13 NBNS1214 T9 PDF

Topic  Clinical
Analysis
9 Pathways
By the end of this topic, you should be able to do the following:

1. Explain clinical pathways.
2. Express how clinical pathways are used in a patient care plan.
3. Describe the causes of „variances‰.
4. Identify the benefits of clinical pathways to patients,
clinicians/practitioners, and healthcare managers.
Did you know that for you to understand the nursing process, it requires
you to think about its use in the context of todayÊs changing world? One of the
ways is to use clinical pathways which can give you a big picture of factors
influencing the use of nursing process today. It is one of the clinical approaches
to health care delivery today which is also known as critical paths, critical
pathways, or care maps (Wilkinson, 2000).
Clinical pathways can be viewed as algorithms in as much as they offer a flow

chart format of the decisions to be made and the care to be provided for a
given patient or patient group for a given condition in a step-wise sequence.
This approach of clinical management aims to improve, in particular, the
continuity and coordination of care across different disciplines and sectors.
Copyright © Open University Malaysia (OUM)

240  TOPIC 9 CLINICAL ANALYSIS PATHWAYS
Let us learn more on clinical pathways in the following subtopics. As you go

through this last topic, hopefully you have gained a lot from this exciting module.
Enjoy this last topic!
9.1 CLINICAL PATHWAYS, CRITICAL PATHS,

CRITICAL PATHWAYS, OR CAREMAPS
How do you define clinical pathways? Generally, this is how we define them.
Clinical pathways are printed guidelines to usual care provided for patients
having certain procedures done or having certain illnesses.
These are standard multidisciplinary plans used to predict and determine care
for specific problems, which are refined and improved. Treatment and outcome
data are tracked and there are more evidence-based protocols. For example,
if you have hypertension, you will be likely to receive specific anti-hypertensive
drugs proven to be effective from the human and cost perspectives.
Did you know that clinical pathways were introduced in the early 1990s in
the UK and the US? Now, they are being increasingly used throughout the
developed world. It is usually developed for specific diagnosis with the
collaboration of members of the healthcare team. It is outcome driven and
provides a timeline to achieve specified goals. For example, for a patient
undergoing appendicectomy, parts of the clinical pathway are shown in Table 9.1.
Table 9.1: The Clinical Pathway for a Patient Undergoing Appendicectomy
Aspect Post-Operative Day 1 Post-Operative Day 2
Outcomes Will verbalise pain to nurse. Will verbalise pain to nurse.
Will state pain is <5 on a 1–10 Will state pain is <2 on a 1–10
scale. scale.
Interventions Patient-controlled analgesia as Paracetamol 500mg orally as

per set. needed not exceeding four doses
in 24 hours.

TOPIC 9 CLINICAL ANALYSIS PATHWAYS  241
The four main components of clinical pathways are as follows (Hill, 1994;
Hill, 1998):
• A timeline.
• The categories of care or activities and their interventions.
• Intermediate and long-term outcome criteria.
• The variance record (to allow deviations to be documented and analysed).
Why do we use clinical pathways? Clinical pathways are used to describe

and implement clinical standards. They help to provide quality and efficient
patient care.
How are clinical pathways implemented? The implementation starts with

the physician. He orders clinical pathways for appropriate patients. The clinical
pathway documents are part of the patientÊs permanent record and are
integrated into the clinical documentation.
In order to form a care pathway, the first step is to identify the members of
the multidisciplinary team that are to be involved (Kitchiner, 1996). This includes
all the providers of care; nurses, medical and allied staff involved in the
treatment of a particular patient group. It is often a surprise to discover how
many different individuals are involved in the treatment of a particular
patient group. If professionals do not work in a coordinated way, it is likely
that the results of treatment will be variable. It is also important to remember
that patients and their carers are part of the team too and efforts need to be
made to incorporate them into it.
Once the team has been identified, its members need to discuss the existing
patient journey and map it out (Wigfield, 1996). The process needs to be followed
through from GP referral, clinic attendance, in-patient treatment, discharge
from hospital, and then aftercare. Storyboards may help to visualise this journey.
The range of delays at all stages of the pathway should be recorded to identify
areas where change would have the most effect. PatientsÊ views on when they feel
least supported and informed and most vulnerable should be used to support
these interventions. „We initially used and continue to use input from individual
patientsÊ comments, gathered from talking to patient support groups, and via
community health council reports‰ (Wigfield, 1996).

Important Notes
Clinical pathways are also called interdisciplinary plan, multidisciplinary

plan, collaborative plan, critical plan, and action plan outlines, by time.
The crucial assessments and interventions must be performed by nurses,

physicians, and other health team members.
The daily (or even hourly) patient outcomes are necessary in order to achieve
discharge goals within the defined length of stay.
As mentioned earlier, most clinical pathways are developed for medical or

surgical diagnosis, conditions, or procedures (such as tests, treatments). Thus,
they tend to emphasise biomedical problems and interventions. They are useful in
cases that occur frequently in the organisation or that have relatively predictable
outcomes.
Keep in mind that a different clinical pathway is created for each case type.
For example, myocardial infarction, appendicectomy, and so on. It addresses the
needs of all patients with a certain common condition. It does not consider a
patientÊs unique needs; this must be addressed by an individualised nursing
care plan, sometimes through „variances‰. So, what does a variance occur?
A variance occurs when an outcome is not met in the specified time or an

intervention is not performed at the specified time. For example, if the clinical
pathway states „by the second day after surgery, the patient will be out of bed
in a chair three times a day‰ but the patient is not well enough to be out of bed
three times a day due to wound breakdown, you have identified a care variance.
What would you do if you identified a care variance? Care variances should
trigger you to perform additional assessment to determine whether the delay
is justified or whether actions need to be taken to improve the likelihood of
achieving the outcome.

Remember, you will have to compare your patientÊs actual situation to the
clinical pathway for safe and effective nursing care.
Important Notes
When using clinical pathways, never assume your patient is ready to progress
as planned; look for care variances.
What is the format of clinical pathways? Let us look at the format.
Format
It is organised with a column (sometimes page) for each day
of hospitalisation. There are as many columns (or pages)
on the plan as the pre-set number of days allowed for the
patientÊs diagnostic-related group (DRG).
Here is an example of one clinical pathway (see Figure 9.1).

Figure 9.1: An Example of Clinical Pathway

ACTIVITY 9.1
1. Plot down what you think nurses can do to prevent care variances
in clinical pathways.
2. How are you going to explain to your client if a variance has

occurred in his care plan?
Discuss the answers in the myINSPIRE forum.
9.1.1 Advantages and Disadvantages

What are the advantages of clinical pathways? Do you have any idea? Clinical
pathways can result in cost savings, increased patient satisfaction and the
communication that occurs in creating them as they tend to enhance collaborative
practice.
How about the disadvantages? Unfortunately, they are time consuming to

develop and may jeopardise individualised care as the focus is usually more
medical than holistic. The need to achieve outcomes within rigidly specified
time frames may create the danger of focusing on efficiency more than quality
of care.
9.1.2 The Benefits of Clinical Pathways

Clinical pathways have given many benefits to patients, clinicians/practitioners,
and healthcare managers as stated as follows:
• Benefits to Patients
− Improved organisation and continuity of care.
− Avoidance of duplication of effort.
− Involvement of the patient in the planning of care.
− Use of evidence-based, locally-agreed best practice.
− Provision of integrated services from more than one organisation.

− Provision of a „manager‰ to monitor and record progress against a

care pathway or plan.
− Receipt of a printed or electronic copy of own care pathway or plan.
• Benefits to Clinicians/Practitioners
− Availability of patientÊs record on-line for viewing.
− Capture of clinical terminology and codes to improve quality, and aid

subsequent analysis.
− Availability of the most up-to-date guidelines and best practice.
− Ability to feed into the development process to provide continual

improvement.
− Ability to monitor progress along a care pathway.
− Ability to measure deviance from a care pathway with reasons for that
deviance.
− Ability to integrate local and national standards.
− Ability to document by exception.
• Benefits to Healthcare Managers
− Improved ability to plan and measure the use of personnel and resources.
− Ability to measure the difference between planned and actual care.
− Delivery of more standardised care, linked to protocols and treatment

plans.
− Redesign of healthcare delivery is made possible, thereby avoiding

safety and quality risks posed by existing outmoded ways of working.
− Ability to continually improve care pathways.
− Ability to document by exception.

Important Notes
Its advantages are, it is outcome driven with a timeline to achieve specified

goals. It also provides opportunities for healthcare worker to collaborate
and establish dynamic plans that consider the patientÊs needs. They are
developed for medical or surgical diagnosis, conditions, or procedures (for
example, tests, treatments) and tend to emphasise biomedical problems and
interventions. They are useful in cases that occur frequently in the organisation
or that have relatively predictable outcomes.
However, they are time consuming to develop and individualised care may be
lost as the focus is usually more medical than holistic. The need to achieve
outcomes within rigidly specified time frames may create the danger of
focusing on efficiency more than quality of care.
SELF-CHECK 9.1
1. State the advantage and disadvantage of clinical pathways.
2. Create a table which describes the benefits of clinical pathways

to patients, clinicians/practitioners, and health managers.
• Clinical pathways are recognised as essential tools for case management.

Clinical pathways are used by case managers to plan, assess, implement,
and evaluate care. Variance analysis of the clinical pathway is used to evaluate
the pathway.
• Clinical pathways explicate the common trajectory for a homogeneous group

of patients, and variance analysis indicates when and how patients differ
from this clinical trajectory.
• Many synonyms exist for the term clinical pathways including critical paths,
critical pathways, care maps, interdisciplinary plan, multidisciplinary plan,
collaborative plan, critical plan, and action plan outlines.

• Clinical pathways differ from practice guidelines, protocols, and algorithms

as they are utilised by a multidisciplinary team and have a focus on the
quality and co-ordination of care.
• There are a lot of benefits of clinical pathways. These benefits are different
between patients, clinicians/practitioners, and healthcare managers. Some of
them are:
‒ Patients: Improved organisation and continuity care.
‒ Clinicians/practitioners: Ability to document by exception.
‒ Healthcare managers: Ability to continually improve care pathways.
Appendicectomy – The surgical removal of the appendix.
Clinical pathways – Printed guidelines to usual care provided

for patients having certain procedures
done or having certain illnesses.
Critical pathways – Tools for case management used by

managers.
Myocardial infarction – An occlusion or blockage of arteries

supplying the muscles of the heart,
resulting in injury or necrosis of the
heart muscle (heart attack).
Patient-controlled analgesia (PCA) – A method of pain relief in which the

patient controls the amount of pain
medicine that is used. When pain relief
is needed, the person can receive a
pre-set dose of pain medicine by pressing
a button on a computerised pump that
is connected to a small tube in the body.

1. Discuss the advantages and disadvantages of using clinical pathways in

nursing practice.
2. What should you and your team do if variances occur?
Question 1
What are the goals of utilising clinical pathways?
Answer 1
When critical pathways are used to plan medical care, the specific goals usually
include the following:
• Selecting a „best practice‰ when practice styles vary unnecessarily.
• Defining standards for the expected duration of hospital stay and for the
use of tests and treatments.
• Examining the interrelations among the different steps in the care process
to find ways to coordinate or decrease the time spent in the rate-limiting steps.
• Giving all hospital staff a common „game plan‰ from which to view and
understand their various roles in the overall care process.
• Providing a framework for collecting data on the care process so that providers
can learn how often and why patients do not follow an expected course during
their hospitalisation.
• Decreasing nursing and physician documentation burdens.
• Improving patient satisfaction with care by educating patients and their

families about the plan of care and involving them more fully in its
implementation.

Question 2
How do I develop a new clinical pathway?
Answer 2
Before developing a clinical pathway, it is necessary to determine if this patient
group is suitable. Patient groups which suit the clinical pathway model are those
patients who follow a predictable course.
• Determine If It Is Appropriate
− The most important issue, when determining if a particular patient group

is suited to pathway implementation is that there is some form of
pattern to their episode(s) of care, and that there is a well-defined patient
population.
− In surgical cases, this may mean that the patients have their surgical
procedure, then stay for a particular number of days.
− For a medical case, this may mean that they follow particular phases in
their recovery, or the management changes at distinct points. It is not
necessary to restrict the time over which the path lasts, or restrict it to
one inpatient stay.
− Pathway methodology can also be used for patients in the community,

rehabilitation, or palliation.
• Speak with Your Unit Manager/Department Manager
− Ensuring that you have support from you unit manager is an important
step. You may need some time away from the ward area to spend
developing the path, which the unit manager may be able to provide.
− This could also be a good time to speak with the doctors or surgeons
involved and any other allied health members who will have a significant
input into the path.
• Contact the Clinical Path Coordinator

Speak with the care coordination manager so that they can meet with you
and discuss each of the steps involved. The care coordination manager
should be able to provide you with all the support you need to help you
through the process.

• Follow the Clinical Path Development/Review Plan
− This will provide you with a list of all the steps involved, with provision
for setting dates, which can be very important to stay on track. There is
also a guide for the review of histories in the development of paths.
− The plan must be discussed with the care coordination manager before
any work commences.
Question 3
What are the general benefits of clinical pathways?
Answer 3
• Supports the introduction of evidence-based medicine and use of clinical

guidelines.
• Supports clinical effectiveness, risk management, and clinical audit.
• Improves multidisciplinary communication, teamwork, and care planning.
• Can support continuity and co-ordination of care across different clinical

disciplines and sectors.
• Provide explicit and well-defined standards for care.
• Help reduce variations in patient care (by promoting standardisation).
• Help improve clinical outcomes.
• Help improve and even reduce patient documentation.
• Support training.
• Optimise the management of resources.
• Can help ensure quality of care and provide a means of continuous quality
improvement.
• Support the implementation of continuous clinical audit in clinical practice.
• Support the use of guidelines in clinical practice.

• Help empower patients.
• Help manage clinical risk.
• Help improve communications between different care sectors.
• Disseminate accepted standards of care.
• Provide a baseline for future initiatives.
• Not prescriptive; do not override clinical judgement.
• Expected to help reduce risk.
• Expected to help reduce costs by shortening hospital stays.
Question 4
What are the potential problems and barriers to the introduction of clinical
pathway?
Answer 4
• May appear to discourage personalised care.
• Risk increasing litigation.
• Do not respond well to unexpected changes in a patientÊs condition.
• Suit standard conditions better than unusual or unpredictable ones.
• Require commitment from staff and establishment of an adequate

organisational structure.
• Problems of introduction of new technology.
• May take time to be accepted in the workplace.
• Need to ensure variance and outcomes are properly recorded, audited,

and acted upon.

Question 5
What is the significance of variance tracking and analysis in a clinical pathway
programme?
Answer 5
• Variance has been defined as „any deviation from the proposed standard of
care listed in the pathway‰ (Dalton et al., 2000). According to Zander (2002),
„Variance is the difference between the item stated, within the time period
stated and the actual event.‰
• Reporting of a variance within a pathway is the first step in activating and

implementing an intervention.
• Monitoring of these deviations is a step towards maintaining quality in

health care today in that it can lead to change in practice or change in the
patient pathway.
• If clinical pathways are tools for improving patient outcomes by guiding

care along the best evidence available then variance tracking and analysis
become the tools for ensuring that continuous quality improvements are
attained.
• Use of variance also acknowledges the individuality of the patient.
• Variance recording is an essential part of the documentation involved in

a clinical pathway as it can capture the individuality of the patient,
clinician, or organisation and adds to the flexibility of the document.
• It was stated that a well-designed clinical pathway should capture

60–80 per cent of the patients within a defined group.
• Variances can be positive or negative, and can include patient complications.
• Variance tracking can also provide the database for research and evidence
base for change in practice.

Question 6
When would negative variances occur?
Answer 6
Negative variances can occur when:
• a patient does not meet the predetermined outcome of the pathway, whether
due to their own choice or condition;
• there are delays in meeting expected outcomes;
• any unexpected intervention is needed to move the patient along the pathway;
or
• any planned or expected interventions do not take place.
Question 7
When would positive variances occur?
Answer 7
Positive variances can occur when:
• a patientsÊ progress or recovery is shorter than anticipated;
• an intervention or care component is not required for an individual patient;
• selected interventions or resources (such as pain relief) are unnecessary; and
• an intervention results in the patient being discharged earlier.

Question 8
What are the possible reasons for not conducting variance analysis?
Answer 8
Some of the reasons for not conducting variance analysis may relate to the „issues‰
including:
• resource intensity;
• lack of staff understanding on how to record and use pathways;
• poor pathway uptake and poor documentation recording;
• pathway design which does not allow for variance recording and analysis; and
• the pathways are at a preliminary stage of implementation.
Alfaro-LeFevre, R. (2002). Applying nursing process: Promoting collaborative

care. Lippincott.
Dalton, P., Macintosh, D. J., & Pearson, B. (2000). Variance analysis in clinical
pathways. Journal of Quality of Clinical Practice, 20, 145–149.
Paul, R. (1990). Critical thinking. Sonoma State University.
Polanyi, M. (1966). The tacit dimension. Doubleday & Company.
Wigfield, A., & Boon, E. (1996). Critical care pathway development: The way
forward. British Journal of Nursing, 5(12), 732–735.
Wilkinson, J. M. (2001). Nursing process and critical thinking (3rd ed.). Prentice
Hall.

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Topic  Clinical

By the end of this topic, you should be able to do the following:

Clinical pathways can be viewed as algorithms in as much as they offer a flow

Copyright © Open University Malaysia (OUM)

Let us learn more on clinical pathways in the following subtopics. As you go

9.1 CLINICAL PATHWAYS, CRITICAL PATHS,

Table 9.1: The Clinical Pathway for a Patient Undergoing Appendicectomy

Aspect Post-Operative Day 1 Post-Operative Day 2

Outcomes Will verbalise pain to nurse. Will verbalise pain to nurse.

Interventions Patient-controlled analgesia as Paracetamol 500mg orally as

Copyright © Open University Malaysia (OUM)

• The categories of care or activities and their interventions.

• Intermediate and long-term outcome criteria.

• The variance record (to allow deviations to be documented and analysed).

Why do we use clinical pathways? Clinical pathways are used to describe

How are clinical pathways implemented? The implementation starts with

Copyright © Open University Malaysia (OUM)

Clinical pathways are also called interdisciplinary plan, multidisciplinary

The crucial assessments and interventions must be performed by nurses,

As mentioned earlier, most clinical pathways are developed for medical or

A variance occurs when an outcome is not met in the specified time or an

Copyright © Open University Malaysia (OUM)

What is the format of clinical pathways? Let us look at the format.

Here is an example of one clinical pathway (see Figure 9.1).

Copyright © Open University Malaysia (OUM)

Figure 9.1: An Example of Clinical Pathway

Copyright © Open University Malaysia (OUM)

2. How are you going to explain to your client if a variance has

Discuss the answers in the myINSPIRE forum.

9.1.1 Advantages and Disadvantages

How about the disadvantages? Unfortunately, they are time consuming to

9.1.2 The Benefits of Clinical Pathways

− Improved organisation and continuity of care.

− Avoidance of duplication of effort.

− Involvement of the patient in the planning of care.

− Use of evidence-based, locally-agreed best practice.

− Provision of integrated services from more than one organisation.

Copyright © Open University Malaysia (OUM)

− Provision of a „manager‰ to monitor and record progress against a

− Receipt of a printed or electronic copy of own care pathway or plan.

− Availability of patientÊs record on-line for viewing.

− Capture of clinical terminology and codes to improve quality, and aid

− Availability of the most up-to-date guidelines and best practice.

− Ability to feed into the development process to provide continual

− Ability to monitor progress along a care pathway.

− Ability to integrate local and national standards.

− Ability to document by exception.

• Benefits to Healthcare Managers

− Ability to measure the difference between planned and actual care.

− Delivery of more standardised care, linked to protocols and treatment

− Redesign of healthcare delivery is made possible, thereby avoiding

− Ability to continually improve care pathways.

− Ability to document by exception.

Copyright © Open University Malaysia (OUM)

Its advantages are, it is outcome driven with a timeline to achieve specified

1. State the advantage and disadvantage of clinical pathways.

2. Create a table which describes the benefits of clinical pathways

• Clinical pathways are recognised as essential tools for case management.

• Clinical pathways explicate the common trajectory for a homogeneous group

Copyright © Open University Malaysia (OUM)

• Clinical pathways differ from practice guidelines, protocols, and algorithms

‒ Patients: Improved organisation and continuity care.

‒ Clinicians/practitioners: Ability to document by exception.