Pathways and Guidelines: An Approach to Operationalizing Patient Safety and Quality Improvement

Abstract

The reduction of unnecessary variability is a key component to attaining high reliability, as has been demonstrated in other industries outside of healthcare and addressed elsewhere in this text. Clinical pathways and guidelines have been used as a tool to mitigate unnecessary variability in clinical care. The most successful clinical pathways and guidelines are much more than just algorithms to standardize clinical care, however. At their minimum, they are representations of an evidence- and consensus-based approach to care, and at their best, they are clinical and analytic tools that drive safety, quality, outcomes, and organizational strategy. This chapter will utilize a case-based approach to describe the essential elements of successful clinical pathways and guidelines. The case vignettes will pose examples of several different organizational strategic opportunities with a discussion of how clinical pathways are an essential component of the solution. The chapter will provide the reader with tools to build a team and outline a development process that will lead to effective measurement and data dissemination to drive improvement. Finally, this chapter will demonstrate the widespread impact of successful clinical pathways throughout the organization.

Chapter Review Questions

• 1. Describe how clinical pathways and guidelines can have impact beyond just clinical outcomes.

  Answer: Impact may include improvements in patient and family experience, reduction of hospital readmissions and/or returns to the emergency department, improvements in provider experience and reduction of provider burnout, enhancements to organizational patient flow and workflow, reduction of length of stay, as well as positive economic outcomes. Additionally, pathways and guidelines may help to drive organizational strategy.

• 2. What are the differences between measurement of care intended and care delivered?

  Answer: Care intended represents what is ordered and is often measured by use of an order set or by pulling specific orders from the EMR. Care delivered represents the care that actually happens, i.e., the care that reaches the patient. Examples of measurement include medication administration data (MAR) data, imaging tests completed, and labs drawn.

• 3. Describe how measurement of care delivered can lead to improvements in systems of care.

  Answer: Care intended may not always represent the care that actually makes it to the patient, i.e., care delivered, and thus may not fully represent the true patient care experience. Measuring care delivered allows for discovery of opportunities for improvement when the care intended and the care delivered do not align.

• 4. What are the elements of successful and impactful clinical pathways and guidelines?

  Answer: Successful and impactful clinical pathways and guidelines are as follows:

  • Evidence- and consensus-based

  • Inter- and multidisciplinary

  • Integrated into the EMR and workflow

  • Measurement and feedback/data dissemination process

  • Education and rollout process to ensure buy-In

  • Alignment with organizational strategy

• 5. Describe the benefits of integrating clinical champions and IT expertise.

  Answer: Clinicians provide the clinical guidance, and the IT team turns this into the logic. As the logic is tested and data is pulled, this is then reviewed with the clinical experts, and tweaks to the logic are made. The measurement process becomes refined over time. The result is pathways with adherence and impact data that are trusted by clinicians and, thus, are truly able to change behavior and affect change

• 6. Who should be on the team for the design and implementation of a successful and impactful clinical pathway?

  Answer: Key stakeholders should be included. Some examples are the following:

  • Clinical champions, i.e., providers, nurses, pharmacists, RTs, etc.

  • IT experts (data pull, logic, order set builds, dashboards, and data analytics)

  • Clinical education specialists (buy-in and rollout)

  • Marketing/communication specialists (internal and patient-/family-facing educational materials)

  • Finance representation (costs of care, resource utilization, financial impact)

• 7. True or false: The success of clinical pathways is driven by measurement and data dissemination and feedback.

  Answer: True

• 8. Based on the discussions in this chapter, which of the following are essential for widespread impact of clinical pathways?

  • A. Measurement and feedback/data dissemination

  • B. Representation of champions representing all stakeholders

  • C. Strategic alignment

  • D. Evidence- and consensus-based

  • E. All of the above

  Answer: E