Overcoming Clinical Path Implementation Barriers

A successful clinical path-based patient management strategy starts with clinician buy-in. And yet all too often outcries of "cook book medicine" and "no one is going to tell me how to practice" become major barriers to implementing path-based patient care. Those organizations who have effectively introduced clinical paths have found these barriers easier to overcome with understanding, education, and a quality-first attitude.

Clinicians must understand what a clinical path is. It is not a standard of care, nor is it necessarily the right way to manage every patient. A clinical path is a description of key events in the process of patient care which the healthcare team presumes will most likely result in maximum quality at minimal costs. Realizing that no one knows the absolute correct way to manage patients is the first step in developing the clinical path hypothesis. A clinical path is the result of everyone's collaborative effort toward determining what might be the best way to treat the average patient.

A clinical path is very much like the standing orders hospitals have for patients admitted to the Intensive Care Unit (ICU). These standing orders are a description of what the average patient admitted to this unit will most likely require. The orders were developed by a group of physicians and other clinicians who represent the practitioners managing patients in the ICU. The standing orders are not absolute; the physician can change, delete, and add to these orders to suit their patient's unique requirements. Likewise, a clinical path is not a description of all the interventions that each patient must have. The physician can change, delete, and add to these interventions to suit their patient's unique requirements. Standing orders and clinical path are merely a guide that the physician and other clinicians can use to constantly remind them of what the average patient might require.

Clinicians must also be educated as to why the organization is adopting path-based practice. That is why clinical path development should start with the collection of information about current patient management practices with a projection of how they will be improved by path-based patient care. The types of quality and utilization difficulties that may be resolved by using a clinical path patient management tool include:

System breakdowns
For example: supplies/equipment not available when needed, therapies not started the same day as ordered, surgery room not available when patient needs it, patient's discharge needs not assessed early in the hospitalization, etc.

Communication breakdowns
For example: parenteral drugs not advanced to oral administration when patient can tolerate oral intake, consultant fails to visit patient when requested, transportation not arranged for patient's anticipated discharge day, etc.

Variations in practice patterns without notable improvements in patient outcomes
For example: differing ordering habits and patient lengths of stay among physicians without corresponding outcome improvements.

Determine whether you have these types of problems and how often they occur. Share information about the incidence of these situations with clinicians. Educate them about how clinical paths will reduce and/or eliminate patient care problem areas. Physicians and other members of the healthcare team need to know what you are trying to fix with path-based patient management, otherwise they're likely to question the need for paths.

Ideally, a clinical path patient care strategy is built on a quality-first attitude. While many organizations have discovered that clinical paths reduced patient lengths-of-stay and costs, clinician buy-in is more likely if quality improvement is your ultimate goal. Promote a quality-first attitude by integrating the clinical path tool into your organization's continuous quality improvement strategy. Examples of quality-first tactics include:

Have your quality council oversee the development and implementation of clinical paths. Don't relegate the path design
process to the utilization management committee, for example, if they're not seen as a "quality-first" committee in your organization.

Start your first clinical paths in those patient groups where quality problems are suspected.

By promoting quality improvement in the process of patient care clinician buy-in will be enhanced!

To Learn More: Patrice L. Spath is available for inhouse presentations on this and other health care quality improvement subjects. For further details, visit the Brown-Spath & Associates' web page at http://www.brownspath.com. Address comments or correspondence to: Brown-Spath & Associates, PO Box 721, Forest Grove, OR 97116.

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