Bismillah, alhamdulillah

You may have come across the term Clinical Pathway and wondered what exactly they were. If you are a doctor you might at first think this is another word for Clinical Guideline but this is not actually the case. Having being victim of the same confusion I decided to read up on the issue and write myself a simplified guide to crystallise the concepts behind the idea.

Clinical pathways have come from industrial quality management from the 1950s from the aviation and construction industry. They developed a method to “analyze the involved tasks in completing a given project, especially the time needed to complete each task, and identifying the minimum time needed to complete the total project.” (Wikipedia) Then two nurses, Karen Zander & Kathleen Bower, introduced the same concepts to
health care in the mid 80’s. Ever since then health systems have been trying to introduce the concept of clinical pathways to hospitals.

In the perfect world the aim of the all the above is to be able to ‘process map’ the progress of a patient from admission to discharge and recording almost everything possible that happens to a patient at various points in this process. Doctors are used to clinical guidelines which tell doctors what to do and are evidence based. Clinical pathways add to clincal guidelines by adding two important and additional questions beginning with ‘w’ : who and when. Who should be doing something to the patient and by when they should be doing it. The who’s are not limited to doctors but to anyone involved in the patients progress through hospital – you can start your Clinical Pathway from the first point of contact with an ambulance officer, include porters, administrative staff, nurses etc.

All the times can be added up together to give a total time for the best patient with a given condition. If the next patient takes longer or shorter this is called a variance. If you have recorded all the data correctly you should be able to work out why the variance occurred, if it is was a positive (i.e. good) variance you change your Clinical Pathway to make sure it happens all the time, and if it was negative then you try and remove the causative factor. Other ways of looking at variance is to look how many times the patient is readmitted, deaths and if you have enough data you can even calculate the cost of looking after a patient.

So that is my very simplified guideline to the concept of Clinical Pathways. A good Clinical Pathway will be in the form of a flow diagram, with each point telling you what should be done, by whom and by when. The flow diagram will offer a decision making process with branches and different possible subpathways dealing with the most commmon possibilities i.e. patient needs X-ray or not.

Here is a possibe overview of a patient coming into ER with a swollen and painful ankle: Step 1 : Patient admitted by admitting officer, details recorded within 10 minutes and head nurse informed within 10 minutes. Step 2: Head nurse assigns patient to ER doctor within 2 minutes of being alerted of new patient and ….. Step 9. Ankle swelling with following Evidence Based Criteria will be entered by the physician for an X-ray with 5 minutes after completing the assessment of the patient … Step 99 Happy patient leaves in less than 3 hours from arriving to ER with a clear written instructions given by the ER
physician.

The use of Clinical Pathways with patients who are complex (what doctors will recognise as more medical and less surgical patients) with difficult to ring fence problems requires an ever more richer and complex way of capturing data. Complex data gathering can only be done with more complex and presumably costly IT systems to allow the analysis to show what is being done, when is it being done and by whom. This in turn has generated a commercial sector that caters to the health industry and allows administrators to keep their fingers on the pulse of patient’s progress through the hospital and the ‘bottlenecks’ in the system.

It is not surprising that doctors will find this degree of administrative oversight disconcerting. They are worried that administrators will try and use this as a stick to make sure doctors work in strict adherence to the Clinical Pathway and this in turn will remove clinical independance and end up with poorer patient care or at best a marginal increase in care with a vast and cumbersome ovrehead of bureaucracy. The counter argument states that this is the way of the future and with the ever increasing demand on resources the most efficient way of getting things done has to be worked out and analysed if a health system is to be successful with limited resources. Whether or not this administrator’s dream lives up to its claims or ends up being a clinician’s nightmare only time will tell.

Additional Reading:

Wikipedia article on  Clinical Pathways – good starting point
An American doctor’s sceptical point of view
The European Way
The NHS in the UK seems to have run out of money for this
Examples but seems to be offline
The New Zealand Experience
If you got to here you are doing well!

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