Clinical pathways can help you track data

Ensure services are provided in a timely manner

If you’re not using your clinical pathways on a regular basis, you’re missing an opportunity to facilitate the collection of quality indicators and outcomes information and to affect your patients’ length of stay.

Many hospitals have gone to the trouble of developing clinical pathways but have stashed them away in a drawer somewhere, and few staff members use them, says Teresa Fugate, RN, BBA, CPHQ, CCM manager, Pershing, Yoakley & Associates, a Knoxville, TN-based health care consulting firm.

"Many patients who would be perfect for a clinical pathway aren’t on them because physicians don’t use them," she adds. More hospitals are using physician order sets instead of clinical pathways, but the order sets don’t replace the pathways.

"What we’re seeing is almost two separate things — physician order sets and multidisciplinary clinical pathways. In many cases, the clinicians have the option to use them or not use them as they see fit," Fugate says.

Hospitals need a multidisciplinary clinical path to guide the treatment team in what they need to be doing when the physician isn’t around, she adds.

"The importance of developing clinical pathways is for the multidisciplinary team to focus in on the timeliness and efficiency of the services provide by the team. When there is not guidance on time frames and important issues, there often are delays in services or some tests or procedures are not done."

For instance, if the quality initiatives call for a patient to be given an antibiotic within the first four hours and the case manager doesn’t review the patient immediately after admission, it’s unlikely any omissions will be caught.

"Even when the physicians are following the clinical pathway, if the interdisciplinary team isn’t using them, services can fall through the cracks, directly impacting the length of stay and leading to avoidable days," Fugate notes.

Documenting core measures

Clinical pathways make it easier for busy nurses and physicians to document the core measures rather than having to write it down in their notes, she explains.

Pathways can be great documentation tools for case managers, allowing them to determine whether or not the services were rendered in a timely and efficient manner, Fugate adds.

They also can give case managers the ability to easily collect information, particularly when it comes to collecting information for the Centers for Medicare & Medicaid Services (CMS) and making sure that the core measures are documented in the record, Fugate says.

"If it’s on the clinical pathway and nobody has signed off on it, the case manager automatically knows it didn’t occur, and they can prompt someone to make sure it happens. If they have to check through the nurse and physician notes to find the information, it takes a much longer time, and they might miss something," she points out.

"What CMS is doing with the core measures is looking to improve the efficacy of services to patients. Hospitals should incorporate these national standards in their care plan to improve the process of care," Fugate adds.

Clinical pathways make it much easier to create reports, demonstrate outcomes, track the quality initiatives required by CMS, and comply with Joint Commission on Accreditation of Healthcare Organizations and other accrediting organization standards, says Jeff Rose, MD, vice president of clinical excellence informatics for Ascension Health, a 63-hospital system based in St. Louis.

"Pathways allow anyone on the interdisciplinary team to look and see where the patient is on the plan. There are a lot of other ways to make sure patients get good, high-quality care, but the clinical pathways pull it all together. For those people who do use the clinical pathways, there is a lot of accumulated evidence that they have better outcomes and better reporting," he adds.

The fact that many hospitals still are using pathways on paper is one roadblock to their continuous use, Rose adds. "In order to make really good use of a clinical pathway, you have to have an automated system. Paper has long limited our capability. If a nurse has the care plan, but it’s in her pocket, it doesn’t do anyone else any good."

Ascension Health is helping the hospitals in its system develop pathways in a collaborative way and rolling them out with the clinical information system. "Ascension Health hospitals that do not yet have an electronic medical record system are more likely to use the pathways if they have an older automated system rather than pathways that are on paper, he adds.

In developing its clinical pathways, Ascension Health has chosen 55 of the most common diagnoses, based on DRGs and the kinds of care that are delivered. Nurses are heavily involved in creating interdisciplinary plans of care because most are largely nursing-driven, Rose says.

Ascension is developing its pathways in modular forms so that some sections may be incorporated into multiple pathways.

For instance, a clinical pathway for fall prevention can be incorporated into the overall pathway if a patient is elderly or frail or comes in with neurological problems or another condition that makes him or her at risk for falls, he adds.

The University of Wisconsin Hospitals and Clinics, based in Madison, has more than 200 clinical pathways developed by a team that typically includes nurses, case managers, staff from each unit, and a physician champion, says Barbara Liegel, RN, MSN, director of coordinated care. Her department includes case management, social work, utilization review, and discharge planning.

"Our initial vision is that they would be multidisciplinary; but as it evolved, we have found that it would be even more beneficial to have standardized physician order sets matched to the pathway, and the pathways became more of a nursing tool," she explains.

The clinical pathways are on paper, and where they are kept and how they are used varies from unit to unit. The case management department is accountable for the pathways and physician order sets and drives the review process.

"It’s a huge challenge to make sure they reflect the current best practices," Liegel says.

Some pathways have fallen by the wayside because they simply don’t fit a lot of the severely ill patients on the medical units, she adds.

"It’s hard to fit everybody into a peg, especially on the medical side where patients often have severe comorbidities, and it’s hard to know which pathway to put them on. It’s much easier for surgical patients to fit on a pathway because their care is more predictable," Liegel notes.

The hospital is in the process of instituting an electronic medical record and is likely to eventually develop an electronic version of the pathway, she says.

"My sense is that we’re moving beyond pathways. When they first became widespread, there weren’t a lot of electronic systems. Now the patient moves so quickly that we need a better way for care providers in all settings to have the information they need about the patient, rather than consulting a paper pathway," Liegel adds.

Fugate recommends that the case management and quality improvement departments join together and prompt a revitalization of clinical pathways.

If you have clinical pathways and they aren’t being used, consider simplifying them to make them easier to follow. "One of the problems with clinical pathways in the past is that people have put everything that can be done on the care path. Too many pathways include too many things that aren’t key steps, and this makes it overwhelming," she notes.

Fugate suggests focusing on your top DRGs and developing an action plan that includes the key activities that each member of the interdisciplinary team must perform to assure timeliness of care.

Make sure the CMS quality indicators are listed on your pathways and protocols, she adds. "When the CMS quality indicators are on clinical pathways and protocols, there’s a lot better compliance and documentation and the overall quality of care increases," Fugate says.

Make sure staff are held accountable for following the pathways. If no one is accountable for their use, they’re less likely to use them, she points out.

When a clinical pathway is implemented or revised, Children’s National Medical Center in Washington, DC, publicizes the fact through posters in the lounges, table tents in the cafeteria, notices to all the residents and nursing managers, and e-mails to everyone who should be following the pathway.

When Fran R. Cogen, MD, CDE, director of the diabetes program is called on to give a lecture on diabetes to new interns, she teaches it with the diabetes pathway in front of her, emphasizing the importance of following the guidelines.

"The reality is, it is a constant struggle to get people to follow the pathway. When we started seeing results and people were getting good care and being discharged, people began paying more attention to the pathway," Cogen adds.