In 1990 health care providers had just began to discover what appeared to be a very powerful tool for reducing variation in patient care practices - clinical paths. A clinical path includes descriptions of key events that, if performed by caregivers as described, are expected to produce the most desirable outcomes for patients with specific conditions or procedures. By the late 1990s, caregivers started to question the benefits of clinical paths. Organizations reported problems integrating the pathway document into patient records, thus dampening caregiver enthusiasm for using the pathway. Physicians, nurse, and other clinicians found the pathways difficult to apply to all patient populations. A variety of factors may be causing clinical paths to look like yesterday’s failed solution, when in fact the lessons learned during years of pathway development are being put to good use in many organizations.

Today caregivers are adopting outcomes-based practice methods to achieve desired patient care goals. Outcomes-based practice (sometimes called outcomes management) involves a combination of teamwork, continuous quality improvement, and process and outcome measurement. These collaborative multidisciplinary efforts build on the pathway development work of the 1990s. It’s quite likely that outcomes-based practice would not have been possible if caregivers hadn’t learned how to work together while designing clinical paths. All of those multidisciplinary meetings to develop paths were not a waste of time!

Paths and Outcomes-Based Practice

Caregivers have discovered that an “as needed” pathway philosophy seems to work best. Clinical paths were never intended to solve every documentation challenge, eliminate every unnecessary cost, or be used for every patient. Instead of trying to develop an unlimited number of clinical paths, organizations are now adopting outcomes-based practice as the goal. Paths are viewed as one of the many different tools caregivers can use to achieve that goal. An outcomes management initiative starts with the decision to improve clinical care for a particular group of patients. All involved caregivers must agree that it is important to study and improve the process. Improving a clinical process is hard work and unless the physicians, nurses, and other team members are rooting for project success, their interest in the initiative will be short-lived. Administrative and medical staff leaders should jointly define the goals for the project.

Once the patient population for the project is chosen a multidisciplinary team of people involved in caring for these patients is formed. After studying current patient care practices, the outcomes management team selects the actions necessary for achieving the project goals. What people have learned from their clinical pathway experiences is that the process improvement actions should be chosen after everyone knows what needs fixing. Otherwise organizations end up with "solutions in search of a problem" rather than measurable improvements.

Any number of actions can be taken to achieve the goals of an outcomes management project. For example, if data show that physician practices vary widely for no particular reason and reducing variation is a goal, then physician-friendly tools are developed. It’s unlikely that physicians will use a clinical path located in the nursing section of the patient’s hospital record. That’s why hospitals are designing physician-friendly point-of-care reminder tools such as pre-printed order forms. As order entry becomes computerized, written order sets can easily be converted to an electronic format. Computerized decision support systems are another effective tool for changing physician practices. These automated systems offer physicians point-of-care treatment advise for a variety of conditions and diseases.

Protocols are also an effective strategy for reducing undesirable variation in patient care practices. Unlike clinical paths that cover all aspects of care for a particular group of patients, protocols are designed for specific clinical situations, e.g. administration of heparin, management of postoperative nausea, treatment of pressure sores, etc. Protocols can be used by themselves or in combination with clinical paths. In the latter situation, the protocol serves as an expanded definition of the ideal plan of care found on the pathway. For example, a clinical path for oncology patients undergoing chemotherapy might state, “Initiate anti-emetic protocol.” The path helps to remind physicians and nurses that the anti-emetic protocol should be implemented at a particular time. The protocol contains all the treatment details that would be impossible to completely spell out in a less detailed clinical path.

Good Data is Essential

The outcomes management project team focuses on fundamental changes in systems and practices hat are most likely to produce positive long-term gains. The team does this by determining the barriers to goal attainment and then incrementally investing in strategies to achieve these goals. The project team must learn how to analyze practice pattern data to determine the best interventions and then monitor the success of various strategies. Each initiative requires timely feedback of process and outcome measures to the clinicians.

Clinical paths are not close to extinction. These patient management tools will continue to be key components of the outcomes management initiatives in many organizations. However, unlike the situation in the 1990s, a clinical path will not be the primary tool used to control costs and improve patient outcomes. Clinical paths have been joined by a variety of different tools and techniques which are all intended to improve patient outcomes and reduce unwarranted practice variation. Regardless of how health care organizations implement outcomes-based practice, there’s one certainty – caregivers will always need valid, reliable and timely information about important clinical processes and patient outcomes.

Copyright 2003 by Brown-Spath & Associates

To Learn More: Patrice L. Spath is available for in-house presentations on this and other health care performance improvement topics. For further details, visit Brown-Spath & Associates on the web at: http://www.brownspath.com or write to: Brown-Spath & Associates, PO Box 721, Forest Grove, OR 97116.

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