Clinical pathways are an effective and efficient approach in standardizing diagnosis, treatment and facilitate clinical decision making. In previous articles, we explored their impact on care quality, how to create hospital-specific customized clinical pathways and shared our thoughts about having a standardized language in order to facilitate their implementation. In the current one, we’ll share some tips on how to conduct a design session with UpHill Health Notation to develop a clinical pathway.

Clinical engagement when developing care pathways

Before moving forward, let’s take some time to reflect on how important it is to involve your team on clinical pathways development process. The answer is clear: successful implementation of care pathways, to a large extent, depends on the involvement and investment of both clinical service providers and managers. [1,2] In other words, engagement of all relevant staff is necessary to ensure proposed aims are achieved, at each stage from pathway adoption, implementation and maintenance.

All in all, as stated by Jeffrey Braithwaite, [3] systems use to reject change when the sole strategy is to mandate solutions from the top down.

Going a bit deeper on this topic, literature points out several barriers which impede clinical engagement and uptake of care pathways. It may occur at the staff level - clinician or management - or healthcare organization level - management, resources, and financial or institutional structures - or even be influenced by external factors. And focusing on clinician-related barriers, researchers distinguish several scenarios:

  • Lack of awareness and familiarity
  • Lack of applicability to certain clinicians
  • Conflicting information among different sets of guidelines
  • Lack of outcome expectancy

Additionally, pathways may be perceived to be externally imposed, may compromise the individual aspect of practice, and may be driven by reasons related to management or cost restriction rather than patient outcome improvement.

So, the very first advice to successfully start this journey: ensure your team is aware of the benefits of clinical pathways and engage them in the whole process.

A practical framework

1) Gather a team

Bearing in mind the previous context, the first step for success is having the right team engaged. But do not worry, to start designing a clinical pathway you will only need two people. Based on our previous experience working side by side with physicians, we found it important to have the help of a colleague and to ask each other questions about each action, decision or chain of elements.

2) Choose your tools

To start representing an algorithm, you need to have the right tools, but there is no need to turn it more complex than it really is. Here are our suggestions:

> Whiteboard or a blank paper

> Post-its

> Marker

Choose a white surface, like a paper or a board. Define the initial moment, represent the actions with post-its and connect them by using a marker. In this way, it will be easier and faster to change actions order whenever necessary and adjust the algorithm.

3) Regulate the time

Actually, there is no time limit to execute an algorithm. However, you should control the process duration from the beginning to the end. This will allow you, along with your team, to be able to identify points that consume more time and need improvements.

4) Register the final result

When finished, it's time to save your final product. Take pictures of the algorithm you built and make sure you don’t lose information.


Conclusion

Successful implementation of care pathways is dependent on the development process. As with any quality improvement intervention which involve changing provider behavior, this is a continuous process.  Engage your team, keep it simple, and count on UpHill to help you in all stages.

References

[1] Evans-Lacko, S., Jarrett, M., McCrone, P. et al. Facilitators and barriers to implementing clinical care pathways. BMC Health Serv Res 10, 182 (2010). https://doi.org/10.1186/1472-6963-10-182

[2] Gosfield AG, Reinertsen JL. Sharing the quality agenda with physicians. Trustee. 2007 Oct;60(9):12-4, 16-7, 1. PMID: 18030910.

[3] Braithwaite Jeffrey. Changing how we think about healthcare improvement BMJ 2018; 361 :k2014