Clinical Pathways and Variance Analysis

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Clinical Pathways and Variance Analysis
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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.

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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.

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Why does JCI recognize pathways

• Pathways reflect care that is
• Planned
• Standardized
• Organized
• Documented

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Why pathways?
Pathways can improve team communication and
coordination of care, thus preventing medical
errors.
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Why pathways?
Pathways can improve team communication and
coordination of care, thus preventing medical
errors.
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How is a TMC pathway developed

1. Pathway topics are chosen from Medical Citys
   high-volume, high-risk or problem-prone cases.
2. MQIO forms a multidisciplinary pathway team.
3. The team defines population of patients to be
   covered by the pathway.
4. 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

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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

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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

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Parts of a Clinical Pathway

• Pathway title
• Inclusion and exclusion criteria
• Patients information
• Physicians 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)

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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)

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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 patients 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)

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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
• Dont 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

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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

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Parts of a clinical pathway
1. Pathway title
2. Eligibility exclusion criteria
3. Patients data
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Parts of a clinical pathway
4. Physicians notes (SOAP)
5. Orders
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Parts of a clinical pathway
Bulleted interventions are mandatory interventions
Interventions with tick boxes are optional
interventions
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Parts of a clinical pathway
6. Pathway activation
7. Pathway acknowledgment
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Parts of a clinical pathway
8. Variance column
9. Signature column
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How are clinical pathways used?

• General guidelines in using pathways
• The pathway is a permanent part of the patients
  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.

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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 doctors order set
• The APs / residents 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.

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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

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The Nurses 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

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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

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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

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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.

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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 residents 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.

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Documenting variances
The Variance column where care team members
write the Variance code
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VARIANCE CODES
A. Patient/family 1. Patients 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
5. Other reasons 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.
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How to analyze pathway variances

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

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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.

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Reviewing outcomes MDs 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 patients progress against
  intermediate and discharge outcomes on a daily
  basis.
• And for revising the plan of care based on the
  review of patients outcomes.

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Reviewing outcomes nurse-in-charges role

• Reviews patients 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.

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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

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Discontinuing the pathway

• The pathway will be discontinued whenever
• The patients primary diagnosis changes
• The patients 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
  patients 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.

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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.

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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
• All of the above
• Answer D. Complete activation requires approval
  by the managing physician and acknowledgment by
  the nurse in charge.

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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

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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
• d. All of the above
• Answer D

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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

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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.

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