Aleksandar Višnjić
Public Health Institute Niš, Serbia Abstract
Objectives: A care pathway is a complex intervention for the mutual decision making and organisation of care processes for a well-defined group of patients during a well-defined period. Care pathways provide better health care and reduce unnecessary variations in practice. It is a relatively new clinical process improvement tool that has been gaining popularity across various healthcare institutions worldwide. A care pathway defines the optimal care process, sequencing and timing of interventions by healthcare professionals for a particular diagnosis or procedure. The objective of the study was to to find out whether there is universal care pathway pattern for health care facilities and to derive key characteristics of care pathways.
Materials and methods: Our investigation was done in UCSC, Rome, Italy, from March to April 2014. Our search strategy was finding proper information on Pubmed and Embase, for which we used the following terms: "care pathway", "critical pathway", "clinical pathway" or
"integrated care pathway". We also searched the reference lists of relevant articles. To approach the best analyses, the DELPHI method was used.
Results: We focused on 32 existing articles about care pathways developed by individual hospitals for specific diseases. Care paths were developed through collaborative efforts of physicians, nurses, pharmacists, and others to improve the quality and value of patient care.
They were designed to minimize delays and resource utilization and to maximize quality of care. Care pathways were also used as a tool to implement local and national guidelines into everyday practice. But, national health systems are different from each other, and healthcare institutions within the same system have their own individual characteristics. When selecting an appropriate topic to develop a care pathway, the criteria like common condition or high-risk condition was mostly taken into account. They became a documented sequence of clinical interventions that help a patient progressively move through a clinical experience to a desired outcome.
Conclusions: There is no universal form of care pathway that could be consistently applied in all health facilities. It is necessary for each institution in accordance with their needs to develop its own care pathways, because they are specific. Physicians and practitioners have to be the key players in any pathway development and implementation. There is a real danger when critical pathways are brought in from external sources on the basis of administrative attempts to reduce costs.
Main messages: Physicians have to be the key players in any pathway development and implementation. It is essential to design and implement care pathways into organisational strategy which will provide its improvement into everyday practice.
191 INTRODUCTION
Many synonyms exist for the term ICPs (Integrated Care Pathways) including: Clinical Pathways, Critical Pathways, Multidisciplinary pathways of care, Pathways of Care, Care Maps, Collaborative Care Pathways, Critical or Clinical Paths.
Critical Path and Process Mapping methodology was used in industry, particularly in the filed of engineering from as early as the 1950s. In the 1980’s, clinicians in the USA began to develop the pathway tool within Managed Care; they were redefining the delivery of care and attempting to identify measurable outcomes. They were focusing on the patient rather than the system, but needed to demonstrate efficient processes in order to fulfill the requirements of the insurance industry. Developed and used initially for the purpose of cost containment, in the UK in the late 1980s, the emphasis has been to use clinical pathways as a quality tool.
They were developed in response to the initial Diagnostic Research Group based prospective reimbursement system of the early 1980’s at the New England Medical Center by Karen Zander and Kathleen Bower, among others. In the early 1990’s the NHS in the U.K. funded a patient focused initiative to support organizational change. This resulted in the investigation and development of concepts such as pathways.
Clinical Pathways as introduced in the early 1990s in the UK and the USA were being increasingly used throughout the developed world. Clinical or Critical Pathways are structured, multidisplinary plans of care designed to support the implementation of clinical guidelines and protocols. They are designed to support clinical management, clinical and non-clinical resource management, non-clinical audit and also financial management. They provide detailed guidance for each stage in the management of a patient (treatments, interventions etc.) with a specific condition over a given time period, and include progress and outcomes details.
Clinical Pathways aim to improve, in particular, the continuity and coordination of care across different disciplines and sectors.
Care Pathways can be viewed as algorithms in as much as they offer a flow chart format of the decisions to be made and the care to be provided for a given patient or patient group for a given condition in a step-wise sequence. A clinical pathway is a tool used in achieving coordinated care and desired outcomes within an anticipated time frame by utilizing the appropriate resources available. It is a blueprint that guides the clinician in the provision of care. ICPs are preconceived patient care algorithms, or paths, that are intended to reduce variability and cost, increase efficiency, and ultimately improve patient care. Pathways provide patient focused care with benefits to the patient, family and members of the multi-disciplinary team. They allow for the continuous evaluation and improvement of clinical practice and help to stimulate research. Their use represents a new approach to patient care, fulfilling many of the demands of clinical practice.
Critical pathways as care plans that detail the essential steps in patient care with a view to describing the expected progress of the patient have four main components:
• a timeline
• the categories of care or activities and their interventions
• intermediate and long term outcome criteria and
• the variance record (to allow deviations to be documented and analysed).
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Critical paths are developed through collaborative efforts of physicians, nurses, pharmacists, and others to improve the quality and value of patient care. They are designed to minimize delays and resource utilization and to maximize quality of care. Clinical Pathways differ from practice guidelines, protocols and algorithms as they are utilised by a multidisciplinary team and have a focus on the quality and coordination of care. The approach and objectives of clinical pathways are consistent with those of total quality management (TQM) and clinical continuous quality improvement (CQI).
A clinical pathway is a method for the patient-care management of a well-defined group of patients during a well-defined period of time. A clinical pathway explicitly states the goals and key elements of care based on Evidence Based Medicine (EBM) guidelines, best practice and patient expectations by facilitating the communication, coordinating roles and sequencing the activities of the multidisciplinary care team, patients and their relatives; by documenting, monitoring and evaluating variances; and by providing the necessary resources and outcomes.
The aim of a clinical pathway is to improve the quality of care, reduce risks, increase patient satisfaction and increase the efficiency in the use of resources.
The European Pathway Association (EPA) defines a care pathway as “a complex intervention for the mutual decision making and organization of care processes for a well-defined group of patients during a well-defined period”.
It is important that physicians and practitioners be key players in any pathway development and implementation. There is a real danger when critical pathways are brought in from external sources and implemented on the basis of administrative attempts to reduce costs.
The real impact of critical pathways and appropriateness protocols is their use as tools for collection of information. Pathways can serve as a screening test for inefficient care. The danger is that a pathway with too many critical areas under review will be too sensitive, resulting in the review of a large number of marginally appropriate cases. Review of critical pathway data should be focused on the highest-impact areas in terms of either cost, quality of care, or preferably, both.
But the first issue is that critical pathways address processes in the “ideal” patient and in some cases do not address issues in the majority of patients who enter the path. Identification of appropriate patients to enter the pathway is an important issue in implementation. In general,
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critical pathways are more applicable to patients with uncomplicated illnesses who are undergoing procedures or surgery.
Integrated Clinical Pathway development: