CRITICAL PATHWAY

(Unit-ix: fiscal planning)

Introduction

Clinical Pathways: multidisciplinary plans of best clinical practice. Many synonyms exist
for the term Clinical Pathways including: Integrated Care Pathways, Multidisciplinary pathways
of care, Pathways of Care, Care Maps, and Collaborative Care Pathways.

Clinical Pathways were introduced in the early 1990s in the UK and the USA, and are
being increasingly used throughout the developed world. Clinical Pathways are structured,
multidisciplinary plans of care designed to support the implementation of clinical guidelines and
protocols. They are designed to support clinical management, clinical and non-clinical resource
management, clinical audit and also financial management. They provide detailed guidance for
each stage in the management of a patient (treatments, interventions etc.) with a specific
condition over a given time period, and include progress and outcomes details.

 Clinical Pathways have four main components (Hill, 1994, Hill 1998)

1. A timeline

2. The categories of care or activities and their interventions

3. Inter-mediate and long term outcome criteria

4. The variance record (to allow deviations to be documented and analyzed).

 Critical Pathway Development

 Select a Topic .

Topic selection in general should concentrate on high-volume, high-cost diagnoses and

procedures. Critical pathway development has focused on several cardiovascular diseases and
procedures because of volume and costs. These include bypass surgery, diagnostic
catheterization, coronary angioplasty, acute myocardial infarction, and unstable angina. These
diagnoses and procedures tend to be more suitable for critical pathway development because of
the predictable course of events that occur during the hospitalization. In addition, marked
variation in care has been observed in these conditions, which makes the goal of decreased
variation and reduction in resource utilization possible. Furthermore, there has been evidence of
noncompliance with guideline recommendations. In this case, the pathways might improve
guideline compliance and potentially improve quality of care.
 Select a Team .

It is important to develop a multidisciplinary team for critical pathway development. Active

physician participation and leadership is crucial to the development and implementation of the
pathway. It is important to include representatives from all groups that would be affected by the
pathway, for example, house staff, physical therapy personnel, and dietary personnel. The lack of
involvement of physicians has been cited as a reason for failure of a pathway.

 Evaluate the Current Process of Care .

In this step, data, rather than anecdotal reports, are key to understanding current variation. For
systems with electronic medical records, this process may be more automated. For other systems,
a careful review of medical records is necessary to identify the critical intermediate outcomes,
rate-limiting steps, and high-cost areas on which to focus.

 Evaluate Medical Evidence and External Practices .

After key rate-limiting steps have been identified, the critical pathway team must evaluate the
literature to identify evidence of best practices. For most rate-limiting steps, there are few data
available to define optimal processes of care. The critical pathway development team will often
lack answers to specific questions such as appropriate observation period or length of stay. In the
absence of evidence, comparison with other institutions, or "benchmarking," is the most
reasonable method to use.

 Determine the Critical Pathway Format .

The format of the pathway may vary widely. Important features include a task-time matrix in
which specific tasks are specified along a timeline. There is a spectrum of pathways that range
from a form that takes the place of the medical record to a simple checklist. A reduction in
charting that may occur with more complicated pathways is a benefit. However, if the pathway
format is too difficult to follow, it will not be used. Critical pathways have become widely
available in electronic format, where electronic charting and pathway compliance are obtained
simultaneously.

One disadvantage to this method is the absence of a standard medical record. This may result in
duplication of efforts and possible noncompliance with the pathway.

 Document and Analyze Variance .

Variances are patient outcomes or staff actions that do not meet the expectation of the pathway.
In general, variance in clinical pathways is a result of the omission of an action or the
performance of an action at an inappropriate time period. Because the critical pathway is a series
of time-associated actions, this analysis of variance can be overwhelmed by multiple data points.
Computer-assisted pathway analysis can help with this issue.

 Critical Path Analysis And Pert Charts

Critical Path Analysis and PERT are powerful tools that help to schedule and manage
complex projects. They were developed in the 1950s to control large defense projects, and have
been used routinely since then.

As with Gantt Charts, Critical Path Analysis (CPA) or the Critical Path Method (CPM)
helps to plan all tasks that must be completed as part of a project. They act as the basis both for
preparation of a schedule, and of resource planning. During management of a project, they allow
to monitor achievement of project goals. They help to see where remedial action needs to be
taken to get a project back on course.

Within a project it is likely that will display final project plan as a Gantt chart (using
Microsoft Project or other software for projects of medium complexity or an excel spreadsheet
for projects of low complexity).The benefit of using CPA within the planning process is to help
develop and test plan to ensure that it is robust. Critical Path Analysis formally identifies tasks
which must be completed on time for the whole project to be completed on time. It also identifies
which tasks can be delayed if resource needs to be reallocated to catch up on missed or
overrunning tasks. The disadvantage of CPA, if use it as the technique by which project plans are
communicated and managed against, is that the relation of tasks to time is not as immediately
obvious as with Gantt Charts. This can make them more difficult to understand.

A further benefit of Critical Path Analysis is that it helps to identify the minimum
length of time needed to complete a project. Where need to run an accelerated project, it helps to
identify which project steps should accelerate to complete the project within the available time

 PERT (Program Evaluation and Review Technique)

PERT is a variation on Critical Path Analysis that takes a slightly more skeptical view of time
estimates made for each project stage. To use it, estimate the shortest possible time each activity
will take, the most likely length of time, and the longest time that might be taken if the activity
takes longer than expected.

Use the formula below to calculate the time to use for each project stage:

Shortest time + 4 x likely time + longest time

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  Importance

Critical Path Analysis is an effective and powerful method of assessing:

• What tasks must be carried out.

• Where parallel activity can be performed.

• The shortest time in which you can complete a project.

• Resources needed to execute a project.

• The sequence of activities, scheduling and timings involved.

• Task priorities.

• The most efficient way of shortening time on urgent projects.

 CPM - Critical Path Method

In 1957, DuPont developed a project management method designed to address the challenge of
shutting down chemical plants for maintenance and then restarting the plants once the
maintenance had been completed. Given the complexity of the process, they developed the
Critical Path Method (CPM) for managing such projects.

CPM provides the following benefits:

 Provides a graphical view of the project.

 Predicts the time required to complete the project.
 Shows which activities are critical to maintaining the schedule and which are not.

CPM models the activities and events of a project as a network. Activities are depicted as nodes
on the network and events that signify the beginning or ending of activities are depicted as arcs
or lines between the nodes.

 Steps in CPM Project Planning

1. Specify the individual activities.

2. Determine the sequence of those activities.

3. Draw a network diagram.

4. Estimate the completion time for each activity.

5. Identify the critical path (longest path through the network)

6. Update the CPM diagram as the project progresses.

1. Specify the Individual Activities

From the work breakdown structure, a listing can be made of all the activities in the project. This
listing can be used as the basis for adding sequence and duration information in later steps.

2. Determine the Sequence of the Activities

Some activities are dependent on the completion of others. A listing of the immediate
predecessors of each activity is useful for constructing the CPM network diagram.

3. Draw the Network Diagram

Once the activities and their sequencing have been defined, the CPM diagram can be drawn.
CPM originally was developed as an activity on node (AON) network, but some project planners
prefer to specify the activities on the arcs.

4. Estimate Activity Completion Time

The time required to complete each activity can be estimated using past experience or the
estimates of knowledgeable persons. CPM is a deterministic model that does not take into
account variation in the completion time, so only one number is used for an activity's time
estimate.

5. Identify the Critical Path

The critical path is the longest-duration path through the network. The significance of the critical
path is that the activities that lie on it cannot be delayed without delaying the project. Because of
its impact on the entire project, critical path analysis is an important aspect of project planning.

 The critical path can be identified by determining the following four parameters for
each activity:

• ES - earliest start time: the earliest time at which the activity can start given that its precedent
activities must be completed first.

• EF - earliest finish time, equal to the earliest start time for the activity plus the time required
completing the activity.

• LF - latest finish time: the latest time at which the activity can be completed without delaying
the project.
• LS - latest start time, equal to the latest finish time minus the time required to complete the
activity.

The slack time for an activity is the time between its earliest and latest start time, or between its
earliest and latest finish time. Slack is the amount of time that an activity can be delayed past its
earliest start or earliest finish without delaying the project.

The critical path is the path through the project network in which none of the activities have
slack, that is, the path for which ES=LS and EF=LF for all activities in the path. A delay in the
critical path delays the project. Similarly, to accelerate the project it is necessary to reduce the
total time required for the activities in the critical path.

6. Update CPM Diagram

As the project progresses, the actual task completion times will be known and the network
diagram can be updated to include this information. A new critical path may emerge, and
structural changes may be made in the network if project requirements change.

 CPM Limitations

CPM was developed for complex but fairly routine projects with minimal uncertainty in the
project completion times. For less routine projects there is more uncertainty in the completion
times, and this uncertainty limits the usefulness of the deterministic CPM model. An alternative
to CPM is the PERT project planning model, which allows a range of durations to be specified
for each activity.

 Benefits
 Support the introduction of evidence-based medicine and use of clinical guidelines
 Support clinical effectiveness, risk management and clinical audit
 Improve multidisciplinary communication, teamwork and care planning
 Can support continuity and co-ordination of care across different clinical disciplines and
sectors
 Provide explicit and well-defined standards for care
 Help reduce variations in patient care (by promoting standardisation)
 Help improve clinical outcomes
 Help improve and even reduce patient documentation
 Support training
 Optimise the management of resources
 Can help ensure quality of care and provide a means of continuous quality improvement
 Support the implementation of continuous clinical audit in clinical practice
 Support the use of guidelines in clinical practice
 Help empower patients
 Help manage clinical risk
  Help improve communications between different care sectors
 Disseminate accepted standards of care
 Provide a baseline for future initiatives
 Not prescriptive: don't override clinical judgement
 Expected to help reduce risk
 Expected to help reduce costs by shortening hospital stays

Issues with Critical Pathways

 The first issue is that critical pathways address processes in the "ideal" patient and in some
cases do not address issues in the majority of patients who enter the path. Identification of
appropriate patients to enter the pathway is an important issue in implementation. In general,
critical pathways are more applicable to patients with uncomplicated illnesses who are
undergoing procedures or surgery. For patients treated with medical conditions such as acute
coronary syndromes, it is difficult to define "appropriate" treatment for the majority of
patients. Therefore, critical pathways will tend to identify a great deal of variance in the care
of these patients that may or may not be wasteful or potentially harmful. The goal of placing
most patients within pathways may not benefit the individual patient.

 A second issue is how to evaluate critical pathways as an effective tool in improving patient
care. As we have mentioned, little controlled research has been performed on the
effectiveness of pathways. One reason for this is that at any one medical center, "pathway"
care cannot be easily differentiated from "usual" care because of contamination from the
pathway intervention. Randomized trials with the unit of randomization at the medical center
would be the optimal evaluation method.

 The real impact of critical pathways and appropriateness protocols is their use as tools for
collection of information. Pathways can serve as a screening test for inefficient care. The
danger is that a pathway with too many critical areas under review will be too sensitive,
resulting in the review of a large number of marginally appropriate cases.Review of critical
pathway data should be focused on the highest-impact areas in terms of either cost, quality of
care, or, preferably, both.

Issues - potential problems and barriers to the introduction of CPs

 May appear to discourage personalised care

 Risk increasing litigation
 Don't respond well to unexpected changes in a patient's condition
 Suit standard conditions better than unusual or unpredictable ones
 Require commitment from staff and establishement of an adequate organisational
structure
 Problems of introduction of new technology
 May take time to be accepted in the workplace
 Need to ensure variance and outcomes are properly recorded