Clinical Practice Guidelines / Pathways as a Strategy / Tool for Hospital Quality Service Improvement

1. 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

2. 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

3. 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

4. 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)

5. 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)

6. Practice Guidelines
as a Strategy / Tool for Hospital Quality Service
Improvement
Definition 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

11. Column Headings:
• Services Offered
• Steps /
Procedures
• Requirements /
Forms
• Duration
• Fees / Charges
• Persons
Responsible
• Location

16. 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

17. 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

18. 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

19. Practice Guidelines
as a Strategy and Tool for Hospital Quality Service
Improvement
Standard 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

20. Practice Guidelines
as a Strategy and Tool for Hospital Quality Service
Improvement
Standard 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

21. Practice Guidelines
as a Strategy and Tool for Hospital Quality Service
Improvement
Clinical 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

22. Practice Guidelines
as a Strategy and Tool for Hospital Quality Service
Improvement
Clinical 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

23. Clinical Practice Guidelines, Clinical Pathways, and
Clinical Practice Protocols
Clinical
Guideline
Clinical Pathway Practice Protocol
Focuses on Specific clinical
circumstances.
The quality and
co-ordination of
care.
Treatment.
http://www.implementationcentral.com/guidelines_8.html

24. 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 decisi
ons 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

25. 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

26. 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

27. 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

28. 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) Timeline
2) 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

29. Clinical Practice Guidelines, Clinical Pathways, and
Clinical Practice Protocols
Clinical Guideline Clinical Pathway Practice Protocol
Also known
as....
Guidelines
Clinical Practice
Guidelines
Integrated Care
Pathways
Multidisciplinary
Pathways of
Care
Pathways of
Care
Care Maps
Collaborative
Care Pathways
Protocol
Best Practice
Treatment Protocol
http://www.implementationcentral.com/guidelines_8.html

30. Clinical Practice Guidelines, Clinical Pathways, and
Clinical Practice Protocols
Clinical Guideline Clinical Pathway Practice Protocol
Also known
as....
Guidelines
Clinical Practice
Guidelines
Integrated Care
Pathways
Multidisciplinary
Pathways of
Care
Pathways of
Care
Care Maps
Collaborative
Care Pathways
Protocol
Best Practice
Treatment Protocol
http://www.implementationcentral.com/guidelines_8.html
1
2
3
All 3 are clinical practice
guidelines!

31. 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

32. 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

33. Practice Protocols / Clinical Practice
Protocols
(SOPs, Policies and Procedures)
Processes in Development
Identification of subject area (service area)
Formation of technical working group
Formulation of protocol – practice / service
guidelines (with bases – consensus, evidences and
adjusted to local area)
Deliberation and approval of protocol
Deployment and implementation
Tracking of implementation (variances)
Evaluation and review at planned intervals

36. 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

37. 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.

38. 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

39. 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

45. CLINICAL DIAGNOSTIC PROCESS
PROCESSING OF DATA
PATTERN RECOGNITION
-realization that the patient’s presentation
conforms 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

46. 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 common
Disease 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

47. 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 Dx
Different Same
needed not needed

48. Management of a Surgical Patient [Process]
Paraclinical Diagnostic Process - Selection
SELECTION PROCESS
Procedure Benefit Risk Cost (PhP) Availability
Options
1 accuracy 99% acceptable 5000 available
2 accuracy 90% acceptable 3000 available
3 accuracy 50% acceptable 1000 available
Which is the most cost-effective procedure?
Option 2 or Option 1?

49. Management of a Surgical Patient [Process]
Treatment Process - Selection
SELECTION PROCESS
Treatment Benefit Risk Cost (PhP) Availability
Options
1 greatest surv rate acceptable 5000 available
2 rate < 1 > 3 acceptable 4000 available
3 least surv rate acceptable 3000 available
Which is the most cost-effective treatment option?
Option 1

56. 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

57. 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.

70. Clinical Pathways
Processes 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.

71. Clinical Pathways
Basic steps
• Define the processes
• Timing of the processes
• Note target areas that are critical
• Measure variations and make improvement
• Remeasurement

72. Clinical Pathways
Components
• A timeline
• Categories of care or activities and their
interventions
• Intermediate and long-term outcome criteria
• Variance records

73. Clinical Pathways
Components
• A timeline
• Pre-admission
• Admission
• Procedure
• Postop
• Discharge

74. Clinical Pathways
Components
• 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)

75. Clinical Pathways
Components
• 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

76. Clinical Pathways
Variances – result of
• omission of an action
• performance of an action at an inappropriate
(often late) time period

77. Clinical Pathways
Components
• Variance records
• Look for common variances
• Improve pathway
• Improve compliance

78. Clinical Pathways
Variances – result of
• Patient variations
• System variations
• Health professional variations

79. Clinical Pathways
Components
• 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.

80. 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

81. 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)

82. 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

83. 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)

84. 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.

85. 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 / Committee
Senior Management Representative if not the Hospital
Director
Chair (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.)

86. 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 sector
Nursing service sector
Ancillary medical service sector
Administrative or support service sector
Human resource development sector
Finance sector
Secretariat

87. 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.

88. 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
develop
Selection of the multidisciplinary teams for the guidelines
and pathways development
Expected outputs (short- and long-term)
Expected impact (short- and long-term)

89. 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 plan
Evaluation plan (short- and long-term)

90. ROJoson’s Recommendations:
Target clinical pathways.
As pathways are being
develop, input clinical practice
guidelines
and target
Integrated Value-Based Health Care Services

91. 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 stakeholders
Fear of medicolegal suits
Tedious work to formulate and record and evaluate the
pathways

92. 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 evaluation
Integration of standards in all units
Communication
Education

93. 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
Thank you for your kind attention.
For query and feedback:
rjoson2001@yahoo.com
0918-804-0304

94. 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
Thank you for your kind attention.
For query and feedback:
rjoson2001@yahoo.com
0918-804-0304

95. Welcome Queries and Feedback Anytime!
REYNALDO O. JOSON, MD, MHA, MHPEd, MSc Surg
0918-804-03-04
rjoson2001@yahoo.com