clinical practice guidelines / pathways as a strategy / tool for hospital quality service...
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Clinical Practice Guidelines
as a Strategy / Tool for Hospital Quality
Service /Improvement
Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg Short Course on Total Quality Management
June 23 - 27, 2014 UP Manila College of Public Health
Clinical Practice Guidelines / Pathways
as a Strategy / Tool for Hospital Quality
Service /Improvement
Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg Short Course on Total Quality Management
June 23 - 27, 2014 UP Manila College of Public Health
Clinical Pathways as a Strategy / Tool for Hospital Quality
Service /Improvement
Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg Short Course on Total Quality Management
June 23 - 27, 2014 UP Manila College of Public Health
Clinical Practice Guidelines
as a Strategy / Tool for Hospital Quality
Service /Improvement
Outline of Contents of Talk:• Definition of Terms• Why the Strategy• How to Go About It (The Tool)
Clinical Practice Guidelines
as a Strategy / Tool for Hospital Quality
Service /Improvement
Outline of Contents of Talk:• Definition of Terms• Why the Strategy• How to Go About It (The Tool)
Practice Guidelines as a Strategy / Tool for Hospital
Quality Service ImprovementDefinition of Terms:• Clinical Practice Guidelines / Evidence-based
Clinical Practice Guidelines• Clinical Pathways / Care Pathways• Clinical Practice Protocols• Policies and Procedures • Standard Operating Procedures• Citizen’s Charter
Column Headings:
• Services Offered• Steps /
Procedures• Requirements /
Forms• Duration• Fees / Charges• Persons
Responsible• Location
Practice Guidelines as a Strategy and Tool for Hospital
Quality Service Improvement
Citizen’s Charter• Document setting out standards of service • Non-medical and medical services• Government institutions• Manuals and posters• Publicized to clients and staff leading to knowledgeable
clients and staff
QUALITY SERVICE / IMPROVEMENT
Clinical Practice Guidelines as a Strategy for Hospital Quality
Service Improvement Citizen’s Charter
It aimed to improve public services in the UK by:• Making administration accountable and citizen friendly.• Ensuring transparency and the right to information.• Taking measures to cleanse and motivate civil service.• Adopting a stakeholder approach.• Saving time of both executant and the clientele.• Easily under stability and quantified works.
*http://en.wikipedia.org/wiki/Citizen's_Charter
Practice Guidelines as a Strategy and Tool for Hospital
Quality Service Improvement
Citizen’s Charter• Document setting out standards of service • Non-medical and medical services• Government institutions• Manuals and posters• Publicized to clients and staff leading to knowledgeable
clients and staff
QUALITY SERVICE / IMPROVEMENT
• Clinical Practice Guidelines / Evidence-based Clinical Practice Guidelines
• Clinical Pathways / Care Pathways
• Clinical Practice Protocols
• Policies and Procedures• Standard Operating
Procedures
Practice Guidelines as a Strategy and Tool for Hospital
Quality Service ImprovementStandard Operating Procedures, Policies and Procedures, and Practice Protocols • Documents setting out standardization and standards
of practice • Non-medical and medical services• Government and non-government institutions• Manuals and posters• Publicized to clients and staff leading to knowledgeable
clients and staff
QUALITY SERVICE / IMPROVEMENT
Practice Guidelines as a Strategy and Tool for Hospital
Quality Service ImprovementStandard Operating Procedures, Policies and Procedures, and Practice Protocols • Documents setting out standardization and standards
of practice • Non-medical and medical services• Government and non-government institutions• Manuals and posters• Publicized to clients and staff leading to knowledgeable
clients and staff
QUALITY SERVICE / IMPROVEMENT
• Clinical Practice Guidelines / Evidence-based Clinical Practice Guidelines
• Clinical Pathways / Care Pathways
• Citizen’s Charter
Practice Guidelines as a Strategy and Tool for Hospital
Quality Service ImprovementClinical Practice Guidelines, Clinical Pathways, Clinical Practice Protocols (Hospital Setting)• Documents setting out standardization and standards
of clinical practice (management of patients)• Non-medical (allied medical) and medical services• Government and non-government institutions• Manuals and posters• Publicized to clients and staff leading to knowledgeable
clients and staff
QUALITY SERVICE / IMPROVEMENT
Practice Guidelines as a Strategy and Tool for Hospital
Quality Service ImprovementClinical Practice Guidelines, Clinical Pathways, Clinical Practice Protocols• Documents setting out standardization and standards
of clinical practice (management of patients)• Non-medical (allied medical) and medical services• Government and non-government institutions• Manuals and posters• Publicized to clients and staff leading to knowledgeable
clients and staff
QUALITY SERVICE / IMPROVEMENT
• Practice Protocols• Policies and Procedures• Standard Operating
Procedures• Citizen’s Charter
Clinical Practice Guidelines, Clinical Pathways, and Clinical Practice
Protocols Clinical
GuidelineClinical Pathway Practice Protocol
Focuses on Specific clinical circumstances.
The quality and co-ordination of care.
Treatment.
http://www.implementationcentral.com/guidelines_8.html
Clinical Practice Guidelines, Clinical Pathways, and Clinical Practice
Protocols Clinical Guideline Clinical Pathway Practice Protocol
What is it? Systematically developed statements to assist practitioners and patient make decisions about appropriate health care.
Structured, multi-disciplinary plans of care.
A suggested course of treatment and/or treatment service for a specific diagnosis, functional deficit or problem area.
http://www.implementationcentral.com/guidelines_8.html
Clinical Practice Guidelines, Clinical Pathways, and Clinical Practice
Protocols Clinical Guideline Clinical Pathway Practice Protocol
What does it do?
Makes specific recommendations on health care and links these to research evidence.
Supports the implementation of clinical guidelines and protocols.
Highlights major therapeutic intervention points.Identifies choices of difference courses or paths of treatment.Suggests other diagnosis that could be considered as treatment progresses.
http://www.implementationcentral.com/guidelines_8.html
Clinical Practice Guidelines, Clinical Pathways, and Clinical Practice
Protocols Clinical Guideline Clinical Pathway Practice Protocol
How does it work?
Provides a summary and appraisal of the best available research evidence or expert consensus.Highlights the strength of the evidence underlying each recommendation.
Provides detailed guidance for each stage in the management of a patient.
Provides a logical flow of interventions. Provides detailed recommendations that build on those made in guidelines.
http://www.implementationcentral.com/guidelines_8.html
Clinical Practice Guidelines, Clinical Pathways, and Clinical Practice
Protocols Clinical Guideline Clinical Pathway Practice Protocol
Who uses it? Clinicians, patients and third parties.
A multidisciplinary clinical team.
Specific clinicians.
http://www.implementationcentral.com/guidelines_8.html
Clinical Practice Guidelines, Clinical Pathways, and Clinical Practice
Protocols Clinical Guideline Clinical Pathway Practice Protocol
What are its components?
1) Appraisal of literature (research evidence or expert consensus).2) Summary of recommendations.3) An outline of how guideline should be implemented and how adherence monitored.
1) Timeline2) Categories of care/ intervention.3) Intermediate and long term outcome criteria.4) A variance record.
1) List of major therapeutic interventions.2) Goals: When interventions should be achieved.3) Options for different choices of treatment.4) Differential diagnoses and treatments based on the achievement of these goals.
http://www.implementationcentral.com/guidelines_8.html
Clinical Practice Guidelines, Clinical Pathways, and Clinical Practice
Protocols Clinical Guideline Clinical Pathway Practice Protocol
Also known as....
GuidelinesClinical Practice Guidelines
Integrated Care PathwaysMultidisciplinary Pathways of CarePathways of CareCare MapsCollaborative Care Pathways
ProtocolBest Practice Treatment Protocol
http://www.implementationcentral.com/guidelines_8.html
Clinical Practice Guidelines, Clinical Pathways, and Clinical Practice
Protocols Clinical Guideline Clinical Pathway Practice Protocol
Also known as....
GuidelinesClinical Practice Guidelines
Integrated Care PathwaysMultidisciplinary Pathways of CarePathways of CareCare MapsCollaborative Care Pathways
ProtocolBest Practice Treatment Protocol
http://www.implementationcentral.com/guidelines_8.html
1
2
3All 3 are clinical practice
guidelines!
Clinical Practice Guidelines
• Clinical Practice Guidelines (CPG) - “systematically developed statements to assist
practitioner and patient decisions about appropriate health care for specific clinical circumstances.”
- Institute of Medicine
Practice Protocols / Clinical Practice Protocols
(SOPs, Policies and Procedures)
• “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.”
•May be in narrative form complemented with tables, checklists, algorithms
Practice Protocols / Clinical Practice Protocols
(SOPs, Policies and Procedures)
Processes in DevelopmentIdentification of subject area (service area)Formation of technical working groupFormulation of protocol – practice / service
guidelines (with bases – consensus, evidences and adjusted to local area)
Deliberation and approval of protocolDeployment and implementationTracking of implementation (variances)Evaluation and review at planned intervals
Clinical Practice Guidelines
• Clinical Practice Guideline (CPG) - “systematically developed statement to assist
practitioner and patient decisions about appropriate health care for specific clinical circumstances.”
- Institute of Medicine
Clinical Practice Guidelines
• Evidence-based Clinical Practice Guideline (CPG) - series of recommendations on clinical care,
supported by the best available evidence in the clinical literature.
Clinical Practice Guidelines
• Evidence-based Clinical Practice Guidelines (CPG) - Processes involved in development:
- Formulation of technical working group- Formulation of clinical questions- Search for evidences in the literature- Evaluation of evidences
- Level of evidences (I – II – III)- Interim reports
- Consultation with panel of experts- Consensus gathering (Category A – C)
- Publication - Education- Implementation- Tracking of implementation (variances)- Evaluation (outcomes) and review at planned
intervals
Clinical Practice Guidelines
• Evidence-based Clinical Practice Guidelines (EB-CPG)
• Health-Process-Evidence-Based Clinical Practice Guidelines (HPEB-CPG) [ROJoson]
- to make the conventional evidence-based clinical practice guidelines more relevant and useful in clinical practice in the Philippines
CLINICAL DIAGNOSTIC PROCESS
PROCESSING OF DATA
PATTERN RECOGNITION-realization that the patient’s presentationconforms to a previously learned picture or pattern of disease
PREVALENCE- choice of a diagnosis is based on the frequency of occurrence of the disease in a certain locality, in a certain age and sex group, and in the affected organ and system
CLINICAL DIAGNOSTIC PROCESS
PROCESSING OF DATA
Knowing the common manifestations of 3 different diseases and relative frequency of each as follows:
Disease A - abcd (manifestations) Least commonDisease B - abcd Disease C - abcd Most common
Given a patient manifesting with abcd, your diagnosis is Disease C. What is/are processes used?
Pattern Recognition but mainly Prevalence
Management of a Surgical Patient [Process]
Paraclinical Diagnostic Process - Indication
PROCESSING OF DATA
CERTAINTY OF CLINICAL Dx 1O Dx 60% 99%
needed not needed
TREATMENT PLAN FOR 1O & 2O DxDifferent Sameneeded not needed
Management of a Surgical Patient [Process]
Paraclinical Diagnostic Process - Selection
SELECTION PROCESS Procedure Benefit Risk Cost (PhP) AvailabilityOptions
1 accuracy 99% acceptable 5000 available2 accuracy 90% acceptable 3000 available3 accuracy 50% acceptable 1000 available
Which is the most cost-effective procedure?
Option 2 or Option 1?
Management of a Surgical Patient [Process]
Treatment Process - Selection
SELECTION PROCESS Treatment Benefit Risk Cost (PhP) AvailabilityOptions
1 greatest surv rate acceptable 5000 available2 rate < 1 > 3 acceptable 4000 available3 least surv rate acceptable 3000 available
Which is the most cost-effective treatment option?
Option 1
Clinical Pathways
• Multidisciplinary management tool based on evidence-based practice for a specific group of patients with a predictable clinical course, in which the different tasks (interventions) by the professionals involved in the patient care are defined, optimized and sequenced either by hour (ED), day (acute care) or visit (homecare).
-Wikipedia
Clinical Pathways• A clinical pathway is a printed guideline to usual care
provided for a patient having a certain procedure done or a patient who has a certain illness. • Since all patients are unique, everyone’s care will be
customized to meet their needs while keeping the guidelines in mind.• Clinical pathways are used to describe and implement
clinical standards. They help to provide quality and efficient patient care.
Clinical PathwaysProcesses involved in development:• Identify high-volume, high-cost medical
conditions, diagnoses or procedures.• Form a multidisciplinary team.• Formulate the clinical pathway with task-time
matrix with focus on critical steps.• Deliberate and approve.• Deploy and implement.• Track implementation (variances)• Evaluate variances and patient care outcomes and
review at planned intervals.
Clinical PathwaysBasic steps• Define the processes• Timing of the processes• Note target areas that are critical• Measure variations and make improvement• Remeasurement
Clinical PathwaysComponents • A timeline• Categories of care or activities and their
interventions• Intermediate and long-term outcome criteria• Variance records
Clinical PathwaysComponents • A timeline• Pre-admission• Admission• Procedure• Postop• Discharge
Clinical PathwaysComponents • Categories of care or activities and their interventions• Medical Interventions• Assessment• Tests• Activities• Medications/Treatments• Nutrition/Fluids• Teaching• Discharge Planning• Tubes/Monitoring• Key outcomes (physician/nursing)
Clinical PathwaysComponents • Categories of care or activities and their interventions
• Assessment and Monitoring• Activity/Environmental• Consults• Diagnostics• Operative/Invasive Procedures• Laboratory• Nutrition/I.V. Therapy• Medications• Therapies• Patient/Family Education• Expected Outcomes
Clinical PathwaysVariances – result of • omission of an action • performance of an action at an
inappropriate (often late) time period
Clinical PathwaysComponents • Variance records• Look for common variances• Improve pathway• Improve compliance
Clinical PathwaysVariances – result of • Patient variations • System variations• Health professional variations
Clinical PathwaysComponents • Clinical Pathways Reasons for Variance• Patient’s clinical condition• Patient’s social situation• Associated diagnoses• Changing technology or techniques• Clinician’s discretion• Consultation and internal system services• External issues: primary care, home health care, etc.
Clinical Pathways• Aims• Facilitate introduction of guidelines to improve
the quality of care• Improve multidisciplinary communication• Reach or exceed quality care standards• Decrease unwanted practice variation• Improve patient-clinician communication and
patient satisfaction• Identify research and development questions
Clinical Practice Guidelines
as a Strategy / Tool for Hospital Quality
Service /Improvement
Outline of Contents of Talk:• Definition of Terms• Why the Strategy• How to Go About It (The Tool)
Clinical Practice Guidelines Clinical Pathways
• Patient care algorithms based on best evidences and cost-efficient processes.
• Intended to standardize and use standards of care - minimize variance in management- increase efficiency- improve patient care outcomes- reduce costs
Integrated value-based health care services
Clinical Practice Guidelines
as a Strategy / Tool for Hospital Quality
Service /Improvement
Outline of Contents of Talk:• Definition of Terms• Why the Strategy• How to Go About It (The Tool)
What are the recommended processes in going for clinical practice guidelines / clinical pathways?
Starting point:
Top management decides to have a Clinical Practice Guidelines / Clinical Pathways Project to promote quality service improvement in the hospital.
What are the recommended processes in going for clinical practice guidelines / clinical pathways?
Top management creates a Steering Team / Committee for Clinical Practice Guidelines / Clinical Pathways Project with clear functions and authority.
Membership of Steering Team / CommitteeSenior Management Representative if not the Hospital
DirectorChair (with competency in clinical practice guidelines /
clinical pathways and leadership)Cross-sectoral or multisectoral membership with representatives from key functional areas in the hospital, such as the following:(Note: the senior management team members may constitute the Steering Team / Committee.)
What are the recommended processes in going for clinical practice guidelines / clinical pathways?
Cross-sectoral or multisectoral membership with representatives from key functional areas in the hospital, such as the following:(Note: the senior management team members may constitute the Steering Team / Committee.)
Medical service sectorNursing service sectorAncillary medical service sectorAdministrative or support service sectorHuman resource development sectorFinance sectorSecretariat
What are the recommended processes in going for clinical practice guidelines / clinical pathways?
Steering Team formulates a master plan for Clinical Practice Guidelines / Clinical Pathways Project.
Steering Team seeks commitment for support and collaboration from top, senior, middle, and lower management on Clinical Practice Guidelines / Clinical Pathways Project.
What are the recommended processes in going for clinical practice guidelines / clinical pathways?
Contents of master plan for Clinical Practice Guidelines / Clinical Pathways Project
Goals and objectives of Clinical Practice Guidelines / Clinical Pathways Project (include short- and long-term goals and objectives)Selection and prioritization of guidelines and pathways to developSelection of the multidisciplinary teams for the guidelines and pathways developmentExpected outputs (short- and long-term)Expected impact (short- and long-term)
What are the recommended processes in going for clinical practice guidelines / clinical pathways?
Contents of master plan for Clinical Practice Guidelines / Clinical Pathways Project
Timelines (short- and long-term)Strategies and action plans to achieve expected outputs and impacts (short- and long-term)Budget (short- and long-term)Monitoring and oversight planEvaluation plan (short- and long-term)
ROJoson’s Recommendations:
Target clinical pathways.
As pathways are being develop, input
clinical practice guidelines
and target
Integrated Value-Based Health Care Services
What are the common problems and challenges in clinical practice guidelines and clinical pathway development ?
Common problems and challenges (commitment, cooperation, collaboration, and integration of all stakeholders)
Non-consensus on pathways by the stakeholdersFear of medicolegal suitsTedious work to formulate and record and evaluate the pathways
What are the common problems and challenges in clinical practice guidelines and clinical pathway development ?
Common problems and challenges (commitment, cooperation, collaboration, and integration of all stakeholders)
Weakness in:Leadership Management
Planning, implementation, and evaluationIntegration of standards in all units
CommunicationEducation
Clinical Practice Guidelines / Pathways as a Strategy / Toolfor Hospital Quality
Service /Improvement
Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg Short Course on Total Quality Management
June 23 - 27, 2014 UP Manila College of Public Health
Thank you for your kind attention.For query and feedback:rjoson2001@yahoo.com
0918-804-0304
Clinical Pathways as a Strategy / Toolfor Hospital Quality
Service /Improvement
Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg Short Course on Total Quality Management
June 23 - 27, 2014 UP Manila College of Public Health
Thank you for your kind attention.For query and feedback:rjoson2001@yahoo.com
0918-804-0304
Welcome Queries and Feedback Anytime!
REYNALDO O. JOSON, MD, MHA, MHPEd, MSc Surg0918-804-03-04
rjoson2001@yahoo.com
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