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The way to better care? Establishing clinical pathways in hospitals

Andreas Tecklenburg
Medical Director and Vice-President
Hannover Medical School
Hannover Germany
T: +49 511 532 6030
E: [email protected]

A clinical pathway is a multiprofessional means of working  that makes the very latest medical knowledge available to  individual patients in a real treatment situation and with  the effective exploitation of all resources. This definition  comprises the following essential points:

  • As a multiprofessional means of working, it applies not only to areas that concern the doctor, but also to nursing care, physiotherapy and all staff who deal directly or indirectly with the patient.
  • The term “evidence-based medicine” is deliberately not  used because no evidence-based documents exist for most of the working stages within a  clinical pathway. Accordingly, the tendency is to get a consensus of expert opinions rather  than genuine evidence-based studies.
  • A real treatment situation represents a delimitation on recommendations or guidelines from specialist medical associations, which on an abstract level recommend a specific procedure, diagnosis or therapy. With the clinical  pathway, the structures and forms of organisation that really exist are taken into account and implemented.
  • The effective exploitation of all resources is not, as a rule, the object of recommendations or guidelines from specialist associations. It is in the interests of  individual hospital operators, however, to make effective use of resources – that is, to make the best use of the costs incurred.

The term “clinical pathway” is too narrow for the modern  medical practitioner. Today, medical treatment concepts are  being applied with interlinked outpatient and inpatient  structures, including rehabilitation services. For this  reason, “trans-sectoral planned treatment sequence” is  actually a better term.

A clinical pathway is much more than a simple description  process. Algorithms have not proved their worth in the  medical sector, because too many patients make individual  deviations from the standard path. A better approach is to  build up a clinical pathway on a target-oriented basis. In  other words, the issue is not simply to describe a specific sequence but, more especially, to describe which aims should be achieved with individual means. These aims make it easier for the multiprofessional team to understand the individual work of the other groups and to integrate them into their own procedures.

Creating the pathway
The practical experience of many hospitals that have used  clinical pathways shows the enormous importance of creating  the pathways. This is almost as important as the later  practical implementation.Clinical pathways need to be  created on an interdisciplinary and multiprofessional basis.  Every team that will work with the clinical pathway must be  involved, and it is beneficial if a neutral moderator can  coordinate it. The moderator need not provide the technical  knowledge required, but he must master the tools for  carrying out a target-oriented approach. Creating a clinical  pathway for the first time is very time-consuming, and  everyone needs to be aware of this. The individual  department management must be clear about setting the goals for the clinical pathway and be able to convey this to the staff. Only when the target of the clinical pathway is  accepted can it be implemented in practice, making the  provision of information and the communicating of goals  absolutely essential before the pathway is created. A  standard operating procedure then needs to be developed to  arrive at a clinical pathway.

The internet has proved to be a good forum for exchanging  ideas about clinical pathways and provides a stimulus to  indicate which topics can be covered and what clinical  pathways can look like. They are also useful if they include  a description of how the pathway was arrived at. However, a clinical pathway cannot be copied from one clinic to another – it is precisely the process of creating them in accordance with a specific environment that is the key to success. The adoption of a clinical pathway from another clinic jumps this essential step and seldom leads to success.

A clinical pathway will only achieve success if more than  90% of staff are familiar with it and put it to use. Staff  from neighbouring departments who may come in contact with  the pathway should also not be forgotten. In the surgical  sectors in particular, radiologists, anaesthetists and  consultant internal medicine specialists all need to be  involved, as does the management sector.

Looking after clinical pathways
Once the clinical pathway is in use, it should be reviewed.  Checking and comparing the pathway against guidelines,  recommendation studies and new medical findings on a regular basis is absolutely essential. Even without reference to changes in scientific findings, clinical pathways should still be scrutinised for their relevance about every two years. The sources to be looked at to identify possible  changes need to be established beforehand. It must also be determined which team is going to edit the pathway. A particulary important factor is the issue of editorial  rights – who is entitled to change which parts, and how will  the change be represented? If changes are needed then it  must be ensured that every member of staff concerned is made aware of the changes and makes use of the new version.

Technical support
Clinical pathways must not duplicate workload. Many clinics  introduce procedures that are designed especially for  clinical pathways. One important point is deviation. If  deviation from a clinical pathway becomes necessary, it  needs to be documented separately. On the one hand, this is important for the individual patient, but it is also  significant for the analysis of whether there is a  systematic fault present in the clinical pathway. If a  clinical pathway has been well thought out and structured,  the documentation work will be made substantially easier,  because most of the treatment stages will already have been described. This means that the workings of the clinical pathway can be easily documented in the form of checklists. Hospitals with a hospital information system should incorporate the clinical pathways into this system. Systems with a workflow support are particularly helpful in this context as they allow for support to be provided semiautomatically (the system makes a suggestion to the staff) for actions based on pre-established parameters, such as requesting an examination or ordering a medication.

As well as the practical application and the advantages for  the patient, clinical pathways are also an excellent tool  for formulating medical diagnostics and therapy in a  calculated manner and with the resources of business  management. The precise process analysis that must precede  every clinical pathway is followed by a differentiated costs  analysis, classified according to personnel and material  costs. In addition to this, infrastructure costs for  particular areas and services of other in-house departments  can also be determined by means of the clinical pathway. The  calculation of clinical pathways can be used, among other  things, for working out business plans and developing new  services in diagnostics and therapy. Clinical pathways can  be the basis for the planning of changes to services if it  is intended that specific areas are to be developed or  withdrawn, and they are the basis for future calculations in  those countries in which diagnosis-related groups (DRGs) or similar procedures are used.

Clinical pathways influence treatment costs. Costs can be  reduced by eliminating duplication and losses due to  friction between professional groups. During the creation of  a clinical pathway, individual diagnostic and therapy stages  are checked for their effectiveness. In many clinics, the  creation pro­cess leads to unnecessary laboratory work and  radiology examinations being made redundant – this is a  direct part of the process of cost reduction. Because the  effectiveness of treatment rises with the use of clinical  pathways, more patients can be moved through a clinic with the same use of resources. A further costs reduction effect is achieved from the standardisation of materials. The stock of articles can be reduced, meaning that purchasing batches  can be increased. This can then be added to a reduction in  transaction costs, storage areas and costs due to redundant  material being done away with.

It is also possible, however, for increases in costs to  occur as a result of clinical pathways. Combining new  diagnostics and therapy, which previously was applied  optionally, can lead to a rise in costs. The consistent  application of guidelines can also lead to more diagnostics  being carried out than previously. Experiences so far have  shown, however, that cost reduction clearly outweighs the  increased costs. Clinics with well-made clinical pathways  are more effective and more economical.

A risk management tool
It has been shown that clinical pathways lead to improved  cooperation between teams and departments in a hospital and that effectiveness rises while costs fall. Clinical pathways have positive effects in other areas too; for example, losses due to friction are avoided, as are conflicts caused by mis­understandings. Misunderstandings and lack of communication are the most frequent cause of incidents or near-miss incidents in the hospital sector. Therefore,  clinical pathways actively contribute to risk management,  particularly in diagnostics and therapy.

Clinical pathways allow managers to carry out genuine checks on results. Because the patients included in a clinical pathway are treated according to relatively equal schematic procedures, the result can be better monitored and compared. The results can also be compared with the institution’s own results from the previous year or with those from other clinics, which is of great interest to the hospitals concerned. It is the analysis of comparable processes and different costs that shows the points at which, by increasing efficiency, costs can be reduced without sacrificing quality.

In addition, clinical pathways are mandatorily required if a  hospital or department wishes to be certified in accordance  with DIN ISO. They are also a great aid when cooperating  with other hospitals or other treatment providers such as  outpatient care services or rehabilitation clinics.

What does the patient get from all this?
The patient is the real winner when it comes to clinical  pathways. Diagnostics and therapy are carried out in  accordance with a well-structured schematic arrangement, and every healthcare team concerned knows how the clinical pathway works. Good information is available at all times regarding the current status of treatment, and every member of staff also knows precisely what the next step in the process is, which gives the patient a great deal of  security.

Clinics with clinical pathways have decided to opt for  transparency, and this transparency is something that today is viewed very positively by patients to whom it has been explained. By matching the activities of healthcare teams, errors are avoided and stays in hospital shortened. Regular upkeep of the clinical pathway ensures the patient receives state-of-the-art medication and is provided with information relating to further treatment on discharge. Patients are not able to assess the objective outcome of a treatment and, accordingly, subjective parameters, such as a sense of safety, security and being kept informed, are important surrogates. This is precisely what a clinical pathway can provide, and so contribute to patient satisfaction.

Clinical pathways are a benefit for clinics as well as for  patients. Nevertheless, their introduction and implementation must be something that is desired and then professionally carried out with the backing of the  management for success to be achieved. There are five  parameters that must be filled:

  • Creation of a clinical pathway on an interdisciplinary and multiprofessional basis.
  • Distribution of the information to all concerned.
  • Regular application of clinical pathways to the right  patients.
  • Involvement of neighbouring departments and management.
  • Regular upkeep of the clinical pathway on the basis of the latest medical information available.

If these five major points are respected, clinical pathways  will become an essential element that no modern clinic will  be able to do without.