By Artemis March

Amid our efforts to improve health care quality, we can easily lose sight of the most basic questions. Consider evidence-based clinical guidelines, protocols, and pathways. What are they? How do they relate to each other? What are they trying to achieve?

Guidelines, protocols, and pathways are tools, means to an end, not ends in themselves. At their best, they relate to each other like a skeleton, flesh, and brain. They aim to make the delivery of care seamless by improving the consistency, continuity, and coordination of care.

Relationship Among Guidelines, Protocols, and Pathways
Guidelines are often put forward as high-level recommendations about what to do. They form a skeleton that needs to be fleshed out by protocols detailing the processes and procedures that describe how to implement guidelines in a particular clinical setting. Such protocols empower nurses and medical residents at the bedside. Although hospitals always have protocols, often they are separate and disconnected. Here I am referring to a set of protocols built around a guideline skeleton and linked to each other through that skeleton.

But the multidisciplinary process of developing protocols to flesh out guidelines is not enough to reach the desired level of improvement. Extending the skeleton/flesh metaphor, we also need a brain to run and coordinate clinicians' activities and orders. This becomes especially important when patients are treated across multiple care settings and/or for complex conditions requiring the expertise of many specialists and allied professionals. Clinical pathways are one means of serving this brain function.

Clinical pathways provide a road map for a particular condition's entire care process. They organize the totality of care at a higher level than a set of protocols. Used in this way, pathways represent the integration and coordination of care as worked out by a multidisciplinary team—not in a crisis or dependent on who is on call, but through extensive dialogue among all parties when there is no patient to treat. At its best, the process of developing pathways generates a shared understanding of the reasons participants have coalesced around certain choices, defines their responsibilities, and puts the pieces together in a coherent, non-conflicting way (Table 1)

Table 1. Relationship Among Guidelines, Protocols, and Pathways

Guidelines Skeleton What to do
Protocols Flesh How to do it
Pathways Brain Who is doing it, and why

These tools change both the level and timing of much clinical decision-making:

  • Level: Instead of making all decisions at the level of the individual patient, some decisions are made at the level of the patient population (e.g., asthma patients or those with severe traumatic brain injury).
  • Timing: Instead of relying on the individual in charge to make many key decisions, decisions are made beforehand by representatives from all relevant disciplines.

The result: rather than certain conflicts and problems arising over and over, patient by patient, in crisis after crisis, a consensus is hammered out for each decision point and area of potential conflict. Pathways result from people working out differences in advance and building a road map that integrates consensus interventions.

Goals of Care: 3Cs
What are the ends we are trying to achieve by using these tools? Study after study points to physician behavior as the key factor that needs to change to improve quality. While true, this focus directs our attention to individual clinician behavior, rather than also examining the organizational and structural barriers that shape behavior in hospitals and other health care settings. Our larger challenge is to change the behavior of physicians and get everyone on the same page despite the fragmented structure of health care.

Clinician networks implement guidelines or pathways in considerably different ways, yet they share similar goals. Paramount among these are the "3Cs": consistency, continuity, and coordination of patient care. Those networks that significantly improve outcomes through guideline implementation are able to do so not only because they are making better clinical choices, but because their realignment around a set of protocolized guidelines in itself improves the consistency, continuity, and coordination of patient care.

Consistency of Care Consistency of care means low variability in care from shift to shift, day to day, nurse to nurse, resident to resident, attending to attending, and patient to patient. High variability among practitioners is a major problem throughout the health care system.

Evidence-based clinical pathways, guidelines, and protocols can help reduce wide variations in care, weed out harmful practices, draw attention to critical variables, and prevent inappropriate redundancy. They are the health care equivalent of quality assurance processes in manufacturing. By keeping treatments within a narrow range of practice, the process of care becomes more efficient and the quality of the product—patient outcomes—improves.

Continuity of Care Continuity of care means each shift of caregivers hands off smoothly so that the next shift is well informed about what has been observed and what will need attention. Medical charts are not sufficient: handwriting is often poor, note reading is time-consuming, and caregivers observe and interpret the same patient signs and symptoms in different ways. On the one hand, it is valuable to have different pairs of eyes on a patient—picking up different symptoms and indicators and forming distinct hypotheses. On the other hand, those eyes must still ensure that salient issues and markers are tracked consistently.

Protocolized guidelines can direct each shift's attention to key, evidence-based, agreed-upon indicators identifying parameters that need to be achieved or maintained, describe how to intervene to do so, and say what to do if the interventions have no effect.

Coordination Coordination means working across disciplines to provide unified care to patients. The downside of specialization and independent decision-making is the inadequate attention directed toward the interdependence of bodily systems and potential interactions among drugs and other interventions. Coordinated care means that physicians, nurses, and allied professionals work together to clarify responsibilities, care objectives, and treatment plans, and review prescriptions and their potential interactions. They work together to produce a single, coordinated set of orders.

Clinical pathways and their protocolization are one of the most powerful and efficient means to coordinate care. Coordination is enhanced not only by having these tools in place and ensuring they are followed, but through the process of creating them. An effective, well-facilitated, multidisciplinary development process brings together clinicians who may seldom communicate—making them more aware of their interdependencies and disconnections and allowing them to examine evidence from many angles as the basis for mapping out pathways and/or protocols.

The need for coordination is in proportion to the degree of care fragmentation and the complexity of a patient's situation. Coordination of patient care is so important, and often must be achieved at so many points of potential breakdown, that multiple modes are needed. These might include the processes and outcomes of building pathways and protocols, oversight committees to achieve consistency and coordination of care, and clinical nurse specialists and other specialized integrative roles.

Conclusions and Caveats
Guidelines can help clinicians provide consistent, continuous, and coordinated care—a crucial foundation for all quality improvement efforts.

  1.  From a provider's perspective, coordination across disciplines and among clinicians is needed to provide unified patient care. But, from a patient's perspective, care is seamless only when it is consistent and continuous, as well as coordinated.
  2. The 3Cs model and the brain/skeleton/flesh metaphor are two ways of illustrating the same point. One focuses on the goals of seamless care; the other focuses on a set of tools for reaching them.
  3. Well-implemented guidelines, protocols, and pathways redesign the default care structure for a particular patient population. At their best, these three tools provide clear, well-considered positions from which to deliver care.
  4. These tools must be flexible and responsive to the patient as well as to accumulating bodies of experience and evidence. Excellence in health care requires a balance between redesigned default structures of care and individual patients.
  5. Many decisions can be made for classes of patients, but all decisions ultimately must be tailored to each individual patient and some decisions must start with the patient and/or be made at that level.

 © 2006 Artemis March

Artemis March, Ph.D., M.B.A., is an independent consultant and educator who has created more than 70 diagnostic/learning/change projects for universities, executive education programs, corporate clients, and health care organizations. She can be reached at [email protected].