Striving for the achievement of high quality, patient centered and outcomes based healthcare is something all healthcare providers have in common. They want the best for their patients. That means equipping our hospitals and clinicians with the framework and tools for:
- Providing consistent and evidence-based care
- Providing care that ensures long lasting results and an improved quality of life
- Involving our patients in the development of their care plans and supporting and facilitating their choices.
How can all the above be achieved? As a professional services firm, with a strong healthcare industry focus, we believe that one of the answers lies in standardising treatment and diagnostic pathways. It is not a new concept. But if integrated and implemented consistently, and with the right governance support, this approach has the potential to positively transform the way healthcare services operate.
Why Standardise Clinical Pathways?
The focus on providing safe and high quality care to patients has been at the forefront of industry discussions since the recent, highly publicised and potentially avoidable perinatal deaths at Djerriwarrh Health Services.1 Following an investigation into the incidents by Professor Euan M Wallace and a broader review chaired by Dr. Stephen Duckett2 (both commissioned by the Victorian Minister for Health) the deaths were deemed avoidable because the care the patients received was not in line with best evidence practice. The Duckett report states, “Variability of care indicates that valuable knowledge is not being shared and implemented widely, so that many patients are receiving care that diverges from best practice” (page xi, Duckett, et al, 2016).
Care that diverges from best practice increases the risk of undesirable outcomes for patients, such as unnecessary complications, reduced quality of life or even death. The Duckett report ultimately highlighted the importance of implementing standardised clinical pathways in line with best evidence care and ensuring alignment of practice to these pathways across the health service.
There is a range of existing published clinical standards available to Australian healthcare professionals to help them implement clinical pathways. These include standards and guidelines developed by various Australasian healthcare colleges, as well as state, national and international bodies. Specific examples include:
- The Clinical Care Standards (CCS) being developed by the Australian Commission on Safety and Health Care (the Commission). The CCS provide nationally agreed statements on the care patients should be offered by health professionals based on best evidence practice3
- The Standard Sets being developed by the International Consortium of Health Outcomes Measurements (ICHOM). The Standard Sets are designed to help clinicians and patients decide on a course of care based on defined and measurable outcomes4
- The National Safety and Quality Health Service (NSQHS) Standards (to which all Australian Health Services are accredited), which include standards relating to specific areas such as Infection Control and Antimicrobial Stewardship.5
The aim of the CCS and other standards is to provide a baseline upon which hospitals can build more detailed and targeted standardised pathways that guide clinical decision making and enhance health services’ ability to provide high quality and safe care. They are a tool for facilitating the delivery of care in line with the strategic priorities shared by most Australian health services: to provide high quality, patient centered and outcomes based healthcare to their community.
And, as with any tool, if these standards aren’t implemented properly and consistently, they will not deliver the benefits they are designed to achieve.
Managing Unwarranted Variation
A degree of variation in practice from clinical standards is to be expected. After all, no two patients are the same. Some have pre-existing conditions, such as diabetes or an autoimmune disease, which may cause them to respond differently, or even unfavourably, to standard treatment pathways. Some will have unforeseen complications during their treatment, or will decide that they do not want to receive the treatment recommended by best evidence care. This is referred to as warranted variation as it is a result of clinical need or patient preference.
However, some variation is due to clinician preference and cannot be attributed to clinical need or patient choice. This is referred to as unwarranted variation in practice and should be avoided to minimise the risk of poor quality patient outcomes.
In recognition of this, Standard 1: Governance in the NSQHS Standards Second Edition3 (finalised June 2017) has been updated. It now requires hospitals to actively monitor, measure and reduce unwarranted variation in practice from standardised treatment pathways.
Our experience in the healthcare sector and in other pathway implementation projects has shown that the amount of unwarranted variation from a pathway can be directly influenced by the implementation methods utilised at the individual health service level. That includes:
- An appropriate governance structure to support the adoption of the chosen standards
- Communication of expectations to employees regarding adherence to the standard pathway
- Robust and business-as-usual monitoring of variation in practice and responses to identified instances of unwarranted variation
- A continuous feedback and improvement loop to ensure health service standards are updated in line with latest best evidence care and patient feedback.
The approach undertaken should be tailored dependent on the individual needs of each health service, factoring in the size, culture and business intelligence capabilities of the organisation.
Our Point of View: A Standardised Approach to Standardisation
In our experience, we see many hospitals operating in silos, with each specialty group implementing their own standardised clinical pathways. That results in different specialties adopting different approaches, which leads to inconsistent messaging to clinicians and patients and varying degrees of monitoring performed on unwarranted variation.
This model represents a missed opportunity for learnings to be shared or efficiencies to be gained from the monitoring and reporting of alignment of practice to the chosen standards. It also presents a potential future challenge when the health service is required to evidence their compliance with Standard 1: Governance in the NSQHS Standards, as evidence may be scattered and inconsistently documented.
Standardised processes have a much higher chance of successfully and consistently achieving the desired outcomes. The same is true when considering how best to implement standardised care practices. Healthcare services looking to implement and support alignment to standardised clinical pathways should implement and monitor alignment in a standardised way. In other words, standardise your standardisation approach.
Some of the many challenges inherent in implementing and adhering practice to clinical standards include:
- Culture — A culture that is resistant to change or a workforce that may feel threatened by the monitoring of clinical decisions
- Data Quality and Integrity — In the absence of a robust and reliable dataset with which to facilitate the monitoring of alignment of practice to the standards, the identification and monitoring of unwarranted variation is challenging. Health services must rely on costly and time-consuming manual auditing methods
- Resourcing — Implementing and monitoring adherence to standardised clinical pathways represents an additional resourcing requirement that most health services cannot or are reluctant to afford.
While we acknowledge the challenges, we see significant benefits for the health service, clinicians and patients that far outweigh those challenges:
- Patients — Improved patient safety, high quality outcomes and patient experience given alignment with best evidence care
- Clinicians — Efficiencies in training of junior medical staff and in diagnostic and treatment processes
- The Bottom Line — Reduced likelihood of over-ordering diagnostic procedures. Reduced length of stay for patients, as complications are minimised. Standardised practice also can lead to improved economies of scale for the procurement of prosthetics, surgical instruments and other equipment.
Consistent, safe, best evidence and outcomes based care is within the grasp of Australian healthcare services today. Regardless of the standards adopted at each health service, our experience has shown the recipe for success involves a robust, well governed and coordinated approach to the implementation of standardised care supported by continuous improvement.
Our dedicated healthcare team is comprised of experts in process design and implementation. We can enhance your clinical governance by providing a fresh perspective and relevant insights from other health services on managing unwarranted variation that challenges the status quo.
For more information on how Protiviti can help your health service become a leader in implementing best evidence practice, please contact us.