ADMINISTRATION PROCESS Nursing 005

AS II - Nursing Services Administration PracticeTools to Manage and Evaluation Care:Clinical Pathway & Clinical Practice GuidelinesMary Ann Tejano Adiong, RN, USRN - MasterandUniversity of BoholGraduate School & Professional Studies DepartmentTagbilaran City, Bohol, Philippines

OBJECTIVES:

At the end of this report, the student should be able to: Discuss the definition of clinical pathway and clinical practice guidelines.Identify all involved staff common goals and helping them to understand their roles in the entire care process.Discuss the framework for collecting and analysing data on the care process.Explain how to improve patient satisfaction through improved patient education e.g. better care giver-to-patient communication on the plan of care.

INTRODUCTION: The application of computers to generate, validate, secure and integrate healthcare data to support the decision making activities of clinical and administrative professional has added an entirely new dimension to the functioning of healthcare industry.

Techniques of Quality Management Science are among the newer approaches to managing the delivery of healthcare. One such application of this science to healthcare is Clinical Pathways.

Clinical Pathways (CP) is multidisciplinary plans of best clinical practice for specified groups of patients with a particular diagnosis that aid the coordination and delivery of high quality care. They are both, a tool and a concept, which embed guidelines, protocols and locally agreed, evidence-based, patient-centered, best practice, into everyday use for the individual patient.

Clinical Pathways are structured, multidisciplinary plans of care designed to support the implementation of clinical guidelines and protocols. Introduced in the 1990s in the UK and USAImprove the continuity of care across disciplines Step wise sequencing of care.

Why do we need Clinical Pathways?To improve patient care To maximize the efficient use of resources To help identify and clarify the clinical processes To support clinical effectiveness, clinical audit and risk management

PURPOSE:Facilitate introduction of guidelines to improve the quality of careImprove multidisciplinary communicationReach or exceed quality care standardsDecrease unwanted practice variationImprove patient-clinician communication and patient satisfaction.Identify research and development questions

AS ACTIVE MANAGEMENT TOOLS:Eliminate prolonged lengths of stay arising from inefficiencies, allowing better use of resources

Reduce mistakes, duplication of effort and omission

Improve the quality of work for service providers

Improve communication with patients as to their expected course of treatment

Identify problems at the earliest opportunity and correct these promptly

Facilitate quality management and an outcomes focus

DISTINGUISH CRITICAL PATHWAYS FROM CLINICAL PROTOCOLSProtocols are treatment recommendations that are often based on guidelines. Like the critical pathway, the goal of the clinical protocol may be to decrease treatment variation.

Protocols are most often focused on guideline compliance rather than the identification of rate-limiting steps in the patient care process.

In contrast to critical pathways, protocols may or may not include a continuous monitoring and data-evaluation component.

FOUR COMPONENTS OF A CLINICAL PATHWAY:

A Timeline, Categories of care or activities and their interventions,

Intermediate and long-term outcome criteria,

Variance record

CLINICAL PATHWAY DEVELOPMENTPREREQUISITES:Succeed when the decision to develop is taken on an organizational basis. Senior management commitment and a strong medical and nursing lead are essential.Pathway documentation is more likely to be used if it is simple, clear and user friendly.The process of pathway development considers why tasks and interventions are performed, and by whom; since it promotes greater awareness of the role of each professional involved in the care cycle.

BASIS OF CRITICAL PATHWAY TECHNIQUE:

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VARIATION:Systems variations Health and social care professional variations Patient variations

GUIDELINES FOR THE DEVELOPMENT AND IMPLEMENTATION:Educate and obtain support from physicians and nurse, and establish a multidisciplinary team.Identify potential obstacles to implementation.Use Quality improvement methods and tools.Determine staff interest and select Clinical Pathways to develop.Collect Clinical Pathway data and medical record reviews of practice patterns.Conduct literature review of clinical practice guidelines.Develop variance analysis system and monitor the compliance with documentation on Clinical Pathways.Use a pilot Clinical Pathway for 3 to 6 months; revise as needed.

CONSTITUENTS OF CLINICAL PATHWAYS:Multi-disciplinary, multi-agency, clinical and administrative activitiesStructured Variance TrackingLocal and National standardsEvidence based, locally agreed, best practicesTests, charts, diagrams, information leaflets, satisfaction questionnaires, etc.Scales for measurement of clinical effectivenessOutcomesFreehand notesScalability to add activities to a standard CP for individualized care for a particular patientProblem, Plan, Goal and Notes or similar structured freehand area

OPTIMUM DEVELOPMENT AND IMPLEMENTATION STRATEGIES:SELECT A TOPIC Topic of high-volume, high-cost diagnoses and procedures. For example:- Critical pathway development for cardiovascular diseases and procedures SELECT A TEAM Active physician participation and leadership is crucial Representatives from all groups

EVALUATE THE CURRENT PROCESS OF CAREKey to understanding current variationA careful review of medical records Identify the critical intermediate outcomes, rate-limiting steps, and high-cost areas on which to focus.

EVALUATE MEDICAL EVIDENCE AND EXTERNAL PRACTICESEvaluate the literature to identify evidence of best practicesIn the absence of evidence, comparison with other institutions, or "benchmarking," is the most reasonable method to use.

DETERMINE THE CRITICAL PATHWAY FORMATThe format of the pathway include a task-time matrixspectrum of pathways of the medical record used as a simple checklist

DOCUMENT AND ANALYZE VARIANCEThe most important processes in the critical pathwayIdentification of factors the key features in process improvementVariance in clinical pathways is a result of the omission of an action or the performance of an action at an inappropriate (often, a late) time period.Team to concentrate on a few critical items in the pathway that have been identified in advanceFor example: length of stay in the intensive care unit

BENEFITS: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 and sectors; Provide explicit and well-defined standards for careHelp reduce variations in patient care (by promoting standardization)Help improve clinical outcomes; Help improve and even reduce patient documentation Support trainingOptimize the management of resourcesCan help ensure quality of care and provide a means of continuous quality improvementSupport the implementation of continuous clinical audit in clinical practice Support the use of guidelines in clinical practiceHelp empower patients; Help manage clinical riskHelp improve communications between different care sectors Disseminate accepted standards of careProvide a baseline for future initiativesExpected to help reduce risk; Expected to help reduce costs by shortening hospital stays

May appear to discourage personalized care Risk increasing litigation Don't respond well to unexpected changes in a patient's condition Suit standard conditions better than unusual or unpredictable ones Require commitment from staff and establishment of an adequate organizational structure Problems of introduction of new technology May take time to be accepted in the workplace Need to ensure variance and outcomes are properly recorded, audited and acted upon.

POTENTIAL PROBLEMS AND BARRIERS TO CLINICAL PATHWAYS:

CPGs are statement that include recommendations intended to optimize patient care that are informed by systematic review of evidence and an assessment of the benefits and harms of alternative care options.

Committee on Standards for Developing Trustworthy CPGs (IOM-AHRQ)

THE PROCESS FOR CLINICAL PRACTICE GUIDELINE CONTENT DEVELOPMENT