care pathways the how and why of clinical management pieter degeling
TRANSCRIPT
Care Pathways
The how and why of
clinical management
Pieter Degeling
Policy agenda of health reform
Search for efficiency - 1980’s Funding New management structures Information technology
+ Emerging Clinical Performance Agenda – 1995
Clinical audit Clinical effectiveness Service integration Safety/quality Evidence based Risk management Quality improvement Value for money
Policies are aimed to encourage structured multidisciplinary conversations about questions such as:
Are we doing the right things? In light of assessed health needs and existing resource constraints, are we
delivering value for money? On a condition-by-condition basis, how appropriate and effective are the services
we offer?
Are we doing things right? On a condition by condition basis, how systematized are our care processes? How are we performing on risk, safety, quality, patient evaluation and clinical
outcomes?
Do we have the capacity to get better? On a condition-by-condition basis, what strategies are in place for service and
professional development? What are we doing about clinical mentoring, leadership development, staff
appraisal and review?
Some questions about implementing this approach
At what organizational level should these conversations occur?
Who should be involved?
Who should generate and facilitate these conversations?
What structural and resource supports will these people require?
What methods might they use?
Answers
Org level
Involvement
Responsibility
Structural support
Method
Clinical unit/team
Multidisciplinary team
Clinician managers
Authorisation via CG
Clinical pathways (H/V)
Conventional Hospital Organisation
“Clinical Product Line” ModelFi
nal Pro
du
cts
Intermediate Products
Fin
al Pro
du
cts
Intermediate Products
What was missing was a method
Quality Indicators
Outcome Indicators
Routine Review of Variance
Prospectively Costed
Integrated Care Pathways
Characteristics of Integrated Care Pathways
Characteristics of Integrated Care Pathways
Systematically developed and evidenced based written statements,
About the agreed sequence of diagnostic and therapeutic events in primary, acute and/or community care
Whose occurrence or non occurrence, for high volume case types, will significantly affect, quality, outcomes and cost.
Why high volume case types?
High volume case types are those for which:
we can get the biggest ‘bang for the buck’ as we attempt to improve:
Efficiency Effectiveness Patient Experience Quality
We can generate reliable data for statistical analysis
High volume case types – major teaching hospital
• 40 HRGs (out of 547) account for 46% of all emergency episodes and these HRGs account for 37% of all emergency generated bed days
• 19 of these HRGs reference conditions that have a high risk of readmission that account for 27% of A&E admissions and 15% of A&E generated bed days
• 40 HRGs account for 46% of all elective admissions and these account for 28% of all elective bed days.
• 40 HRGs account for 79% of elective day cases
• 10 HRGs account for 96% of maternity (&birth) admissions and 91% of maternity bed days
High volume case types- DGH (4 )
• Emergency admissions account for 53% of all care episodes and 82.9% of all bed days consumed within the Trusts
• 30 HRGs (out of 547) account for 46% of all emergency episodes and these HRGs account for 39% of all emergency generated bed days within the Trusts.
• 18 of these HRGs reference conditions (usually chronic) with a high risk of repeated emergency admission. These patients tend to account for 32.8% of all emergency patient episodes and 17.6% of all bed days.
• Non day elective episodes account for 17% of all bed days with the Trusts
• 54 HRGs account for 67.9% of all nonday elective episodes. These HRGs account for 63% of elective non day bed days used within the Trusts.
• 30 HRGs account for 75% of all day only elective episodes.
High Volume Emergency Admissions – Repeated AdmHRG HRG label % Adm % B Days
D20 Chron Obstruct Pulmonary Dis/Bronch 37.22 39.16
S16 Poison Toxic Effects /Overdoses 18.25 17.62
P06 Minor Infections (incl Immune Disord) 5.41 7.73
E36 Chest Pain <70 w/o cc 7.47 7.81
D21 Asthma >49 or w cc 1.44 1.41
F47 Gen Abdom Disord <70 w/o cc 4.84 7.85
E33 Angina >69 or w cc 18.11 18.73
H42 Sprains Strains /Minr Open Wounds <70 w/o cc 1.43 1.11
L09 Kidney/Urin Tract Infections >69 or wcc 3.77 2.92
D99 Comp Eld w a Respiratory Sys PDx 6.54 5.81
E18 Heart Fail/Shock >69 or wcc 6.67 5.38
E29 Arrhythmia/Conduction Disord >69 or wcc 4.68 3.37
P13 Other Gastro/Metabol Disord 9.16 15.09
E31 Syncope/Collapse >69 or wcc 2.87 3.31
F46 Gen Abdom Disord >69 or wcc 5.78 4.44
E12 Acute Myocardial Infarction w/o cc 0.66 0.37
P03 Upper Respiratory Tract Disord 5.73 9.07
E35 Chest Pain >69 or w cc 7.26 6.99
P15 Accidental Injury 1.68 1.38
P04 Lower Respiratory Tract Disord 11.37 21.33
E34 Angina <70 w/o cc 13.65 17.11
F17 Stom/Duod Disord >69 or wcc 2.22 2.17
A22 Non-Transient Stroke/CVA >69 or wcc 0.10 0.12
D13 Lobar Atyp/Viral Pneumon >69 or wcc 2.13 2.33
High Volume Elective Cases
HRG HRG label Elec Adm Day Case Tot % Elec Cum % % Day
N12 Other Maternity Events 878 22276 23154 5.38 5.38 96.21
L21 Bladder Minor Endo Px w/o cc 1475 14221 15696 3.65 9.03 90.60
F98 Chemo w a Digestive Sys PDx 5357 8852 14209 3.30 12.33 62.30
B02 Phako Cataract Extract w Lens Implant 3278 8604 11882 2.76 15.09 72.41
F06 Oesophagus - Diagnostic Pxs 901 9313 10214 2.37 17.46 91.18
S01 Haematol Disord w Minor Px 1951 8236 10187 2.37 19.83 80.85
J37 Minor Skin Pxs - Cat 1 w/o cc 1233 8710 9943 2.31 22.14 87.60
A07 Intermediate Pain Pxs 1317 8187 9504 2.21 24.34 86.14
M06 Upper Genital Tract Inter Pxs 3327 5845 9172 2.13 26.47 63.73
M10 Surg Termination of Pregnancy 594 7377 7971 1.85 28.33 92.55
S22 Planned Pxs Not Carried Out 4797 3123 7920 1.84 30.17 39.43
C24 Mouth/Throat Pxs - Cat 3 7089 370 7459 1.73 31.90 4.96
E14 Cardiac Catheterisation w/o Complicat 2147 5160 7307 1.70 33.60 70.62
J98 Chemo w a Skin Breast/Burn PDx 3413 3375 6788 1.58 35.17 49.72
F35 Large Intestine - Endo/Inter Pxs 762 5666 6428 1.49 36.67 88.15
F16 Stom/Duod - Diagnos Pxs 476 5509 5985 1.39 38.06 92.05
S98 Chemo w a Haem Inf Dis Poison /Non-spec PDx 1611 4074 5685 1.32 40.74 71.66
E15 Percutan Translum Coronary Angioplasty (PTCA) 5168 9 5177 1.20 41.94 0.17
H26 Inf Spne Joint/Conn Tiss Disrd <70 or w/o cc 877 4208 5085 1.18 43.12 82.75
M98 Chemo w a Fem Reprod Sys PDx 3478 1240 4718 1.10 44.22 26.28
B05 Other Ophthalmic Pxs - Cat 2 379 4037 4416 1.03 45.24 91.42
E04 Coronary Bypass 3799 0 3799 0.88 46.13 0.00
D17 Cystic Fibrosis 3553 234 3787 0.88 47.01 6.18
M07 Upper Genital Tract Maj Pxs 3522 184 3706 0.86 47.87 4.96
High Volume Elective Cases – % Day CasesHRG HRG label DC % Nat DC % Risk
N12 Other Maternity Events 44.57429 45.57
L21 Bladder Minor Endo Px w/o cc 89.15428 87.56 Hgh Sig
F98 Chemo w a Digestive Sys PDx 61.77682 83.86 Low Sig
B02 Phako Cataract Extract w Lens Implant 71.92777 85.13 Low Sig
F06 Oesophagus - Diagnostic Pxs 88.84755 95.13 Low Sig
S01 Haematol Disord w Minor Px 78.06635 86.21 Low Sig
J37 Minor Skin Pxs - Cat 1 w/o cc 81.00065 82.57 Low Sig
A07 Intermediate Pain Pxs 85.71877 93.62 Low Sig
M06 Upper Genital Tract Inter Pxs 62.60041 74.63 Low Sig
M10 Surg Termination of Pregnancy 91.53741 90.71 Hgh Sig
S22 Planned Pxs Not Carried Out 37.4775 53.3 Low Sig
C24 Mouth/Throat Pxs - Cat 3 4.763131 26.32 Low Sig
E14 Cardiac Catheterisation w/o Complicat 57.29514 63.08 Low Sig
J98 Chemo w a Skin Breast/Burn PDx 49.32768 90.84 Low Sig
F35 Large Intestine - Endo/Inter Pxs 85.84848 93.91 Low Sig
F16 Stom/Duod - Diagnos Pxs 90.11942 96.08 Low Sig
S98 Chemo w a Haem Inf Dis Poison /Non-spec PDx 67.77574 79.73 Low Sig
E15 Percutan Translum Coronary Angioplasty (PTCA) 0.147686 1.97 Low Sig
H26 Inf Spne Joint/Conn Tiss Disrd <70 or w/o cc 74.88877 33.11 Hgh Sig
M98 Chemo w a Fem Reprod Sys PDx 25.61454 72.07 Low Sig
B05 Other Ophthalmic Pxs - Cat 2 87.26762 90.41 Low Sig
E04 Coronary Bypass 0 0.17 Low Sig
D17 Cystic Fibrosis 4.549874 22.67 Low Sig
M07 Upper Genital Tract Maj Pxs 4.336554 1.62 Hgh Sig
A number of important provisos
ICPs are not immutable documents setting out inviolable treatment regimens.
The existence of a pathway does not obviate clinicians’ responsibility to make clinical judgements and to tailor care according to their assessment of the clinical needs of individual patients.
Thus clinical variation remains a ‘to be expected’ (in the sense of an often required) feature of clinical practice.
The matter at issue is what a clinical team can learn from these variations and how they can systematize this learning.
Accordingly, when the care process varies from that described in the pathway, the reasons for the variance are recorded and become the focus of structured across-profession conversations described above.
Benefits of Pathways
Pathways central to:
Clinical work systemisation - improved quality, patient experience and efficiency
Across sector/profession communication
Across time and location benchmarking
Moving clinical governance from issues management to a clinical improvement
Integrating the reform agenda
Clinical systematisation – does it work?
-60
-40
-20
0
20
40
60
-8 -6 -4 -2 0 2 4 6
STRINGENT BUDGETMANAGEMENT ORIENTATION
SOMEPROPENSITYTO WORKPROCESSCONTROL
FORGIVING BUDGET MANAGEMENT ORIENTATION
MINIMALPROPENSITY TO WORK PROCESS CONTROL
Good quality
Variable to poor quality
5
61
2
11
3
12
8
4
7
9 10
Degeling et al 2000
Across profession communication
Cultural orientations of professions
MC
MM
LM
NM
NC
-1.5
-1
-0.5
0
0.5
1
1.5
-1.5 -1 -0.5 0 0.5 1 1.5
All Hospitals
SYSTEMATISED CONCEPTS OF CLINICAL WORK
INDIVIDUALISTIC CONCEPTS OFCLINICAL WORK
Clinical Purism and Opaque Accountability
Financial realism and transparent accountability
The across country (across time) resilience of professional sub-cultures
-1.7
-1.2
-0.7
-0.2
0.3
0.8
1.3
-1.5 -1 -0.5 0 0.5 1 1.5
Australia
England
New Zealand
Wales
MC
MM
LM
NM
NC
Z
SYSTEMATISED CONCEPTS OF
CLINICAL WORK
INDIVIDUALISTIC CONCEPTS OFCLINICAL WORK
Clinical purism and opaque accountability
Financial Realism and transparent accountability
Pathways as mediums for enacting culture change
Clinical/Resource
interconnections
Clinical work systemisation
Shared multidisciplinar
y power
Transparent Accountability
CLINICAL PATHWAY
BASED MANAGEMENT
SYSTEMS
Across sector communication
Acute Care Trusts PCTs General Practice
1 Financial viability Financial viability Quality
2 Quality Equal access Equal access
3Organisational
stabilityOrganisational
stabilityOrganisational
stability
4 Productivity Quality Staff welfare
5 Equal access Staff welfare Financial viability
6 Service innovation Service innovation Productivity
7 Staff welfare Productivity Service innovation
8 Teaching and research
Teaching and research
Teaching and research
Organisational goals ranked across Sectors
Professional SubculturesAcute MC MM GM NM NC AHM AHC
Clinical/ Resource interconnections - + + + +/- + -
Transparent accountability - +/- + + +/- + -
Work systematisation - - +/- +/- +/- +/- -
Multidisciplinary teams - - +/- + + + -
PCT Lead GM NM NC GP PN PM
Clinical/Resource interconnections +/- + + +/- - +/- -
Transparent accountability +/- + + + - - +/-
Work systematisation +/- + + + - +/- +/-
Multidisciplinary teams +/- +/- + + - - +/-
Cultural stances of Professions in hospital and
primary care settings Financial realism and transparent
accountability
Emphasis on clinical purism and opaque accountability
-1.5
-1
-0.5
0
0.5
1
1.5
-1.5 -1 -0.5 0 0.5 1 1.5 2
Acute Care Trusts
Primary Care Trusts
Acute NM
Acute AHM
Acute GMAcute MM
Acute MC
Acute AHC
Acute NC
PCT NM
PCT NC
LC
GP
PCT GM
PN
Individualistic concepts of clinical work
Systematised concepts of clinical
work
Consequences of absence of method for across sector communication
High Volume Emergency Admissions – Repeated AdmHRG HRG label % Adm % B Days
D20 Chron Obstruct Pulmonary Dis/Bronch 37.22 39.16
S16 Poison Toxic Effects /Overdoses 18.25 17.62
P06 Minor Infections (incl Immune Disord) 5.41 7.73
E36 Chest Pain <70 w/o cc 7.47 7.81
D21 Asthma >49 or w cc 1.44 1.41
F47 Gen Abdom Disord <70 w/o cc 4.84 7.85
E33 Angina >69 or w cc 18.11 18.73
H42 Sprains Strains /Minr Open Wounds <70 w/o cc 1.43 1.11
L09 Kidney/Urin Tract Infections >69 or wcc 3.77 2.92
D99 Comp Eld w a Respiratory Sys PDx 6.54 5.81
E18 Heart Fail/Shock >69 or wcc 6.67 5.38
E29 Arrhythmia/Conduction Disord >69 or wcc 4.68 3.37
P13 Other Gastro/Metabol Disord 9.16 15.09
E31 Syncope/Collapse >69 or wcc 2.87 3.31
F46 Gen Abdom Disord >69 or wcc 5.78 4.44
E12 Acute Myocardial Infarction w/o cc 0.66 0.37
P03 Upper Respiratory Tract Disord 5.73 9.07
E35 Chest Pain >69 or w cc 7.26 6.99
P15 Accidental Injury 1.68 1.38
P04 Lower Respiratory Tract Disord 11.37 21.33
E34 Angina <70 w/o cc 13.65 17.11
F17 Stom/Duod Disord >69 or wcc 2.22 2.17
A22 Non-Transient Stroke/CVA >69 or wcc 0.10 0.12
D13 Lobar Atyp/Viral Pneumon >69 or wcc 2.13 2.33
GP Practice Variation – Percentage of Additional Patients with COPD and Asthma by Angina within each Practice
Scatter graph of Percentage of Excess Repeated Episodes COPD & Asthma > 49 w cc by Angina > 69 w cc & Angina < 70 w/o cc
0
10
20
30
40
50
60
70
80
90
0 10 20 30 40 50 60 70 80 90 100
D20 + D21
E33 +
E34
GP Practice
Some thoughts on chronic disease
Application ‘year of care’ concept to long-term conditions
Chronic Disease Progression
Time
Wellness
Stage 1: Self Management
Stage 2: Care Management
Stage 3: Case Management
0
Issues
Can we affect the rate of disease progression? Yes
Who is best placed to do this? Primary Care
What do we require to bring it off? ‘Year of care pathway’
Requires …
Year of care pathways that, for each stage of disease progression (stage 1,2, 3 …),
describe the composite of ‘care activities’ That will be undertaken by both patients and service
providers in the period of a year
Year of care pathways are:
Written statements that,
for nominated conditions and specified stage of progression within a condition
describes the sequence of diagnostic and therapeutic events that will be performed by patients and care providers (often in
different service settings) whose occurrence or non occurrence will significantly affect,
quality, outcomes and cost
For example year of care pathways for patients with: Stage 1 Diabetes or Stage 3 COPD or Stage 2 CHD.
Components of a ‘Year of Care’
Clinical management Diagnostic/Monitoring Drugs Therapy
Patient self-management Empowered patient Patients as co-producer Patient as choice maker
Support Component
Co-producing Patients…
Are patients who take responsibility for managing their condition with respect to:
Knowledge of their disease Self monitoring Therapeutic interventions Diet Exercise Smoking
Paradoxically: this requires structured support from service providers
Potential percentage bed day savings for HRGs with significant repeated admission
ratesPotential Percentage Savings in Bed Days in each of the high volume HRGs with significant repeated
admission rates
0,00
5,00
10,00
15,00
20,00
25,00
30,00
35,00
40,00
45,00
D20 S16 E33 P04 E34 P13 M09 F47 E36 E35 D99 E30 F46 E29 L09 D21
HRG
Per
cen
tag
e
Clinical government benefits of pathways
From issues to clinical performance management
Conventional model of clinical governance
Risk
managem
ent
Clin
ical A
udit
Clin
ical
Eff
ectiv
en
ess
Quality
A
ssura
nce
Rese
arch
D
evelo
pm
ent
Clinical Governance Committee
TRUST
Sta
ff
Clinical Production Focused Model – Acute settings
Each condition/treatment specific report includes data on evidence, cost outcomes, clinical effectiveness, quality, safety, adverse events, variance, complaints/claims
TRUST/MANAGEMENT BOARD/CEO
ORTHOPAEDICS UNIT
Hip Replacement Type 1 Facture Type 1 Fracture Type 2Knee
ReplacementType 1
Hip Replacement Type 2
Clinical Governance Council
Clinical Production Focused Structure – PCT settings
Each condition/treatment specific report includes data on evidence, cost outcomes, clinical effectiveness, quality, safety, adverse events, variance,
complaints/claims
TRUST/MANAGEMENT BOARD
CLINICAL GOVERNANCE COUNCIL(PEC GROUP)
Year of care for Diabetes
Year of care for COPD
Year of care for CHD
Year of care for Self harm
patients
Year of care for Asthma
Pathways as mediums for integrating the modernisation agenda
Instead of silos…
CHOICE
COMMISSION
CLINGOV
INFO
TECH
PERFORMANCE
CAP
RENEWAL
INTEGRATION
WORKFORCE DEVT
An Integrated Agenda
Patient Choice
Service Integratio
n
Workforce Developm
ent
Clinical Pathway Focused
Management Systems
Capital Renewal
Commissioning
Clinical Governance
& Performanc
e Managemen
t
Information
Technology
So what are we waiting for?