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