Care pathways, also known as clinical pathways or care maps, are a core tool to manage quality in health care and achieve standardization of patient care processes. The aim of a care pathway is to develop real-world guidelines that enhance the quality of care provided to a patient throughout treatment. This approach helps improve patient outcomes, promote patient safety, increase patient satisfaction, and optimize the use of resources in evidence- or value-based practice. This article examines key drivers for care pathways in clinical practice and success factors in their implementation.
Drivers and barriers
The Institute for Healthcare Improvement’s Triple Aim of improving population health, improving the patient experience of care (including quality and satisfaction) and reducing the per capita cost of health care has been a major driver for developing care pathways. Clinical or specialty groups within hospital systems or at varying care locations, however, have historically focused on each of the three aims separately. This lack of coordination has led to the need for care pathways that span clinical disciplines and improve the "handoff" to optimize quality and outcomes. Additional efforts are needed to bring these aims together across the locations and processes of care.
Care pathway drivers include known elements of clinical variation — due to factors such as age, disease, allergies or treatment response — and unexplained clinical variation, which is more likely to result in errors and require oversight. Care pathways provide a way to measure care delivery and the variations in approaches used by providers.
Barriers to developing and implementing effective care pathways include the need for evidence to precisely define outcomes of interest, the temptation to begin process definition on too small a scale to product effective results, and clinician resistance to perceived "checklist" medicine and its potential to diminish their role in decisions about patient care. As a result, care pathways must encompass the complexity of care and the context of delivery.
In a study of 581 health care providers — using a randomized controlled trial to assess the impact of care pathways on acute care teams — care pathways were shown to improve patient outcomes and teamwork, increase the level of care, and reduce the risk of burnout for health care teams. (For more, see Svin Deneckere et al., "Better Interprofessional Teamwork, Higher Level of Organized Care and Lower Risk of Burnout in Acute Health Care Teams Using Care Pathways: A Cluster Randomized Controlled Trial," Medical Care, January 2013.)
Care pathway development
There are three important components in the process of developing care pathways. First, providers must gather a fact base to develop clear evidence. In doing so, they must involve neutral parties such as medical associations and prioritize the evidence as the basis for decision-making. It is vital to understand the difference between clinical process-focused measures and clinical outcomes measures. Many clinical conditions do not yet have a rich set of outcomes measures for this purpose.
Second, providers must understand patient flow, including location, timing and manner of service delivery, and targets for improvement. This understanding should involve two categories of evidence: exogenous sources (which are typically perceived to be more objective and neutral) and endogenous sources (which are typically local and configured and may not be as applicable to a broad range of locations of care). As an example, the European Union's Deepening Our Understanding of Quality Improvement in Europe project — a multilevel, cross-sectional study of outcomes across multiple countries — uses a framework to understand patient flow in which endogenous (“patient-level,” “pathway-level,” “hospital-level”) and exogenous (“external”) elements all intersect.
Third, providers must identify the enablers and barriers, including determining what supporting services and structures are needed to deliver services efficiently, and understanding barriers within ambulatory clinical workflows and how to overcome or remove them.
Design, development and optimization of care pathways demand a pragmatic and inclusive approach at the institutional level. All stakeholders should participate in workshops that take into account factors such as local workflows, team composition and availability of technology. Lessons learned should be shared continuously, with iterative improvements to the pathways.
Several elements are central to successful care pathway development at the institutional level:
- A local champion: This engaged, proactive provider drives behavior change by actively engaging colleagues to achieve full care pathway adoption.
- Measure selection: This element is essential for turning clinical evidence and patient insight into a clear set of pathways that work for an institution. The National Quality Forum offers four criteria to help guide measure selection: (1) Focus on priority areas with best evidence for positive impact; (2) maintain scientific rigor so that the pathway will yield reliable, credible results; (3) ensure usability and relevance; and (4) make sure the pathways are feasible to implement without undue burden.
- Change management: This element must be applied to the content and process of care pathways and the broader care delivery environment to keep pathways current while minimizing provider burden.
As a concept, care pathways appear deceptively simple. Their design and implementation, however, can be challenging as a result of institutional complexity, local factors and the wide variety of diseases and care delivery types. The temptation to focus on steps that are relatively well-controlled must be balanced with the need to show improved clinical outcomes, which often continue beyond the particular pathway. Neutral parties can have a valuable role in defining and selecting measures due to the large number of potential stakeholders involved.
Looking ahead, all health care stakeholders have an important role to play in developing and using common, consistent terminology to clearly distinguish between process and outcome measures. All should work together in developing evidence to support care pathways, which hold great promise as a quality management tool.
Jonathan Morris, M.D., is vice president, provider solutions, and chief medical informatics officer, payer and provider solutions, at QuintilesIMS in Durham, N.C. Barbara Arone, M.S., is vice president and global head, biostatistics and data management, real world and late phase research, at QuintilesIMS.
The opinions expressed by the authors do not necessarily reflect the policy of the American Hospital Association.