Clinical Pathways:
Efficiency at Mercy Hospital
David Agriam
Seth Barbanell
Carrie Compton
Eliza DeGuzman
Abstract:
Clinical pathways are essentially guidelines and standards for hospital administration and its staff
that has a predictable clinical course and outcomes. Created in the early 1980s by implementing
adapted procedures used in industrial quality management, it developed necessary protocols for
each level of the healthcare spectrum. Establishing standards and guidelines helps reduce costs to
a healthcare system by providing managers the necessary tools to run their establishment
effectively and efficiently. This paper will be focusing on the implementation of clinical
pathways at Mercy Hospital and their healthcare system, their desired outcome of eliminating
clinical variation, how they plan on achieving this outcome, and what are the benefits of
implementing such standards.
Clinical Pathways, also known as critical pathways, integrated care pathways, care
pathways or care maps, is a multidisciplinary management tool used to guide evidence-based
healthcare that “promote cost-effective, high-quality care” which standardizes “practice
protocols” and effective organized patient care (Kilmer, 1997). The implementation of such a
tool helps reduce the variability in clinical practices and in theory, optimizes outcomes for home
and acute care. Essentially a pathway is a collection of orders, care tasks, outcomes and
documentation that has set criteria in order for hospital administration and its staff to proceed to
the next predictable clinical course. Considered as a type of high-level process map, combining
multiple sub processes, each point has a decision branch and a next step in the pathway, with the
overall outcome linking together the entire giant process map (Wolff, Taylor, & McCabe, 2004).
Patient is
admitted
Patient is
examined
Patient gets
blood work
Is blood work positive
for a heart attack?
No
Patient gets
blood work
(Figure 1-Example of a pathway for chest pain*)
The clinical pathways model, and the increasing economic rationality in healthcare, stands in
contrast to “traditional values such as autonomy, high professional practice, relational care and
empathic attitudes”, with a fear that quality of care will be replaced with instituting cost-cutting
measures (Skogaas, 2011). First implemented in the 1980s, it was a result of trying to improve
efficiency in the use of resources as well as finish work in a timely manner. They adapted
procedures used in industrial quality management as well as Standard Operating Procedures
(SOPs), to achieve these goals. Throughout the coming years, “evidence-based guidelines” have
also been implemented to prevent physician variation in acute and home care (James & Savitz,
2011). In the Intermountain focused study on integration of clinical pathways for physician
variation, they identified and quantified the severity of the primary illness, the co-morbid
conditions, and all hospital complications. Every aspect was evaluated, and a detailed list of
elements that made up the treatment plans was identified. What the study found was that most
hospital admissions for the same reasons were similar in their characteristics and not a single
instance was found in which one physician’s patient was truly sicker than another physician.
This was considered a breakthrough in that most physicians inaccurately believe that the
variation in their practice is due to that particular patient being “sicker” than another (James &
Savitz, 2011). Besides the monetary costs associated with the variation with clinical practices,
“The State of Health Care Quality: 2003 Industry Trends and Analysis NCQA” (NCQA, 2003)
states ““more than 57,000 people die needlessly each year because “physicians practice vary
from standard practice / evidence based guidelines” of what medical science tells us they should
get”, and are not attributed to medical errors or lack of access to care. Implementing these types
of protocols/procedures has minimized costs on an administrative, logistic, and documentation
level by up to 20% while maintaining or increasing the quality of care and reduce variability in
acute care provided by physicians (Moore et al., 2010).
Mercy is the 6th largest catholic health system in the country, composed of 33
hospitals, and 5000+ providers spanning Missouri, Arkansas, Kansas and Oklahoma. Their
corporate headquarters are in St Louis Missouri. They are paperless in the office and in the
hospitals and use EPIC as their Electronic Health Record (EHR). Mercy, taking initiative
from the positive outcomes of clinical pathways integration by Intermountain Healthcare
(James & Savitz, 2011), is following principles of lean design and continuous process
improvement, eliminating variation in clinical practices and creating standard work
through the use of clinical pathways. Mercy is proceeding with a two-step process, with the
first phase being the initial design and construction of the process. The second phase is the
analysis and optimization of the outcomes from phase one.
Why use clinical pathways for clinical care?
Mercy recognized the importance of clinical pathways and eliminating variations in
clinical practices. Below (Chart 1) shows how Mercy treated four CHF (congestive heart
failure) patients within a 24 hour period. If the patients were treated in the same exact
manner, there would be a single point of overlap four times in each box. However, the
variation in treatment is not consistent; multiply that variation by the 150,000 inpatients
Mercy receives per year, and one can appreciated the magnitude of the problem.
(Chart 1 - Variation in Congestive Heart Failure at Mercy*)
How Mercy Plans on Implementing Clinical Pathways:
Mercy starts the process of creating a pathway by having a Masters level nurse initially work
with a Pharmacists, a medical librarian (as needed), and ad hoc non physician members by
drafting each pathway, a flow chart with identified CTP metrics, and attaching it with references.
This process is then repeated multiple times, adding additional members to the team, until a
minimum of three iterations and consensus is obtained. This version is then handed off to the
EPIC build team to incorporate it into the EPIC system for caretakers to use. This, in effect,
affects everyone who “touches” the patient, and not limited to just nurses and physicians.
(Figure 2- Pathway Design Process incorporated at Mercy Hospitals*)
Phase 1 is essentially the initial planning process stated above, but it does not incorporate the
physicians input, thus allowing the offloading of extraneous work on the already highdemanding workload of physicians. Phase 2 incorporates physicians’ input with a repeated on the
initial process, with discussions and research as needed. Phase 3 has two iterations, with the
addition of three SME (subject matter experts) who review and improve the process laid out in
Phase 1 and 2. It then is peer reviewed by approximately 10 physicians who once again review
the process, evaluate, and reevaluate. Phase 4 is where it is then given to the EPIC team to start
integrating the process into the EPIC system. Phase 5 builds on the outcomes from Phases 1-4,
with metrics of the information provided to data teams to start the process of collecting and
displaying the information using business intelligence (BI) tools. Metrics that are considered
include physician utilization and compliance and clinical operational and financial measures that
the teams who created the process agreed to follow. It is also in Phase 5 that the institution
begins educating its staff about the pending and up-coming changes. Phase 6 has the created and
evaluated pathway move into production and submitted to Mercy’s Change Management
process. After Change Management has vetted the pathway, it is released to the public. The
entire process (Phase 1-6) takes approximately 18 weeks to come into full fruition.
Implementing such drastic changes to a system takes the support of all who are involved
and the notion that problems, whether from human or administrative issues, will need to be
mitigated. Mercy has been fortunate that senior leadership, including board members, have given
unwavering support for the incorporation of clinical pathways into the Mercy Healthcare system,
and that without this support, the project to utilize clinical pathways and establish the foundation,
would have failed. This initiative for clinical pathways has been in the works for almost three
years at Mercy, and is now directly tied into one of their five pillars of the ministry’s strategic
plan. Following lean principles of design, Mercy ensures that the people who create the pathway,
such as physicians, nurses and care givers, are the very people who will be utilizing it on a daily
basis. Not only does this lessen costs, but having those that built the process use it, increases
transparency of the process and improves workflows. The process of building each pathway even
ensures that physicians and nurses stay engaged and challenged, to drive the EPIC builders and
proper itself, to improve functionality of the program, and has thus increased the ease of use of
the system over time.
Mercy has been collecting data on the finances, the outcomes, and utilization by the
hospital and physicians, as well as asserting a type of “report card” of each hospital’s utilization
rates to the leadership of the organization. Each hospital and clinic are allowed to see how they
are doing compared to their sister hospitals and clinics. Reactions to these reports have been
overwhelming and have been driving the increased utilization of pathways and an overall change
in the current culture.
The implementation of clinical pathways has had a strategic, operational, cultural and
political impact on the Mercy Healthcare system. Clinical excellence is tied strategically to the
increased use of evidence-based medicine and best care, and thus, pathway work is directly
linked to this strategic initiative. Pathways essentially define how Mercy (clinically) operates as
a healthcare organization, with initial results of the first three pathways showing a decrease in
costs (7- 30%*) and improvement in outcomes and readmission rates. The most difficult
challenge came with redefining an already established culture. Physicians are autonomous and
are used to working alone and being in control. It has been the realization that the
implementation of clinical pathways at Mercy hospitals and clinics is inevitably the way business
will be conducted from now on that has physicians and nurses slowly supporting this drastic
cultural change. The biggest reason, just from Mercy’s statistics alone, show how much is
wasted in the older system, and how implementing clinical pathways can remedy and remove
such wastes as in Figure 3.
(Figure 3 - Potential Costs Savings from Waste at Mercy Healthcare Systems*)
References:
Skogaas, B. (2011). Conflicts and ambivalences: a case study of clinical pathways in Norway.
Journal of Social Work Practice, 25(3), 335-349. doi:10.1080/02650533.2011.597182
Kilmer, M. B. (1997). Clinical pathways can help manage managed care. HFM (Healthcare
Financial Management), 51(2), 40.
Moore, C., McMullen, M., Woolford, S., Berger, B. (2010, May) Clinical Process Variation:
Effect on Quality and Cost of Care. AJMC (2010, May 10), 16(5). Retrieved from
http://www.ajmc.com/publications/issue/2010/2010-05-vol16-5/AJMC_10mayMoore_385to392/
Wolff, A., Taylor, S., and McCabe, J. (2004, October 18). Using Checklists and Reminders in
Clinical Pathways to Improve Hospital Inpatient Care. MJA,181(8), 428-431.
James, B., Savitz, L. (2011, May 19). How Intermountain Trimmed Health Care Costs Through
Robust Quality Improvement Efforts. Health Affairs, 30(6), 1185-1191.
Stanton, T. (2012). Checklists put guidelines into practice: electronic versions recognize
evidence base and individual judgment. AAOS Now, 6+. Retrieved from
http://go.galegroup.com/ps/i.do?id=GALE%7CA282941148&v=2.1&u=nu_main&it=r&p=AON
E&sw=w&asid=de1092d05ac8db39ca09eaa4d59ba0a9
Rotter, T., Kinsman, L., James, E., Machotta, A., Willis, J., Snow, P., Kugler, J. (2011, May)
The Effects of Clinical Pathways on Professional Practice, Patient Outcomes, Length of Stay,
and Hospital Costs: Cochrane Systematic Review and Meta-Analysis. Evaluation & the Health
Professions. Doi: 10.1177/0163278711407313
Homagk, L. L., Wiesner, I. I., Hofmann, G. G., & Zaage, J. J. (2013). Are IT-Based Clinical
Pathways Superior to Hard-Copy Form?. Zentralblatt Für Chirurgie, 138(1), 64-69.
Pavlakis, M., & Hanto, D. W. (2012). Clinical pathways in transplantation: a review and
examples from Beth Israel Deaconess Medical Center. Clinical Transplantation, 26(3), 382-386.
doi:10.1111/j.1399-0012.2011.01564
Young, D. W. (2013, January). Fiscal strategy in an era of reform: hospitals should develop
strategies around four forces that will affect their financial performance in the next five to 10
years. Healthcare Financial Management, 67(1), 56+. Retrieved from
http://go.galegroup.com/ps/i.do?id=GALE%7CA323142108&v=2.1&u=nu_main&it=r&p=AON
E&sw=w&asid=9024f731c08af0b8016e10c3a0812d74
*Seth Barbanell provided figures and charts based on what he and others at Mercy are studying
with regards to clinical pathways and the reduction of variation in clinical practices.