This month, Artemis March, Ph.D., M.B.A., an independent consultant who has studied change processes in health care systems, challenges us to examine the roles of clinical guidelines, protocols, and pathways in quality improvement.
Clinical guidelines, she writes, are recommendations about the most appropriate clinical choices, treatments, and care of people with specific diseases and conditions. Based on the best available evidence, they usually reflect a consensus that has been reached or approximated by experts on the care of a particular patient population. Protocols, in contrast, are detailed procedures for how to implement guidelines, and pathways are broader frameworks for organizing the care of patient populations, such as patients with asthma or traumatic brain injuries. Protocols focus on what is to be done and pathways focus on who should do it, and when it should be done.
In her recently published Fund report, Facilitating Implementation of Evidence-Based Guidelines in Hospital Settings: Learning from Trauma Centers, March suggests that these tools can help to narrow the gaps between disciplines and foster a culture of quality within health care organizations. She focuses on the process of implementing clinical guidelines for severe traumatic brain injury (TBI). Because TBI often involves injury to multiple body systems that must be treated and managed by many clinicians, it presents considerable challenges for clinical guideline implementation. Her study identifies barriers to compliance with traumatic brain injury guidelines and describes how three trauma centers lowered or overcame them. Based on this analysis, March draws out 14 strategies for success and presents a model that directs our attention to the goals of guidelines, protocols, and pathways: consistency, continuity, and coordination—the "3Cs" of seamless patient care.