CLINICAL PATHWAYS

Dewi Lestarini
 STANDAR PELAYANAN KEDOKTERAN
• UU No 29 th 2004 ( UUPK) § 44
(3)

• PERMENKES 1438 TH 2010 Standar

KE
MK Pelayanan Kedokteran (SPK)
ES
• Pedoman Nasional Pelayanan
OP Kedokteran (PNPK) PANDUAN PRAKTIK KLINIS
Dapat dilengkapi
• Standar Prosedur Operasional • CLINICAL PATHWAY
RS (SPO) • ALGORITME
• PROTOKOL
• PROSEDUR
• STANDING ORDER
DEFINISI
• Clinical Pathway (CP) atau alur klinis adalah tatalaksana multidisiplin
dengan pemeriksaan dan intervensi pada kurun waktu tertentu.
• Algoritme adalah format tertulis berupa flowchart digunakan untuk
pengambilan keputusan.
• Protokol adalah panduan tatalaksana untuk kondisi tertentu.
• Prosedur tindakan adalah tatacara melaksanakan tindakan dengan
penjelasan rinci dan sistematis sesuai langkah langkahnya
• Standing order adalah tindakan yang didelegasikan oleh DPJP kepada
dokter/ perawat yang sedang bertugas untuk mengatasi kondisi
darurat
SUMBER :Peratuan Menteri Kesehatan RI No 1438 /PER/X/2010
DEFINISI CLINICAL PATHWAY
• The first use of the term ‘clinical pathway’ was in 1985 by Zander,
Etheredge, and Bower (1987) at the New England Medical Centre (De
Bleser, Depreitere, de Waele, Vanhaecht, and Vlayen, 2006).
• deLuc et al. (2001) found 17 different terms which denoted the concept of
‘clinical pathways’, and discussed that the most common terms were ‘care
pathway’, ‘critical pathway’, ‘integrated care pathway’ and ‘care map’.
• De Bleser, Depreitere, de Waele, Vanhaecht, and Vlayen (2006) conducted
a literature review with the aim to ‘survey the definitions used in
describing the concept and to derive key characteristics of clinical
pathways’.  found 84 different definitions of a clinical pathway between
2000 and 2003.
 DEFINISI CLINICAL PATHWAY
• Kinsman, Rotter, James, Snow, and Willis (2010)  literature review 260 paper
• The intervention was a structured multidisciplinary plan of care.
• The intervention was used to channel the translation of guidelines or evidence into local
structures.
• The intervention detailed the steps in a course of treatment or care in a plan, pathway,
algorithm, guideline, protocol or other ‘inventory of actions’.
• The intervention had time-frames or criteria-based progression (that is, steps were taken
if designated criteria were met).
• The intervention aimed to standardise care for a specific clinical problem, procedure or
episode of healthcare in a specific population.

If an intervention satisfied the first, and then any three of the remaining
four criteria, then it was classified as a clinical pathway.

Emma Aspland , Daniel Gartner and Paul Harper , Clinical pathway modelling: a literature review . HEALTH SYSTEMS
2021, VOL. 10, NO. 1, 1–23 [Link]
CLINICAL PATHWAYS
• Clinical Pathways map out the sequence, timing and expected
outcomes of care for patients with a similar diagnosis or who are
undergoing a similar procedure.
• Clinical Pathways standardise care so that all patients are provided with
the same high quality care, that is timely and cost-effective and enable
the documentation of changes in care, as a result of the patient's health
status.
• Clinical Pathways are used in the following areas
• high cost: hip and knee arthroplasty
• high risk: vascular procedures
• high volume: day surgery
• high interest: mental health.
• Clinical Pathways are suitable for approximately 70% of the population
undergoing a particular procedure or treatment.
Queensland Government. A Toolkit for Developing a Clinical Pathway
 Legal considerations
Using Clinical Pathways has a number of advantages and benefits, which include:
 promoting patient focussed care because patients can participate in what is planned and can give feedback on
whether outcomes have been achieved
 providing for patient education and the provision of information regarding care provided
 facilitating collaboration within the multidisciplinary team in the continuum of care
 identifying tests and investigations to be ordered and completed
 documentation is by exception which reduces duplication within the clinical record
 facilitating the introduction of care and treatment practices that are based on best available evidence adapted to
suit local conditions
 discharge planning is introduced at time of admission and reviewed daily
 reducing documentation. Documentation relating to the patient's care is held at the bedside in a single document
and eliminates duplication of documentation.
 reducing costs and maximising the use of resources, for example minimise unnecessary tests or procedures.
 providing a guide to the care of patients with particular conditions
 providing a legal record for the care provided
 facilitating the collection of clinical indicator data.
 Need for Obtain management Form a multidisciplinary Gather relevant data (pre-
Clinical support and ongoing group with key test) prior to pathway
Pathway commitment from stakeholders (involve the development. Establish if
Identified clinicians and PPT) and nominate there is an existing QH
Update any deficits management project officer (if pathway
in the pathway and necessary)
ACTION
continue
implementation Establish aims, and
PLAN outcome measures for
Supply analysis of evaluating pathway
the outcomes to the
steering committee Clinical Pathway
and the facility
Development Process Collect data evidence for
Flowchart YES pathway clinical
design
Repeat audit Analyse audit
at timely content and design
and survey
intervals users
DO NO
Audit pathways Commence use/ Provide education Obtain quotes for Select a date to start
to establish trial of pathway to clinical staff who printing of pathways using pathway,
compliance and according to will be using involve PPT staff develop timelines for
suitability of planned start pathway – include implementation Gantt
pathways time online education chart
PENYUSUNAN
PPK
MEDIS

PANDUAN PROSEDUR
FARMASI TINDAKAN

CP
ASUHAN PANDUAN
KEPERAWA GIZI
TAN
LANGKAH PENYUSUNAN PPK dan CLINICAL PATHWAY

PPK CP

• PERSIAPAN 1
• PEMILIHAN CP
1
• PENYUSUNAN
3
• PENYUSUNAN 2

3
• UJI COBA
4
• IMPLEMENTASI
4
• IMPLEMENTASI
5
• EVALUASI • EVALUASI
5

6
• TINDAK LANJUT • TINDAK LANJUT
6
 PRINSIP FORMAT
PRINSIP FORMAT PPK CLINICAL PATHWAYS
1. Pengertian
2. Anamnesis • WHY : Mengapa dipilih judul, kriteria
3. Pemeriksaan fisik inklusi dan ekslusi
4. Kriteria diagnosis • WHAT : Diagnosis
5. Diagnosis Kerja • WHERE : RS/tempat pelayanan
6. Diagnosis Banding
7. Pemeriksaan • WHEN ; Rencana sesuai waktu yang
Penunjang ditentukan
8. Terapi • WHO ; Pelaksana
9. Edukasi • HOW : Uraian rinci observasi klinis,
10. Prognosis pemeriksaan penunjang,
11. Kepustakaan tatalaksana
SUMBER :PERMENKES No 1438/MENKES/PER/IX/2010
TUJUAN EVALUASI CP
• Mengetahui apakah CP tersebut mampu laksana
• Mengetahui varian yang terjadi apakah kasus tersebut sudah
dilakukan sesuai dengan CP, baik dalam hal tatalaksana serta jadual
pelaksanaannya
• Mengetahui apakah CP sudah dapat merupakan kendali mutu dan
biaya
• Sebagai dasar dalam melakukan evaluasi kinerja terhadap staf
medis, keperawatan dan pemberi layanan kesehatan lainnya
PRINSIP TINDAK
EVALUASI LANJUT
VARIAN
DIAGNOSIS

VARIAN
LABORATORIUM, • Upaya
• PENYEBAB MENINGKATKAN
VARIAN RCA KEPATUHAN
VARIAN • AUDIT MEDIK • REVISI PPK &CP
RADIOLOGI

VARIAN
TERAPI

VARIAN LOS
Variance Tracking and Analysis in a Clinical Pathway Program

• Variance has been defined as “any deviation from the proposed

standard of care listed in the pathway"
• Zander, “Variance is the difference between the item stated, within
the time period stated and the actual event."
• Reporting of a variance within a pathway is the first step in activating
and implementing an intervention.
• Use of variance also acknowledges the individuality of the patient.
• Variance recording is an essential part of the documentation involved
in a clinical pathway as it can capture the individuality of the patient,
clinician or organisation and adds to the flexibility of the document.
Variance Tracking and Analysis in a
Clinical Pathway Program
Negative variances can occur when:
• A patient does not meet the predetermined outcome of the
pathway, whether due to their own choice or condition
• There are delays in meeting expected outcomes
• Any unexpected intervention is needed to move the patient along
the pathway or
• Any planned or expected interventions do not take place
Variance Tracking and Analysis in a
Clinical Pathway Program
 Positive variances can occur when:
 A patients’ progress / recovery is shorter than anticipated
 An intervention or care component is not required for an individual patient
 Selected interventions or resources (such as pain relief) are unnecessary
 An intervention results in the patient being discharged earlier
Variance Tracking and Analysis in a
Clinical Pathway Program
• Analysis of variance also provides vital information for continuous
quality improvement in health care in that it can lead to change in
practice or change in the pathway.
• If clinical pathways are tools for improving patient outcomes by
guiding care along the best evidence available then variance tracking
and analysis become the tools for ensuring that continuous quality
improvements are attained.
• It can also provide the database for research and evidence base for
change in practice.
 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.