Abstract: For health care organizations, clinical pathways have historically been important tools for translating medical evidence into practice and delivering high-quality, cost-conscious (ie, high-value) care. However, with the ongoing shift toward value-based payment in health care, the pressure to control spending while maintaining or improving quality has arguably never been greater for provider organizations around the United States. Despite existing conceptual frameworks that define pathways, an important gap remains with respect to pathway management, ie, how managers (particularly those new to pathway work) can most effectively lead their teams and manage successful pathway programs. To help address this gap, we merge our collective experience as physician leaders with principles from the theory of value-based management to describe an applied framework that can support the implementation and management of clinical pathway programs aimed at improving value. While it does not represent an approach that must comprehensively apply to all aspects of pathway programs, the framework nonetheless identifies management emphases of 4 key processes that leaders can adopt to create aligned vision, language, and resource allocation approaches for pathway programs: (1) developing evidence-based guidelines; (2) operationalizing guidelines into standard multidisciplinary workflows; (3) characterizing and selecting patient populations; and (4) monitoring and revising pathways. This applied framework can be utilized to derive benefit across different settings, forums, and institutional contexts.
For health care organizations, clinical pathways can be important tools for translating medical evidence into practice and delivering high-quality, cost-conscious (ie, high-value) care. Pathways can reduce unnecessary variation in care, health care costs, and resource utilization.1-4 The need for effective pathways has historically been augmented by financial incentives dating back to the introduction of the diagnosis-related group and other payment approaches that emphasize cost efficiency. With the current shift toward value-based payment, the pressure to control spending while maintaining or improving quality has arguably never been greater for provider organizations around the country.
As physician leaders involved in advancing value-based care delivery, we see these changes as an important opportunity. However, despite existing conceptual frameworks that define pathways5,6 and the processes involved in developing them,7,8 we believe an important “downstream” gap remains with respect to pathway management, ie, how managers can most effectively supervise teams to create a shared vision and execute successful pathway programs. This is particularly true for managers new to such work, for whom a lack of familiarity with pathways and how to contextualize them within organizational culture and initiatives may ultimately create misalignment that undercuts program effectiveness.
Therefore, in this article we describe an applied framework that can support the management of clinical pathway programs aimed at improving value. This framework is a result of our collective experience (based on involvement in pathway programs) and insights from peer organizations (based on discussions about shared goals of utilizing pathways to drive value) merged with principles from existing management theory (value-based management9). The framework emphasizes 4 key components that health systems leaders and managers can utilize to create a harmony of vision, language, and resource allocation approaches for pathway programs.
Framework Development and Management Emphases
We began this process using a widely accepted definition for clinical pathways: structured multidisciplinary plans of care used to translate evidence or guidelines into local structures, with an inventory of actions that standardizes care for a specific population.10 We then leveraged principles from value-based management—a theory that emphasizes the use of governance, change management, organizational culture, and leadership to make strategic and operating decisions to maximize stakeholder value—to translate elements of the definition into 4 cohesive, actionable management emphases (Table 1). We further refined these areas of emphasis by incorporating insight from our own experience, as well as that of colleagues at peer institutions.
Evidence-Based Guidelines
The first emphasis relates to managing the process of identifying or developing evidence-based guidelines. One major challenge related to use of evidence-based guidelines is definitional variation: organizations and teams define guidelines differently, with some equating guidelines to recommendations arising directly from professional societies and others conceiving of guidelines as the end product of primary literature or professional society review and synthesis.
It is for this very reason that management of the process is so important: managers can maximize effectiveness in this aspect of pathway programs by guiding the organizational approach to developing guidelines (qualitatively judged on a scale of resource light to resource intense). Because activities required to create high-value guidelines may include review of primary literature or systematic grading of evidence and local application, organizations with strong expertise will likely possess resources such as medical librarians (to ensure comprehensive literature searches), biostatisticians (to provide rigor to the grading of evidence), engaged clinicians and administrative partners (to evaluate guidelines for local feasibility), and dedicated project managers (to drive the guideline development process at scale across multiple clinical areas).
These organizations are also often able to engage individuals with financial expertise to ensure that the development process retains simultaneous clinical and financial success. In contrast, organizations with lesser degrees of expertise may achieve greater value adopting “off-the-shelf” guidelines from sources such as professional societies and external groups without significant modification or adaptation. Leaders at organizations with moderate expertise could consider intermediate steps, such as synthesis and translation of professional society recommendations into locally-applicable guidelines. To engage clinicians at our institutions, we involve them in the review of primary medical literature and society recommendations to define guidelines for use in pathways.
Translating Guidelines Into Workflows
The second management emphasis in our framework involves operationalizing guidelines into standard workflows. Such workflow integration is a critical step that should not be overlooked by managers because, in our experience, some organizations fail to glean the maximum value from this step in pathway program development as a result of equating standardization with simple dissemination of evidence-based guidelines. As in the process of developing guidelines, managers must determine both specific workflows as well as the degree of resource investment needed to effectively support them.
On one end of the spectrum, managing a lower resource effort could involve coordinating pathway, information technology, and other teams to create electronic medical record order sets. On the other end, management of higher resource activity could involve convening stakeholders to create consensus for workflow changes at multiple points in the arc of care delivery (eg, implementing documentation standards via flowsheets, creating and distributing patient-facing informational materials, and/or developing clinical decision support tools to encourage pathway adherence among affected clinicians). We have explored lower and higher resource efforts at our institutions, applying both to different individual pathways. In general, we have emphasized order sets and elements such as patient-facing materials as core aspects of standard workflows.
Other health systems have combined resources with managerial oversight to create “self-driving” protocols that standardize care by automatically triggering processes by specific care team members. For example, nurses can implement standardized blood glucose and electrolyte testing for a physician-ordered diabetic ketoacidosis protocol without needing the physician to prompt or approve testing. Managers can then close the loop on performance using self-driving protocols to implement improvements.
Stratification of Patients
The third emphasis consists of managing how specific patient populations are characterized and selected. An intuitive and widely used approach is to define populations based on clinical disease states (eg, heart failure exacerbation, pneumonia, severe knee osteoarthritis). However, there may be limitations to exclusively using this approach, especially in cases in which patients have multiple comorbidities.11,12 Other approaches may more fully maximize the value achievable through pathways. For example, patients may be defined based on care setting (eg, preoperative populations, patients in the transition from hospital discharge to post-acute care facilities), encounter type (eg, preventive visit populations), or clinical intervention type (eg, populations receiving central lines or inpatient blood transfusions). In our institutions, we have tested parallel approaches based on disease states and care setting, ultimately allowing flexibility to achieve value in different areas (eg, in some settings, using both disease state and care setting approaches; in other settings, selecting one approach to scale over the other after pilot testing both).
Management focus is important in this component of pathway programs because the paradigm for selecting patient populations also drives stakeholder identification and value propositions. For example, pathways for patients with heart failure could be developed targeting different phases of care: heart failure exacerbation in the emergency department, heart failure treatment in the outpatient setting, transitions from the hospital to post-acute setting, or the insertion of a central line for administration of intravenous inodilators in the intensive care unit.
Updating and Maintaining Pathways
The fourth emphasis within our applied framework centers on pathway monitoring and revision. While pathway success depends heavily on post-implementation engagement from both administrators and front-line clinicians, our experience suggests that organizational management processes for ensuring engagement vary widely. Some institutions distribute accountability for monitoring and revising pathways peripherally to individual clinical units or service lines.
In contrast, other organizations maintain central teams responsible for extracting data, monitoring metrics, providing feedback to clinicians and their administrative partners, and maintaining energy and focus on continuous process improvement. This approach requires more hands-on management of teams comprised of analysts, process improvement consultants, and project managers. While strategies may vary by organizational culture and governance models, we believe, based on our own institutional experience, that most organizations would benefit from some degree of central pathway program management and oversight so that lessons learned from a given pathway can be leveraged to modify processes as early as possible.
Local Applications of the Framework
While our framework does not represent an approach that must comprehensively apply to all aspects of pathway programs, we believe that it can nonetheless be utilized to derive benefit in many settings and forums. In particular, our experience suggests that processes emphasized by our framework can aide managers in creating shared language around evidence-based guidelines, shared vision about how to operationalize guidelines into standard workflows, and unified approaches for supervising teams and resources—important managerial elements that are needed alongside knowledge of pathway definitions to implement successful pathway programs.
That said, leaders and managers can consider each area of emphasis independently, such that different management activities and resource investments in one area need not mirror those in another. For example, a hospital with little available expertise to develop guidelines may maximize value using “off-the-shelf” professional society recommendations while achieving value in population characterization and selection by expending significant energy in defining populations based on both disease state and care phase.
For organizations and managers new to pathways, our framework can support the creation of new pathway programs that align from the start with institutional readiness and capabilities. For organizations with existing experience with pathways, regular assessment of performance in the 4 areas of management emphasis can identify areas for strength or development in pathway programs.
Conclusion
As provider organizations continue in their journey toward value-based payment and care, our applied framework provides one way to couple the goal of managing value in pathways with higher quality and more cost-conscious care.
References
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