Clinical Pathways and

Variance Analysis
 What is a clinical pathway?
 A multidisciplinary proactive plan of care for a
specific diagnosis or procedure.
 It is a timeline of patient care activities which
is used by all disciplines for planning,
anticipating, implementing, and evaluating
care.
Why pathways?
 Enhances interdisciplinary collaboration
 Helps to reduce unnecessary variations in patient
care and outcomes.
 Supports development of care partnerships and
empowers patients and their careers.
 A tool to incorporate local and national guidelines
into everyday practice,
 Manages clinical risk and meets the requirements
of clinical governance.
Why does JCI recognize pathways

Pathways reflect care that is –

• Planned
• Standardized
• Organized
• Documented
Why pathways?
Pathways can
improve team
communication
and coordination
of care, thus
preventing
medical errors.
Why pathways?
Pathways can
improve team
communication
and coordination
of care, thus
preventing
medical errors.
How is a TMC pathway developed
1. Pathway topics are chosen from Medical City’s
high-volume, high-risk or problem-prone cases.
2. MQIO forms a multidisciplinary pathway team.
3. The team defines population of patients to be
covered by the pathway.
4. The team drafts the pathway according to
available evidence, including existing pathways
and evidence-based Clinical Practice Guidelines.
The draft pathway specified (a) Time intervals,
(b) Interventions per element of care and (c)
patient outcomes prior to discharge
 How is a TMC pathway developed

5. The team presents the pathway to the concerned

departments and units for approval
6. The team pilot tests the pathway to ensure ease of
use
7. MQIO monitors and evaluates pathway use by
a. Measuring and analyzing variances
b. Making appropriate modifications to the clinical
content
c. Addressing process improvement
What pathways are implemented
in TMC?
• Acute asthmatic attack
• Acute abdominal pain (non-traumatic)
• Chest pain
• Pneumonia (in adults and children)
• Normal birth
• Acute appendicitis
• Acute diarrhea (in adults and children)
• Coronary artery bypass graft procedure
• Sepsis alert
 Parts of a Clinical Pathway

1. Pathway title
2. Inclusion and exclusion criteria
3. Patient’s information
4. Physician’s Notes
a. S: subjective complaints/symptoms
b. O: objective physical and laboratory findings
c. A: assessment/ working diagnosis/ clinical
impression
d. P: plan of care (diagnostic, therapeutic,
rehabilitative, others)
 Parts of a clinical pathway
5. Orders
 Assessment and Monitoring (vital signs, hemodynamic
monitoring, weights, etc)
 Laboratory tests/Tests/Procedures (Routine diagnostic
tests)
 Treatments (medical and nursing orders, dressing
changes)
 Medications/IVS (IV fluids, blood orders, routine
medications)
 Nutrition (Enteral and parenteral feedings, diet and fluid
restrictions, supplemental feedings)
 Parts of a Clinical Pathway

5. Orders
 Activity/Safety (Activity orders and/or limitations (ex. turn
q 2 hours, PT or OT consult/orders)
 Consults (referrals)
 Psychosocial (assurance that illness is self-limiting,
assuring a mother that she can breastfeed, assuring family
that patient’s usual activity may be resumed in 3-7 days)
 Patient/Family Education (hand hygiene, breastfeeding
education, possible sources of infection)
 Discharge Planning (assessment of patient outcomes,
referrals to home or post-operative care)
 Parts of a Clinical Pathway

Orders or interventions may be mandatory or optional

• Mandatory interventions – marked by bullets (•) and
applicable to 100% of the population
– Must be carried out once a pathway is activated
– Don’t need a checkmark to be carried out
– If deemed not applicable to the patient, may be crossed
out and initialed by AP
• Optional interventions – marked by tick boxes () and may
not apply to 100% of the population
– Option box () should be marked with a check () if
the intervention meets the needs of the patient
– If box is left empty, intervention need not be done
 Parts of a Clinical Pathway

6. Pathway activation
- by the attending physician or resident-in-
charge
7. Pathway acknowledgement
- by the nurse-in-charge
8. Variance column
9. Signature column
 Parts of a clinical pathway 1. Pathway title
PHYSICIAN’S ADMITTING ORDER SHEET
For Clinical Pathway ___________________________________________
Inclusion criteria:
Exclusion criteria: 2. Eligibility & exclusion criteria
PATIENT’S NAME BIRTHDATE PIN

LAST NAME FIRST NAME MIDDLE NAME

3. Patient’s data
ORDERS Var Sign
PHYSICIAN’S NOTES
S – Subjective Complaints / Symptoms Admit to ________ under the service of _________

Vital Signs Monitoring:

Diagnostics/ Procedures

O – Objective Physical / Lab Findings

Medication/IVF

Diet/ Nutrition Order

 Parts of a clinical pathway
PHYSICIAN’S ADMITTING ORDER SHEET
For Clinical Pathway ___________________________________________
Inclusion criteria:
Exclusion criteria: 4. Physician’s
PATIENT’S NAME BIRTHDATE PIN
notes (SOAP)
LAST NAME FIRST NAME MIDDLE NAME

ORDERS Var Sign

5. Orders
PHYSICIAN’S NOTES
S – Subjective Complaints / Symptoms Admit to ________ under the service of _________

Vital Signs Monitoring:

Diagnostics/ Procedures

O – Objective Physical / Lab Findings

Medication/IVF

Diet/ Nutrition Order

Activity/safety order
A – Assessment / Working Impression /
Clinical Diagnosis
1.
2 Consults order
3
4

P – Plan of Care Provide for psychosocial needs

Diagnostic, Therapeutic, Rehabilitative, Others

Provide patient/ family education

 Parts of a clinical pathway
PHYSICIAN’S NOTES ORDERS Var Sign
S – Subjective complaints / Symptoms Vital Signs Monitoring:
 Watch out for signs of respiratory failure Bulleted interventions are
 Watch out for complications such as effusion,
pneumothorax, etc mandatory interventions
Do the following lab tests/ procedures:
 CBC  Pulse oximeter reading
 Chest PA, Lateral  TACS
 ABG  Pleural Fluid Analysis
 Blood C/S  Sputum C/S
Please give
 Oxygen inhalation at ________ l / min
 Bronchodilator: _______________________________
Previous antibiotic intake?  Steroid:
Yes.  Zinc
Details_____________________________ Start IV fluids
 No. Interventions with tick boxes
Diet orders
are optional interventions
 NPO
 Aspiration precautions
 Regular diet
O – Objective physical Please start
 oral amoxicillin (for PCAP A / B):

 Penicillin G Sodium (for PCAP C)

 IV Ampicillin (PCAP C):

 Other antibiotics:_________________________
O – Objective Physical / Lab Findings
Medication/IVF

Parts of a clinical pathway

Diet/ Nutrition Order

Activity/safety order
A – Assessment / Working Impression /
Clinical Diagnosis
1.
2 Consults order
3
4

P – Plan of Care Provide for psychosocial needs 6. Pathway

Diagnostic, Therapeutic, Rehabilitative, Others
activation
Provide patient/ family education

Discharge planning orders 7. Pathway

acknowledgment

Activated by : Acknowledged by:

___________________________ ____/____ ___________________________ ____/____
Signature Over Printed Name Nurse-in-Charge
ATTENDING PHYSICIAN /RESIDENT
 Parts of a clinical pathway
PHYSICIAN’S ADMITTING ORDER SHEET
For Clinical Pathway ___________________________________________
Inclusion criteria:
Exclusion criteria: 8. Variance
PATIENT’S NAME BIRTHDATE PIN
column
LAST NAME FIRST NAME MIDDLE NAME

ORDERS Var Sign

PHYSICIAN’S NOTES
S – Subjective Complaints / Symptoms Admit to ________ under the service of _________

Vital Signs Monitoring:

Diagnostics/ Procedures 9. Signature

O – Objective Physical / Lab Findings
column
Medication/IVF

Diet/ Nutrition Order

Activity/safety order
A – Assessment / Working Impression /
Clinical Diagnosis
1.
How are clinical pathways used?
General guidelines in using pathways
 The pathway is a permanent part of the patient’s
medical record.
 The Pathway may be used in lieu of the Care Plan,
Orders and Notes Sheet accomplished by the
medical staff.
 The Nurse in Charge and Attending Physician will
select the appropriate pathway on admission OR
when the interval of care begins.
 The care delivered and patient outcomes will be
managed against the pathway.
 The role of the MD in using
pathways
The MD activates the pathway.
 The AP / resident-in-charge activates the pathway
by signing at the bottom
 Once activated, the pathway shall serve as a pre-
printed doctor’s order set
 The AP’s / resident’s signature signifies approval of
the orders for the time interval.
 Any additional orders which do not appear on the
pre-printed pathway (e.g., medications, IV fluids,
parenteral nutrition, etc) must be written on the
traditional order sheet.
 The role of the MD in using
pathways
The AP / resident-in-charge
 Sees to it that all mandatory interventions are
applicable to the patient
 Cancels any mandatory intervention NOT
applicable to the patient. REMEMBER: you
must initial any canceled intervention.
 Ticks the optional interventions you think the
patient needs
 The Nurse’s role in using pathways:
 The nurse-in-charge assists the AP in selecting the
appropriate pathway.
 Acknowledges activation of the pathway by signing
at the bottom
 Carries out all mandatory intervention that are not
cancelled and optional interventions that are
checked
 writes his / her initials and the time the order was
done on the Sign column
All the other members of the care team have
active roles in using pathways
Accomplishing interventions
 Therapists, nutritionists, residents, interns, and
clerks do all mandatory observations pertaining to
them that are not cancelled and all optional
interventions that are checked.
 Whenever an intervention is accomplished, the care
team member writes his / her initials and the time
the order was done on the Sign column
 The pathway is a great tool for
communicating to your co-workers:

Use the pathway during

 Nursing shift endorsement
 AP rounds
 Rounds by referred doctors
 Chart rounds
 Interdepartmental conferences
 Variances
A variance is
• any mandatory or checked optional intervention that
was not done.
• an abnormal finding
• An unmet outcome within the time frame
• Variances may be noted by any care team member.
• Whenever a variance is noted, the variance code
and initials is written in the variance column.
 Documenting variances
Whoever noted the variance must make a note to
describe the nature and cause of the variance and any
actions taken.
Variance notes may be written in the
 interns’ or resident’s progress notes, if a MD
noted the variance
 nurses’ notes, if nurse-in-charge noted the
variance
A variance monitoring form, documenting all variances
in the pathway, is filled out by the nurse supervisor
after every pathway patient is discharged.
 Documenting variances The Variance column:
where care team
 ER Order Sheet /  INPATIENT ADMITTING ORDER SHEET
members write the
For Pediatric Patients With Community-Acquired Pneumonia Variance code
on criteria: Patients 3 months to 5 years with cough, tachypnea and / or chest indrawing;
on criteria: chronic lung disease, chronic heart disease, malnutrition, neurological disorders, malignancy,
o-suppressed conditions, asthma, transferred and/or admitted from another hospital
NT’S NAME ATTENDING PHYSICIAN DEPARTMENT

ST NAME FIRST NAME MIDDLE NAME

PHYSICIAN’S NOTES ORDERS Var Sign

bjective complaints / Symptoms Vital Signs Monitoring:
 Watch out for signs of respiratory failure
 Watch out for complications such as effusion,
pneumothorax, etc
Do the following lab tests/ procedures:
 CBC  Pulse oximeter reading
 Chest PA, Lateral  TACS
 ABG  Pleural Fluid Analysis
 Blood C/S  Sputum C/S
Please give
 Oxygen inhalation at ________ l / min
 Bronchodilator: _______________________________
us antibiotic intake?  Steroid:
 Zinc
_____________________________ Start IV fluids

Diet orders
 NPO
 Aspiration precautions
 Regular diet
 VARIANCE CODES
A. Patient/family 1. Patient’s medical condition
2. Patient/family decision
3. Patient/family availability For example,
4. No funds if a mandatory
5. Other reasons
B. Physician 1. Medical order
test is not
2. Provider(s) decision done because
3. Provider(s) response time the patient has
4. Other reasons no money yet,
C. TMC System 1. Results/Data availability the cause of
2. Supplies/Equipment related
3. Appointment Availability
that variance
4. Weekend/Holiday is encoded as
5. Other reasons “A4”.
D. Outside TMC 1. Transportation availability
2. Home Care availability
3. Other reasons
 How to analyze pathway
variances
1. Identify critical pathway orders. These are the
orders which, if not carried, will significantly
put the patient at risk for harm.
2. Using the variance monitoring form, count the
number of variances that occurred in the critical
pathway orders.
3. Perform RCA to determine causes of variances.
4. Pilot test countermeasures.
5. Monitor variance counts and note if they
decrease over time..
 Outcomes
• The measurable outcomes that a patient is
expected to experience is specified in the pathway
for every time interval (e.g., daily, per shift).
• Because outcomes are pre-determined, the
pathway can prompt any member of the care team
to call the attention of the AP if the expected
outcomes are not achieved within the time
interval. Thus, interventions can be modified,
added, discontinued in a timely way.
 Reviewing outcomes:
MD’s role
All care team members must review the problem list,
variances and outcomes daily. Pathways ensure that
the members of the care team are looking at the same
plan of care.
 AP and all referred MDs are accountable for
reviewing the patient’s progress against intermediate
and discharge outcomes on a daily basis.
 And for revising the plan of care based on the review
of patient’s outcomes.
 Reviewing outcomes: nurse-in-
charge’s role
 Reviews patient’s progress daily against
intermediate and discharge outcomes
 Review variances daily and report them to the
AP and the rest of the care team.
 Ensures that all variances result in re-
evaluation of plan of care by appropriate
disciplines.
 Reviewing outcomes
 A met outcome – should be initialed; no other
documentation necessary
 An unmet outcome – consider as variance
 Outcome not met within time frame - may require
adjusting the intervention
 Variance due to unmet outcome – describe in
progress notes in SOAP format
 Outcome met earlier than expected – a positive
variance; document/initial on the date it was met
 Discontinuing the pathway
The pathway will be discontinued whenever:
 The patient’s primary diagnosis changes
 The patient’s condition significantly worsens
 The patient fails to meet clinical outcomes for 24-48
hours
To discontinue the pathway, a progress note (SOAP) is
written by the MD outlining the patient’s new plan of
care and new orders. A new nursing plan of care is
also written. The pathway is then filed in the patient
record.
 Keys to pathway success
 Make pathways part of your quality program.
 Ensure strong collaboration between all relevant
disciplines, with a strong medical lead.
 Select appropriate medical conditions in making
pathways.
 Base the pathway orders on best available evidence
/ best practice.
 Collect and analyze variances and involve the staff
in interventions to decrease variances.
 Incorporate adherence to pathway policies in
performance appraisal of all staff members.
 Are you a pathway warrior?
1. A pathway is
a. A time-bound clinical algorithm
b. A standard treatment protocol with pre-specified outcomes
c. A pre-printed order set
d. All of the above
Answer: D
2. A pathway is completely activated by
a. The nurse in charge
b. The attending physician
c. The emergency room physician
d. All of the above
Answer: D. Complete activation requires approval by the managing
physician and acknowledgment by the nurse in charge.
 Are you a pathway warrior?
3. The following personnel must write his/her initial and time done next to
each pathway order after it has been done:
a. Resident in charge or on duty
b. Nurse in charge
c. Intern in charge or on duty
d. All of the above
Answer: D.
4. If an additional order not on the pathway is desired, such an order must
be written
a. On the pathway
b. On the standard Order Sheet
c. On the Progress Notes
d. Any of the above
Answer: B
 Are you a pathway warrior?
5. Who reviews the pathway daily?
a. Nurse In Charge
b. Resident In Charge
c. Intern In Charge
d. All of the above
Answer: D
6. A variance is recorded as a variance code in the variance column when
a. A lab test is not done during the care interval
b. An outcome is not met during the care interval
c. A treatment is not done during the care interval
d. All of the above
Answer: D
 Are you a pathway warrior?
7. Which of the following pathway/s is/are implemented in TMC?
a. Coronary artery bypass graft
b. Pneumonia in children
c. Normal birth
d. All of the above
Answer: D
8. If the admitting staff fails to activate a pathway in a patient whose
condition is covered by a TMC pathway, what should be done on the
succeeding hospital days?
a. continue writing orders on the standard Order Sheet
b. look for the admitting staff member so that a pathway can be
activated in retrospect
c. activate the pathway on the succeeding days
d. do not activate the pathway anymore
Answer: C. Even if the pathway has not been activated upon admission,
the patient can still be managed according to pathway orders on
succeeding days provided he meets the inclusion criteria
 Are you a pathway warrior?

8 out of 8 – your patients are cared for in an evidence-

based, standardized fashion
6 or 7 out of 8 – your patients are nearly at par with those
in other JCI accredited hospitals
4 or 5 out of 8 – some of your patients are not being cared
for according to world class levels of quality
2 or 3 out of 8 – you can improve the quality of your
patients’ care!*
0 or 1 out of 8 – let us try again*
* Please go over the slides again.
 This SIM Card certifies that

______(please overwrite with your name, thank you)__, MD

has successfully completed the
Self Instructional Module on
Clinical Pathways.
(Sgd) Dr Alfredo Bengzon (Sgd) Dr Jose Acuin
President and CEO Director, Medical Quality Improvement