INTRODUCTION TO CLINICAL PATHWAYS

JANE LAVELLE, MD, JOSEPH ZORC, MD, MSCE, AND AILEEN SCHAST, PhD

BACKGROUND

Medical professionals must increase focus on providing healthcare with high value—that which provides the best outcomes achieved with the least cost. Over the past several decades, variation in clinical care has been recognized as a core problem in achieving high value care. Variation results from a number of causes including: 1. Clinical uncertainty: high quality evidence is available to the guide the care of patients only 10% to 20% of the time; 2. Growth in medical knowledge: the exponential growth in new knowledge of clinical medicine has made it impossible for a single provider to assimilate and apply this information to current practice; 3. The growing complexity of patient conditions and treatments which requires strong team collaboration, and, finally; 4. Misaligned financial incentives for providers that allows reimbursement for unnecessary testing, procedures and treatments. Healthcare utilization across different geographic regions has been documented to show wide variation. This variation cannot be explained by illness, best practice evidence or well-informed patient preferences. Variation has also been documented across all types of providers, and within an individual provider’s practice, confirming that some portion of variation comes from individual provider preference. Finally, as research enters the mainstream, translation to the bedside is often left to clinician judgment, applied inconsistently, often without measurement.

QUALITY IMPROVEMENT THEORY

Quality improvement theory provides powerful tools to increase value in healthcare through standardization of healthcare processes and promotion of strong clinician teamwork. Principles of process improvement, coupled with organizational/behavioral psychology and the scientific method form the basis of quality improvement theory. It directs the management’s focus onto processes and systems rather than individual clinicians, and it provides a set of principles by which teams of clinicians can measure and document the best patient outcomes at the lowest necessary cost.

Healthcare delivery is a process—a series of linked steps designed to achieve a certain outcome. The healthcare system is a series of processes interacting together. Through designing process interventions, testing change, and measuring outcomes, quality improvement theories can be applied to healthcare in meaningful ways.