what would prove one wrong are critical steps to avoid cognitive errors What else could it be? Is something else going on? Is there anything that does not fit? Seeking feedback on your decisions by following up on patients after admission or discharge and attending morbidity and mortality conferences improve diagnostic ability Continuing to look up information as you practice or after a shift is part of deliberate practice and reinforces the importance of not relying on experience alone CONCLUSION Reflecting on all these elements of quality emergency care for children, we hope this edition of the textbook will serve as a valuable resource for all emergency medicine practitioners with its improved accessibility to key information and attention to quality measures for each clinical condition Suggested Readings and Key References Alessandrini E, Varadarajan K, Alpern ER, et al Pediatric Emergency Care Applied Research Network Emergency department quality: an analysis of existing pediatric measures Acad Emerg Med 2011;18(5):519–526 American Academy of Pediatrics, Committee on Pediatric Emergency Medicine, American College of Emergency Physicians, et al Joint policy statement—guidelines for care of children in the emergency department Pediatrics 2009;124(4):1233–1243 American Academy of Pediatrics, Committee on Pediatric Emergency Medicine Overcrowding crisis in our nation’s emergency departments: is our safety net unraveling? Pediatrics 2004;114(3):878–888 Chamberlain JM, Krug S, Shaw KN Emergency care for children in the United States Health Aff (Millwood) 2013;32(12):2109–2115 Committee on Pediatric Emergency Medicine, American Academy of Pediatrics, Krug SE, et al Patient safety in the pediatric emergency care setting Pediatrics 2007;120(6):1367–1375 Croskerry P, Singhal G, Mamede S Cognitive debiasing 1: origins of bias and theory of debiasing BMJ Qual Saf 2013;22(Suppl 22):ii58–ii64 Institute of Medicine, Committee on the Quality of Health Care in America Crossing the Quality Chasm: A New Health System for the 21st Century Washington, DC: National Academies Press; 2001 Institute of Medicine Emergency Care for Children: Growing Pains Washington, DC: National Academies Press; 2006 Macias CG, Loveless JN, Jackson AN, et al Delivering value through evidence-based practice Clin Pediatric Emer Med 2017;18(2):89–97 Neale G, Hogan H, Sevdalis N Misdiagnosis: analysis based on case record review with proposals aimed to improve diagnostic processes Clin Med 2011;114:317–321 Pediatric Emergency Department Performance Indicators Available online at https://emscimprovement.center/resources/toolboxes/emergencydepartment-pediatric-performance-measures-toolbox/ Accessed April 15, 2019 Weick KE, Sutcliffe KM Managing the Unexpected: Resilient Performance in an Age of Uncertainty 2nd ed San Francisco, CA: Jossey-Bass; 2007 CHAPTER ■ INTRODUCTION TO CLINICAL PATHWAYS JANE LAVELLE, CYNTHIA R JACOBSTEIN, JOSEPH J ZORC, CRYSTAL A COOPER, AILEEN SCHAST BACKGROUND Medical professionals must increase focus on providing health care with high value—that which provides the best outcomes achieved with the least cost Over the past several decades, variation in clinical care has been recognized as a core problem in achieving high-value care Variation results from a number of causes Exponential growth of scientific knowledge has resulted in a “knowing–doing” gap, and despite awareness of this gap, implementation of evidence at the bedside remains poor Clinical practice guidelines (CPGs) attempt to bridge this gap As defined by the IOM 2011 report, a CPG is a statement that includes recommendations intended to optimize patient care, that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options Although CPG have continued to improve over time, they tend to be lengthy, present high-level information, lack detail about specific clinical situations, and not provide information about implementation Additionally, clinical uncertainty persists because available high-quality evidence is able to guide the care of patients only 20% of the time Finally, it is impossible for a single provider to assimilate this available evidence and then consistently apply it to current practice Pronovost identified a second problem to be our failure to view the delivery of health care as a science, which calls out the practical aspect of integrating evidence into the workflows of bedside care efficiently As medical complexity continues to increase, the health care system needs to ensure that it can respond effectively to patients with common problems but also to patients with new/rare problems to assure innovation that will allow outcomes to continue to improve QUALITY IMPROVEMENT THEORY The science of quality improvement provides powerful tools to bring evidence to the bedside and support clinical teams meaningfully at the point of care Principles of process improvement, coupled with organizational/behavioral psychology and the scientific method form the basis of quality improvement theory It directs the management’s focus onto processes and systems rather than individual clinicians, and it provides a set of principles by which teams of clinicians can measure and document the best patient outcomes over time Health care delivery is a process—a series of linked steps designed to achieve certain outcomes The health care system is a series of processes interacting together Through designing process interventions, testing change, and measuring outcomes, quality improvement theories can be applied to health care in meaningful ways and create an environment of continuous learning, where evidence informs practice, but practice measurement can inform future evidence By applying these principles, our health care system can continuously learn and improve APPROACH TO CLINICAL PATHWAY DEVELOPMENT In 2004, in response to the “knowing–doing gap,” the presence of unwarranted variation, and the lack of organized, efficient, patient-centered care systems and optimal team work, the ED at Children’s Hospital of Philadelphia embarked on a road to develop clinical standards, now known as the Clinical Pathways Program A clinical pathway is a structured, multidisciplinary plan of care which can be used to translate guidelines, evidence, and expert consensus into local care structure It details the steps in a care plan as an inventory of actions and aims to standardize care for a specific population, clinical process, or chief complaint Arguably, this standardized process results in more meaningful measurement of outcomes Organizational efficiency, clinical effectiveness, and care coordination can be improved Resource utilization can be optimized to improve value Clinical pathways can support training, orientation, and education Importantly, pathways provide a mental model in the form of a written paradigm for the health care team which sets expectations and can serve as a foundation for effective communication and systematic improvement within the team It is meant to guide clinical decision making for 80% of eligible patients The other 20% of patients require individualized decision ... Clin Med 2011;114:317– 321 Pediatric Emergency Department Performance Indicators Available online at https://emscimprovement.center/resources/toolboxes/emergencydepartment -pediatric- performance-measures-toolbox/...Institute of Medicine Emergency Care for Children: Growing Pains Washington, DC: National Academies Press; 2006... Macias CG, Loveless JN, Jackson AN, et al Delivering value through evidence-based practice Clin Pediatric Emer Med 2017;18(2):89–97 Neale G, Hogan H, Sevdalis N Misdiagnosis: analysis based on