Clinical Pathway as A Form of Inter-

Professional Collaboration in Hospital

Ns. Hendra Firmansyah, SKep

Background
Healthcare is a complex process
Involving so many healthcare professionals (multidiscipline)
Each professionals have different approaches, techniques
and goals, when dealing with patients
Inter-professional and inter-organizational
collaboration is an essential component of healthcare
services, especially in hospital setting
Effective healthcare integration requires effective
communication, teamwork and commitment to deliver
integrated care
Outline
Definition of CP
History of CP
Characteristics of CP
Aim of CP
Selection Criteria
Components of CP
CP in RSCM (10 years experience)
 Definition
Multidisciplinary management tool based
on evidence base practice for a specific
group of patients with predictable clinical
course in which the different tasks
(interventions & outcomes) by the
professionals involved in the patient care
are defined, optimized and sequenced
either by hour, day, or visit
(Clinical Pathway. In Wikipedia. Retrieved March 19, 2016 from:
http://en.wikipedia.org/wiki/Clinical_pathway)
Definition:
Journal of Nursing
Management, 2006
Clinical pathway is a method for the patient care
management of a well-defined group of patients during a
well defined period of time
CP explicitly states the goals and key elements of care
based on evidence Based Medicine guidelines, best
practice and patient expectations
CP facilitating the communication, coordinating roles and
sequencing the activities of the multidisciplinary care
team, patients and their relatives
CP is a tool for documenting, monitoring and evaluating
variances and by providing the necessary resources and
outcome
 EPA (European Pathways
Association)
5intervention
1. The Criteria's of CP
was structured multidisciplinary plan of care
2. The intervention was used to translate guidelines or evidence
into local structures
3. The intervention detailed the steps in a course of treatment or
care in a plan, pathway, algorithm, guideline, protocol or other
inventory of actions
4. The intervention had timeframes or criteria based progression
5. The Intervention aimed to standardize care for specific clinical
problem, procedure or episode of healthcare in a specific
population
 History of CP
1950s: Industry (Aviation and Construction Work)Critical Path Methods (CPM) and Program Evaluation and Review
Techniques (PERT) were used to control and manage complex processes.
1980s: Karen Zander & Kathleen Bower translated critical pathways into case management plans and later clinical
pathways.
1997, Sue Johnson edited the book: Pathways of Care.
1997 Walter Sermeus wrote the first article in Belgium on clinical pathways (The use of clinical pathways for nursing
practice).
1998 the first studies in Belgium on the development, implementation and evaluation of clinical pathways were
performed by students at Leuven University. All these studies were supervised by Sermeus and took place within the
University Hospitals Leuven.
2000 the Belgian Dutch Clinical Pathway Network started.
2002: the Smartgroup on Clinical Pathways- was founded by Jen Guezo
2004: European Pathway Association
2005: first international survey on the prevalence and use of clinical pathways in 23 countries.
2009: the European Pathway Association was asked by the Royal Society of Medicine Press (UK) to take over the JICP. The
journal was restructured and the International Journal of Care Pathways was launched.
They Both are NURSES
 Characteristics of
CP
An explicit statement of the goals and key elements of
care based on evidence, best practice, and patients
expectations and their characteristics;
The facilitation of communication among team
members and with patients and families;
The coordination of the care process by coordinating
the roles and sequencing the activities of the
multidisciplinary care team, patients and their relatives;
The documentation, monitoring, and evaluation of
variances and outcomes; and
The identification of the appropriate resources.
 Aim of CP
Improve the quality of care across the continuum by
Improving risk adjusted patient outcomes
Promoting patient safety
Increasing patient satisfaction
Optimizing the use of resources (including human
resources)
(Internation Journal of Care Pathways, 2010)

Does it increase collaboration among healthcare

professionals?
Selection
Criteria
High Cost
High Volume
High Risk

Based on Diseases
Based on Procedures
Components of
CP
A timeline,
The categories of care or activities and their
interventions,
Intermediate and long term outcome criteria, and
The variance record (to allow deviations to be
documented and analyzed).
(Hill, 1994, Hill 1998):
Timelin
e
Categori
es of
Care
Activities/
Interventio
ns

Outcome
Criteria

Varianc
e
CP in RSCM
10 Years Experience
 The Development of CP in
RSCM

2005: First developed in the Integrated

Cardiovascular Services Unit(PJT RSCM)
2010: CP for the implementation of INA CBG
(Ministry of Health)
2012: CP for Sectio Cesarean, AMI, TOF, Stroke,
Cataract
2014-2016: Developing CP for other diseases/
procedures (on progress)
 CP in PJT SCM (Cardiac
Unit)

Background:
Different approach on cardiovascular
diseases: surgery vs non surgery, open heart vs
closed heart
90% Nursing staffs were Fresh Graduates
Limited Resources
Cardiovascular services: High Cost, High Volume,
High Risk
 CP in PJT SCM (Cardiac
Unit)

Objectives:
To ensure that the entire procedure had been
done
Improve coordination between the clinic staff
CP as a guideline
Negotiation with the insurance (BPJS)
Tool for clinical audit
Complex Process in Cardiac
Care:
Same Diagnosis Different
Intervention
PCI CABG

Non Surgical Surgical

Procedure Procedure
Complex Process in Cardiac Care:
Same Diagnosis Different
Intervention
ASD Closure With Device ASD Closure With Surgery

Non Surgical Surgical

Procedure Procedure
 CP in PJT SCM (Cardiac
Unit)
Based on Procedures
CABG CP
PCI CP
ASD Closure CP
etc.

Cover all services

Ward
CICU
Operating Theater
Cath Lab

Activity Base Costing Hospital rates

Evaluation of CP in 2005
(Before and after the application of the CP)

ALOS decrease from +14 days to +7 days

Pre-operative preparation done in outpatient
Decreased mortality rate of approximately
8% (2004) to 5.8% (2005)
There were improvement of processes and
outcomes in every phase of services (pre, intra,
post operative)
 Evaluation of CP in 2006

Population: VSD Closure Patients

Expected LOS: 7 days
Result:
ALOS: 5 days
70% of the activities met the CP
Variance: (positive)
7 patients discharged earlier (day 5)
2 patients not undergo catheterizations pre operative
 Evaluation of CP in 2007

CP evaluation in OT and Cath lab

All physicians were encouraged to make a report
as soon as the intervention have been completed
(previously reports were created on the next day)
No interventions in every phase were missed
Staff Efficiency occur in the cath lab a clear
division of tasks:
Before CP: 7 nurses, 1 radiographer
After CP: 1 scrub nurse, 2 circular nurses, 1 hemodynamic
nurse, 1 radiographer
 Multidisciplinary
evaluation meeting

Attended by Head of Cardiac Unit, Cardiologist,

Surgeon, Anesthetist, Head Nurse of the Ward, ICU, OT,
Cathlab, Outpatient Clinic
Once a week, every Friday
Analyze compliance with CP and
Analyzing variants occur (morbidity, mortality,
inaccurate diagnosis, appropriate care is not standard)
Determine an action plan to improve services
 BARRIERS TO THE
IMPLEMENTATION OF CP

Duplication of care documentation

CP has not been considered as part of
the medical record
The variation of the patient's
condition (patients with comorbid)
- PDA with PH
- CABG + Valve Replacement
 Recommendations

Need support from top

management to increase the
commitment of staff to implement and
evaluate CP
CP as part of the medical records
to reduce the duplication of
documentation
 Conclusions

CP is a road map for patient and

healthcare professionals
CP must describe coordination of the
care process based on evidence base
practice
CP have the potential to support inter-
professional collaboration
Thank You