Archive November 2000 I, No. 11

How to Develop Clinical Pathways

Alex Macario, MD, MBA


A few years ago, we realized that we had significant financial problems with one of the most frequently performed procedures in our hospital. Performing knee replacement surgery was costing us $21,709 per procedure, significantly more than the average reimbursement for the procedure. To help solve the problem, our hospital managers decided to develop clinical pathways, which is a nice way of saying we standardized and developed guidelines for some of our surgical procedures. It took some doing, but after we got our surgeons and staff on board, hammered out the processes, and took steps to make sure they were followed, we realized substantial costs savings.

If you have some "problem" procedures in your facility-procedures that are too costly or take too long, or you feel you may be able to improve the quality of your care-clinical pathways may work for you, too. In this article, I'll describe the eight steps you can take to establish clinical pathways in your facility. Please note that even though our clinical pathways were for inpatient surgical procedures, the same steps apply to outpatient cases as well.

1. Identify a problem that would have significant impact on finances or patient outcomes if it were improved.
Developing clinical pathways requires investment of time and resources. I recommend doing this only when there is an excellent chance for a good return on your efforts. For example, if you are doing a significant volume of procedures that are losing money, expending the effort to develop a clinical pathway would be reasonable step. Alternatively, if you're doing a large volume of knee arthroscopies and want to increase clinical quality, a clinical pathway may be helpful. At least at first, focus only on your highest volume cases. Otherwise, the impact of implementing the pathway will not outweigh the cost of developing it.

2. Gather Data.
Before proposing the idea of a pathway to your surgeons and staff, get your facts straight. Collect germane data about your current practices, such as average time per case, average cost per case and complication rates. Assemble the data in easy-to-understand graphs and charts to help you clearly communicate the issues to the other team members. This can consume a lot of time; one way to make it easier may be to borrow templates from other facilities that have implemented clinical pathways.

3. Plan to develop the pathway from the ground up.
You must involve everyone who plays a part in the surgical process from the very beginning. Otherwise, you will not succeed. Organize a meeting that includes surgeons, anesthesiologists, nurses and staff. Explain the problem as you see it and then propose your solution. Use all the facts at your disposal to show how the pathway could improve the bottom line of the facility and/or the quality of care. Expect some resistance. Do not get discouraged.

4. Be specific.
When you get down to writing the pathway, define every step, from pre-op care to discharge requirements, in as much detail as you can; don't leave room for interpretation. For example, our pathway for knee replacement surgery defines, in short, clear sentences, the following items:

  • what pre-op lab tests are needed;

  • antibiotic choices;

  • the exact number of autologous blood units that each patient shall receive;

  • recommended times for OR setup, procedure time, OR turnover time, and PACU stay; and,

  • the exact types and numbers of instruments that make up a total knee surgical pack.

Be aware that it will take a significant amount of time to define every step and agree on the best approach-our knee replacement pathway took us almost a year to complete.

Also, be sure to allow for clinical flexibility in the guidelines. Surgeons and staff need to be able to circumvent the pathway relatively easily if there are unforeseen or unusual circumstances during a case. After the pathway is finished and approved, make sure you print it up and distribute it to everyone on the surgical team.

5. Use point of service reminders to increase adherence to the pathway.
Don't let the final document lie forgotten in a drawer somewhere-provide constant reminders and references to it throughout your facility until the guidelines become second nature. For example, to reinforce your pharmaceutical guidelines, post a sign at the point where drugs are supplied. If guidelines exist for pulmonary artery (PA) catheters, the anesthesia technician can remind the physician about the guideline, or attach it to the PA catheter package. When a patient is scheduled for a surgery defined by a clinical pathway, attach a reminder to the patient's chart to remind your team that this is a "pathway patient."

6. Measure the effect of the pathway on outcomes, cost, and patient satisfaction.
This is essential to evaluate the impact of the pathway and also to provide positive feedback. Immediately after you implement the pathway, start collecting current practice data. No more than a month after you've put the pathway in place, analyze your data to see what impact the pathway has had, and make the results available to your staff.

7. Provide incentives.
We circulate a newsletter to our OR staff to inform them of the changes that the pathway has brought about and thank them for a job well done. It's important to let people know that they are appreciated, and the recognition provides them with an incentive to incorporate the pathway into their daily routines.

8. Monitor compliance.
Keep a log of every clinical pathway case; monitor how often your surgical teams deviate from the clinical pathway and review repeated instances. If your surgeons and staff are constantly ignoring or deviating from the guidelines, this may mean that you have to change the basic pathway itself to better reflect actual practices. Encourage and provide a mechanism for getting feedback on how the pathway is working; remember that it will probably never be "done;" rather, the process will always be evolving.

Our clinical pathway for knee replacement surgery saved us approximately $3,000 per case and decreased our average hospital stay by one day. Encouraged by its success, we've developed other pathways for CABG surgery and intracranial aneurysm surgery, and we have seen similar successes. It may take a lot of time and effort, but we believe that the benefits of implementing clinical pathways are worth the investment.


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