Clinical pathways: A special report

How to build a pathway program from scratch

Starting from the ground up requires flexibility

Even if your facility has never had a clinical pathway program, you can still initiate one in your case management department, or create new pathways for diseases and situations you encounter in your facility, says Carol Freeborn, RN, who was a nurse case manager at Mercy Hospital in Toledo, OH, before becoming manager of the call center for disease management at Matria Healthcare in Marietta, GA. It’s a matter of taking the right steps and anticipating changes, because that is the one guarantee: There will be changes. Here, Freeborn shares her experience and her advice:

1. Conduct the chart review and the initial research. Two things had to be considered when Mercy started its program: the number of patients and cost of care. "When we first started developing pathways, we had to pick one DRG [diagnosis-related group] to start with. First, we looked for highest volume. You wouldn’t want, in the beginning, to do a pathway on something that you only received a few patients for." The case managers also began an in-depth analysis of hospital data to find out how much these cases were costing. "If we had a large number of patients that were, for example, fractured hip cases, but they really weren’t costing anything more in comparison to what a national average was, or what Medicare was covering us for, then we didn’t worry about those."

Start with your out-of-balance DRGs, Freeborn explains. DRGs with high patient volume, where the hospital spends more than it is reimbursed for are the obvious priorities. "For our particular hospital, they were congestive heart failure [CHF], chronic obstructive pulmonary disease, diabetic ketoacidosis, and pneumonia. I also was going to conferences, researching best practices, and finding out that those were the same ones everybody was working on, so that’s where we decided to focus," she notes.

Once you’ve chosen an area to concentrate on, you begin the intensive research, both inside and outside the walls of your facility, to see what’s out there. Leslie Shain, RN, CCRN, MA, nurse case manager at New York University Medical Center in New York City, says the majority of the preliminary research work is done by case managers. "For me, I went to the American Heart Association and the American College of Cardiology Practice Guidelines, [which] you can get right off the Web. You take their recommendations, and tailor them to what everyone feels is important." Shain also suggests contacting other hospitals for copies of their pathways. "People usually are pretty good about giving them [out]," she says, unless their facility has a corporate policy against it.

The internal chart review is the next essential step in this early stage of pathway development, because it allows you to discover what patterns of practice already are being used by the physicians in your hospital, and then compare those to the best practice guidelines that are published. "Prior to our chart review," Freeborn explains, "there was no specific practice, and that’s kind of what a clinical path does: It takes a best-case scenario and then tries to put that out there as a model."

She adds that Mercy’s case managers spent a long time searching for patterns in treatment for the particular DRG they were studying. "It was pretty labor-intensive. We did a lot of charts." Most important, the chart review has to be an ongoing thing, Freeborn stresses. Even after the pathway is established, you "continue to do chart review. It tells you how successful your pathway is."

2. Form the interdisciplinary team. After the initial research, it’s time to get others involved. Forming an interdisciplinary team requires the inclusion of everyone who might use the pathway — doctors, nutritionists, nursing staff, and physical therapists. "You even need somebody from the lab, so they can help with what tests will be ordered," Freeborn says. Especially important are those with recent clinical experience, because "they know whether something is going to work, and they’re going to tell you," she notes. Working together, the team can develop what it feels is the best practice scenario, using your research and its knowledge of the day-to-day routine, Freeborn says.

"Physicians are vitally important in the beginning, because you need to know what the orders are. The orders drive the costs." Besides the medical knowledge you need from them, physicians and others need to be educated about what you’re trying to do with the pathway. If you don’t have people knowledgeable about what you’re putting out, you’re just spinning your wheels," Freeborn says. "It’s really important to get the right people on your team and to get buy-in from them in the beginning."

Getting the other health care workers to buy into your pathway is probably the most vital and most challenging part of the job, experts say. Many physicians will try to tell you that care pathways are just "cookbook medicine," and that you, as a supporter of the pathway, are trying to tell them how to do their jobs. (See related article, p. 54.) Position your pathway as a result of research, Freeborn suggests.

"[You can say], This is simply what we’ve found: If we order this particular test on day one, then it tends to come back on day two, rather than day three." For example, when Mercy was developing its pneumonia pathway, a clinical guideline was issued stating that administering antibiotic in the emergency room would reduce patients’ length of stay (LOS). So Freeborn added that to the pathway — and found that it worked well. "Always keep in mind that this is a tool. It’s an agent that effects change and should always be benefiting the staff and not burdening them," she adds.

Shain agrees. "It’s really a guideline; it’s not set in stone.

3. Put it on paper — several times. Don’t be fooled into thinking that your first attempt at a pathway will be right on the mark. "You just take a stab at it and put it down on paper," Freeborn says, and you revise it many, many times. "No pathway for us was ever set in stone. We always called it a work in progress.’" Freeborn adds that it is important to start small. "You know, if you make a goal too big, you can’t achieve it, and no one’s going to get anywhere." When her first CHF pathway was released, the goal for LOS was seven days. After the team had lowered LOS by a day or so, it revised the pathway to indicate it had a new goal. "You have to be right on top of your pathways all the time, revising them and looking at them," she adds.

As works in progress, pathways will be changed and supplemented through the years. "We’d put one out there," Freeborn says, "and later add patient education to it. Then we’d ask, What’s a better way to document on it?’ We would change it as we went along."

Change has to be something you build into it, she stresses, either through quarterly meetings or by taking nurse and physician suggestions along the way. "If you’ve got an old pathway out there and someone hasn’t looked at it at least quarterly, you don’t have a viable tool," she notes. In her current position as manager of the call center for disease management at Matria Healthcare, Freeborn knows the value of the pathway approach. Her practice setting is no longer acute care.

"We actually use pathways, in a different version, in disease management. They’re a valuable tool in telephonic case management, too, to better educate patients " she explains.

[For more information, contact:

Carol Freeborn, RN, Manager, Call Center for Disease Management, Matria Healthcare, 1850 Parkway Place, Marietta, GA 30067. Telephone: (770) 767-8133.

Leslie Shain, RN, CCRN, MA, Nurse Case Manager, New York University Medical Center, 560 First Ave., New York, NY 10016. Telephone: (212) 263-0493.]