care pathways the how and why of clinical management pieter degeling

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?