Using a trusted change management model to establish standardized, evidence-based care across the continuum
by Leigh A. Resnick, M.H.A., R.R.T.
Healthcare spending was estimated to top $2.8 trillion in the United States1
in 2013, according to U.S.
News and World Report. Increased spending occurs due to multiple factors, namely variation in care.
Cost drivers include overtreatment (or defensive medicine), advances in technology and individuals
living longer with chronic diseases. In inpatient settings, care variation leads to adverse health outcomes
and longer hospital stays.
Creating and implementing clinical pathways is an effective way to curb healthcare spending.
Clinical pathways are structured, multidisciplinary plans of care surrounding an intervention. The
pathway provides an evidence-based and detailed step-by-step treatment course arranged in an
algorithm, guideline or protocol, which is accompanied by a timeframe or criteria-based progression.2
The concept of reducing variation through standardization was first demonstrated in the engineering
field as early as 1950. It was later adopted by healthcare in the 1980s.3
A study of six health organizations in Italy showed pathway use resulted in reduced variation in
aspects such as length of stay, testing and therapeutic prescriptions.4
This study also found that patients suffering from heart failure showed decreased mortality and reduced outcome variation when treated using pathways. After implementing the care pathway, health outcomes for left ventricular assessment, a clinical core process, increased from 40% of patients receiving the assessment to 100%.5
Total inpatient mortality decreased from more than 17% to less than 5%, with the same effect observed in readmissions rates. Before the use of the pathways, readmissions occurred for about 7% of patients.
Post-intervention, this decreased to less than 3%.
Although pathways are not a new concept, there remains a wide bandwidth of provider
acceptance. In Liverpool, England, two reports were published focusing on provider perception of
clinical pathways. These reports focused on the Liverpool Care Pathway (LCP), which were used
throughout the United Kingdom and developed to enhance end-of-life treatment with the goal of
allowing patients to die with dignity.6
This care pathway was developed in the 1990s as concerns grew within the U.K. medical community that end-of-life care was fragmented and not provided consistently throughout the nation, resulting in patients who were not being treated according to best hospice practices.7
Patients may have spent their final days suffering from pain, hunger and possibly
dehydration. The controversy over LCP arose from reports stating patients were placed on the pathway
without their or their family’s knowledge. The reports also alleged that other patients may have been
enrolled too soon (imminent death was not near).8
Published studies validated the effectiveness of the LCP as a standard to treat patients. Issues
regarding the perception of its use remained, however. Relatives and clinicians were unaware their
family member or patient remained on the pathway for weeks without review or reevaluation of care,
according to Mark Pickering, M.D.9
The reports implanted fear in the general public about end-of-life care using the LCP. Physicians were less likely to place their patients on the LCP in light of public
concern.
Cookbook medicine?
Aside from concerns over how patients are treated once a pathway is initiated, some medical providers
feel that standardization leads to “cookbook” medicine or medical care that is prescriptive and restricts
creativity, intuition and clinical judgment. Although some physicians feel standardization will stifle
innovation, the optimal way to treat patients is through standardized care models, according to an
article published in Modern Healthcare.10 Kedar Mate, M.D., vice president of the Institute for
Healthcare Improvement, stated that standardizing parts, processes and individual roles results in a
reduction of errors and patient harm.11
Creating pathways involves the collaboration of individuals from diverse backgrounds, such as
physicians, nurses, case managers, pharmacists and others. The tactical development of pathways must
be supported through a change management model that ensures successful development,
implementation and sustainability of pathways. Understanding why transformation efforts fail improves
the likelihood of developing a successful pathway. John Kotter, professor at the Harvard Business School
and head of research at Kotter International, identifies eight reasons why transformation efforts fail in
Table 1.12
This systematic change management approach addresses the common reasons initiatives fail
and ensures diverse groups can meet goals and deliver high-quality outcomes with limited resistance.
When starting any initiative, there first must be a sense of urgency—a reason that suggests the status
quo is more dangerous than the unknown. Along with urgency comes a guiding coalition of like-minded
individuals that can be leveraged to initiate momentum away from the current state. Having a clear and
communicable vision provides an end point or destination for individuals. During the implementation or
change journey, several barriers and obstacles may arise. Frustration occurs when these roadblocks are
not removed. Leadership must be willing and committed to resolve them as they occur. Generating short-term wins injects bursts of energy in teams, rewarding quick turnarounds and small gains amidst a
larger effort.
Changing the culture
Although short-term wins are important to maintain momentum, it is critical not to declare victory too
soon. Progress must be celebrated, but teams must focus on the end goal. Lastly, sustainability occurs
when changes are hardwired into an organization’s culture. The future state resembles the initial vision,
and individuals incorporate the implemented changes in their daily responsibilities.
Although data supports the use of clinical pathways, medical providers may remain resistant to
adopt this approach. To position a pathway effort for success, a systematic change management model
should be applied. As discussed, Kotter’s model provides a framework for shaping, communicating,
executing and hardwiring change. This model can be adapted for the effective creation and
implementation of clinical pathways.
http://rube.asq.org/health/2014/09/change-management/paving-clinical-pathways.pdf?utm_content=&utm_source=email&utm_medium=email&utm_campaign=editorial_hcu_092514
