Chapter 2

CEIS Health Report 2006
3.7.2 Healthcare management by processes
During the last decade, there has been a rising interest on clinical pathways 4 and tools,
initially applied in an inpatient setting, that allow for the representation of activities,
resources and expected outputs for each time flag that marks the progress of a process,
as it develops throughout a determined organization. Those integrated plans of care are
a basis for tracking variance that normally takes place in everyday practice, in a continuous
quality improvement fashion.
For developing a care pathway, representatives from the different professions or disciplines
produce a single draft with the support of staff (from quality or controlling staff, or
from medical direction), that usually looks like the one presented in the table 5 .
The columns distinguish the main phases of the pathway, together with the setting and
timing for the completion of each episode. Details of the characteristic activities are
reported beneath each column, organized by care categories, and expected intermediate
outcomes.
The care pathway is therefore the tool underlines the best productive process of a determined
organization (reference pathway) and that allows, through the systematic evaluation
of the variance that arise benchmarking on it the management of single patients (real
pathways), to promote continuous quality improvement 6 .
Process knowledge is the basis for benchmarking the pathways and professional standards
of other organizations from guidelines (in the form of recommendations), from
scientific literature or from Clinical Governance programs. That benchmarking itself can
bring to a completely different pathway (target pathway) which, in order to be implemen-
4 Many studies have evidenced that, during the Nineties, clinical pathways acquired a growing popularity in the USA, Australia,
the UK, the Netherlands and Belgium, and in many western countries. The same movement has been endorsed, in the last decade,
by the Italian National Health Service. The interest towards care pathways has been determined by the growing number of
early applications both with national and regional plans and regulations. National laws established the duty to develop clinical
pathways since 1996, and all regional Health Plans have been asking health trusts and districts to fulfil that objective with
regard to specific diseases and interventions. The development and auditing of integrated healthcare plans with the aim of promoting
continuous quality improvement is required by ISO certification, the European Foundation for Quality Management
model (EFQM), Italian public institutional accreditation and by the Joint Commission model (JCAHO - JCI).
5 Usually, this representation of the pathway is the same used for monitoring purposes, tracking variances on single patients on
separate sheets together with the reasons why they occurred (patient’s specific conditions or compliance, organizational problems,
professional choices due to the perception of determined opportunities or risks…). Activities can therefore be detected that arise
too early or too late, missing activities, activities that take place in ways and with times which differ from the expected and, last
but not least, a variance is tracked each time the patient does not meet expected outcomes, and all that this implied in the management
of his/her pathway.
6 In practice, two different approaches have been spreading about the way a continuous improvement cycle can get started on a
care pathway. One of them starts from the recognition of the different ways a process actually performs and chooses the best; the
other starts from the statement of standards the process should assure and subsequently deploy it on organizational constraints
and actual performance. In both cases, knowledge of the different disciplines and scientific research results determine the contents
and in which ways they should be used in the pathway; having at the same time a clinical, organizational and economic relevance.
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