The Development of a Clinical Pathway for COPD
Please note the following:
- As a student, you are prohibited from administering pre/post-tests, conducting surveys or questionnaires, collecting or analyzing private/public data, evaluating outcomes, soliciting feedback, and/or auditing medical records.
- Avoid the use of first person. Examples of first person are the following: I, me, we, our, and us. You may refer to yourself as the author or the student.
The Development of a Clinical Pathway for COPD
Your topic selection should align with your specialty track. If you are in the leadership and management track, then your project should align with this specialty. If you are in the education track, then your project should align with this specialty.
Clinical/Organizational Problem
Identify a nursing problem within your organization that needs to be addressed with an evidence-based practice change, quality improvement, or innovation. Provide a clear description of the background to the problem with enough contextual detail to establish why it is important.
Virtua Health has a significant opportunity to improve patient care and decrease cost of care for the COPD population. High cost of care drivers are generally grouped into two categories, clinical practice variations and operational inefficiencies. Identified were opportunities to reduce clinical variation and the need for a standardized process to address key cost drivers.
Description of Problem
Provide a description of why the identified problem requires an evidence-based practice change, quality improvement, or innovation.
Individual drivers often materialize through key performance indicators (KPIs) in the form of increased patient length of stay and high standard deviation in direct cost per COPD encounter.
Explanation of Causes
Describe the factors, issues, or phenomenon that helped to create the problem. What are some causes of the problem? What factors contribute to the problem?
The lack of clinical pathways is a major driver of variance, likely contributing to unnecessary testing, increased drug utilization, increased clinical supplies and consults leading to extended days and increased cost. The lack of a clinical pathway is contributing to overutilization of medication due to prolonged treatment duration and waste due to inappropriate dosing of medication. It also contributes to incomplete medication reconciliation leads to lack of consolidation of original patient medications with new medications. It also contributes to the use of brand name vs generic medications, administration of intravenous medication vs oral medication, and physician preference medications with similar clinical efficacy but higher cost compared to alternative medications within same drug class. The lack of a clinical pathway is also contributing to inappropriate level of care, for example the use of Intensive Care Units in situations where patient warrants acute medical unit. It also contributes to unsuitable monitoring methods such as cardiac monitoring for patients in which is not clinically indicated, or is no longer required. Also contributing to request for radiology or lab tests without appropriate clinical indication, for example, serial chest X-rays continued after clinical necessity and daily labs without clinical necessity. The lack of clinical pathways contributes to duplicative tests without appropriate clinical indication, for example, echocardiogram performed on previous admission with change in symptoms. It also contributes to test performed outside of clinical indication, for example, mammograms when a patient admitted for unrelated medical diagnosis. The lack of a clinical pathway contributes the use of clinical supplies when not clinically indicated, for example, long-term oxygen therapy in stables patients used when not clinically indicated.
Identification of Stakeholders
Your stakeholders are people internal or external to your organization who have a key interest in or can have a significant impact on your proposed change. Examples of stakeholders include, but are not limited to patients, nurses, physicians, administrators, support or ancillary care staff, family members, volunteers, etc. You will need to include the positions or roles each of the stakeholders hold in your discussion.
- Physicians:
Interest:
Power
Influence
- Medical Director
Interest:
Power
Influence
- Vice President of Integrated Care Management
Interest:
Power
Influence
- Director of Nursing
Interest
Power
Influence
- Nurse Manager
Interest
Power
Influence
- Staff Nurse
Interest
Power
Influence
- Quality Director of Integrated Care Management
Interest
Power
Influence
- Pharmacist
Interest
Power
Influence
- Financial Representative
Interest
Power
Influence
Discussion of Stakeholders
This section involves a more detailed discussion about the specific interest, power, and influence that each stakeholder has in relation to your proposed change. For example, hospital administration or the administration of a university can be a stakeholder. The stakeholder would have a heavy interest in any changes made within its facility and has the power to approve or deny your project. Physicians, practitioners, or nurses may have a positive or negative influence on your project. Informal leaders also have power and influence. Speak to all 3: interest, power, and influence for each stakeholder, and explain why or why not the stakeholder possesses each trait.
Explanation of Project
This is a purpose statement that should align with the problem, with an aim to improve or alleviate the problem. This section should include a detailed description of what the proposed evidence-based project will accomplish.
Design a care pathway by applying high impact drivers of variability to COPD to enable targeted reduction to root causes of high cost of care. The Care Pathways will outline daily activities to be performed by the care delivery team members.
Proposed Solution
This section involves presenting a description of your proposed evidence-based project. The description must include specific information about what you intend to propose or implement. The proposed solution should include who will be involved, what will be done, and w here your project will take place. This represents the “What” of your project - the general plan.
To remove the barriers that prevent timely discharge and increase a patient’s length of stay (LOS) beyond what is medically necessary.
Evidence Summary
The evidence summary is preliminary support for the proposed evidence-based project. This involves a narrative discussion (synthesis of ideas), in paragraph format, identifying the areas of consensus among researchers. Consider the common themes or best practices among the group of articles. Write a broad statement describing one common theme/best practice identified in the literature review. Follow this statement with at least one sentence per research article supporting that common theme/best practice. In this sentence, summarize or paraphrase the researchers’ conclusion, including an in-text citation. Continue adding common themes/best practices along with evidence to support the statement. Use citations to support your assertions and be sure that all 5 articles are cited at least once. NOTE: Peer-Reviewed
Sources/Reference List. According to APA, all references should be listed within the
References section and not in the body of the paper.
Plan of Action
This section should provide a detailed plan of action. This is the “How” of your project and must have great detail. You will need to provide information about the specific steps that will be required to complete your Capstone project. You will discuss what you will independently develop and deliver. This section may also include a description of meetings and agreements (support commitments or negotiations) in preparation for your project, your literature review, your development plan and content, your delivery plan, and your post-delivery discussions with stakeholders. While a full launch is not required, you must create a scalable deliverable.
Timeline
Your timeline will involve correlating each of the steps discussed in your plan of action with a week or weeks in your timeline of when you plan to accomplish each step (do not use specific dates). You should keep your timeline between 4-6 weeks, and your timeline should be in accordance with your organization’s timeline and within your term. Remember the implementation activity that you will focus on may only include the first step of a full scale implementation plan. For example, Week 1 of the project will include…. Weeks 2-4 will involve….. Week 5 will involve, etc.
| Week 1 | · Secured Preceptor (VP of ICM)
· Meeting with Preceptor · Meeting with Quality Director, Financial Representative and Preceptor · Developed a Plan |
| Week 2 | · Conducted Literature Reviews
· Met with Director of Nursing, Nurse Manager and Staff Nurse to review order sets for COPD. · Met with Stakeholders |
| Week 3 | · Selected Best Practice
· Selected Change Theory · Developed Clinical Pathway · Created Power Point · Presented to Stakeholder and received feedback |
| Week 4 | · Updated Clinical Pathway after additional feedback received |
| Week 5 | · Met with Stakeholders reviewed Clinical Pathways and Order Sets for COPD |
| Week 6 | · Implementation process begins |
Resources and Personnel
This section involves a narrative discussion about any resources required for your Capstone project. Resources may include equipment, meeting rooms, etc. Personnel will include an explanation of the roles of any individuals that you may need to assist you in the development and implementation of your project.
Proposed Change Theory
This discussion should identify the specific change theory or model you have chosen to guide and inform your project. You will need to include the details of the change theory you believe will be most effective in guiding your change process. You will also discuss how the steps or concepts of the Change Theory/Model correlate with the actions/activities involved in your project. In-text citation(s) are required in this section.
Barriers to Implementation
This section involves a detailed discussion about potential barriers you may encounter with the implementation of your project: resistance to change, organization culture, time, etc.
- Staff Responsibilities: Ensure clinical and administrative staff are allocated appropriate time in their schedules to perform identified responsibilities to support initiatives, against competing priorities.
- Employee Engagement: Obtain buy-in from clinical and operational teams to support initiative; refine initiatives for teams to contribute to initiative design and better drive towards objective.
- Accountability: Provide education to ensure stakeholders understand importance of accountability, together with knowledge of monitoring tools, metrics and KPIs.
- Technology Requirements: Ensure dashboards, electronic reports and alerts are operating effectively, and appointed individual overlooks and monitors these
- Initiative Design and Development: Align on timeline for initiative design, development and implementation. Consider pilot methods prior to organization-wide changes
- Ongoing compliance monitoring: Ensure responsible individual and committees are utilizing performance results effectively to identify variation from targets, and escalate/ address accordingly
References
Please note that this document outline is only a guide. The written paper, including all in-text citations, must be written in proper APA 6th style. All references (sources) should be identified using in-text citations in the body (narrative portion) of the paper. All of the sources included in the body of the paper should be included in the References section.
Brij, Seema O., Chatterji, Sumit & Marquette, Malcolm. (2016). Chronic Obstructive Pulmonary Disease (COPD) Clinical Pathways in Emergency Medicine, 245-257. doi:10.1007/978 81-322-2710-6_19 New Delhi: Springer Nature America, Inc.
Huang, Zhengxing, Dong, Wei, Ji, Lei & Duan, Huilong. (2016). Predictive monitoring of clinical pathways Expert Systems with Applications, 56, 227-241. doi:10.1016/j.eswa.2016.02.052
Mull, Nikhil, Leas, Brian, Lavenberg, Julia, Patel, Neha, Williams, Austin, Umscheid, Craig & Mitchell, Matthew. (2017). OP68 An Evidence-Based Clinical Pathways Program Reduces Low-Value Care International Journal of Technology Assessment in Health Care, 33(S1), 29-30. doi:10.1017/S0266462317001490
Plishka, Christopher, Rotter, Thomas, Kinsman, Leigh, Hansia, Mohammed Rashaad, Lawal, Adegboyega, Goodridge, Donna, Penz, Erika & Marciniuk, Darcy D.. (2016). Effects of clinical pathways for chronic obstructive pulmonary disease (COPD) on patient, professional and systems outcomes: protocol for a systematic review Systematic Reviews, 5(1), 135. doi:10.1186/s13643-016-0311-8
Shabaninejad, Hosein, Alidoost, Saeide & Delgoshaei, Bahram. (2018). Identifying and classifying indicators affected by performing clinical pathways in hospitals: a scoping review International Journal of Evidence-Based Healthcare, 16(1), 3-24. doi:10.1097/XEB.0000000000000126
Thomas Rotter, Christopher Plishka, Mohammed Rashaad Hansia, Donna Goodridge, Erika Penz, Leigh Kinsman, Adegboyega Lawal, Sheryl O’Quinn, Nancy Buchan, Patricia Comfort, Prakesh Patel, Sheila Anderson, Tanya Winkel, Rae Lynn Lang & Darcy D.
Marciniuk. (2017). The development, implementation and evaluation of clinical pathways for chronic obstructive pulmonary disease (COPD) in Saskatchewan: protocol for an interrupted times series evaluation BMC Health Services Research, 17(1), 1-7. doi:10.1186/s12913-017-2750-x
