Health care in the United States is plagued by errors, inconsistencies, and inefficiencies. It is also extremely costly. Clinical pathways can drive high-value care and high reliability within a health care organization. Clinical pathways are much more than just guidelines or order sets as a part of a protocol of care, however; they must incorporate multiple elements that are critical to their successful implementation and sustainability. Additionally, clinical pathways can be utilized to accomplish strategic goals of the organization while fulfilling the quality, safety, and clinical aspects of the organization’s mission.
Key points
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Health care in the United States is largely delivered in systems of care that are complex, inefficient, error prone, and costly. There currently exists a high degree of variability in the delivery of care between providers and settings of care. Other industries outside of health care have been successful at reducing inefficiencies and eliminating waste through the standardization of processes. Clinical pathways allow for an opportunity to reduce variability in the delivery of health care.
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Clinical pathways can have positive impact on the quality of care delivered to individual patients, on the health of populations of patients with particular diseases or conditions, on the workflow of frontline providers, and on processes within the health care organization. Additionally, clinical pathways can drive positive economic results and can have impact on advancing the strategic mission of the health care organization.
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Clinical pathways will be most successful if they are interdisciplinary and multidisciplinary, if they are evidence-based as well as consensus-based for the local health care environment, if there is the ability to engage in ongoing and real-time measurement with a commitment to making results actionable, and if the pathways are aligned with the strategy of the organization.
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The potential barriers to the successful implementation of clinical pathways can often be negated by a commitment to both the development and the sustainability of the pathway by all levels of the organization.
Introduction
Health care providers and consumers in the United States exist in a system that is fraught with errors, inconsistencies, and inefficiencies. The Institute of Medicine has estimated that nearly 100,000 people die every year because of medical errors. It is also known that the US health care system remains one of the most costly in the world. There is much to be learned from those industries outside of health care that have come to be known as high-reliability organizations. Of the many qualities that set apart these industries as leaders and innovators in error reduction and process improvement, one of the overriding themes embraced by these industries is a reduction of variability. Lean methodology derived from the Toyota Production System, as well as six sigma, were developed by and employed in the manufacturing industry for process improvement. Both of these methodologies are now being applied in many service industries as well as within health care.
The complexity of the health care industry allows for many opportunities to reduce variability through the standardization of numerous processes. There are many nonclinical processes within health care that are analogous to the manufacturing industry to which these types of methodologies can readily be applied (eg, central sterilization and laboratory specimen receiving and processing). The application of such methodologies to clinical care, however, may seem less intuitive because of the dynamic presentation of diseases and patients’ response to medical treatment. Clinical care has historically been seen as highly individualized, with clinical judgment and medical decision making solely owned by each health care provider and tailored specifically to each individual patient.
Certainly, the human factor is unique to the practice of medicine, and unlike cars on a production line, an industry that specializes in taking care of people will inherently encompass situations in which variability cannot be negated. The key, however, is to focus on the reduction of inappropriate or unnecessary variation, which often occurs when care is not evidence-based or clinical decisions are not based on specific clinical factors. Standardization begins by a focus on evidence-based care in the context of the individual patient’s clinical picture.
As evidence-based medicine has become paramount to medical decision making and clinical judgment, there is strong support for the standardization of the delivery of clinical care. The development of clinical pathways is an example of a strategy to reduce variability.
In addition to the reduction of variability, clinical pathways have direct impact on the care of individual patients, including improved quality of care and improved safety. Clinical pathways can also impact the population of patients with a specific disease or condition, including streamlining ambulatory care and potentially reducing emergency department and urgent care center visits, reducing hospital admissions, and reducing readmissions by ensuring that patients are discharged with the right resources and that they have appropriate and timely postdischarge follow-up. Combined, adherence to the elements of a pathway lead to an overall reduction in the cost of health care. Thus, clinical pathways fulfill each component of The Triple Aim, as defined by the Institute for Healthcare Improvement.
This article will define clinical pathways and further describe the elements and tools that are necessary to successfully implement and sustain clinical pathways.
Making a Case for Pathways: a Rapidly Changing Environment and its Effect on the Evolution of Health Care
The very challenges that necessitate a new approach to the delivery of care in the United States also serve as the barriers. The spending on health care is increasing, but the pool of money to fund that spending is decreasing. Health care spending is on the rise. It is estimated that 86% of health care expenditures is used for the treatment of chronic conditions, which currently account for almost half of the population. As modern medicine advances, people are living longer with chronic conditions, many of which were formerly untreatable, especially within pediatrics. Furthermore, chronic diseases will be the leading cause of death for 59% of mortalities in developing countries by the year 2030. The increase in complexity of patients, as well as the aging population, forces one to realize that the current state is not sustainable.
The demand for fiscal stewardship among health organizations by federal and private payers, as well as the general public, has led to a tenuous economic climate for health care providers. Additionally, there is growing public demand for complete transparency for quality of care, outcomes, patient safety, and cost. In this environment, hospitals struggle to find the balance between providing high-value care, and reducing resource utilization ( Fig. 1 ).
Clinical Pathways Defined—Beyond the Algorithm
Clinical pathways are intended to reduce variability, and thus it is somewhat ironic that there is considerable variation in how clinical pathways have been defined. Often used interchangeably with clinical guidelines, protocols, care pathways, care maps, and critical pathways, it is not surprising that the definition of what constitutes clinical pathways varies among institutions.
In a recent Cochrane review of the impact of clinical pathways in hospitals, researchers recognized the considerable variability in the definition of clinical pathways. They identified 5 criteria that were common to clinical pathways among the publications describing their use:
- 1.
The intervention was a structured multidisciplinary plan of care
- 2.
The intervention was used to channel the translation of guidelines or evidence into local structures.
- 3.
The intervention detailed the steps in a course of treatment or care in a plan, pathway, algorithm, guideline, protocol or other inventory of actions.
- 4.
The intervention had timeframes or criteria-based progression (that is, steps were taken if designated criteria were met).
- 5.
The intervention aimed to standardize care for a specific clinical problem, procedure, or episode of health care in a specific population.
The authors have used the criteria as derived from the Cochran review, as a foundation to develop our proposal for the elements of a successful pathway ( Fig. 2 ).
Introduction
Health care providers and consumers in the United States exist in a system that is fraught with errors, inconsistencies, and inefficiencies. The Institute of Medicine has estimated that nearly 100,000 people die every year because of medical errors. It is also known that the US health care system remains one of the most costly in the world. There is much to be learned from those industries outside of health care that have come to be known as high-reliability organizations. Of the many qualities that set apart these industries as leaders and innovators in error reduction and process improvement, one of the overriding themes embraced by these industries is a reduction of variability. Lean methodology derived from the Toyota Production System, as well as six sigma, were developed by and employed in the manufacturing industry for process improvement. Both of these methodologies are now being applied in many service industries as well as within health care.
The complexity of the health care industry allows for many opportunities to reduce variability through the standardization of numerous processes. There are many nonclinical processes within health care that are analogous to the manufacturing industry to which these types of methodologies can readily be applied (eg, central sterilization and laboratory specimen receiving and processing). The application of such methodologies to clinical care, however, may seem less intuitive because of the dynamic presentation of diseases and patients’ response to medical treatment. Clinical care has historically been seen as highly individualized, with clinical judgment and medical decision making solely owned by each health care provider and tailored specifically to each individual patient.
Certainly, the human factor is unique to the practice of medicine, and unlike cars on a production line, an industry that specializes in taking care of people will inherently encompass situations in which variability cannot be negated. The key, however, is to focus on the reduction of inappropriate or unnecessary variation, which often occurs when care is not evidence-based or clinical decisions are not based on specific clinical factors. Standardization begins by a focus on evidence-based care in the context of the individual patient’s clinical picture.
As evidence-based medicine has become paramount to medical decision making and clinical judgment, there is strong support for the standardization of the delivery of clinical care. The development of clinical pathways is an example of a strategy to reduce variability.
In addition to the reduction of variability, clinical pathways have direct impact on the care of individual patients, including improved quality of care and improved safety. Clinical pathways can also impact the population of patients with a specific disease or condition, including streamlining ambulatory care and potentially reducing emergency department and urgent care center visits, reducing hospital admissions, and reducing readmissions by ensuring that patients are discharged with the right resources and that they have appropriate and timely postdischarge follow-up. Combined, adherence to the elements of a pathway lead to an overall reduction in the cost of health care. Thus, clinical pathways fulfill each component of The Triple Aim, as defined by the Institute for Healthcare Improvement.
This article will define clinical pathways and further describe the elements and tools that are necessary to successfully implement and sustain clinical pathways.
Making a Case for Pathways: a Rapidly Changing Environment and its Effect on the Evolution of Health Care
The very challenges that necessitate a new approach to the delivery of care in the United States also serve as the barriers. The spending on health care is increasing, but the pool of money to fund that spending is decreasing. Health care spending is on the rise. It is estimated that 86% of health care expenditures is used for the treatment of chronic conditions, which currently account for almost half of the population. As modern medicine advances, people are living longer with chronic conditions, many of which were formerly untreatable, especially within pediatrics. Furthermore, chronic diseases will be the leading cause of death for 59% of mortalities in developing countries by the year 2030. The increase in complexity of patients, as well as the aging population, forces one to realize that the current state is not sustainable.
The demand for fiscal stewardship among health organizations by federal and private payers, as well as the general public, has led to a tenuous economic climate for health care providers. Additionally, there is growing public demand for complete transparency for quality of care, outcomes, patient safety, and cost. In this environment, hospitals struggle to find the balance between providing high-value care, and reducing resource utilization ( Fig. 1 ).
Clinical Pathways Defined—Beyond the Algorithm
Clinical pathways are intended to reduce variability, and thus it is somewhat ironic that there is considerable variation in how clinical pathways have been defined. Often used interchangeably with clinical guidelines, protocols, care pathways, care maps, and critical pathways, it is not surprising that the definition of what constitutes clinical pathways varies among institutions.
In a recent Cochrane review of the impact of clinical pathways in hospitals, researchers recognized the considerable variability in the definition of clinical pathways. They identified 5 criteria that were common to clinical pathways among the publications describing their use:
- 1.
The intervention was a structured multidisciplinary plan of care
- 2.
The intervention was used to channel the translation of guidelines or evidence into local structures.
- 3.
The intervention detailed the steps in a course of treatment or care in a plan, pathway, algorithm, guideline, protocol or other inventory of actions.
- 4.
The intervention had timeframes or criteria-based progression (that is, steps were taken if designated criteria were met).
- 5.
The intervention aimed to standardize care for a specific clinical problem, procedure, or episode of health care in a specific population.
The authors have used the criteria as derived from the Cochran review, as a foundation to develop our proposal for the elements of a successful pathway ( Fig. 2 ).
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