Clinical pathways are not new, but their prominence has grown in recent years. An increased focus on value-based medical care1 has brought strategies that provide optimal treatment at a favorable cost to the forefront of the medical conversation. Providers, payers, and administrators across the spectrum—from independent private practices to large health care networks—have sought methods to standardize treatment protocols, reduce the reliance on potentially ineffective interventions, and curb wasteful spending.
Christiana Care Health System (Wilmington, DE) has emerged as a leader in the development and implementation of clinical pathway programs in the Mid-Atlantic region. With facilities located throughout Delaware, Christiana Care regularly services patients residing throughout the Tri-State region, including Pennsylvania, New Jersey, and Maryland. Christiana Care operates the only Level I trauma center in Delaware, as well as the state’s only delivering hospital with a Level III neonatal intensive care unit.2
In 2016, Christiana Care introduced nine clinical pathway programs, developed and designed based on up-to-the-minute clinical practice guidelines.3 Subspecialties represented in these pathway programs include acute medicine, which introduced a pathway for the treatment of chronic obstructive pulmonary disease; behavioral health, which designed a pathway to address the growing epidemic of opioid addiction; medical oncology, which standardized procedures for patients with operable stage II non–small cell lung cancer; and primary care, with an educational and interventional program for type 2 diabetes. Later in the year, Christiana Care introduced additional pathway programs, addressing issues ranging from supportive care to suicide prevention.4 The research associated with designing these programs occurred in collaboration with Christiana Care’s Value Institute,5 which is dedicated to improving health care delivery across the medical spectrum, and each pathway’s clinical clinical leadership.
Journal of Clinical Pathways recently spoke with Kenneth L Silverstein, MD, MBA, Christiana Care’s chief clinical officer, and a longtime proponent of value-based medical care. Dr Silverstein described the process by which Christiana Care simultaneously integrated multiple clinical pathways, and offered advice for other hospital administrators considering clinical pathways.
When and how did Christiana Care begin to recognize the importance of clinical pathway programs? How were they implemented?
It is important to remember that clinical pathways are not a new concept. Looking at our website, we found pathways that were published in the 1980s, so it is fair to say that we have been in this business for a while. What we recognized was that we needed to really focus on variation and care delivery. There are times when variation is appropriate, but there are many times when variation is unnecessary and does not promote optimal outcomes. Our primary focus, then, should be on care standardization, which as a field has evolved as evidence has been collected in different areas that support true best practice.
When we first launched the initiative to tackle pathways in a 21st century way, we were very deliberate in introducing language about care standardization methodology and the reduction of unnecessary variation in care. We used our annual operating plan to drive improvement activities, because it includes goals that we set and present to our board of directors. We set as a goal for the fiscal year 2016 that we would launch one clinical pathway for each of our nine service lines. On the surface that might not sound like a lot, we understood that it would take a fair amount of work to achieve this.
I refer to these pathways as “capital P pathways.” This is not your 1985 clinical algorithm, protocol, or guideline. This is something that is intended to be a pathway that truly describes the patient’s journey through an episode of care on many, many levels, so that all providers who interact with a patient on that pathway would know their role and the expectations on them within the care continuum.
Can you talk a little bit about the development process for the pathway programs?
As I said, Christiana Care has nine distinct service lines, ranging from acute medicine to behavior health, cancer, etc. We are a coalescence of our individual departments, so we created a more coordinated view through the service line model. The leadership teams within each service lines were tasked with developing the guidelines, and we let them go off on their own. We felt that the clinical expertise in each subspecialty was strong enough that they could come up not only with what area would be most successful, but how it should be developed. We let that simmer for a bit on its own, and then we pulled everyone together to get a check on where things were going.
The clinical content was locally developed, and once we engaged our organizational excellence and project management teams, we looked to go out and survey whether each service line was in a position to move from the development of pathways to the implementation of pathways. We created a gap analysis between what we thought were the necessary elements of pathway implementation and what each service line had. We added what we affectionately call “the PIT”—for pathway integration team—to determine what elements of implementation needed system-level support to be most effective in each service line. The elements of the PIT are really centered around education and communication, data acquisition and analysis, information technology support, support from health care delivery science research, and project management support. Those were the elements that we thought were critical to be centralized. This culminated in a large retreat people from all the service lines and the PIT came together and figured out what we needed to get these pathways launched. That was a phenomenal learning experience.
Another key component is that we set deadlines during that first year of the roll out, which stretched from July of 2015 to June of 2016. The deadline for the first patient entering into a pathways was January 1, 2016. So, the folks had those first 6 months to do the work of creating design, developing clinical content, connecting with the PIT, and making sure everything would be up and running. In this respect, we were successful, as we began to launch patients into pathways as of January 1.
The nine initial pathway programs address a wide range of diseases and stages, from drug addiction to cancer care. In which areas have you already seen success?
I am going to be bold and say that we are seeing success in all areas, because we have all of these pathways up and running. We are tracking outcomes for all of our pathways, and we are close to having dashboards for all of these areas available regarding key outcomes. The primary success has been getting patients enrolled in the pathways, and every service has shown success doing this.
That said, we have seen dramatic improvements in certain areas. In our surgical pathway, which involved complex ventral hernia repair, the decreases in length of stay have been pronounced. We are also tracking the change in total volume of intravenous fluids administered to those patients. There are clear changes in the implementation of care based on the clinical pathway.
The same is true in our heart and vascular service, for which the clinical pathway is focused on non-ST-segment-elevation myocardial infarction. The time intervals for the blood draws in the setting of a heart attack was greatly improved. In behavior health, the new assessment for opioid addiction is now identifying patients who otherwise might not have been without the implementation of the pathway. Each specialty has had a measure of success, and what we have accomplished in a relatively short period of time is the complete adoption of a culture of care standardization. There is now a full recognition that variability of care is often not appropriate, leads to an unnecessary increase in costs, and promotes potentially less than optimal outcomes. The idea of launching a single pathway was to develop institutional competency, with the ultimate goal that we will think about this in every aspect of care. It was always about getting people to have conversations across disciplines, and about getting people to connect the care of patients as they move through episodes of care.
What advice would you give to another medical officer who was considering implementing pathways?
Pulling in people from across specialties and bringing them into the conversation is essential for designing clinical pathways. Patients rarely have a single disease; there are often multiple things going on with one patient at a given time. The multidisciplinary approach is really supported in the planning and development process, and as an institution, you need to decide what lives locally and what lives centrally. Creating the PIT was critical for us, because the service lines had an intense spirit of ownership around their pathways.
We have also thought a lot about how patients might interpret pathways. We are very careful about how we bring the message of care standardization to patients, and explaining how teamwork is involved in providing care.
The last thing I would tell anyone is that developing and implementing a pathway is not where the journey ends. You have to assure that you are developing operational infrastructure that will sustain pathways, which means measuring key outcomes and rapidly implementing improvements accordingly. In order for pathways to remain sustainable, they cannot be stagnant. There is planning, there is development, there is implementation, and there is sustainment: each one of those phases is equally important.
References
1. Value-based care: better care, better health, lower costs. Aetna website. https://news.aetna.com/2015/01/value-based-care-better-care-better-health-lower-costs/. Accessed February 24, 2017.
2 Christiana Care hospitals & facilities. Christiana Care website. https://christianacare.org/facilities/. Accessed February 24, 2017.
3 Clinical pathways promise to make great care even better. Christiana Care website. https://news.christianacare.org/2016/01/christiana-care-introduces-clinical-pathways/. Published January 26, 2016. Accessed February 24, 2017.
4 Clinical pathways lead to high-value care. Christiana Care website. https://news.christianacare.org/2016/11/clinical-pathways-lead-to-high-value-care/. Published November 4, 2016. Accessed February 24, 2017.
5 Value Institute. Christiana Care website. https://christianacare.org/valueinstitute/. Accessed February 24, 2017.
