A Tale of Three Pathways: The Experience of RBWH Mental Health

BACKGROUND AND LITERATURE REVIEW

Clinical Pathways have been defined by Coffey et al. as an ‘optimal sequencing and timing of interventions by physicians, nurses and other staff for a particular diagnosis or procedure, designed to better utilize resources, maximize quality of care and minimize delays’.[4] Typically, clinical pathways are developed for high-volume, high-risk, high-cost and high-interest diagnoses, procedures and events.[5],[6] The concept of a pathway originated in the construction and engineering fields[7] The health-care environment explored their use when casemix funding was introduced and concerns were expressed about clinical effectiveness, cost containment and evidence-based practice. With this change in focus, routines or patient protocols were developed as a useful means to standardize care.[8] Clinical pathways are intended to facilitate the care process and to be able to evaluate treatment and its costs and effectiveness using a casemix classification. Utilizing casemix applications also allows hospital management to improve health provision by examining clinical practice through comparing results from the use of clinical pathways, case management systems, quality assurance and resource utilization reviews.[9]

Our review of the literature revealed extensive information about developing pathways in the medical and surgical areas, but a lack of information about pathway development in mental health. It further suggested that a mental health pathway could provide the same benefits as other pathways including reduced length of stay, assessment of quality of care and standardization of patient care.10–13

One of the many challenges in developing mental health clinical pathways is how to accommodate the large range of possible presenting symptoms and behaviours. It is commonly believed that this variability in the symptoms of the patients who present to mental health services limits the use of standardized treatments.[14] However, a pathway does not have to limit treatment. Rather, it can provide a framework to deliver a minimum standard of treatment and to ensure that important aspects of management are not overlooked. Brown et al. have suggested that the variability in mental health conditions provides an even stronger need to implement pathways to reduce variation of treatment.[15]

At a qualitative level, a clinical pathway has been viewed as a way of improving communication between members of the multidisciplinary team and has also been shown to clarify each person's role within the clinical team. Homan further supports this idea, suggesting additional benefits including reduced length of stay, improved direct patient care and facilitated assessment of quality of care.[12] Dunn et al. reported that the pathway provided a single working document used by all care providers, thus eliminating duplication of care.[16] A pathway predetermines the outcome measures, thereby enabling the form to be customized specifically in the medical record. Additionally, the pathway can monitor and document unplanned clinical events, resource utilization and special needs. Other benefits include increased satisfaction among staff members through improved communication and changes in organizational culture through the process of pathway development, which promotes commitment to collaboration and a strategy that promotes interdisciplinary action.[17] Lerner reported that there are many benefits associated with the use of clinical pathways, especially for patients who have complex social and family problems.[18] Where these problems are complex, the pathway allows for the integration of interventions so that the multidisciplinary team can provide coordination of quality care. Discharge planning from the beginning of the care process and providing outcome measurement scores on admission and discharge are seen as other important aspects of treatment addressed by a pathway.[19],[20]

On the other hand, major barriers in this area relate to the difficulty in defining the nature, individuality and variability of mental illness.[14] To allow for patient individuality and variability (i.e. for events that occurred outside the pathway), a variance system focusing on accurate data collection and evaluation is needed. Pathway variances are defined as a deviation from patient care activities included on the clinical pathway, and variance can be measured only by relating it to an established standard.[21] The purpose of identifying variances is to determine the areas in which the pathway needs to evolve. Variances are often viewed by staff as a negative event, but in reality variances recognize the individuality of patients and their conditions.[22] For this process to be effective, an organization needs to dedicate staff resources to provide continuing support, education and feedback to staff about pathway results.

Schriefer states that the literature does not provide clear guidelines on how to document, collect and analyse the data gathered from the use of clinical pathways.[21] He recommends that variance groups are coded and reports are formulated from the results. These reports include (i) patient demographics (e.g. length of stay, variation in length of stay, morbidity and discharge time); (ii) processes of care (e.g. identifying types of variance); and (iii) quality assurance (e.g. types of complication and at what time these were occurring).

Reports should be completed monthly or bimonthly. It was also noted that resources are often concentrated on developing pathways, but there is frequently a lack of direction as to how they are monitored and evaluated. Consequently, benefits from the pathway are not evident to staff. The literature strongly suggests that clinical pathways should be included within the service improvement programme of the organization.[21],[22]

There are several frameworks for implementing clinical pathways. Most include similar steps and follow a process. Harkleroad et al. have analysed the common frameworks and identified strong similarities, including the focus and recognition stage, which looks at identifying the need for a clinical pathway.[23] This is followed by the assessment and analysis phase to decide what is relevant for inclusion in the pathway. The development stage involves multidisciplinary consultation, including all members of the team, and the implementation phase looks at revising the final draft and sharing it with different stakeholders. Last, there is refining and evaluation of the pathway by examining existing variances from the pilot study. When examining different frameworks, it was found that there was a similar process of identifying essential categories in order to build and refine the development of a pathway.

CLINICAL PATHWAYS IN MENTAL HEALTH, ROYAL BRISBANE AND WOMEN'S HOSPITAL

Our pathway development began in 2001 with the appointment of a full-time project officer. A multi-disciplinary steering committee was established to oversee the development. The committee consisted of the Divisional Director, Nursing Director, Director Inner North Brisbane Mental Health Service, a staff psychiatrist, two clinical nurse consultants and a senior allied health professional. The steering com-mittee met fortnightly. A project plan was established to identify goals and milestones to be achieved over the project. A framework developed from the quality improvement team from the Corporate Office of Queensland Health was easily adapted for our mental health project (Table 1). A project officer to coordi-nate the process was essential.

The aim was to develop and trial two inpatient clinical pathways on psychosis and depression. These two conditions were chosen because of the high volume of admissions, high costs and high risks.

In the first 2 months, the project officer began the development of the psychosis pathway. Data were gathered from the hospital health information sys-tem on the relevant diagnostic related group (DRG) and length of stay data to identify current practice. A review of 40 clinical files and the draft clinical practice guidelines on the treatment of schizophrenia from the RANZCP were undertaken. From these data, it was decided that the time-frame for our pathway would be 14–16 days based on the length of stay data for the relevant DRGs. Phases, rather than days, as is common in most pathways, were selected as the most suitable intervals to use for this population due to the individuality of the illness. The pathway was organ-ized around four phases: (i) assessment; (ii) initial treatment; (iii) treatment; and (iv) discharge.

The assessment phase was to be completed in the assessment area, and the final three phases in the ward where the person was admitted.

The draft phases were developed by the end of 3 months. The project officer then began the critical process of liasing with, informing and educating staff about the pathway.

Over the next 3 months, the steering committee continued to meet to provide the clinical input to the pathway. The project officer continued to hold regu-lar education sessions for the inpatient staff, outlining the purpose and benefits of a clinical pathway.

Once completed, the psychosis pathway was trialed on an inpatient ward over 6 months. Such a trial was essential in order to have a realistic pathway. Initially, there was resistance by staff who were concerned about the additional paperwork and time needed to complete the documentation. Further education sessions provided staff with a better understanding of the purpose and role of the pathway. Providing opportu-nities for staff to give feedback increased interest and compliance in the use of the pathway. The primary role of the project officer during the implementation stage was to monitor, support and provide updates and feedback to staff on the progress of the clinical pathway. Unfortunately, half way through the trial, the project officer accepted another position and the use of the pathway declined.

With the arrival of a new project officer in late 2001, our initial trial was evaluated. This revealed that:

the pathway was seen by staff as ‘too complicated’ and required ‘double entry’ for staff;

Following the trial, a large number of amendments was made. The pathway form was extensively reworked to make it simpler and was integrated into the clinical notes to reduce duplication of documen-tation. The new format was designed as a checklist to ensure that clinical staff cover all basic requirements during the admission.

During this process, the clinical pathway for depression was also completed. Further trials of both path-ways were undertaken during 2002. Evaluation of the two pathways revealed that:

the new format was found to be more user friendly by staff;

This last finding resulted in the steering group agreeing to combine the pathways into one acute inpatient pathway. The acute inpatient pathway was for use on all adult admissions, excluding people admitted with a primary diagnosis of personality disorder, eating disorder and patients in the geriatric psychiatry unit. A copy of this pathway is available from the authors.

In September 2003 the Division began the process of introducing the acute inpatient pathway to our three inpatient units. Parameters that are being used to evaluate the effectiveness of the pathway are given in Table 2.

Our research and evaluation psychologist has been allocated the role of managing the variances and evaluating the usefulness of the pathway. We await the outcome with interest to see whether the path-way assists in improving the care provided to our patients. If, over 12 months, it is determined that the pathway is just another documentation burden to staff without significant benefit, an undertaking has been given to staff that it will be removed from use. However, if it is found to be beneficial to care and improves patient outcomes, the next step could be the development of a community pathway.

CONCLUSION

Mental Health care is complex. For this reason, mental health clinical pathways have to remain flexible and innovative. With our project, we found that pathways were not suited for specific diagnoses, so that they evolved into a single acute inpatient pathway.

We found that the process of developing the pathway within the multidisciplinary team was as crucial as the completed pathway document itself. Based on our experience, it would seem problematic to import pathways that have not been locally developed. Own-ership of the pathway by the medical staff was a key factor to its successful implementation. Our trial implementation phase was also important, as was the need for a project officer to steer and develop the project. Other factors integral to the success of any clinical pathway project are the support and commit-ment of management and staff.