J Integr Care Pathw 2008;12:56-60
doi:10.1258/jicp.2008.008008
© 2008 Royal Society of Medicine Press
Introducing clinical pathways as a strategy for improving care
Sander Feuth and
Leonie Claes
Department of Quality, Catharina Hospital, Eindhoven, The Netherlands
Correspondence to: LC Email: Leonie.Claes{at}cze.nl
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ABSTRACT
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This article describes the way in which Catharina Hospital introduced
clinical pathways to its workforce. The hospital, one of the
largest non-academic teaching hospitals in The Netherlands,
developed the first clinical pathway in 2004. Since then, clinical
pathways have been presented as a strategic tool for improving
care. In preparation for an organization-wide project, a team
investigated and adapted the methodology as designed by the
Clinical Pathway Network to the specific situation of Catharina
Hospital. Staff were educated, which in return provided project
teams with methodology and tools for development. Started small,
the aim of the project is to achieve a snowball effect in the
use of clinical pathways. Having started in 2006, six pathways
are currently under construction, more of which are considered
for development. An evaluation of the methodology and results
in the summer of 2007, showed that the method was of great help
in optimizing care processes and developing multidisciplinary
agreements.
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BACKGROUND
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Catharina Hospital is located in Eindhoven, the Netherlands,
serving a large population of people in the south-east of the
Netherlands. The hospital (Table
1) is one of the largest
non-academic teaching hospitals in The Netherlands and the primary
referral centre for eight surrounding hospitals. It has 140
physicians, who cover 30 medical specialties, and offer education
and professional training in cooperation with universities and
colleges. Catharina Hospital is leading in the use of advanced
technology for diagnosis and therapy in the areas of cardiology,
cardiosurgery and oncology.
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HISTORY
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Clinical pathways, also known as critical pathways or integrated
care pathways have been used in health care for the past 20
years.
1 A clinical pathway defines the optimal care process,
sequencing and timing of interventions by health-care professionals
for a particular diagnosis or procedure.
2 It is a clinical process
improvement tool that has been gaining popularity across hospitals
and various health-care organizations in many parts of the world.
In the Netherlands, integrated care is still in its infancy and has been slow to get off the ground.3 Dutch hospitals have implemented a variety of disease-related ‘care pathways’ with the aim of speeding up the care process for distinct patient groups. Examples are the vein care pathway, cataract care pathway and pelvic floor pathway. In 2004, over half of the hospitals had a cataract care pathway.4
In Catharina Hospital, the term clinical pathway was first introduced in 2004 by the Department of Cardiosurgery with the development of a coronary artery bypass grafting (CABG) pathway.5 Similar process improvements were made (though not named clinical pathways) by coordinating care for patients suffering from breast cancer and by developing various surgical pathways, for instance, for cataract care, oesophageal varices and fractures.
Initiatives however were limited to departments who could free-up the resources for development (for example by assigning nurse practitioners for development, CABG pathway) or who follow a nation-wide trend in developing pathways for specific patient groups (cataract care pathway).
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CONTRIBUTING ASPECTS
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In the course of 2004, process improvement had national focus
due to a report on patient logistics, goods logistics and medicine
logistics by Peter Bakker, CEO of the mail company TPG, which
stated that logistics improvements could improve efficiency
by 20-25%.
6
A second factor that influenced the development of clinical pathways in the Catharina Hospital was preparation for the upcoming NIAZ (Netherlands Institute for Accreditation of Hospitals) accreditation in 2005. Established in 1998, NIAZ accredits hospital on their request, i.e. they can have their organization evaluated by peer review. The development of this accreditation system started in 1989 as a response to the Dekker Commission's report on the state of the national health-care system.7 Catharina Hospital was among the first hospitals to be accredited in 2001. Wanting to focus on continuous improvement programmes to receive a second accreditation in 2005, four areas for improvement were determined by the Hospital's Board of Directors: patient safety, project management, policy deployment and clinical pathways.
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INTRODUCING CLINICAL PATHWAYS
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While some clinical pathways have been developed in the hospital
in or before 2004, knowledge of the concept was not widespread.
To achieve a shared meaning, a meeting was organized in September
2004 for physicians, nurses and management. Experiences in developing
the CABG pathway were discussed and an expert was asked to explain
the methodology.
By the end of 2004, hospital management instigated a project team on patient logistics to determine an overall vision on optimizing patient processes and logistics. To affirm its importance, the project was named as one of the ‘top ten’ projects during 2005.
The project team started analysing the various initiatives on process improvements that had been developed in the previous years. To determine in which areas improvements would have greatest effect, the project team gathered data from Diagnosis Treatment Combinations (DBCs; Dutch hospital financing system) to determine the largest patient groups by volume. For DBCs where regulated market principles have been introduced (the so-called b-segment), price comparison was made with peer hospitals. Results were presented to the management as a tool for selecting the best patient groups.
After analysing the different projects and methodologies, the project team finished its assignment by the end of 2005 advising the Board of Directors to set up a project organization for creating an organization-wide basis for the development of clinical pathways.
Commitment and interest of the medical staff were gained by presenting results of the earlier developed CABG-pathway by a physician.
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GETTING SMART
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In preparation for the organization-wide introduction of clinical
pathways, hospital management looked out for help on methodology
and tools. By the end of 2005, Catharina Hospital joined the
Clinical Pathway Network (
www.nkp.be).
Launched in 2000 by the Center for Health Services and Nursing Research in Leuven, Belgium, the network started as a joint effort by Belgian hospitals to develop, implement and evaluate clinical pathways in the organization of their practice. Dutch hospitals joined, and since 2003, a joint venture with the Dutch Institute for Healthcare Improvement (CBO) has been established. In addition to supporting multidisciplinary teamwork, in-hospital projects on pathways and multicentre research projects and benchmarking, the Clinical Pathway Network provides education on the concept and methodology of pathways and care management.
Started in December 2005, two staff members joined the 10-day course on developing, implementing and evaluating clinical pathways. Lessons learnt during the course were shared among the organization through various workshops and teaching sessions.
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ORGANIZATION
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The project organization for implementation of clinical pathways
was described in a document summarizing roles and responsibilities
for project management and supporting parties (Figure
1).
Organization consisted of seven parties:
- Board of directors – initiates, facilitates use of methodology, optimizes cooperation with external partners;
- Physicians and management:
- Physicians – select with hospital management the right patient groups;
- Management – selects the right patient groups; supports the project teams in planning and monitoring; facilitates;
- Project teams, consist of different members:
- Project-leader – authorizes use of the clinical pathway; is responsible for choices made in development. Supports the efficient and effective development, and is responsible for follow-up and evaluation and adjusting the clinical pathway after implementation;
- Process support – quality advisor; facilitates development with methods and tools;
- Project-members – represent all disciplines involved in the specific patient process;
- Department of communications – are invited by project teams to join in the development of patient brochures and general communication;
- Clinical Pathway Network – are invited when necessary; support in network sessions with other hospitals;
- Department of quality has three distinct functions:
- Manager – coordinates top-level decision-making with Board of Directors; commissions on integrated quality and management;
- Clinical Pathway Coordinators – support decision-making; helpdesk for project teams, create tools and methodology; share knowledge in workshops and teaching sessions with quality staff and project members;
- Quality staff – provide process support for physicians, management and project teams; share knowledge in workshops and teaching sessions with project members;
- Commission on integrated quality (IKC) – is instigated by the Medical Staff. Coordinates planning, supports and encourages medical staff, acts as ‘ambassador’.
After meetings
between physicians and management, the following six patient
groups were selected to develop clinical pathways:
- Patients with diseased arteries of the heart (PCI);
- Chemotherapy;
- Brachytherapy;
- Gynaecological oncology;
- Bronchus carcinoma;
- Children with diabetes.
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PREPARING THE TOOLS
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In spring 2006, the suggested project organization was approved
by the Board of Directors and medical staff. Coordinators described
the methodology of developing a clinical pathway by adjusting
the steps suggested by the Clinical Pathway Network to Catharina
Hospital's project management methodology, which consists of
five phases:
- Defining the problem, organizing the project;
- Measuring and diagnosing current process;
- Designing improvements;
- Implementation;
- Keeping the results.
Each phase comprises several steps
that are laid out and explained in a clinical pathway roadmap
that is used by project members. In each phase, project members
can use a variety of tools and methods that are explained in
a toolbox. By developing standardized tools, a uniform way of
development is achieved.
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KICK OFF
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In May 2006, a kick-off meeting was organized to officially
start the development of the suggested pathways. In preparation
for this kick off, project groups were established comprising
the various disciplines that managed care for a specific patient
group. After the kick off, project teams started with development
of the clinical pathways; each project team was supported by
a quality advisor. Advisors used the clinical pathway roadmap,
coordinators provided tools and education. Each advisor teamed-up
with a coordinator in a buddy system for additional support.
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EVALUATION
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The effect of the introduction of clinical pathways was evaluated
in 2007 and showed that the method was of great help in optimizing
care processes and developing multidisciplinary agreements:
- Physicians and team-members were actively involved in the change-process;
- Insight was gained into the whole health-care process; all tasks of involved caregivers were aligned and made transparent;
- The developed clinical pathway gave an overview of all other documents (protocols, procedures, guidelines);
- The number of documents used in the care process was greatly reduced;
- Information for patients was optimized by developing one integrated, multidisciplinary patient brochure;
- While developing the pathway, information was gained through retrospective analysis of patient files, and patient surveys, thus creating immediate possibilities for improvement;
- Methods were developed in which variances in the care process can be monitored and reduced by immediate action.
Results of two clinical pathways (renal calculi and fast-track
deviating thorax X-ray) are described below.
Renal calculi
A Hendrikx, Urologist, MD PhD, Department of Urology, Catharina Hospital, The Netherlands:
‘The kidney stone care pathway is a pathway for patients with kidney stone related complaints. The key element of this care pathway is to diagnose patients and start with their treatment within 28 hours starting from their first hospital visit. Of all patients whom have been enrolled in this pathway, 88% has been diagnosed and started with treatment within 28 hours. The remaining 12% could not be treated partly due to lack of capacity of this new project and due to patients’ co-morbidity. The capacity will soon be increased as a consequence of a rising demand for this care pathway. Patient satisfaction is also high. All patients who filled in the patient satisfaction questionnaire, rated the service of this care pathway with a minimum mark of 7 and an maximum mark of 10, with a median of 8.5. All of them would recommend this care pathway to other patients.'
Outpatient fast-track clinical pathway for suspect chest X-ray
B van den Borne, MD PhD, Department of Pulmonary Diseases, Catharina Hospital, The Netherlands:
‘Patients having a suspect chest X-ray remain in great uncertainty as to whether they have a life-threatening illness. In order to speed up the diagnosis, the departments of pulmonary diseases, nuclear medicine, radiology and pathology have developed an outpatient fast-track clinical pathway: suspect chest X-ray’. All disciplines involved share an identical goal: to provide the patient with a definite diagnosis as soon as possible. The outpatient fast-track clinical pathway, which covers a period of three days, was tested in a pilot prior it's implementation On the third day, the final results were discussed with the patient.
The fast-track clinical pathway involves several stages. First, the chest X-ray of a patient is requested by the general practitioner (GP) and if suspect for lung cancer, the patient is immediately offered the fast track programme. At the same time, an extensive package with information regarding the various investigations as well as a day-to-day programme is sent to the patient. On day one, a medical history and physical examination are done by the pulmonary physician and a blood analysis, lung function tests and PET/CT is performed. The following day the patient undergoes a bronchoscopy whereby biopsies, brushes and washings of the suspected area of the lung are taken. On the third day the patient returns to the outpatient clinic for the final results.
The pilot was conducted in 2007, from April to December and included a total of 44 patients. Results showed that the postulated goals were achieved: all 44 patients were included in the fast track within a week and received the diagnostic results within 3 days. The main goal of the new fast-track clinical pathway (to reduce the throughput time of the regular track) was also achieved. We reduced the throughput time by 12 days. Moreover, evaluation showed that patients were very satisfied with the fast track. Their main concern was to reduce their fears and uncertainty by hearing the definite diagnosis as soon as possible. Patients indicated that the benefits of the fast results far outweighed the strain of the large number of investigations in a short period of time. The fast-track clinical pathway is now fully implemented and serves about 100 patients each year.'
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CURRENTLY
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Results for the six initially developed clinical pathways were
promising. In the course of 2007 and 2008, nine other clinical
pathways were developed or, are under development. The roadmap,
tools and methods are continuously tested for their utility,
and are adapted and refined when necessary.
Clinical pathways are embedded in the day-to-day routine and standard work processes. The methodology is standardized and tailored to meet the specific demands of our organization. It now serves as an organization-wide strategy for improving care.
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Footnotes
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Sander Feuth MSc, Advisor;
Leonie Claes BSc, Advisor, Department of Quality, Catharina Hospital, Eindhoven, PO Box 1350, 5602 ZA Eindhoven, The Netherlands.
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References
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- Vanhaecht K, Bollmann M, Bower K, et al. Prevalence and use of clinical pathways in 23 countries – an international survey by the European Pathway Association. J Integr Care Pathways 2006;10:28–34
- Cheah J. Clinical pathways – an evaluation of its impact on the quality of care in an Acute Care General Hospital in Singapore. Singapore Med J 2000;41:335–46[Medline]
- Inspection of Healthcare (IGZ). The state of health care: coordination of care (seamless care) for chronically ill patients. Utrecht: 1GZ, 2003
- Westert GP, Verkleij H, eds. Dutch Health Care Performance Report. Bilthoven: Centre for Prevention and Health Services Research (RIVM), 2006
- Smeulders C, Brugmans S. Preoperative screening op de schop. Nursing 2006;13(10):14
- TPG. Het kan echt: betere zorg voor minder geld. Eindrapportage TPG, 2004
- Van Gennip EMSJ, Sillevis Smitt PAESr. The Netherlands Institute for accreditation of hospitals. Int J Qual Health Care 2000;12:259–62[Free Full Text]
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ABSTRACT
BACKGROUND
