Until recently, the dominant notion was that healthcare providers were a collection of unrelated units. This view had several implications to the quality of care but most notably, to performance management. The misconception that cost defines quality and insistence on meeting certain minimum requirements did not afford healthcare industry the kind of outcome management robustness of other sectors. In essence, healthcare is often viewed as an ethical discipline rather than a business enterprise that should be subjected to robust evaluation and implementation of programs to improve the quality of outcomes (Heinemann, Fisher Jr, & Gershon, 2006). However, the increased public pressure on healthcare providers for accountability of the outcome of care to continuously improve the care delivery processes. To this end, there is the need for a paradigm shift to re-think evaluation of patient outcomes and to track any variations. The purpose of outcome management thus is to create an integrated system of units that have a mutual and collaborative effect on quality of care. In such a system, the new focus is the quality of each unit of the institution. It emphasizes the collaboration of the various components to identify faults thereby fostering teamwork rather than competing interests. Consequently, the organizations focus is to the healthcare professionals, patients, and the community (Dy et al., 2005).
Clinical pathways are an increasingly essential protocol for achieving optimal patient care outcomes. In an article on clinical pathways and outcomes management, Hoxie (1996) explained in detail the application of the concept of clinical pathways for the achievement of optimal outcomes. Although it incorporates steps similar to those Edwards Deming (Cited in Hoxie, 1995) outlined in the continuous monitoring and improvement process model, clinical pathways concept involves a more comprehensive link to the structures and processes of healthcare paradigms. Consequently, clinical pathways permit the establishment of critical points along the treatment process in which interventions occur and achieve a defined outcome (Hales, Terblanche, Fowler, & Sibbald, 2007). Whereas the conventional monitoring and evaluation programs of the components of the treatment process, clinical pathways cover all care settings, caregivers, and patient support programs. Another distinguishing factor with the traditional guidelines is the aspect of timelines along the care continuum (Horning & Stasiulis, 2015). In other words, critical pathways enhance the concept of collaboration among healthcare professionals and allow the evaluation of the impact of different care providers and settings. Patient satisfaction is one of the most important parameters of care outcomes that can be traced to specific units along the treatment continuum. Critical pathways allow for the evaluation of patient satisfaction at any component of the care process.
The critical points created by the clinical pathways are of significant importance in the assessment process. Variation analysis of the critical points provides a feedback loop of the various components of the treatment process. An important function of the variation analysis is to identify needs for change or faults for corrective measures and improvement. There is a growing body of literature addressing the issue of how clinical pathways and variance analysis are used to evaluate care outcomes. For example, Widjaja and colleagues (2005) conducted a study to identify factors affecting the length of stay of stroke patients in a hospital. Using the stroke pathway, their comparative analysis identified four factors viz availability of the waiting bed, delayed radiographic scans, the delayed family decision on discharge plan, and often incomplete application to facilities. Based on these findings, Widjaja et al. recommended the appropriate action plan for stroke patients in the facility. An earlier study by Cabello (2000) used a kidney pathway and variance analysis outcomes and reported that variance analysis has the potential to optimize patient care outcomes. A related study demonstrates that the critical role clinical pathways and variance analysis can reinforce collaborative care to improve the outcomes of care (Mosimaneotsile, Braun & Tokishi, 2000). Mosimaneotsile, Braun & Tokishi reported excellent patient outcomes and reduced length of stay of an integrated delivery model of care for stroke patients in a rehabilitation hospital. These studies demonstrate the practical and efficacious role of clinical pathways and variance analysis in the continuous improvement of care.
Variances in care delivery play a critical role in improving the in improving patient outcomes. Of vital importance is the continuous tracking of any variations from the anticipated outcomes along the treatment continuum. Edwards Deming is considered by most as the founder of continuous monitoring and improvement process concepts. He identified two types of process variances i.e. common causes and special causes. Hoxie (1995) defined common causes as those variations common to every incident in a care process. The causes have different characteristics at different at different times, and although they do not produce any particular pattern of outcomes, they are rather predictable. It is noteworthy that all clinical processes have variations of common causes type. Where the process consists of only common cause variances, it is thought to be in statistical control. In the case of suture manufacturing, for example, certain materials used may cause discomfort in convalescing patients who have undergone surgery. Therefore, it is important to monitor and improve the performance of such irritating materials. If the problem persists in the subsequent sutures, the design process or materials will have to be replaced.
Regarding special causes, they are variations that affect a fraction of or components of a treatment continuum. In other words, they are sentinel events which occur abruptly in a small group of treatment components. They may only be sporadic and disappear within a short while, or they may persist for prolonged periods of time. In statistical terms, processes bearing this type of variation are considered out of statistical control. A sentinel event is likely to cause a total failure of a unit resulting in a potential injury to the patient. The role of performance outcome evaluation is to monitor both common causes and special causes through statistical methods. According to Hoxie (1995), the essence of monitoring the variances is to identify the points along the care process where events are likely to occur and appropriate actions taken to remove the special causes while reducing the occurrence of common causes.
In conclusion, critical pathways are critical to outcome improvement in healthcare. With the increasing public pressure on care providers to improve the outcomes, there is need to embrace the clinical pathways methodology in the monitoring and evaluation of patient care programs. The most significant advantage of this method is inherent in its ability to evaluate a broad spectrum of factors affecting the delivery of quality care, i.e., the settings, providers, and patients. Variance analysis at critical points of care holds enormous potential to identify areas for improvement and to monitor events continuously.
References
Cabello, C. C. (2000). Use of variance outcomes to improve the management of the adult kidney transplant patient. Outcomes management for nursing practice, 5(4), 153-8.
Dy, S. M., Garg, P., Nyberg, D., Dawson, P. B., Pronovost, P. J., Morlock, L., ... & Wu, A. W. (2005). Critical pathway effectiveness: assessing the impact of patient, hospital care, and pathway characteristics using qualitative comparative analysis. Health services research, 40(2), 499-516.
Hales, B., Terblanche, M., Fowler, R., & Sibbald, W. (2007). Development of medical checklists for improved quality of patient care. International Journal for Quality in Health Care, 20(1), 22-30.
Heinemann, A. W., Fisher Jr, W. P., & Gershon, R. (2006). Improving health care quality with outcomes management. JPO: Journal of Prosthetics and Orthotics, 18(6), P46-P50.
Horning, J., & Stasiulis, E. (2015). Evaluation of Ontarios Emergency Department Clinical Pathway for Children and Youth with Mental Health Conditions.
Hoxie, L. O. (1995). Outcomes Measurement: A Primer for Orthotic and Prosthetic Care. JPO: Journal of Prosthetics and Orthotics, 7(4), 132-136.
Hoxie, L. O. (1996). Outcomes Measurement and Clinical Pathways. JPO: Journal of Prosthetics and Orthotics, 8(3), 93-95.
Mosimaneotsile, B., Braun, K. L., & Tokishi, C. (2000). Stroke patient outcomes: Does an integrated delivery model of care make a difference?. Physical & Occupational Therapy in Geriatrics, 17(2), 67-82.
Widjaja, L. S., Chan, B. P., Chen, H., Ong, B. K., & Pang, Y. T. (2002). Variance analysis applied to a stroke pathway: how this can improve efficiency of healthcare delivery. Annals of the Academy of Medicine, Singapore, 31(4), 425-430.
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