An introduction to critical paths

A critical path defines the optimal sequencing and timing of interventions by physicians, nurses, and other staff for a particular diagnosis or procedure. Critical paths are developed through collaborative efforts of physicians, nurses, pharmacists, and others to improve the quality and value of patient care. They are designed to minimize delays and resource utilization and to maximize quality of care. Critical paths have been shown to reduce variation in the care provided, facilitate expected outcomes, reduce delays, reduce length of stay, and improve cost-effectiveness. The approach and goals of critical paths are consistent with those of total quality management (TQM) and can be an important part of an organization's TQM process.     

An introduction to critical paths

A critical path defines the optimal sequencing and timing of interventions by physicians, nurses, and other staff for a particular diagnosis or procedure. Critical paths are developed through collaborative efforts of physicians, nurses, pharmacists, and others to improve the quality and value of patient care. They are designed to minimize delays and resource utilization and to maximize quality of care. Critical paths have been shown to reduce variation in the care provided, facilitate expected outcomes, reduce delays, reduce length of stay, and improve cost-effectiveness. The approach and goals of critical paths are consistent with those of total quality management (TQM) and can be an important part of an organization's TQM process.     

Dirigo Health. Leading the way

Maine this summer will launch an ambitious public/private program called Dirigo Health to guarantee health coverage to all its citizens. Hospitals have promised to limit costs and margins in the hope that universal coverage will enhance public health and reduce uncompensated care. The rest of the nation will be keeping a close eye on Maine's efforts.     

Mothers’ perceptions and experiences of using maternal health-care services in Rwanda

Reducing barriers to use maternal health care is one of the critical components to improving maternal health. Rwanda is among the countries that have made tremendous efforts to reduce maternal mortality. However, the current maternal mortality ratio is still high which calls for further efforts to be considered. This study used a qualitative approach to understand mothers’ perceptions and experiences of using maternal health care in Rwanda. Using in-depth interviews and focus group discussions, data were collected in the Western and Eastern provinces of the country where forty-five women participated in the study from June to August 2014. This paper highlights perceptions of these participants regarding issues that contribute to suboptimal use of maternal health-care services. The geographical, financial, and social–cultural barriers that emerged in this study highlight the need to understand mothers’ experiences and perceptions when using maternal health care as Rwanda and other countries strive to reduce negative maternal health outcomes.     

Thinking outside the box: linkages between admissions and case management

Admissions gatekeeping can enhance integration of case management efforts focusing on problems prior to care provision. Most effective as a part of the continuum of care currently being called medical management, it helps to eliminate variability and waste in processes. This medical management approach can increase quality of care, reduce cost, and draw outcomes toward a median that payers, patients, and physicians can expect and accept.     

Critical Pathways: Occupational Therapists' Role in Development and Utilization

Managed care is mandating that healthcare facilities implement cost containment measures. Critical pathways are one popular tool used to meet this demand. The purpose of this study was to explore current involvement of occupational therapists (OTRs) in the use and creation of critical pathways.

Results of a national survey showed 70.5% of the respondents reported they are not currently using critical pathways. A majority of OTRs are not and have not taken an active role in critical pathway development. Furthermore, the majority indicated having no knowledge of future critical pathway implementation in their facilities.

Information gathered from those OTRs reporting critical path use included most common diagnoses using the paths and percentages of OTRs utilizing critical paths in specific occupational therapy areas.

The conclusions drawn by the researchers indicated the need for OTRs to become more involved in the development and utilization of this multi-disciplinary approach to treatment. For OTRs to maintain and enhance their positions within the allied health profession, proactive involvement with these managed care driven quality assurance methods is essential.     

Opportunities for community health workers to contribute to global efforts to end tuberculosis

ABSTRACT

Tuberculosis (TB) has emerged as the leading infectious cause of death globally. New paradigms are needed to reduce TB rates and mortality. Programs harnessing the potential of community health workers (CHWs) to enhance TB prevention and care have shown great promise. In this perspective article, we review the history of CHW-based efforts to prevent and treat TB, present evidence illustrating the effectiveness of CHWs across the entire cascade of TB care, and outline additional opportunities for CHWs to address challenges particular to the TB pandemic. Despite many promising studies, knowledge gaps persist and we suggest an agenda for future research on the role of CHWs in TB prevention and care.     

Lost in (knowledge) translation!

Critical care nutrition guidelines have been developed to help busy practitioners decide how to feed their critically ill patients. However, despite the publication of guidelines and efforts to disseminate and implement them, there are large gaps between what the recommendations say and what is happening at the bedside. Consequently, the nutrition therapy received by many patients remains suboptimal. Knowledge translation is a term increasingly used in healthcare to describe the process of moving evidence learned from clinical research and summarized in clinical practice guidelines to incorporation into clinical and policy decision making. In this article, knowledge about the implementation of critical care nutrition guidelines is applied to Graham et al's knowledge-to-action model to illuminate the issues pertinent to knowledge translation in critical care nutrition. This model has 2 components: knowledge creation and action. The action component consists of 8 phases of the action cycle that represent activities needed to move knowledge into practice and are derived from planned-action theory. Components of this model are illustrated via empirically derived research, commentaries, and published studies from the field of critical care nutrition. It is hoped that this article and related articles in this issue of JPEN will help critical care nutrition practitioners to better understand the often complex and convoluted road of translating knowledge into practice so that as a community we are no longer "lost" but have direction that can bring about positive changes in nutrition practice.     

The Great Lakes Regional Stroke Network experience

Stroke is a leading cause of disability and the third leading cause of death among adults in the United States and in the Great Lakes states of Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin. The Great Lakes Regional Stroke Network was created to enhance collaboration and coordination among the Great Lakes states to reduce the burden of stroke and stroke-related disparities associated with race, sex, and geography. Three priorities were identified for reducing the effects of stroke in the Great Lakes region: 1) build epidemiologic capacity to improve stroke prevention and control efforts, 2) facilitate systems-level changes and collaborative efforts to improve acute stroke care and rehabilitation, and 3) promote awareness of the warning signs of stroke and the need to call 911. The Great Lakes Regional Stroke Network has work groups in the areas of epidemiology and surveillance, health care quality improvement, and public education. These groups recommend initiatives to states for their efforts to reduce the effects of stroke within the Great Lakes region. Examples of recommended initiatives include identifying and prioritizing state research evaluation needs for stroke, conducting a stroke education media campaign, and developing a statewide emergency medical services protocol for stroke.     

基于临床信息系统及知识管理的临床路径信息系统研究与开发

临床路径作为提升医疗质量、控制医疗成本、优化医疗服务流程的管理工具,在国内外的医院管理中得到了广泛的应用。以医院知识管理为指导思想,建立在临床信息系统基础上的临床路径信息系统,有利于科学定制临床路径、减少医护人员的工作量,保证快速、高效临床路径信息的共享及反馈机制的建立。本文就临床路径信息系统的需求分析、系统设计及功能实现等方面作了深入的探讨并对该系统在未来的应用作了可预期的展望。     

Strict hand hygiene and other practices shortened stays and cut costs and mortality in a pediatric intensive care unit

Efforts to reduce infections acquired during a hospital stay through improvements in the quality of care have had measurable results in many hospital settings. In pediatric intensive care units, the right quality interventions can save lives and money. We found that improving practices of hand hygiene, oral care, and central-line catheter care reduced hospital-acquired infections and improved mortality rates among children admitted to a large pediatric intensive care unit in 2007-09. In addition, on average patients admitted after the quality interventions were fully implemented spent 2.3 fewer days in the hospital, their hospitalization cost $12,136 less, and mortality was 2.3 percentage points lower, compared to patients admitted before the interventions. The projected annual cost savings for the single pediatric intensive care unit studied was approximately $12 million. Given the modest expenses incurred for these improvements-which mainly consisted of posters for an educational campaign, a training "fair," roughly $21 per day for oral care kits, about $0.60 per day for chlorhexidine antiseptic patches, and hand sanitizers attached to the walls outside patients' rooms-this represents a significant return on investment. Used on a larger scale, these quality improvements could save lives and reduce costs for patients, hospitals, and payers around the country, provided that sustained efforts ensure compliance with new protocols and achieve long-lasting changes.     

Correction: Emotional impact of screening: A systematic review and meta-analysis

The experiences of the past 10 years have shown that it is feasible to treat HIV infected patients with ART even in severely resource constrained settings. Achieving the levels of antiretroviral coverage necessary to impact the course of the HIV epidemic remains a challenge and antiretroviral therapy coverage in most nations remains short of even current recommendations. Though treatment as prevention and seek, test, treat and retain strategies are attractive, realization of the benefits of these strategies will require the ability to successfully engage key hard to reach populations such as sex workers. The successes engaging these populations in research settings as seen in the article by Huet et al are encouraging, however key questions remain regarding the sustainability of these efforts as patients are transitioned back to national HIV control programs, many of which are struggling even to maintain the current panels in care in the face declining external funding for HIV care. To achieve the critical goals of increasing treatment uptake and retention and thereby curtail the epidemic of HIV, advocacy from both medicine and public health providers will be critical to generate the support and political will necessary to sustain and enhance the necessary HIV care programs worldwide.     

Increasing the value of cardiac care: the Dartmouth approach

A cardiac services team at Dartmouth-Hitchcock Medical Center (DHMC) launched multiple efforts to improve the quality and value of their services. The team developed a critical path for coronary artery bypass grafting (CABG) and tracked important clinical outcomes, such as mortality rates and wound complications. The team also studied the patient's view of the process. Staff used focus groups and surveys to distill the "voice of the customer" into six quality characteristics and developed methods to better involve patients in clinical decision making and evaluation of treatment efficacy. Results: CABG mortality declined from 5.7 percent in 1992 to 2.7 percent in 1994, 16 months after the critical path was developed. Mean total intubation time for patients following open-heart surgery was reduced from 22 hours to 14 hours. Median postoperative length of stay decreased from seven days to six for elective CABG patients. The number of patients discharged in five days or less increased from 20 percent to 40 percent. Readmission to the hospital following discharge remained stable, despite the shorter length of stay.     

Protecting hospice patients: a new look at falls prevention

Falls prevention is a critical priority in hospice and palliative care settings. To keep patients safe and comply with national standards, hospice professionals must have available appropriate assessment, prevention, and intervention tools. Existing procedures engaging patients in strengthening exercises and reducing or eliminating medications that cause dizziness, imbalance and confusion are fitting and useful in environments where first-line fall reduction efforts are possible. These current tools are based on research in facilities for nonhospice patients and run counter to the goals of palliative care. By definition, hospice patients have a terminal illness and are, or will become, too weak to manage strengthening exercises. Without their medications, many would experience intolerable pain and unmanageable anxiety and depression. This article proposes assessment guidelines and pragmatic interventions to reduce the risk of falling that are consistent with the hospice philosophy of comfort.     

Health, housing, and public policy

With federal funding of affordable housing declining, health care and housing organizations must work together to advocate sound policy and reasonable funding in this realm. Federal agencies like the U.S. Department of Housing and Urban Development (HUD) and the U.S. Department of Agriculture traditionally have been the primary source of low income housing funds. But key housing programs like HUD's Section 8 have lost a significant amount of funding. Through advocacy efforts, health care and housing organizations can urge legislators to retain or restore these vital programs. They also can support the preservation of affordable housing units in order to counterbalance the trend of these homes being "lost to the market." Also, health care and housing agencies can partner to enhance housing services. Vulnerable populations-such as the elderly, individuals at risk for homelessness, those with disabilities, and the mentally ill-can benefit greatly from the supportive services that health care organizations can offer.     

Continuity of care: important, but only the first step

ABSTRACT: Continuity of care is critical to achieving the best outcomes, especially for patients with chronic conditions. Israel's strong commitment to primary care as a central organizing concept of the health system, accompanied by investments in health information technology and training primary care physicians, has contributed to its impressive levels of continuity of care. Taking the next steps toward a comprehensive system of patient- and population-centered care for proactive management of patients with chronic conditions has much potential to further enhance outcomes and reduce costs. This is a commentary on http://www.ijhpr.org/content/1/1/21/     

Patient safety: solutions in managed care organizations?

Despite the growing acknowledgment of the necessity for patient safety initiatives to address medical errors, the role of managed care organizations (MCOs) in these programs has only recently been challenged. Managed care quality improvement programs have mainly focused upon pay-for-performance initiatives, largely ignoring specific patient safety efforts. To effectively reduce medical errors, MCOs must leverage their unique positions to influence and educate both providers and consumers. This article describes MCOs' self-implemented barriers to quality improvement, and early initiatives by MCOs to encourage safe practices, including pay-for-performance. An approach for MCOs to facilitate progress and inspire a culture of patient safety is discussed. Avenues for strengthening the organizational and technological infrastructure of the health care system from a managed care perspective are examined, and strategies for implementing best practices within the constraints of managed care are explored. System-wide solutions that address the critical areas of culture, infrastructure, and best practices are necessary to continue to make significant strides in reducing medical errors and prioritizing patient safety.     

Internal marketing, nurse loyalty and relationship marketing: an exploratory study of German nurses

Nurse loyalty and retention are critical issues facing the healthcare industry. A lack of continuity in the nursing staff compromises the quality of the care, results in significant costs, and leads to patient concerns about the viability of the healthcare facility. Conversely, a motivated and committed nursing staff creates a solid foundation for implementing initiatives for the improvement of healthcare quality. This article employs the "Relationship Marketing Paradigm" as a framework to understand and enhance nurse loyalty through internal marketing efforts. The results indicate that financial, social and structural bonds have significant, albeit different, impacts on nurse loyalty. Managerial implications and future research directions are discussed.     

A Community Development Approach to Rural Recruitment

ABSTRACT: Programs designed to empower rural communities for health care provider recruitment have usually focused on the health care sector without aggressively addressing broader community development issues. The Recruitable Community Project (RCP) in West Virginia includes community education on recruiting and also assessments of and recommendations to rural communities on broad-based community development, aiming to enhance communities' recruiting potential. The project provides multidisciplinary university-based planning assistance programs for small communities, involving collaborative community visits. The project also uses a project manager as a "community encourager" who participates in community education and in the formulation of sustained community recruiting efforts. From August 1999 through August 2001, 7 underserved rural communities completed the RCP organizational processes and hosted planning assistance teams. Members of community recruitment boards gave high marks to the RCP process, its planning assistance teams, and its usefulness in establishing community ties to state and academic agencies. Since working with the RCP, the 7 communities have recruited 27 providers, success possibly stimulated by their RCP involvement (data current as of September 2002). This model of community training and development to empower rural communities to better recruit health professionals shows early promise. This model could be broadened to include more collaboration of community development and health science disciplines programs for recruitment and retention efforts.