Push past pathway limits to cut resource use
Cutting LOS should be secondary goal, expert says
With lengths of stay (LOS) apparently set to rebound despite the best efforts of case managers, some experts maintain that clinical pathways must be used more as tools to standardize patient care and foster a team approach and less as a way to shave hospital days.
"Reducing length of stay is not a high priority now for pathways, because financial incentives have already driven lengths of stay down," says Patrice Spath, ART, a health care quality and resource management specialist with Brown-Spath and Associates in Forest Grove, OR. "If we want to continue to use pathways as one of our tools, then they’re going to have to meet the needs of tomorrow — and the needs of tomorrow involve reduced resource use."
Spath contends that LOS remains an important variable to measure, but that doesn’t mean pathways have to be structured using the traditional day-by-day time line approach. More useful, she maintains, is a flowchart approach that lets all care providers know what’s expected when a patient presents with a given clinical condition. "I don’t care if it’s day three, day seven, or day 30; the question is whether the patient needs that third chest X-ray," Spath says.
She adds that while pathways can be useful in such discussions of resource use, pathways aren’t always necessary. "It’s the old story of putting the cart before the horse," she says. "Sometimes people want to develop a pathway and that becomes their end goal, when their goal should be instead to reduce unnecessary resource use, streamline processes, or eliminate hand-offs. People continue not to have a good understanding of the goals they’re trying to achieve. They’ve taken the traditional pathway and thrown it at every problem, hoping that it will stick somewhere."
Spath notes that one recent study from researchers at Stanford University Medical Center demonstrated how small hospitals could save money with knee replacement pathways.1 But, Spath points out, the researchers found that most of the cost savings came not from cutting length of stay but rather from standardizing the equipment used. "You can’t just create a pathway that says scrub nurse cleans site and drapes it,’" Spath says. "You’ve got to talk about things like what drapes we are using and how many basins."
The fact is that traditional pathways sometimes have been geared so much toward reducing length of stay that they haven’t really been effective tools when it comes to cutting unnecessary resource use. For example, a traditional hip replacement pathway might list key nursing and physician activities for preadmission, the day of surgery, and postoperative days one and two. (See sample hip pathway, p. 86.) But the pathway doesn’t address the surgical episode of care itself, where much of the resources are spent. "Consequently, a lot of the dollars that we were trying to save really didn’t get saved because we didn’t address the most resource-intensive piece of it," Spath notes.
A more effective approach would be to factor in a perioperative pathway that would actually be used to manage the surgical minutes, streamline the process of care, and ease hand-offs among providers in the operating room. (See sample perioperative pathway, p. 91.) But even the addition of a perioperative pathway won’t automatically lead to cost reductions. To identify and decrease unnecessary resource use, you must analyze what’s really being used in the operating room and what physicians really want and need. "In order to reduce costs, in addition to perioperative pathways, you need to dig into those preference lists and standardize them," Spath says.
Other examples of possible cost-saving measures in the operating room include:
• Suggest/require use of lower-cost pharmaceutical alternatives.
• Restrict albumin use.
• Reduce waste (e.g., medications, supplies, etc.).
• Increase use of low-flow anesthesia.
• Improve control of accessibility to expensive pharmaceuticals.
• Reduce inventory.
For more information, contact Patrice Spath, ART, health care quality and resource management specialist, Brown-Spath and Associates, P.O. Box 721, Forest Grove, OR 97116. Telephone: (503) 357-9185.
Reference
1. Macario A, Horne M, Goodman S, et al. The effects of a perioperative clinical pathway for knee replacement surgery on hospital costs. Anesth Analg 1998; 86:978-984.
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