Change is required. There is a process of change, just as there is a process of manufacturing, or for growing wheat.
W. Edwards Deming
Change seems to be the prevailing experience in health care settings these days. During the 1980s it became apparent that health care costs were skyrocketing and needed careful management. Continuous Quality Improvement (CQI) or Total Quality Management (TQM) was adopted by many health care organizations (providers, purchasers, and insurers alike). CQI, which focuses on processes and systems to improve the efficiency and effectiveness of service delivery, is a methodology designed to improve quality by reducing variance, therefore eliminating inefficiency, rework and waste, and reducing cost.
Recent health care reform activities have heightened concerns about quality and cost containment and added the expectations that care be patient-focused and effective as demonstrated by valid outcomes measures. Although federal health care initiatives may be stalled, the health care “market place” continues to rapidly “re-form” itself under the umbrella of Managed Care. In the minds of many, the term “managed care” is synonymous with negotiated limits from third party payers, or “external sources.” The broader reality, however, is that “provider-controlled managed care” has played a key role in the delivery of health care services for quite some time through such familiar activities as team coordination and case management.
The need for such efforts is understandable when one looks at the delivery of health care in this country. By the 1970s health care delivery had become sufficiently complex that a number of distinctly separate, but interdependent health care professions were well established. Today, the management of most health problems has come to require a breadth and depth of knowledge and skill beyond that of any single individual or discipline, which has led to the evolution of health care teams (Falconer, J.A., Roth, E. J., Sutin, J. A., Strasser, D. C., & Chang, R. W., 1993). Although delivering care through teams has become a recognized standard in health care, the processes by which health care teammembers coordinate their work are varied and have received little systematic analysis (Falconer, et al., 1993). Critical paths are a framework for coordinating team work, a route to streamlining health care delivery. They are clinical management tools that organize, sequence, and time the major interventions of health care providers. Critical pathways are grounded in CQI methodology and use its scientific tools, such as teams, flowcharts, data collection, analysis of variance, and so. A critical path can be thought of as a project management plan, or the equivalent of the AAA Trip-Tic, “the most efficient way to reach your destination” (Zander, 1992).
The Critical Path Method (CPM) was originally developed in the 1950s as a tool for project planning in industrial engineering and managerial sciences. It has been used extensively with great success for projects as diverse as construction, civil engineering, town planning, marketing, ship building, product design, and equipment installation (Falconer, et al, 1993). CPM’s first application in the health care arena was for administrative planning projects. Karen Zander (who developed the CareMap System) began reporting on the clinical application of CPM in the health care literature in the mid 1980s, following her use of the methodology to review patient care delivery at the New England Medical Center in Boston (Zander, 1993).
The number of hospitals using CPM to improve the quality and efficiency of their patient care has grown rapidly. Such efforts to standardize and coordinate clinical practice are known by various names, such as clinical pathways, templates, critical paths, CareMaps, practice guidelines, collaborative care, physician-directed care, nursing-directed care, care processing modeling, case management, etc. In some facilities members of the existing staff are selected to serve on multidisciplinary teams charged with developing critical paths. Other facilities assign critical pathway development to case managers, or hire outside consultants to develop the pathways. Sometimes, more than one approach is used, as was our case. At the George Washington University Medical Center, a multidisciplinary team developed the Joint Replacement Pathway. Subsequently, another team was formed for the Craniotomy for Ruptured Aneurysm Pathway. This latter team refined their pathway through the expertise of an outside consultant.
Developing Critical Pathways
Consistent with CQI philosophy, pathway development teams must have input from all process stakeholders, so they typically include representatives of the patient population and a variety of caregivers. Team members for a Cranial Base Surgery Pathway may include an audiologist, dietitian, ICU nurse, neuroradiologist, neurosurgeon, neurotologist, neuroscience nurse, OR nurse, occupational therapist, pharmacist, physical therapist, speech-language pathologist, and so forth. Team membership may vary from one facility to another, or across settings. A team organized to develop a stroke pathway in an acute care setting may include an administrator, dietitian, neurologist, neuroscience nurse, occupational therapist, pharmacist, physical therapist, speech-language pathologist, and appropriate others. In a rehabilitation setting, such a team may also include a recreational therapist, psychologist, physiatrist, and so on.
It is better to be inclusive (versus exclusive), as input from all stakeholders is valuable. The pharmacist on the team will know of alternative routine medications that may be substantially less costly but just as effective; the social worker will know if early discharge planning is needed with a particular population. It is often helpful to the team to include previous patients or their family members in order to have their input regarding important needs and possible gaps in the care plan. On our ruptured aneurysm pathway team, a patient who was on vasospasm precautions reported needing more reassurance that the level of physical therapy activity was not too vigorous to induce vasospasm. Another patient emphasized the need for more comprehensive patient education regarding medication side effects, such as gum bleeding and skin rashes with Dilantin.
Pathways are usually developed for a particular diagnostic (diagnostic related group or DRG) category (for example, craniotomy), subset (for example, cranial base craniotomy) or condition (for example, failure to wean). Once a team is formed, the members may start with a thorough assessment of the “status quo.” Administrative data on the actual length of stay (LOS), volume, referral and reimbursement patterns for a particular DRG may be studied. The records of completed cases can be analyzed to determine prevalent patterns and variations of care. Major clinical interventions are identified and categorized along such dimensions as medications, consults, teaching, diagnostic tests, treatment, diet, and discharge planning are identified. Specific intervention categories vary by setting. In an acute care setting they may include assessment/monitoring, consultation, procedure/test, treatment, activity, medication, nutrition, patient/family education, psychosocial needs, discharge planning, and so on. A rehabilitation facility might organize the categories along functional lines, such as health management/medical status, psychosocial/behavioral, functional mobility/endurance, self-care skills, cognition, communication, swallowing, community reintegration, and continued care.
A clinical pathway is typically presented along two axes (see Figure 1). The abscissa (horizontal X axis) marks time. Depending on facility or institutional preference, time can be divided into smaller increments (such as 1 hour) or greater (such as 24 hours). Smaller increments organized around a day are used in institutions where dynamic change occurs (for example, acute care with its various intensive critical care areas). Institutions that have somewhat slower course, such as a rehabilitation hospital or outpatient facility, may divide time in a 24-hour interval at admission, progress to a 72-hour interval, then use 1-week intervals until discharge. The major clinical interventions are plotted along the vertical axis.
When developing a critical pathway, the team needs to search carefully and critically for elements of “best practice” (such as a lower incidence of postoperative nausea and vomiting associated with the use of one medication rather than another) and “opportunities for improvement” (such as reducing the number of needlesticks by coordinating the timing of blood values required by pharmacists, physicians, respiratory therapists, and so on) (Jones & Mullikin, 1994). Equally important, team members need to articulate their preferred practice of patient care. The speech-language pathologist on a craniotomy for ruptured aneurysm team would indicate that a dysphagia screening needs to be conducted before the patient’s first meal. If the screening indicates the patient has problems swallowing, consultation to speech-language pathology becomes automatic (that is, screening for dysphagia is specified on the critical path, as a standing physician order). Another example would be the team’s speech-language pathology representative requesting that consults for patients with a diagnosis of cerebrovascular accident (CVA) be routinely initiated on the first day of admission.
A critical pathway can begin at any point in the health care delivery continuum. In developing a critical path for cranial base surgery, for example, a variety of pre-operative tests and consults may need to be specified (for example, embolization by neuroradiology or full pre-operative audiologic assessment). Health care institutions that have home care or outpatient services may choose to include these components in certain critical pathways, in which case the path will not end at hospital discharge.
Zander (1993) suggests that the key steps to establishing the care plan are:
- consider what can realistically be accomplished within a given length of stay and what needs to be included in a discharge plan;
- discuss how the patient will progress through a hospitalization;
- determine patient problems and outcomes related to the diagnosis, including intermediate outcomes;
- discuss the daily goals to be met within the expected LOS;
- determine interventions necessary to achieve the established outcomes and format them according to consults, diagnostic studies, and so forth;
- decide which time units (e.g., hour, day, week) to use in specifying the interventions and outcomes.
Zander counsels that a clinical pathway is like a jigsaw puzzle: one needs to revise outcomes and interventions until they “fit” together.
Using Critical Pathways in Clinical Practice
Once completed, a critical pathway stipulates the preferred pattern of service delivery, although variation will undoubtedly occur. Monitoring and tracking the variance is also an integral part of critical pathway use. Variances may be coded into different categories, such as patient/family, provider, hospital, community, or event not applicable. Causes of the variation can also be identified and tracked by category, such as bed/appointment availability, information/data availability, supplies/equipment availability, department overbooked/closed, weekend, and hospital-other.
A critical pathway can be viewed in CQI terminology as PDCA: Plan Do Check Act. The critical path is the Plan; the clinical intervention is the Do; the documentation of variance is the Check; further revision of the delivery of care in the critical pathway is the Act. Pathways are not intended to be cookbooks or rigid programs of care. As stated earlier, they are intended to be tools that organize, sequence, and time the major interventions of health care providers. Some organizations customize the critical pathway for each patient hospitalization. At Memorial Hospital in Easton, Maryland, each critical pathway is individualized within 24 hours of a patent’s admission and becomes a part of the patient’s permanent medical record. Deviations (variances) from the pathway and the associated corrective action plans are recorded on a monitoring tool. Such variances are viewed as opportunities for improvement and reviewed for possible system changes (Jones & Mullikin, 1994). Falconer, et al. (1993) described a study in which the critical path method was used as a vehicle for enhancing interdisciplinary team interactions. Care team members specified prerequisite goals and activities for patients on admission to a rehabilitation facility and estimated the time for completion of each activity. This information was integrated into a computer program that generated a road map and the critical path for each patient’s rehabilitation program. The resulting road maps were revised or modified during the team’s semiweekly conferences, when the team also monitored progress along the critical path and discussed problems and overall program direction.
Depending on the organization, availability of consultants, patient population, and other variables, full institution-wide implementation of critical pathways can take from one to two years or longer. The development and implementation of critical pathways includes various stages. Those identified by Hoffman (1993) are:
- Literature search—attend conferences, review books and articles.
- Steering group—convene a committee to oversee project implementation.
- Targeting strategy—decide which diagnoses to put on the path.
- Paperwork design—create a form and procedure for the critical pathway.
- Gaining consensus—enlist support from key people.
- Pilot program—implement on a limited scale.
- Preliminary findings—gather and review the early data.
- Refine the program—measure, adjust, and revise program.
- Full implementation—expand the critical path project further.
Zander (1993) views critical pathways as one component of “provider-controlled managed care.” Her CareMap system includes six components: (1) CareMap tools, (2) variance analysis; (3) communication; (4) case consultation; (5) health care team meetings; and (6) CQI. Zander sees many benefits from such an approach:
- Accommodate managed care contracts.
- Decrease fragmentation of service and increase access to services.
- Improve patient/family satisfaction.
- Operationalize CQI at the patient care level.
- Enhance collaboration between disciplines.
- Provide a database(through variance) for CQI efforts.
- Link actual costs to care given.
- Decrease the length of stay when appropriate.
- Improve patient/family participation and education.
- Conduct action research.
- Restructure accountability models.
- Conform to 1994 JCAHO requirements.
- Streamline documentation.
- Decrease readmissions.
- Develop realistic outcomes management approaches.
- Develop accurate models of resource, staffing, and materials management needs.
- Prepare for computerization of medical records.
- Achieve more legal protection with CareMaps.
Critical pathways are increasingly common in health care practice. A review of the literature shows that they have been developed with diverse patient populations, including craniotomy, carotid endarterectomy, nervous system neoplasms, cerebrovascular accidents, transient ischemic attacks, seizures, stapedectomy, pulmonary embolus, pneumonia, angina, asthma, cardiac valve replacement, myocardial infarct, cardiac catheterization, congestive heart failure, syncope, joint replacement, and so on.
When deciding on which parameters to base a clinical pathway, Zander suggests selecting a patient population: (a) with a large volume; (b) that is problematic in cost and/or quality data; (c) with a perceived opportunity to improve efficiency and effectiveness of medical and hospital staff interventions; (d) with applicability of the diagnosis/procedure to a written pathway; (e) with written standards, guidelines, and protocols available in authoritative sources; and (f) priority of service.
Gary Pehrson (1994), Vice President for InterMountain Health Care, offered the following lessons based on his experience with pathways.
- Developing critical paths is hard work! Don’t underestimate the complexity of the task.
- Involve multidisciplinary teams. Include staff from finance, planning, patient care disciplines, and others in the decision making process. Use data to help make decisions.
- Show leadership. Use the team approach and prioritize where to spend your time based on what is best for the organization and where you can gain measurable results.
- Be diplomatic. Facilitate the process and remove all barriers to success.
- Be market driven. It will speed the development of the process of care.
- Appoint physician-led teams. Physician involvement is critical to making process improvement happen. Physicians will join the effort quickly if you work with them, not around them.
- Measurement and outcome are critical. Competing in the market means being able to demonstrate low cost and high quality to purchasers.
- Be patient. Realize that quality improvement in critical pathways is a never-ending process.
From their experience at the Memorial Hospital in Easton, Maryland, Jones and Mullikin (1994) identify the positive outcomes of critical pathways as:
- Standardized care from one unit to another and one outpatient center to another.
- Improved communication among departments and disciplines.
- Promotion of the professional development and satisfaction of health care providers.
- Increased patient satisfaction from early discharge planning and patient/family teaching.
- Less fragmentation of care.
- Daily coordination and evaluation of patient care activities.
Critical pathways are valuable management tools. They provide professionals with a common language, encourage collaborative practice, and provide a forum for consumers to be more informed and more involved in their own health care. Such involvement, coordination, and communication can result in improved quality of care. To date, this approach has been applied successfully in industry and health care. There does not appear to be any documented evidence of its application in clinical settings outside of health care. However, the basic concepts of coordinating, timing, sequencing, and monitoring the delivery of team-based care are undoubtedly universal and equally applicable to any setting.
Lana Shekim, PhD
American Health Consultants. (1993). To post or not to post: Empowering patients through the critical paths. Hospital Case Management, 1, 1–3.
Falconer, J. A., Roth, E. J., Sutin, J. A., Strasser, D. C., & Chang, R. W. (1993). The critical path method in stroke rehabilitation: Lessons from an experiment in cost containment and outcome improvement. Quality Review Bulletin, 19(1), 8-16.
Hoffman, P. (1993). Critical pathway method: An important tool for coordinating clinical care. Journal of Quality Improvement, 19(7), 235–246.
Jones, R. A., & Mullikin, C. (1994). Collaborative care: Pathways to quality outcomes. Journal of Healthcare Quality, 16(4), 10–13.
Pehrson, G. (1994). Using care process models to improve quality while controlling cost. The Quality Letter for Health Care Leaders, 6(3), 24–27.
Zander, K. (1992). Critical pathways. In Melumim & M. Sinions (Eds.), Total quality management. Chicago: American Hospital Association Publishing.
Zander, K. (1992b). Focusing on patient outcomes: Case management in the 90s. Dimensions of Critical Care Nursing, 3, 127–29.
Zander, K. (1993, December). Intensive consultation curriculum. Course manual from a workshop in South Natik.
The Center for Case Management for the CareMap Tool and the staff at Barnes Hospital, St. Louis, MO, for sharing the CVA Care Path.
Sharon Waski, MS, RN and Jennifer Covich, MA, Co-directors of the Clinical Map Program at The George Washington University Medical Center, Washington, DC.
About the Author
Lana Shekim is the Clinical Director of Speech Pathology and Audiology at The George Washington University Medical Center. She is an Assistant Professor of Speech-Language Pathology at The George Washington University where she teaches a course on dysphagia.