Hospital achieves 90% compliance with pathways

JCAHO awards hospital with Codman

Clinical pathways often are hailed as a premier quality improvement tool, but they also are seen as pie-in-the-sky solutions because they don’t do any good if clinicians don’t actually use them after all the fanfare of introducing them. Compliance can be the weak point in implementing even one clinical pathway, but a pediatric hospital in San Diego has proved that you can get an astounding compliance rate even when introducing dozens of pathways.

Children’s Hospital and Health Center in San Diego has implemented more than 60 clinical pathways in the past eight years and boasts a 90% compliance rate. Data show that the pathways have improved quality of care while significantly decreasing costs, says Paul Kurtin, MD, vice president for clinical innovation and director of the Center for Child Health Outcomes, the department that develops and implements the pathways. He says the hospital’s experience holds lessons for any organization introducing clinical pathways, whether you’re introducing one or 100.

"Data are key to making clinical pathways work. When you have the right data, you can show that they’re the right way to treat patients, and the physicians will comply when they see that their patients benefit." Children’s is the first pediatric hospital to win the Codman Award from the Joint Commission on Accreditation of Healthcare Organizations, which recognizes outstanding quality improvement projects.

Clinical pathways are nothing new, of course, having been around since the mid-1980s. While they initially were dismissed by some clinicians as cookbook medicine, pathways are gaining acceptance as more data prove their effectiveness. Kurtin says the Children’s experience shows that a careful implementation, keeping in mind the objections that sometimes get in the way of compliance, can make all the difference.

The benefits of clinical pathways are hard to ignore. In addition to decreased costs and improved quality, The hospital’s president and CEO Blair L. Sadler says they provide effective, consistent training for new pediatric residents and interns, nurses, clinical technicians, and other support staff. Each Children’s pathway is developed in collaboration with physicians, nurses, and other clinical and hospital staff, including respiratory therapists, social workers, and dietitians. "Pathways provide irrefutable evidence that quality care can be measured. And we know they lead to the safest, most effective treatment for kids."

Kurtin says research indicates there can be as much as a 15-year lag between when best practices in medicine are identified and when they are put into everyday use. While the national average of physicians who comply with pathways is between 15% and 20%, physicians at Children’s are 90% compliant, he says.

"It’s easy to make claims of quality care; it’s much harder to prove it," Sadler says. "Pathways provide irrefutable evidence that quality care can be measured. And we know they lead to the safest, most effective treatment for kids."

The effort to implement clinical pathways began 10 years ago, spurred in part by the growing financial pressure from managed care. There also was a growing call for accountability and data on outcomes. Kurtin was hired to head the Center for Health Outcomes, and he says the experience at Children’s offers lessons any hospital can use in implementing pathways:

Lesson 1: Actively engage the physicians in implementing the pathways.

"Nursing-led projects hadn’t been successful," Kurtin says. "We wanted to devise a program that made sense with how physicians think and practice." The first step was getting physicians to acknowledge that there were different levels of care, with great variations in how the same patients were treated. Data on outcomes and treatment patterns helped show physicians that most of the variation was unnecessary and driven by physician practice and habit rather than patient need. Simply saying that wasn’t enough, because every physician sincerely thinks his or her treatment choices are justified by the particulars of the individual patient. Data make all the difference, he says. "When a physician stands up and says, I’ve been practicing for 20 years and don’t need a clinical pathway,’ I’ll ask what his outcome has been over that time. They never have an answer because individual physicians don’t have outcomes data. But I can show our outcomes with this pathway, and they know they’d be happy to have that kind of outcomes record with their name on it."

Lesson 2: Use a team that includes everyone involved in the patient’s care, not just one group such as nurses or physicians.

Children’s adopted a systems approach to implementing pathways, not leaving it to non-physicians to develop and then expecting physicians to follow them, and not relying only on physicians to develop pathways that would be used by nonphysicians as well. Instead, the hospital includes a wide range of professionals included in patient care — nurses, dietitians, social workers, surgeons, and many others. The team is selected anew for each clinical pathway slated for development, putting together a team that is especially familiar with that issue.

Lesson 3: Start with the most common, obvious needs.

The first clinical pathway addressed asthma care, and it didn’t take long for the physicians and others on the pathways team to determine that there was a lot of room for improvement. Clinical organizations had developed asthma guidelines that nearly everyone agreed were valid, but Children’s wasn’t following them, and neither was hardly any other hospital in the country.

Lesson 4: Don’t make the pathways mandatory.

The asthma project revealed strategies that would be carried forward to many other clinical pathways. For starters, Kurtin and the clinicians involved made it clear that the pathways were not mandatory — seemingly a contradiction to the effort to achieve the highest compliance possible. But they knew that physicians would rebel at being required to practice medicine exactly as prescribed in the pathways. Instead, they wanted to bring the physicians on board willingly.

"Nothing interferes with what the physician thinks is best for the patient," Kurtin says. "But we got the support of key physicians who believed in the pathways and promoted them. We got about a 20% compliance rate at first, which is typical."

Lesson 5: Do make the pathways the default treatment plan.

Once the data started building and clinicians saw that those following the pathways had better outcomes, the compliance rate grew steadily over the next eight years. Soon, Kurtin went to the department of pediatrics and asked that the clinical pathway be made the default care plan for asthma, so it automatically is followed unless the physician specifies otherwise. "Before that, the physician had to take action to put the child on the pathway; and at 3 a.m., that often didn’t happen."

Though the pathways still are not mandatory, that change greatly increased compliance. Now the hospital sees a 98% compliance rate with the asthma pathway. Kurtin explains that the hospital doesn’t even want 100% compliance because there always will be legitimate outliers who need to deviate from the pathway.

The hospital’s asthma pathway has reduced a child’s average length of stay in the hospital from 2.2 to 1.6 days and cut the average cost of care in half, from nearly $1,800 to $900. In addition, asthma patients have needed fewer in-hospital respiratory treatments, says John Bastian, MD, director of allergy/immunology at Children’s.

"Pathways help us provide the best evidence-based care for all patients with a given disease," he says. "They form the framework for our dedicated staff to provide excellent one-child-at-a-time care."

Lesson 6: Streamline the pathways to make them more usable.

Over time, Children’s developed more than 60 pathways and continues to take on more projects. At first, the pathways teams took about nine months to develop each one, but now that process has been pared down to only one month. The format for the pathways was pared down from a very detailed, multipage document that looked almost like a nursing care plan, laid out day by day, to a series of algorithms on one side of one page. "That format also works better because that’s the way physicians think: If this, then do that," Kurtin says.

Lesson 7: Don’t waste time debating what already is proven in the literature.

The development process also speeded up when the teams started doing the literature review before consulting the involved physicians. The first meeting used to consist of deciding what papers to look at, but now the first meeting involves a few members presenting a summary of what the literature shows and what care standards are recommended in the literature. Team members receive a packet of information that summarizes the research before the entire team meets for the first time. "We can say the literature agrees on these six steps, but there’s no agreement on these three steps, so how do we want to handle them at Children’s?" Kurtin says. "That way, we avoid wasting time agreeing on what’s already established in the literature."

Lesson 8: Find an enthusiastic proponent who can promote the pathway to peers.

Every clinical pathway has a physician champion who promotes its use. This person usually isn’t a physician with great authority such as a department chairman but is a senior physician who is well respected in that field. That ensures the other physicians can follow the champion’s lead without feeling that they’re being ordered to.

When choosing targets for any new clinical pathways, Children’s goes after the usual suspects — high volume, high risk, and high cost. Now that the pathways are accepted readily in the hospital, physicians often approach Kurtin with new ideas. The first priorities for pathways were the most common illnesses, but now the hospital is willing to target issues that may affect only 25 patients per year. The hospital also is broadening the scope of its pathways to include specific procedures, such as high-tech procedures in the intensive care unit, to make sure the procedure is done correctly. The pathways also include safety measures.

Lesson 9: Regularly consider the need to update pathways in response to new research.

"At least twice a year, we review the pathways for content. Is there a new drug or a new paper out now?" Kurtin says. "We also can do it ad hoc if the need arises. If a physician in charge of the pathway says there’s a new drug out there and it needs to be included, we’ll pull the team together and address that. We see them as living documents."

Children’s recently studied its 100 sickest asthmatics, including one who had visited the emergency department (ED) 72 times in one year, and developed a pathway that includes the care of a specialist, home care, and intervention at school. That pathway lowered the hospital’s cost of care for those patients by 82%, mostly by keeping them well and out of the ED.

Overall, the benefits have been tremendous over the past eight years, and Kurtin says they stem directly from the strategies that yielded the high compliance rate. The hospital has saved more than $5 million in direct variable costs, the costs that physicians can control, he says.

Lesson 10: Trumpet your achievements beyond your own organization.

Showing those cost savings to brokers and HMOs has helped increase the hospital’s market share by 12% over the past eight years. The data show that patients do better at Children’s at a lower cost, so insurers want their patients there. And the pathways have minimized admissions and length of stay so much that the hospital has not met its capacity as soon as it otherwise might have, Kurtin says.

Without the pathways, Children’s probably would have reached its limits already. Using pathways also changed the way Children’s nurses work with physicians in treating patients, says Lesley Ann Carlson, director of medical/surgical services. "Because pathways are approved in advance, they are reliable plans of care," she says.

"We know exactly how to start treatment from the minute a parent puts a child in our hands; there’s no wasted time or energy in providing care."

Kurtin says the hospital is continuing to develop new pathways and now is considering using the system for other types of projects, such as improving patient flow. Teams now are working on pathways to ensure that every child in the intensive care unit truly needs to be there and is there for the shortest time necessary.

"In many cases, the child could be in a step-down unit but the physician just feels more comfortable with the patient in intensive care," he says. "There’s very little evidence on this, so we’re trying to build a consensus that the doctors can agree to. But we’re sure that the pathways concept can work for more than strictly clinical treatment issues."

[For more information, contact:

Children’s Hospital and Health Center, 3020 Children’s Way, San Diego, CA 92123. Telephone: (858) 576-1700.]