Hospital achieves 90% compliance with pathways

Facility wins Ernest A. Codman Award

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in Oakbrook Terrace, IL, recently presented the Ernest A. Codman Award, which recognizes excellence in the use of outcomes measurement by health care organizations to achieve improvements in the quality and safety of health care, to Children’s Hospital and Health Center in San Diego. Established in 1954, Children’s Hospital is the San Diego region’s only designated pediatric trauma center and the only area hospital dedicated solely to pediatric care.

Children’s was the recipient of the award in the hospital category for the use of evidence-based, multidisciplinary clinical plans that focus on quality and coordination of care to provide optimal care for its young patients. According to JCAHO, more than 60 pathways have been implemented during the past eight years, dramatically improving the coordination and delivery of care for thousands of patients and resulting in an extraordinary 90% rate of adherence to pathway protocols.

Paul Kurtin, vice president of clinical innovations and director of the Centers for Child Health Outcomes, says the initiative has resulted in a major culture change within the hospital, and physicians have benefited from a significant increase in patient volume. The hospital saved $5.2 million as a result of reductions in per-patient asthma treatment costs, reduced respiratory treatment requirements, and other resource efficiencies, he adds.

Kurtin says the proliferation of pathways has much to do with differences in the epidemiology of disease in adults vs. children. In adults, a pathway for coronary heart disease, cancer, or hip replacement typically is applicable to a large percentage of the total patient population. By contrast, pediatric care often involves a relatively small number of children with a broad range of conditions. "Once you go beyond diseases such as asthma or pneumonia, you find fairly rare conditions," he explains. "In order to cover a large percentage of our patients, we needed to create many pathways."

When the process started, it was up to the physicians to act proactively by ordering the pathway and getting their patients on the pathway. Kurtin and his colleagues went to the department of pediatrics and the department of surgery and asked if the pathway could become the default mechanism of care. Once that change was implemented, children automatically were placed on the pathway unless the attending physicians objected. "Now, if it is 3:00 a.m., we do not rely on the house staff to think about whether there is a pathway connected with asthma or another condition," he reports.

Kurtin says that change in process improved the rate of compliance with pathways from 20% to the low 90s. It probably will be difficult to exceed the current rate of compliance, he adds, because not every child should be on a pathway. "There are outliers, and there are children with more complicated conditions," he explains. "We are very happy staying in the 90% to 93% range, where we have been for the last couple of years."

Kurtin says the rate of compliance with pathways nationwide typically is in the 15% to 25% range. In some instances, it may reach 40% to 50%, he says. "We have probably at least doubled, if not tripled, the national average," he says. "That has a lot to do with our ability to feed back results of how the children are doing on the pathway almost in real time."

Good results encourage physicians

According to Kurtin, physicians became confident over time that good things were happening in terms of patient care. "It was not a leap of faith," he asserts. "If we had found that the pathways were not helping, I am sure that we would be at zero percent."

Kurtin says the process has become almost self-perpetuating. As more pathways are established, more physicians become engaged. "Because we were able to demonstrate — both by clinical outcomes and financial outcomes — that things were better on the pathway, we received tremendous support," he says. "They see by the data that it is working for their patients, and some of our biggest skeptics in the beginning are our biggest champions now."

He says much was accomplished by coordinating care and making sure the physicians, nurses, respiratory therapists, and, if necessary, the dietitian or social worker were all on the same page. "It was coalescing the teamwork around the child as well, and that really impressed a lot of the physicians," he says.

According to Kurtin, Children’s uses physician champions for each of the pathways, in addition to relying on multidisciplinary quality improvement teams. He says the organization’s first pathway took nine months to complete. Today, he says, it takes only about a month to develop and fully implement a pathway.

Docs line up to request pathway development

Once the organization got through the learning curve and people began to accept pathways, people started to request them, Kurtin says. "We literally had a line forming for physicians who wanted us to develop pathways."

Kurtin says physician champions are absolutely essential. "It is not worth doing if you cannot get a physician champion, in my opinion," he argues. Champions do not have to be a hierarchical leader, such as the chairman of pediatrics or a division chief, but they do have to be fairly senior, well-respected clinicians. Not only must champions help in designing the pathway, but they also must be able to attract the attention of other physicians, he maintains.

The third role physician champions must fulfill is to talk to their peers and encourage them to use the pathways, Kurtin says. Finally, physician champions are expected to keep the rest of the staff abreast of new developments in the clinical research literature. "We try to update the pathways every six months," he reports.

Kurtin says that final task is important because, with 60 different pathways, the hospital would not otherwise be able to stay abreast of 60 different diseases and all the new drugs, diagnostics, and treatments for those diseases. "They are very proactive in making sure everything is state-of-the-art," he says. "Physician champions are absolutely critical."

In short, Kurtin says the pathway process has succeeded because it gets the whole team engaged, and it lets the nurses know what is going on with the patients. "It has really become ingrained over the years within the culture of our organization," he says.