Guidelines

as a Strategy / Tool
for Hospital Quality
Service /
Improvement

Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg

Short Course on Total Quality Management
June 23 - 27, 2014
UP Manila College of Public Health
 Pathways
as a Strategy / Tool
for Hospital Quality
Service /
Improvement

Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg

Short Course on Total Quality Management
June 23 - 27, 2014
UP Manila College of Public Health
 Clinical Pathways
as a Strategy / Tool
for Hospital Quality
Service /
Improvement

Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg

Short Course on Total Quality Management
June 23 - 27, 2014
UP Manila College of Public Health
 Guidelines
as a Strategy / Tool
for Hospital Quality
Service /
Improvement

Outline of Contents of Talk:

Definition of Terms
Why the Strategy
How to Go About It (The Tool)
 Guidelines
as a Strategy / Tool
for Hospital Quality
Service /
Improvement

Outline of Contents of Talk:

Definition of Terms
Why the Strategy
How to Go About It (The Tool)
 Practice Guidelines
as a Strategy / Tool for Hospital
Quality Service Improvement
Definition of Terms:
Clinical Practice Guidelines /
Evidence-based Clinical Practice
Guidelines
Clinical Pathways / Care Pathways
Clinical Practice Protocols
Policies and Procedures
Standard Operating Procedures
Citizens Charter
 Column
Headings:

Services
Offered
Steps /
Procedures
Requiremen
ts / Forms
Duration
Fees /
Charges
Persons
Responsible
Location
 Practice Guidelines
as a Strategy and Tool for Hospital
Quality Service Improvement
Citizens Charter
Document setting out standards of
service
Non-medical and medical services
Government institutions
Manuals and posters
Publicized to clients and staff leading to
knowledgeable clients and staff

QUALITY SERVICE /
IMPROVEMENT
 Clinical Practice Guidelines
as a Strategy for Hospital Quality
Service Improvement

Citizens Charter

It aimed to improvepublic servicesin the UK by:

Making administration accountable and citizen friendly.
Ensuring transparency and the right to information.
Taking measures to cleanse and motivate civil service.
Adopting a stakeholder approach.
Saving time of both executant and the clientele.
Easily under stability and quantified works.

*http://en.wikipedia.org/wiki/Citizen's_Charter
 Practice Guidelines
as a Strategy and Tool for Hospital
Quality Service Improvement
Citizens Charter

Clinical Practice
Document setting out standards of /
Guidelines
service Evidence-based
Clinical Practice
Non-medical and medical services
Guidelines
Government institutions Clinical Pathways
/ Care Pathways
Manuals and posters Clinical Practice
Protocols
Publicized to clients and staff leading
Policies and to
knowledgeable clients and staff
Procedures

Standard
QUALITY SERVICE Operating
/
Procedures
IMPROVEMENT
 Practice Guidelines
as a Strategy and Tool for Hospital
Quality Service Improvement
Standard Operating Procedures, Policies
and Procedures, and Practice Protocols
Documents setting out standardization and
standards of practice
Non-medical and medical services
Government and non-government institutions
Manuals and posters
Publicized to clients and staff leading to
knowledgeable clients and staff

QUALITY SERVICE /
IMPROVEMENT
 Practice Guidelines
as a Strategy and Tool for Hospital
Quality Service Improvement
Standard Operating Procedures, Policies
and Procedures, and Practice Protocols
Documents setting out standardization and
standards of practice
Clinical Practice
Non-medical and medical services Guidelines /
Government and non-government Evidence-based
institutions
Clinical Practice
Manuals and posters Guidelines
Publicized to clients and staff leading
Clinicalto
Pathways
knowledgeable clients and staff / Care Pathways
Citizens Charter

QUALITY SERVICE /
IMPROVEMENT
 Practice Guidelines
as a Strategy and Tool for Hospital
Quality Service Improvement
Clinical Practice Guidelines, Clinical
Pathways, Clinical Practice Protocols
(Hospital Setting)
Documents setting out standardization and
standards of clinical practice (management of
patients)
Non-medical (allied medical) and medical services
Government and non-government institutions
Manuals and posters
Publicized to clients and staff leading to
knowledgeable clients and staff

QUALITY SERVICE /
IMPROVEMENT
 Practice Guidelines
as a Strategy and Tool for Hospital
Quality Service Improvement
Clinical Practice Guidelines, Clinical
Pathways, Clinical Practice Protocols
Documents setting out standardization and
standards of clinical practice (management of
patients) Practice
Non-medical (allied medical) and medical
Protocols
services Policies and
Procedures
Government and non-government institutions
Standard
Manuals and posters Operating
Publicized to clients and staff leading
Procedures
to
knowledgeable clients and staff Citizens Charter
QUALITY SERVICE /
IMPROVEMENT
 Clinical Practice Guidelines, Clinical
Pathways, and Clinical Practice Protocols
Clinical Clinical Practice
Guideline Pathway Protocol
Focuses on Specific The quality Treatment.
clinical and co-
circumstanc ordination
es. of care.

http://www.implementationcentral.com/guidelines_
 Clinical Practice Guidelines, Clinical
Pathways, and Clinical Practice Protocols
Clinical Clinical Practice
Guideline Pathway Protocol
What is Systematically Structured, A suggested
it? developed multi- course of
statements to disciplinary treatment
assist plans of and/or
practitioners care. treatment
and service for a
patientmake specific
decisions diagnosis,
about functional
appropriate deficit or
health care. problem area.

http://www.implementationcentral.com/guidelines_
 Clinical Practice Guidelines, Clinical
Pathways, and Clinical Practice Protocols
Clinical Clinical Practice
Guideline Pathway Protocol
What Makes specific Supports Highlights
does it recommendati the major
do? ons on health implementa therapeutic
care and links tion of intervention
these to clinical points.
research guidelines Identifies
evidence. and choices of
protocols. difference
courses or
paths of
treatment.
Suggests other
http://www.implementationcentral.com/guidelines_
 Clinical Practice Guidelines, Clinical
Pathways, and Clinical Practice Protocols
Clinical Clinical Practice
Guideline Pathway Protocol
How does Provides a Provides Provides a
it work? summary and detailed logical flow of
appraisal of guidance interventions.
the best for each Provides
available stage in the detailed
research managemen recommendatio
evidence or t of a ns that build on
expert patient. those made in
consensus. guidelines.
Highlights the
strength of
the evidence
http://www.implementationcentral.com/guidelines_
 Clinical Practice Guidelines, Clinical
Pathways, and Clinical Practice Protocols
Clinical Clinical Practice
Guideline Pathway Protocol
Who uses Clinicians, A Specific
it? patients and multidiscipli clinicians.
third parties. nary clinical
team.

http://www.implementationcentral.com/guidelines_
 Clinical Practice Guidelines, Clinical
Pathways, and Clinical Practice Protocols
Clinical Clinical Practice
Guideline Pathway Protocol
What are 1) Appraisal of 1) Timeline 1) List of major
its literature 2) Categories therapeutic
component (research of care/ interventions.
s? evidence or intervention. 2) Goals: When
expert interventions
consensus). 3)
Intermediate should be
2) Summary of and long term achieved.
recommendations outcome 3) Options for
. criteria. different choices
3) An outline of 4) A variance of treatment.
how guideline record. 4) Differential
should be diagnoses and
implemented and treatments based
how adherence on the
http://www.implementationcentral.com/guidelines_
monitored.
 Clinical Practice Guidelines, Clinical
Pathways, and Clinical Practice Protocols
Clinical Clinical Practice
Guideline Pathway Protocol
Also Guidelines Integrated Protocol
known Clinical Care Best Practice
as.... Practice Pathways Treatment
Guidelines Multidiscipli Protocol
nary
Pathways of
Care
Pathways of
Care
Care Maps
Collaborativ
e Care
http://www.implementationcentral.com/guidelines_
 Clinical Practice Guidelines, Clinical
Pathways, and Clinical Practice Protocols
Clinical Clinical Practice
Guideline Pathway Protocol
Also Guidelines Integrated Protocol
known Clinical Care Best Practice
as.... Practice Pathways Treatment
Guidelines Multidiscipli Protocol
2 nary
Pathways of
Care
3 1
All 3 are clinical Pathways of
practice Care
guidelines!
Care Maps
Collaborativ
e Care
http://www.implementationcentral.com/guidelines_
 Clinical Practice
Guidelines
Clinical Practice Guidelines (CPG)
- systematically developed
statements to assist practitioner
and patient decisions about
appropriate health care for specific
clinical circumstances.
- Institute of Medicine
 Practice Protocols / Clinical Practice
Protocols
(SOPs, Policies and Procedures)

systematically developed
statements to assist practitioner
and patient decisions about
appropriate health care for specific
clinical circumstances.

May be in narrative form

complemented with tables,
checklists, algorithms
 Practice Protocols / Clinical Practice
Protocols
(SOPs, Policies and Procedures)

Processes in Development
Identification of subject area (service area)
Formation of technical working group
Formulation of protocol practice / service
guidelines (with bases consensus, evidences and
adjusted to local area)
Deliberation and approval of protocol
Deployment and implementation
Tracking of implementation (variances)
Evaluation and review at planned intervals
 Clinical Practice
Guidelines
Clinical Practice Guideline (CPG)
- systematically developed
statement to assist practitioner
and patient decisions about
appropriate health care for specific
clinical circumstances.
- Institute of Medicine
 Clinical Practice
Guidelines
Evidence-based Clinical Practice
Guideline (CPG)
- series of recommendations on
clinical care, supported by the
best available evidence in the
clinical literature.
 Clinical Practice
Guidelines
Evidence-based Clinical Practice Guidelines
(CPG)
- Processes involved in development:
- Formulation of technical working group
- Formulation of clinical questions
- Search for evidences in the literature
- Evaluation of evidences
- Level of evidences (I II III)
- Interim reports
- Consultation with panel of experts
- Consensus gathering (Category A C)
- Publication
- Education
- Implementation
- Tracking of implementation (variances)
- Evaluation (outcomes) and review at planned
intervals
 Clinical Practice
Guidelines
Evidence-based Clinical Practice
Guidelines (EB-CPG)

Health-Process-Evidence-Based
Clinical Practice Guidelines (HPEB-
CPG) [ROJoson]
- to make the conventional evidence-
based clinical practice guidelines more
relevant and useful in clinical practice in
the Philippines
 CLINICAL DIAGNOSTIC PROCESS

PROCESSING OF DATA

PATTERN RECOGNITION
-realization that the patients presentation
conforms to a previously learned picture or
pattern of disease
PREVALENCE
- choice of a diagnosis is based on the frequency
of occurrence of the disease in a certain locality, in a
certain age and sex group, and in the affected
organ and system
 CLINICAL DIAGNOSTIC PROCESS

PROCESSING OF DATA

Knowing the common manifestations of 3 different diseases and

relative frequency of each as follows:
Disease A - abcd (manifestations) Least common
Disease B - abcd
Disease C - abcd Most common
Given a patient manifesting with abcd, your diagnosis is Disease C.

What is/are processes used?

Pattern Recognition but mainly Prevalence

 Management of a Surgical Patient [Process]

Paraclinical Diagnostic Process - Indication

PROCESSING OF DATA

CERTAINTY OF CLINICAL Dx
1O Dx 60% 99%
needed not needed

TREATMENT PLAN FOR 1O & 2O Dx

Different Same
needed not needed
 Management of a Surgical Patient [Process]

Paraclinical Diagnostic Process - Selection

SELECTION PROCESS
Procedure Benefit Risk Cost (PhP) Availability
Options

1 accuracy 99% acceptable 5000 available

2 accuracy 90% acceptable 3000 available
3 accuracy 50% acceptable 1000 available

Which is the most cost-effective procedure?

Option 2 or Option 1?
 Management of a Surgical Patient [Process]

Treatment Process - Selection

SELECTION PROCESS
Treatment Benefit Risk Cost (PhP) Availability
Options

1 greatest surv rate acceptable 5000 available

2 rate < 1 > 3 acceptable 4000 available
3 least surv rate acceptable 3000 available

Which is the most cost-effective treatment option?

Option 1
 Clinical Pathways
Multidisciplinary management tool
based on evidence-based practice
for a specific group of patients with
a predictable clinical course, in
which the different tasks
(interventions) by the professionals
involved in the patient care are
defined, optimized and sequenced
either by hour (ED), day (acute care)
or visit (homecare).

-Wikipedia
 Clinical Pathways
A clinical pathway is a printed guideline to
usual care provided for a patient having a
certain procedure done or a patient who
has a certain illness.
Since all patients are unique, everyones
care will be customized to meet their needs
while keeping the guidelines in mind.
Clinical pathways are used to describe and
implement clinical standards. They help to
provide quality and efficient patient care.
 Clinical Pathways
Processes involved in development:
Identify high-volume, high-cost medical
conditions, diagnoses or procedures.
Form a multidisciplinary team.
Formulate the clinical pathway with task-
time matrix with focus on critical steps.
Deliberate and approve.
Deploy and implement.
Track implementation (variances)
Evaluate variances and patient care
outcomes and review at planned
intervals.
 Clinical Pathways
Basic steps
Define the processes
Timing of the processes
Note target areas that are critical
Measure variations and make
improvement
Remeasurement
 Clinical Pathways
Components
A timeline
Categories of care or activities and
their interventions
Intermediate and long-term outcome
criteria
Variance records
 Clinical Pathways
Components
A timeline
Pre-admission
Admission
Procedure
Postop
Discharge
 Clinical Pathways
Components
Categories of care or activities and their
interventions
Medical Interventions
Assessment
Tests
Activities
Medications/Treatments
Nutrition/Fluids
Teaching
Discharge Planning
Tubes/Monitoring
Key outcomes (physician/nursing)
 Clinical Pathways
Components
Categories of care or activities and their
interventions
Assessment and Monitoring
Activity/Environmental
Consults
Diagnostics
Operative/Invasive Procedures
Laboratory
Nutrition/I.V. Therapy
Medications
Therapies
Patient/Family Education
Expected Outcomes
 Clinical Pathways
Variances result of
omission of an action
performance of an action at an
inappropriate (often late) time
period
 Clinical Pathways
Components
Variance records
Look for common variances
Improve pathway
Improve compliance
 Clinical Pathways
Variances result of
Patient variations
System variations
Health professional variations
 Clinical Pathways
Components
Clinical Pathways Reasons for Variance
Patients clinical condition
Patients social situation
Associated diagnoses
Changing technology or techniques
Clinicians discretion
Consultation and internal system
services
External issues: primary care, home
health care, etc.
 Clinical Pathways
Aims
Facilitate introduction of guidelines to
improve the quality of care
Improve multidisciplinary communication
Reach or exceed quality care standards
Decrease unwanted practice variation
Improve patient-clinician communication
and patient satisfaction
Identify research and development
questions
 Guidelines
as a Strategy / Tool
for Hospital Quality
Service /
Improvement

Outline of Contents of Talk:

Definition of Terms
Why the Strategy
How to Go About It (The Tool)
 Clinical Practice Guidelines
Clinical Pathways
Patient care algorithms based on best
evidences and cost-efficient processes.
Intended to standardize and use standards of
care
- minimize variance in management
- increase efficiency
- improve patient care outcomes
- reduce costs
Integrated value-based health care
services
 Guidelines
as a Strategy / Tool
for Hospital Quality
Service /
Improvement

Outline of Contents of Talk:

Definition of Terms
Why the Strategy
How to Go About It (The Tool)
What are the recommended processes in going for clinical practice guidelines / clinical pathways?

Starting point:

Top management decides to

have a Clinical Practice
Guidelines / Clinical
Pathways Project to
promote quality service
improvement in the
hospital.
What are the recommended processes in going for clinical practice guidelines / clinical pathways?

Top management creates a Steering Team /

Committee for Clinical Practice Guidelines /
Clinical Pathways Project with clear functions and
authority.

Membership of Steering Team / Committee

Senior Management Representative if not the
Hospital Director
Chair (with competency in clinical practice
guidelines / clinical pathways and leadership)
Cross-sectoral or multisectoral membership
with representatives from key functional
areas in the hospital, such as the following:
(Note: the senior management team
members may constitute the Steering Team /
Committee.)
What are the recommended processes in going for clinical practice guidelines / clinical pathways?

Cross-sectoral or multisectoral membership with

representatives from key functional areas in the
hospital, such as the following:
(Note: the senior management team members
may constitute the Steering Team / Committee.)
Medical service sector
Nursing service sector
Ancillary medical service sector
Administrative or support service sector
Human resource development sector
Finance sector
Secretariat
What are the recommended processes in going for clinical practice guidelines / clinical pathways?

Steering Team formulates a master plan for

Clinical Practice Guidelines / Clinical
Pathways Project.

Steering Team seeks commitment for

support and collaboration from top, senior,
middle, and lower management on Clinical
Practice Guidelines / Clinical Pathways
Project.
What are the recommended processes in going for clinical practice guidelines / clinical pathways?

Contents of master plan for Clinical Practice Guidelines / Clinical Pathways

Project

Goals and objectives of Clinical Practice

Guidelines / Clinical Pathways Project
(include short- and long-term goals and
objectives)
Selection and prioritization of guidelines
and pathways to develop
Selection of the multidisciplinary teams for
the guidelines and pathways development
Expected outputs (short- and long-term)
Expected impact (short- and long-term)
What are the recommended processes in going for clinical practice guidelines / clinical pathways?

Contents of master plan for Clinical Practice Guidelines /

Clinical Pathways Project

Timelines (short- and long-term)

Strategies and action plans to
achieve expected outputs and
impacts (short- and long-term)
Budget (short- and long-term)
Monitoring and oversight plan
Evaluation plan (short- and long-
term)
 pathways.
As pathways are
being develop, input
clinical practice
guidelines
and target
Integrated Value-Based Health Care
Services
What are the common problems and challenges in clinical practice guidelines and clinical pathway development ?

Common problems and challenges

(commitment, cooperation,
collaboration, and integration of
all stakeholders)

Non-consensus on pathways by
the stakeholders
Fear of medicolegal suits
Tedious work to formulate and
record and evaluate the pathways
What are the common problems and challenges in clinical practice guidelines and clinical pathway development ?

Common problems and challenges

(commitment, cooperation,
collaboration, and integration of all
stakeholders)

Weakness in:
Leadership
Management
Planning, implementation, and evaluation
Integration of standards in all units
Communication
Education
Guidelines / Pathways
as a Strategy / Tool
for Hospital Quality
Service /
Improvement
Thank you for your kind
attention.
For query and feedback:
rjoson2001@yahoo.com
0918-804-0304
Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg
Short Course on Total Quality Management
June 23 - 27, 2014
UP Manila College of Public Health
 Clinical Pathways
as a Strategy / Tool
for Hospital Quality
Service /
Improvement
Thank you for your kind
attention.
For query and feedback:
rjoson2001@yahoo.com
0918-804-0304
Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg
Short Course on Total Quality Management
June 23 - 27, 2014
UP Manila College of Public Health
Welcome Queries and Feedback
Anytime!

REYNALDO O. JOSON, MD, MHA, MHPEd, MSc

Surg