Clinical Pathways and Variance Analysis

What is a clinical pathway? A multidisciplinary proactive plan of care for a specific diagnosis or procedure. It is a timeline of patient care activities which is used by all disciplines for planning, anticipating, implementing, and evaluating care.

Why pathways? Enhances interdisciplinary collaboration Helps to reduce unnecessary variations in patient care and outcomes. Supports development of care partnerships and empowers patients and their careers. A tool to incorporate local and national guidelines into everyday practice, Manages clinical risk and meets the requirements of clinical governance.

Why does JCI recognize pathways Pathways reflect care that is – Planned Standardized Organized Documented

Why pathways? Pathways can improve team communication and coordination of care, thus preventing medical errors.

Why pathways? Pathways can improve team communication and coordination of care, thus preventing medical errors.

How is a TMC pathway developed Pathway topics are chosen from Medical City’s high-volume, high-risk or problem-prone cases. MQIO forms a multidisciplinary pathway team. The team defines population of patients to be covered by the pathway. The team drafts the pathway according to available evidence, including existing pathways and evidence-based Clinical Practice Guidelines. The draft pathway specified (a) Time intervals, (b) Interventions per element of care and (c) patient outcomes prior to discharge

How is a TMC pathway developed 5. The team presents the pathway to the concerned departments and units for approval 6. The team pilot tests the pathway to ensure ease of use 7. MQIO monitors and evaluates pathway use by Measuring and analyzing variances Making appropriate modifications to the clinical content Addressing process improvement

What pathways are implemented in TMC? Acute asthmatic attack Acute abdominal pain (non-traumatic) Chest pain Pneumonia (in adults and children) Normal birth Acute appendicitis Acute diarrhea (in adults and children) Coronary artery bypass graft procedure Sepsis alert

Parts of a Clinical Pathway Pathway title Inclusion and exclusion criteria Patient’s information Physician’s Notes S: subjective complaints/symptoms O: objective physical and laboratory findings A: assessment/ working diagnosis/ clinical impression P: plan of care (diagnostic, therapeutic, rehabilitative, others)

Parts of a clinical pathway 5. Orders Assessment and Monitoring (vital signs, hemodynamic monitoring, weights, etc) Laboratory tests/Tests/Procedures (Routine diagnostic tests) Treatments (medical and nursing  orders, dressing changes) Medications/IVS (IV fluids, blood orders, routine medications) Nutrition (Enteral and parenteral feedings, diet and fluid restrictions, supplemental feedings)

Parts of a Clinical Pathway 5. Orders Activity/Safety (Activity orders and/or limitations (ex. turn q 2 hours, PT or OT consult/orders) Consults (referrals) Psychosocial (assurance that illness is self-limiting, assuring a mother that she can breastfeed, assuring family that patient’s usual activity may be resumed in 3-7 days) Patient/Family Education (hand hygiene, breastfeeding education, possible sources of infection) Discharge Planning (assessment of patient outcomes, referrals to home or post-operative care)

Parts of a Clinical Pathway Orders or interventions may be mandatory or optional Mandatory interventions – marked by bullets (•) and applicable to 100% of the population Must be carried out once a pathway is activated Don’t need a checkmark to be carried out If deemed not applicable to the patient, may be crossed out and initialed by AP Optional interventions – marked by tick boxes () and may not apply to 100% of the population Option box () should be marked with a check () if the intervention meets the needs of the patient If box is left empty, intervention need not be done

Parts of a Clinical Pathway 6. Pathway activation - by the attending physician or resident-in-charge 7. Pathway acknowledgement - by the nurse-in-charge 8. Variance column 9. Signature column

Parts of a clinical pathway 1. Pathway title 2. Eligibility & exclusion criteria 3. Patient’s data

Parts of a clinical pathway 4. Physician’s notes (SOAP) 5. Orders

Parts of a clinical pathway Bulleted interventions are mandatory interventions Interventions with tick boxes are optional interventions

Parts of a clinical pathway 6. Pathway activation 7. Pathway acknowledgment

Parts of a clinical pathway 8. Variance column 9. Signature column

How are clinical pathways used? General guidelines in using pathways The pathway is a permanent part of the patient’s medical record. The Pathway may be used in lieu of the Care Plan, Orders and Notes Sheet accomplished by the medical staff. The Nurse in Charge and Attending Physician will select the appropriate pathway on admission OR when the interval of care begins. The care delivered and patient outcomes will be managed against the pathway.

The role of the MD in using pathways The MD activates the pathway. The AP / resident-in-charge activates the pathway by signing at the bottom Once activated, the pathway shall serve as a pre-printed doctor’s order set The AP’s / resident’s signature signifies approval of the orders for the time interval. Any additional orders which do not appear on the pre-printed pathway (e.g., medications, IV fluids, parenteral nutrition, etc) must be written on the traditional order sheet.

The role of the MD in using pathways The AP / resident-in-charge Sees to it that all mandatory interventions are applicable to the patient Cancels any mandatory intervention NOT applicable to the patient. REMEMBER: you must initial any canceled intervention. Ticks the optional interventions you think the patient needs

The Nurse’s role in using pathways: The nurse-in-charge assists the AP in selecting the appropriate pathway. Acknowledges activation of the pathway by signing at the bottom Carries out all mandatory intervention that are not cancelled and optional interventions that are checked writes his / her initials and the time the order was done on the Sign column

All the other members of the care team have active roles in using pathways Accomplishing interventions Therapists, nutritionists, residents, interns, and clerks do all mandatory observations pertaining to them that are not cancelled and all optional interventions that are checked. Whenever an intervention is accomplished, the care team member writes his / her initials and the time the order was done on the Sign column

The pathway is a great tool for communicating to your co-workers: Use the pathway during Nursing shift endorsement AP rounds Rounds by referred doctors Chart rounds Interdepartmental conferences

Variances A variance is any mandatory or checked optional intervention that was not done. an abnormal finding An unmet outcome within the time frame Variances may be noted by any care team member. Whenever a variance is noted, the variance code and initials is written in the variance column.

Documenting variances Whoever noted the variance must make a note to describe the nature and cause of the variance and any actions taken. Variance notes may be written in the interns’ or resident’s progress notes, if a MD noted the variance nurses’ notes, if nurse-in-charge noted the variance A variance monitoring form, documenting all variances in the pathway, is filled out by the nurse supervisor after every pathway patient is discharged.

Documenting variances The Variance column: where care team members write the Variance code

VARIANCE CODES A. Patient/family 1. Patient’s medical condition 2. Patient/family decision 3. Patient/family availability 4. No funds 5. Other reasons B. Physician 1. Medical order 2. Provider(s) decision 3. Provider(s) response time 4. Other reasons C. TMC System 1. Results/Data availability 2. Supplies/Equipment related 3. Appointment Availability 4. Weekend/Holiday D. Outside TMC 1. Transportation availability 2. Home Care availability 3. Other reasons For example, if a mandatory test is not done because the patient has no money yet, the cause of that variance is encoded as “A4”.

How to analyze pathway variances Identify critical pathway orders. These are the orders which, if not carried, will significantly put the patient at risk for harm. Using the variance monitoring form, count the number of variances that occurred in the critical pathway orders. Perform RCA to determine causes of variances. Pilot test countermeasures. Monitor variance counts and note if they decrease over time..

Outcomes The measurable outcomes that a patient is expected to experience is specified in the pathway for every time interval (e.g., daily, per shift). Because outcomes are pre-determined, the pathway can prompt any member of the care team to call the attention of the AP if the expected outcomes are not achieved within the time interval. Thus, interventions can be modified, added, discontinued in a timely way.

Reviewing outcomes: MD’s role All care team members must review the problem list, variances and outcomes daily. Pathways ensure that the members of the care team are looking at the same plan of care. AP and all referred MDs are accountable for reviewing the patient’s progress against intermediate and discharge outcomes on a daily basis. And for revising the plan of care based on the review of patient’s outcomes.

Reviewing outcomes: nurse-in-charge’s role Reviews patient’s progress daily against intermediate and discharge outcomes Review variances daily and report them to the AP and the rest of the care team. Ensures that all variances result in re-evaluation of plan of care by appropriate disciplines.

Reviewing outcomes A met outcome – should be initialed; no other documentation necessary An unmet outcome – consider as variance Outcome not met within time frame - may require adjusting the intervention Variance due to unmet outcome – describe in progress notes in SOAP format Outcome met earlier than expected – a positive variance; document/initial on the date it was met

Discontinuing the pathway The pathway will be discontinued whenever: The patient’s primary diagnosis changes The patient’s condition significantly worsens The patient fails to meet clinical outcomes for 24-48 hours To discontinue the pathway, a progress note (SOAP) is written by the MD outlining the patient’s new plan of care and new orders. A new nursing plan of care is also written. The pathway is then filed in the patient record.

Keys to pathway success Make pathways part of your quality program. Ensure strong collaboration between all relevant disciplines, with a strong medical lead. Select appropriate medical conditions in making pathways. Base the pathway orders on best available evidence / best practice. Collect and analyze variances and involve the staff in interventions to decrease variances. Incorporate adherence to pathway policies in performance appraisal of all staff members.

Are you a pathway warrior? A pathway is A time-bound clinical algorithm A standard treatment protocol with pre-specified outcomes A pre-printed order set All of the above Answer: D A pathway is completely activated by The nurse in charge The attending physician The emergency room physician Answer: D. Complete activation requires approval by the managing physician and acknowledgment by the nurse in charge.

Are you a pathway warrior? 3. The following personnel must write his/her initial and time done next to each pathway order after it has been done: a. Resident in charge or on duty b. Nurse in charge c. Intern in charge or on duty d. All of the above Answer: D. 4. If an additional order not on the pathway is desired, such an order must be written a. On the pathway b. On the standard Order Sheet c. On the Progress Notes d. Any of the above Answer: B

Are you a pathway warrior? 5. Who reviews the pathway daily? a. Nurse In Charge b. Resident In Charge c. Intern In Charge d. All of the above Answer: D 6. A variance is recorded as a variance code in the variance column when a. A lab test is not done during the care interval b. An outcome is not met during the care interval c. A treatment is not done during the care interval

Are you a pathway warrior? 7. Which of the following pathway/s is/are implemented in TMC? a. Coronary artery bypass graft b. Pneumonia in children c. Normal birth d. All of the above Answer: D 8. If the admitting staff fails to activate a pathway in a patient whose condition is covered by a TMC pathway, what should be done on the succeeding hospital days? a. continue writing orders on the standard Order Sheet b. look for the admitting staff member so that a pathway can be activated in retrospect c. activate the pathway on the succeeding days d. do not activate the pathway anymore Answer: C. Even if the pathway has not been activated upon admission, the patient can still be managed according to pathway orders on succeeding days provided he meets the inclusion criteria

Are you a pathway warrior? 8 out of 8 – your patients are cared for in an evidence-based, standardized fashion 6 or 7 out of 8 – your patients are nearly at par with those in other JCI accredited hospitals 4 or 5 out of 8 – some of your patients are not being cared for according to world class levels of quality 2 or 3 out of 8 – you can improve the quality of your patients’ care!* 0 or 1 out of 8 – let us try again* * Please go over the slides again.

This SIM Card certifies that ______(please overwrite with your name, thank you)__, MD has successfully completed the Self Instructional Module on Clinical Pathways. (Sgd) Dr Alfredo Bengzon (Sgd) Dr Jose Acuin President and CEO Director, Medical Quality Improvement