Paving Clinical Pathways Using a trusted change management model to establish standardized, evidence-based care across the continuum

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

http://rube.asq.org/health/2014/09/change-management/paving-clinical-pathways.pdf

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. 

References: 

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