Bob Luttman, Robert Luttman & Associates
The Next Generation Quality Model
Clinical Pathways
Clinical Pathways
Clinical Pathways are not cookbook medicine. They are the best practice clinical care process for a given patient population.
Clinical pathways are the foundation of the Next Generation Quality model for exactly that reason: they are designed process of care. they provide the roadmap for planning the patients' care and for monitoring their progress. They also provide the context for analyzing variance and outcomes data.
Without a process, you have nothing to base management or improvement efforts on.
With that said, let's consider some Do's and Don'ts for producing better pathways in a more effective process.
- Do use multiple pathways for a given population. The human body is the most complex entity on Earth (next to the US tax code perhaps). It is inherently variable, even the most common procedures and conditions have variation.
Avoid the cookbook mentality and create best/expected/worst case pathways for a population.
- Do use process design tools such as the Activity Network Diagram (a.k.a. the PERT chart). This tool is the origin of the term "critical path" used in first generation pathway programs. The tool builds a model of the process based on the relationship between activities and outcomes and the length of time needed to complete the activity or achieve the outcome.
The model identifies the rate limiting steps in the process and provides a mechanism for performing "what if...?" and "best/expected/worst case" analyses. Consider the following example:
The boldfaced boxes are the rate limiting steps in the process. Patients will not progress through this pathway any faster than they can complete these activities or achieve these outcomes.
- Do use a multidisciplinary team to develop and manage pathways. These are not Nursing things, or Case Management things. Their power and utility comes from the coordination of care across disciplines and organizational boundaries. Consider involving payors on the teams, or at least consult with them. Add people from referring physician offices, rehab facilities, VNA's, SNF's and other community based healthcare resources.
- Do not stop with writing the pathway. The real work begins after the pathway is written. Process changes to accommodate the pathway's new process is necessary before implementation. Variance data and continuous improvement are required to keep the pathway going, and to improve (yes, rewrite) the pathway to keep it current and effective.
Finally, remember that the pathways are part of a system for providing excellent clinical care. They are not cast in concrete comply or else edicts.
