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We believe emphatically that clinical pathways, properly done, are an essential part of any healthcare improvement strategy. These are not medical "cookbooks"; they are the embodiment of statistical and process thinking to clinical care.
With clinical pathways you can:
- Improve care through more standardized processes and better coordination
- Improve care documentation
- Improve care measurement by linking process and outcomes through the variance management system
- Improve communication between the care team
Our four part model, shown in Figure 1, is a holistic system for designing, managing, and improving care. Derived from the Baldrige quality criteria, we call our model Next Generation Quality. A different approach to pathways, variances, documentation, and quality improvement. This article will focus on the pathway component of the model. For more details on the Next Generation Quality Model please the NGQ Short Takes. For more on variance management systems see our Variance Management Systems Short Take.
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Frequently Asked Questions.
To put the clinical pathways portion of the model we would like to answer some common questions about pathways.
What are Clinical Pathways?
Clinical pathways are an explicitly designed care process for a defined patient population.
How are pathways developed?
A multidisciplinary team develops each individual pathway, or should. The pathway should include the clinical practice guideline upon which it is based; the ancillary and support activities which make the practice guideline a reality; and, the intermediate and end state outcomes the patient's are to achieve.
Where did pathways come from?
Clinical pathways were developed in response to the initial DRG based prospective reimbursement system of the early 1980's (remember that?). The were originally developed at the New England Medical Center by a Karen Zander and Kathleen Bower, among others. This group is now the Center for Case Management, an RLA partner and publisher of How to Design Clinical Pathway Variance Systems for Continuous Improvement, our variance analysis book.
How are pathways used?
That depends on the specific organization, patient population, and need. Pathways, as our Next Generation Quality model indicates, are useful for case management, costing services for pricing and contracting, quality improvement, documentation improvement, and a myriad other uses as healthcare and pathways evolve.
How are pathways documented?
Pathway documentation is also unique to individual organizations. The most common format is the Activity/Outcome vs. Time matrix that shows activities and outcomes on one axis and time (usually in days) on the other axis. Others, including our pathway system use a separate page for each time period (again, usually days) of the patient's treatment. The latter model is a more robust model in the face of changing patient condition - especially one that extends a patient's stay.
What is a variance?
Technically, any deviation from the pathway is a variance. At RLA we distinguish between compliance variances (where an activity was not performed or an outcome not achieved as planned) and effectiveness variances (where the desired outcomes and performance measures - such as planned LOS - were not attained). Much more information on variance management is in our Variance Management Short Take.
That is too much data, isn't there and easier way to collect and analyze variance data?
Yes. Two methods for reducing variance data woes are possible. One, is to identify key, or critical, variances; those activities or outcomes deemed essential to the patient population's care. Another method, our Gateway method, identifies key milestones - "gateways" - in the care process and collects data on why patients are delayed passing through the gateway. The following model illustrates a two gateway model, such as a post-op stay with an ICU phase and a step-down unit phase.
At each gateway the patient can take one of three pathways: continue as planned, delay their progress for at least a day, or falloff the pathway. Those delayed at the gateway continue their pathway using an insert - or add on - day document which duplicates the pathway document with the addition of a box to collect the reason for the delay. This is the gateway variance which, for this pathway, reduces the data collection to two data points. Add some critical variances and a powerful database is created with little effort. The detail variances, all those activities and outcomes on the pathway, have their variances recorded in the documentation, where it is available for process improvement efforts.
It is the insert day that provides the increased robustness of the Gateway system's documentation. The care team no longer must switch from 'regular' to pathway documentation as the patient's progress changes.
Much more information on variance management is in our Variance Management Short Take.
How do clinical pathways fit into an overall process improvement strategy?
Clinical pathways define a care process for a patient population. Processes are the essence of any improvement strategy. So is data, which pathways - through the variance management system - can provide in abundance.
We see pathways and the variance system as the heart of a 'double-loop' improvement process, as shown in the following illustration. In the Design phase the care team focuses on designing a viable pathway and making the process improvements necessary for the pathway's success. In the Management phase, the team uses the pathway to manage care and the variance system to identify improvement opportunities. If changes in clinical practice or the variance data indicate that significant process reengineering is necessary the process goes through another Design phase.
Two loops, two opportunities to improve care.
Robert Luttman & Associates offers many other clinical pathways services. We have published, presented, taught, and lectured on clinical pathways, variance management systems, and continuous improvement around the world. Some of the services you will find on this site are:
OnLine Consulting
We offer you the opportunity to connect with us from the convenience of your desktop, on any topic, at no charge. Simply visit our OnLine Consulting page to choose the most convenient way for you to contact us. We will answer any and all questions related to healthcare performance improvement. If Online Consulting is not for you then call us at: (508) 359-9630.
OnLine Workshops
We offer online versions of our workshops, two of which center around clinical pathways. The first is Variance Management Systems which focuses on the multitude of issues (legal, statistical, and operational) affecting pathways, the various strategies - including our Gateway system - for addressing these issues, how to analyze variance data using quality management tools and techniques, and integrating variance data into an overall organizational performance measurement system. Second, is Next Generation Quality which looks at the overall clinical pathways system and its relationship to an organizational performance excellence program. The workshop addresses such issues as how pathways fit into an organizational improvement strategy, cost accounting and pathways, variance management systems, and creating balanced scorecards from clinical pathways and variance data.
OnSite Consulting and Workshops
We offer extensive consulting and training services. We can help your organization develop and implement a clinical pathways program or its components; integrate your pathways program into a Next Generation Quality program; design and implement a process improvement program; and train your staff in the tools and techniques they need to succeed.
Gateway Variance Management System
Created at a large teaching hospital as a vehicle to drive process improvement and clinical pathways, our Gateway system is a set of templates for creating clinical pathway documentation using the Gateway methodology and an Excel spreadsheet model for entering gateway and critical variances concurrently for analysis and reporting. A free beta version of release 1 is available now, release 2 is scheduled for release in April 2000.
Publications
We can honestly say that we wrote the book on clinical pathways variance analysis. Our variance book, How to Design Clinical Pathways Variance Systems for Continuous Improvement, is available from the Center for Case Management, (508) 651-2600.
We have scoured the Internet for clinical pathways materials. At our Bookstore you will find an assortment of books available for on-line ordering. The Center for Case Management also carries a wide assortment of materials on pathways and case management, especially our variance book: How to Design Clinical Pathways Variance Systems for Continuous Improvement. You can contact the Center at (508) 651-2600. Brown-Spath Associates also has materials on clinical pathways, process improvement, and case management. Call Patrice Spath at (503) 357-9185.
The New Economy of virtual worldwide organizations is also the model of Robert Luttman & Associates. Our connections span the globe and include the finest consultants in the healthcare field. Our clinical pathways partners, in particular, offer tremendous services and products.
Center for Case Management
In the mid-1980's a group of dedicated and visionary nurses and other healthcare professionals invented the clinical pathway. Since then they have gone on to create the Center for Case Management, the best clinical pathways and case management organization in the world. We are proud that the Center and RLA have forges a partnership that combines our respective strengths. The Center's knowledge, experience, publications, conferences, and client network are breathtaking. They provide the tools, techniques, and thinking necessary for navigating the turbulent waters of managed care, clinical integration, clinical pathways, and performance improvement.