nursing, clinical pathway, clinical practice guidelines, masteral

1. University of Bohol
Graduate School & Professional Studies Department
Tagbilaran City, Bohol, Philippines
AS II - Nursing Services
Administration Practice
Tools to Manage and Evaluation Care:
Clinical Pathway & Clinical Practice Guidelines
Mary 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 practice
guidelines.
2. Identify all involved staff common goals and helping them to
understand their roles in the entire care process.
3. Discuss the framework for collecting and analysing data on
the care process.
4. Explain how to improve patient satisfaction through
improved patient education e.g. better care giver-to-patient
communication on the plan of care.

3. 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.

4. “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”.

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

6. 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

7.  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

8. 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

9. DISTINGUISH CRITICAL
PATHWAYS FROM CLINICAL PROTOCOLS
 Protocols 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.

10. FOUR COMPONENTS OF A CLINICAL
PATHWAY:
 A Timeline,
 Categories of care or activities and
their interventions,
 Intermediate and long-term outcome
criteria,
 Variance record

11. CLINICAL PATHWAY DEVELOPMENT
PREREQUISITES:
 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.

12. BASIS OF CRITICAL
PATHWAY TECHNIQUE:

13. VARIATION:
Systems variations
Health and social care
professional variations
Patient variations

14. 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.

15. Multi-disciplinary, multi-agency, clinical and administrative
activities
Structured Variance Tracking
Local and National standards
Evidence based, locally agreed, best practices
Tests, charts, diagrams, information leaflets, satisfaction
questionnaires, etc.
Scales for measurement of clinical effectiveness
Outcomes
Freehand notes
Scalability to add activities to a standard CP for
individualized care for a particular patient
Problem, Plan, Goal and Notes or similar structured
freehand area

16. 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 fromall groups
EVALUATE THE CURRENT PROCESS OF CARE
o Key to understanding current variation
o A careful review of medical records
o Identify the critical intermediate outcomes, rate-limiting steps, and high-cost
areas 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 PATHWAY
FORMAT
 The format of the pathway include a task-time
matrix
 spectrum of pathways of the medical record
used as a simple checklist
DOCUMENT AND ANALYZE VARIANCE
o The most important processes in the critical
pathway
o Identification of factors the key features in
process improvement
o Variance 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.
o Team to concentrate on a few critical items
in the pathway that have been identified in
advance
For example: length of stay in the intensive
care 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 and
sectors;
 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 hospital
stays

19. POTENTIAL PROBLEMS AND
BARRIERS TO CLINICAL PATHWAYS:
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.

21. CPG’s 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
CPG’s (IOM-AHRQ)

28. THE PROCESS FOR CLINICAL PRACTICE
GUIDELINE CONTENT DEVELOPMENT