Integrated Care Pathways: A Toolkit for Neurosurgeons

Brett Youngerman

Neurosurgery Resident, Columbia University Medical Center

New York, NY

In the constantly evolving health care climate in the United States, health care systems are always seeking an edge to improve clinical reputation as well as the bottom line. Two recent trends in health care redesign have been improving the quality of care while also increasing efficiency across the continuum of care. Various stakeholders are adopting alternative payment models — including pay-for-performance, bundled payments and accountable care organizations — to promote adherence to evidence-based practices for certain conditions and to develop efficiencies in specific episodes of treatment. Care pathways have emerged as a tool for organizations to standardize care based on available evidence and integrate system resources with the goal of optimizing both quality and efficiency.

A care pathway represents steps or processes of care in the management of a specific condition or treatment. A Cochrane review proposed several criteria for an intervention to meet the definition of a care pathway, including that it:

  • Is a structured multidisciplinary plan of care;
  • Translates guidelines or evidence into local structures;
  • Details the steps in the course of care;
  • Employs timeframes or criteria-based progression; and
  • Aims to standardize care for a specific clinical problem, procedure, or episode of care in a specific population. 

Neurosurgeons work in complex and high-stakes health care environments where many people must come together to provide optimal care for patients. Care pathways aim to maximize clinical efficacy and efficiency by improving adherence to steps believed to add value for the patient and eliminating those that do not.

Care pathways grew from process mapping which was used for decades in manufacturing and other industries to improve quality and efficiency. They have been adopted in a variety of settings with largely positive results. The impact on outcomes and efficiency can be difficult to quantify, and there remain concerns about potential detrimental effects on clinical practice. Taken to an extreme, care pathways can justify “cookbook” medicine at the expense of clinical judgment and reasoning. However, used appropriately, they are a powerful tool to optimize the complex process of health care delivery for neurosurgical patients. Hospital and health plan administrators are increasingly attracted to the use of care pathways in care redesign and to improve institutional efficiency. Neurosurgeons should be fluent in the language of care pathways and facile with their design and implementation for the interest and benefit of patients.

The Council of State Neurosurgical Societies (CSNS) Medical Practice Committee has developed a practical guide for designing a care pathway with nuances specific to neurosurgical patient populations and practice. Clinical pathway implementation typically follows the Plan, Do, Study, Act (PDSA) cycle for testing change ideas. Process map redesign is heavily rooted in lean management principles adopted from manufacturing. Institutions may also have their own site-specific resources that include integration into electronic clinical information systems. Many medical centers also employ quality improvement personnel, service line directors, or clinical engineers who can support care pathway redesign.

Table 1 outlines the key steps described in this toolkit.  While there is some variability in the precise sequence and organization of care pathway development, most resources include these common key steps.

The full toolkit is available to CNS and AANS members by clicking here. The CSNS is fully engaged in developing solutions for practicing neurosurgeons to navigate the increasingly complex systems of care for their patients. The Care Pathway Toolkit is just one way the CSNS is empowering neurosurgeons to be leaders in their health care systems.

References:

The CSNS toolkit was developed from several resources for process mapping and redesign, which can be referenced for further guidance by clicking here.

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