking measures to cleanse and motivate civil service.• Adopting a stakeholder approach.• Saving time of both executant and the clientele.• Easily under stability and quantified works.

*http://en.wikipedia.org/wiki/Citizen's_Charter


Quality Service Improvement

Citizen’s Charter• Document setting out standards of service • Non-medical and medical services• Government institutions• Manuals and posters• Publicized to clients and staff leading to knowledgeable

clients and staff


• Clinical Practice Guidelines / Evidence-based Clinical Practice Guidelines

• Clinical Pathways / Care Pathways

• Clinical Practice Protocols

• Policies and Procedures• Standard Operating

Procedures


Quality Service ImprovementStandard Operating Procedures, Policies and Procedures, and Practice Protocols • Documents setting out standardization and standards

of practice • Non-medical and medical services• Government and non-government institutions• Manuals and posters• Publicized to clients and staff leading to knowledgeable

clients and staff



Quality Service ImprovementStandard Operating Procedures, Policies and Procedures, and Practice Protocols • Documents setting out standardization and standards

of practice • Non-medical and medical services• Government and non-government institutions• Manuals and posters• Publicized to clients and staff leading to knowledgeable

clients and staff


• Clinical Practice Guidelines / Evidence-based Clinical Practice Guidelines

• Clinical Pathways / Care Pathways

• Citizen’s Charter


Quality Service ImprovementClinical Practice Guidelines, Clinical Pathways, Clinical Practice Protocols (Hospital Setting)• Documents setting out standardization and standards

of clinical practice (management of patients)• Non-medical (allied medical) and medical services• Government and non-government institutions• Manuals and posters• Publicized to clients and staff leading to knowledgeable

clients and staff



Quality Service ImprovementClinical Practice Guidelines, Clinical Pathways, Clinical Practice Protocols• Documents setting out standardization and standards

of clinical practice (management of patients)• Non-medical (allied medical) and medical services• Government and non-government institutions• Manuals and posters• Publicized to clients and staff leading to knowledgeable

clients and staff


• Practice Protocols• Policies and Procedures• Standard Operating

Procedures• Citizen’s Charter

Clinical Practice Guidelines, Clinical Pathways, and Clinical Practice

Protocols Clinical

GuidelineClinical Pathway Practice Protocol

Focuses on Specific clinical circumstances.

The quality and co-ordination of care.

Treatment.

http://www.implementationcentral.com/guidelines_8.html


Protocols Clinical Guideline Clinical Pathway Practice Protocol

What is it? Systematically developed statements to assist practitioners and patient make decisions about appropriate health care.

Structured, multi-disciplinary plans of care.

A suggested course of treatment and/or treatment service for a specific diagnosis, functional deficit or problem area.




What does it do?

Makes specific recommendations on health care and links these to research evidence.

Supports the implementation of clinical guidelines and protocols.

Highlights major therapeutic intervention points.Identifies choices of difference courses or paths of treatment.Suggests other diagnosis that could be considered as treatment progresses.




How does it work?

Provides a summary and appraisal of the best available research evidence or expert consensus.Highlights the strength of the evidence underlying each recommendation.

Provides detailed guidance for each stage in the management of a patient.

Provides a logical flow of interventions. Provides detailed recommendations that build on those made in guidelines.




Who uses it? Clinicians, patients and third parties.

A multidisciplinary clinical team.

Specific clinicians.




What are its components?

1) Appraisal of literature (research evidence or expert consensus).2) Summary of recommendations.3) An outline of how guideline should be implemented and how adherence monitored.

1) Timeline2) Categories of care/ intervention.3) Intermediate and long term outcome criteria.4) A variance record.

1) List of major therapeutic interventions.2) Goals: When interventions should be achieved.3) Options for different choices of treatment.4) Differential diagnoses and treatments based on the achievement of these goals.




Also known as....

GuidelinesClinical Practice Guidelines

Integrated Care PathwaysMultidisciplinary Pathways of CarePathways of CareCare MapsCollaborative Care Pathways

ProtocolBest Practice Treatment Protocol




Also known as....

GuidelinesClinical Practice Guidelines

Integrated Care PathwaysMultidisciplinary Pathways of CarePathways of CareCare MapsCollaborative Care Pathways

ProtocolBest Practice Treatment Protocol


1

2

3All 3 are clinical practice

guidelines!


• Clinical Practice Guidelines (CPG) - “systematically developed statements to assist

practitioner and patient decisions about appropriate health care for specific clinical circumstances.”

- Institute of Medicine

Practice Protocols / Clinical Practice Protocols

(SOPs, Policies and Procedures)

• “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.”

•May be in narrative form complemented with tables, checklists, algorithms

Practice Protocols / Clinical Practice Protocols

(SOPs, Policies and Procedures)

Processes in DevelopmentIdentification of subject area (service area)Formation of technical working groupFormulation of protocol – practice / service

guidelines (with bases – consensus, evidences and adjusted to local area)

Deliberation and approval of protocolDeployment and implementationTracking of implementation (variances)Evaluation and review at planned intervals


• Clinical Practice Guideline (CPG) - “systematically developed statement to assist

practitioner and patient decisions about appropriate health care for specific clinical circumstances.”

- Institute of Medicine


• Evidence-based Clinical Practice Guideline (CPG) - series of recommendations on clinical care,

supported by the best available evidence in the clinical literature.


• Evidence-based Clinical Practice Guidelines (CPG) - Processes involved in development:

- Formulation of technical working group- Formulation of clinical questions- Search for evidences in the literature- Evaluation of evidences

- Level of evidences (I – II – III)- Interim reports

- Consultation with panel of experts- Consensus gathering (Category A – C)

- Publication - Education- Implementation- Tracking of implementation (variances)- Evaluation (outcomes) and review at planned

intervals


• Evidence-based Clinical Practice Guidelines (EB-CPG)

• Health-Process-Evidence-Based Clinical Practice Guidelines (HPEB-CPG) [ROJoson]

- to make the conventional evidence-based clinical practice guidelines more relevant and useful in clinical practice in the Philippines

CLINICAL DIAGNOSTIC PROCESS

PROCESSING OF DATA

PATTERN RECOGNITION-realization that the patient’s presentationconforms to a previously learned picture or pattern of disease

PREVALENCE- choice of a diagnosis is based on the frequency of occurrence of the disease in a certain locality, in a certain age and sex group, and in the affected organ and system

CLINICAL DIAGNOSTIC PROCESS

PROCESSING OF DATA

Knowing the common manifestations of 3 different diseases and relative frequency of each as follows:

Disease A - abcd (manifestations) Least commonDisease B - abcd Disease C - abcd Most common

Given a patient manifesting with abcd, your diagnosis is Disease C. What is/are processes used?

Pattern Recognition but mainly Prevalence

Management of a Surgical Patient [Process]

Paraclinical Diagnostic Process - Indication

PROCESSING OF DATA

CERTAINTY OF CLINICAL Dx 1O Dx 60% 99%

needed not needed

TREATMENT PLAN FOR 1O & 2O DxDifferent Sameneeded not needed


Paraclinical Diagnostic Process - Selection

SELECTION PROCESS Procedure Benefit Risk Cost (PhP) AvailabilityOptions

1 accuracy 99% acceptable 5000 available2 accuracy 90% acceptable 3000 available3 accuracy 50% acceptable 1000 available

Which is the most cost-effective procedure?

Option 2 or Option 1?


Treatment Process - Selection

SELECTION PROCESS Treatment Benefit Risk Cost (PhP) AvailabilityOptions

1 greatest surv rate acceptable 5000 available2 rate < 1 > 3 acceptable 4000 available3 least surv rate acceptable 3000 available

Which is the most cost-effective treatment option?

Option 1

Clinical Pathways

• Multidisciplinary management tool based on evidence-based practice for a specific group of patients with a predictable clinical course, in which the different tasks (interventions) by the professionals involved in the patient care are defined, optimized and sequenced either by hour (ED), day (acute care) or visit (homecare).

-Wikipedia

http://en.wikipedia.org/wiki/Clinical_pathway

Clinical Pathways• A clinical pathway is a printed guideline to usual care

provided for a patient having a certain procedure done or a patient who has a certain illness. • Since all patients are unique, everyone’s care will be

customized to meet their needs while keeping the guidelines in mind.• Clinical pathways are used to describe and implement

clinical standards. They help to provide quality and efficient patient care.

Clinical PathwaysProcesses involved in development:• Identify high-volume, high-cost medical

conditions, diagnoses or procedures.• Form a multidisciplinary team.• Formulate the clinical pathway with task-time

matrix with focus on critical steps.• Deliberate and approve.• Deploy and implement.• Track implementation (variances)• Evaluate variances and patient care outcomes and

review at planned intervals.

Clinical PathwaysBasic steps• Define the processes• Timing of the processes• Note target areas that are critical• Measure variations and make improvement• Remeasurement

Clinical PathwaysComponents • A timeline• Categories of care or activities and their

interventions• Intermediate and long-term outcome criteria• Variance records

Clinical PathwaysComponents • A timeline• Pre-admission• Admission• Procedure• Postop• Discharge

Clinical PathwaysComponents • Categories of care or activities and their interventions• Medical Interventions• Assessment• Tests• Activities• Medications/Treatments• Nutrition/Fluids• Teaching• Discharge Planning• Tubes/Monitoring• Key outcomes (physician/nursing)

Clinical PathwaysComponents • Categories of care or activities and their interventions

• Assessment and Monitoring• Activity/Environmental• Consults• Diagnostics• Operative/Invasive Procedures• Laboratory• Nutrition/I.V. Therapy• Medications• Therapies• Patient/Family Education• Expected Outcomes

Clinical PathwaysVariances – result of • omission of an action • performance of an action at an

inappropriate (often late) time period

Clinical PathwaysComponents • Variance records• Look for common variances• Improve pathway• Improve compliance

Clinical PathwaysVariances – result of • Patient variations • System variations• Health professional variations

Clinical PathwaysComponents • Clinical Pathways Reasons for Variance• Patient’s clinical condition• Patient’s social situation• Associated diagnoses• Changing technology or techniques• Clinician’s discretion• Consultation and internal system services• External issues: primary care, home health care, etc.

Clinical Pathways• Aims• Facilitate introduction of guidelines to improve

the quality of care• Improve multidisciplinary communication• Reach or exceed quality care standards• Decrease unwanted practice variation• Improve patient-clinician communication and

patient satisfaction• Identify research and development questions





Clinical Practice Guidelines Clinical Pathways

• Patient care algorithms based on best evidences and cost-efficient processes.

• Intended to standardize and use standards of care - minimize variance in management- increase efficiency- improve patient care outcomes- reduce costs

Integrated value-based health care services





What are the recommended processes in going for clinical practice guidelines / clinical pathways?

Starting point:

Top management decides to have a Clinical Practice Guidelines / Clinical Pathways Project to promote quality service improvement in the hospital.


Top management creates a Steering Team / Committee for Clinical Practice Guidelines / Clinical Pathways Project with clear functions and authority.

Membership of Steering Team / CommitteeSenior Management Representative if not the Hospital

DirectorChair (with competency in clinical practice guidelines /

clinical pathways and leadership)Cross-sectoral or multisectoral membership with representatives from key functional areas in the hospital, such as the following:(Note: the senior management team members may constitute the Steering Team / Committee.)


Cross-sectoral or multisectoral membership with representatives from key functional areas in the hospital, such as the following:(Note: the senior management team members may constitute the Steering Team / Committee.)

Medical service sectorNursing service sectorAncillary medical service sectorAdministrative or support service sectorHuman resource development sectorFinance sectorSecretariat


Steering Team formulates a master plan for Clinical Practice Guidelines / Clinical Pathways Project.

Steering Team seeks commitment for support and collaboration from top, senior, middle, and lower management on Clinical Practice Guidelines / Clinical Pathways Project.


Contents of master plan for Clinical Practice Guidelines / Clinical Pathways Project

Goals and objectives of Clinical Practice Guidelines / Clinical Pathways Project (include short- and long-term goals and objectives)Selection and prioritization of guidelines and pathways to developSelection of the multidisciplinary teams for the guidelines and pathways developmentExpected outputs (short- and long-term)Expected impact (short- and long-term)


Contents of master plan for Clinical Practice Guidelines / Clinical Pathways Project

Timelines (short- and long-term)Strategies and action plans to achieve expected outputs and impacts (short- and long-term)Budget (short- and long-term)Monitoring and oversight planEvaluation plan (short- and long-term)

ROJoson’s Recommendations:

Target clinical pathways.

As pathways are being develop, input

clinical practice guidelines

and target

Integrated Value-Based Health Care Services

What are the common problems and challenges in clinical practice guidelines and clinical pathway development ?

Common problems and challenges (commitment, cooperation, collaboration, and integration of all stakeholders)

Non-consensus on pathways by the stakeholdersFear of medicolegal suitsTedious work to formulate and record and evaluate the pathways

What are the common problems and challenges in clinical practice guidelines and clinical pathway development ?

Common problems and challenges (commitment, cooperation, collaboration, and integration of all stakeholders)

Weakness in:Leadership Management

Planning, implementation, and evaluationIntegration of standards in all units

CommunicationEducation

Clinical Practice Guidelines / Pathways as a Strategy / Toolfor Hospital Quality




Thank you for your kind attention.For query and feedback:[email protected]

0918-804-0304

mailto:[email protected]

Clinical Pathways as a Strategy / Toolfor Hospital Quality




Thank you for your kind attention.For query and feedback:[email protected]

0918-804-0304

mailto:[email protected]

Welcome Queries and Feedback Anytime!

REYNALDO O. JOSON, MD, MHA, MHPEd, MSc Surg0918-804-03-04

[email protected]

Clinical Practice Guidelines / Pathways as a Strategy / Tool for Hospital Quality Service Improvement

Healthcare

technical

systematically

key functional

guidelinesclinical

paraclinical

citizens charterdocument

specific clinical

carecare mapscollaborative