Applying Lessons from an Inaugural Clinical Pathway to Establish a Clinical Effectiveness Program

Abstract

Introduction: Clinical effectiveness (CE) programs promote standardization to reduce unnecessary variation and improve healthcare value. Best practices for successful and sustainable CE programs remain in question. We developed and implemented our inaugural clinical pathway with the aim of incorporating lessons learned in the build of a CE program at our academic children's hospital.

Methods: The Lucile Packard Children's Hospital Stanford Heart Center and Center for Quality and Clinical Effectiveness partnered to develop and implement an inaugural clinical pathway. Project phases included team assembly, pathway development, implementation, monitoring and evaluation, and improvement. We ascertained Critical CE program elements by focus group discussion among a multidisciplinary panel of experts and key affected groups. Pre and postintervention compared outcomes included mechanical ventilation duration, cardiovascular intensive care unit, and total postoperative length of stay.

Results: Twenty-seven of the 30 enrolled patients (90%) completed the pathway. There was a reduction in ventilator days (mean 1.0 + 0.5 versus 1.9 + 1.3 days; P < 0.001), cardiovascular intensive care unit (mean 2.3 + 1.1 versus 4.6 + 2.1 days; P < 0.001) and postoperative length of stay (mean 5.9 + 1.6 versus 7.9 + 2.7 days; P < 0.001) compared with the preintervention period. Elements deemed critical included (1) project prioritization for maximal return on investment; (2) multidisciplinary involvement; (3) pathway focus on best practices, critical outcomes, and rate-limiting steps; (4) active and flexible implementation; and (5) continuous data-driven and transparent pathway iteration.

Conclusions: We identified multiple elements of successful pathway implementation, that we believe to be critical foundational elements of our CE program.

Fig. 1.

Key driver diagram for the postoperative management of TOF. Key drivers for the postoperative care of TOF reflected patient and system factors. The multidisciplinary core development team generated potential interventions for these key drivers and updated both key drivers and interventions regularly during the iteration and improvement phase.

Fig. 2.

Excerpt from the clinical pathway for the postoperative management of TOF. Formatting courtesy of Cincinnati Children’s Hospital TOF clinical pathway.^, ABG, arterial blood gas; ATC, around-the-clock; CBC, complete blood count; CMP, complete metabolic panel; CR, cardiorespiratory; CT, chest tube; CV: central venous; CXR: chest x-ray; EKG, electrocardiogram; IV, intravenous; IVF, intravenous fluids; MRSA: methicillin- resistant Staphylococcus aureus; MRSE: methicillin- resistant Staphylococcus epidermidis; PO: per os, “by mouth”; PR, per rectum; PRN, pro re nata, “as needed”; RA, right atrial; TP, transannular patch type of TOF repair; VS, valve-sparing type of TOF repair.

Fig. 3.

Data and variance collection form for TOF clinical pathway. Formatting courtesy of Cincinnati Children’s Hospital TOF clinical pathway.^, POD, postoperative day; TP, transannular patch type of TOF repair; VS, valve-sparing type of TOF repair.

Fig. 4.

Family satisfaction after implementation of a TOF clinical pathway. Likert Scale Chart demonstrating respondent results to postintervention family satisfaction survey through 7-day post discharge standardized phone survey with the above 5 questions measured on a Likert scale (1 = very poor, 2 = poor, 3 = fair, 4 = good, 5 = very good). The encircled numbers indicate mean respondent scores. No participants responded 1 or 2. Light gray corresponds to response 3 (fair), medium gray to response 4 (good), and dark gray to response 5 (very good).

Fig. 5.

Postoperative LOS after primary TOF repair before and after clinical pathway implementation. This individual-X statistical process control chart demonstrates improvement in mean LOS and outcome variability in the postintervention period. Each data point indicates consecutive individual patients. CL, control limit; LCL, lower control limit; UCL, upper control limit.