making As this shared model is incorporated into culture, communication, teamwork, and quality improve, and unnecessary variation and costs decrease Thus, standard clinical processes/pathways and robust targeted measurements can serve as a platform from which a dynamic, continuously learning health care system can be created Clinical pathways provide a mechanism to bring guidelines, evidence, and expert consensus to the health care team using strategies such as new work flows, care models, and technology as well as strategic clinical decision support employing a human factors approach This strategy converts knowledge into actions that can improve patient outcomes Criteria used for strategic pathway development may include highvolume or high-cost conditions, high-complexity conditions, known existing practice variation, availability of existing evidence, guidelines and experts, or known concerns for safety/quality issues The most important characteristic for success is the presence of a will for change A multidisciplinary clinician group is formed with representation from all relevant knowledge experts and stakeholders and led by a strong, credible clinical champion/s best represented by a physician, advanced practice provider, and nurse team Important additional team members include an improvement advisor (IA) and a data analyst (DA) who facilitate the process and steer the project to completion The team uses Children’s Hospital Model for Improvement during development which consists of four phases: Define, Diagnose, Test and Implement, and Sustain and Spread The team reviews existing evidence, guidelines, generates expert consensus, and develops an algorithm that defines the steps in the processes of care Supplementary guidance is provided via hyperlinks to specific decision nodes on the algorithm The algorithm/hierarchical process map becomes the foundation for care; the shared mental model promotes strong teamwork and effective team communication The hyperlinks on the hierarchical process map represent subprocesses which include details of the subprocess and importantly the “why” around the actions The pathway is then imbedded at the point of care This work includes new care models, staffing, training and education, physical layout, supplies, new technologies, and the development of patient and family education materials and electronic medical record (EMR) clinical decision support The pathway is then shared with stakeholders to recruit support and to incorporate important feedback The pathway, including the algorithm, hyperlinks, supporting evidence, important policies/procedures, and websites is then posted on the internet for easy access for all clinicians Each pathway has a decision support in the form of an electronic order set, including prechecked selections that highlight recommended tests and medications and doses appropriate for the particular clinical problem These tools make it easy for the clinician to provide the care recommended in the pathway, but not prevent the provider from making different choices if necessitated by the patient’s unique presentation During the implementation phase, it is recommended that the team perform chart reviews of patients for whom the pathway was used to assure that the recommendations support the clinical care appropriately An easily accessible, explicitly written pathway with strong evidence and known local experts can result in significant standardization of care By reviewing charts and discussing issues, the pathway teams often identify further opportunities for improvement They can then request support from an IA and DA to develop, implement, and measure new interventions to further improve care MEASURING IMPROVEMENT The Pathway Team chooses a few key measures to follow during implementation and improvement Aims, which detail how much improvement is to be made by a targeted date are documented The team designs iterative Plan-Do-Study-Act (PDSA) cycles to test whether changes made in the care delivery process result in improvements At weekly huddles, the team meets to review the most recent data and design the next test of change This process continues until the aim is achieved Monitoring of the process continues to ensure that the change has taken hold Statistical Process Control (SPC) charts are an ideal way to track the process, separating deviation arising from differences in patient presentation (appropriate, common or random variation) and those arising from external practice patterns (inappropriate, special or assignable cause) The goal is to eliminate unnecessary variation across clinicians over time and to retain variation that arises from important individual patient differences Some examples of improvement through this process of bringing evidence and expert consensus to the point of care include: reducing unnecessary albuterol use, chest radiographs and viral respiratory testing for bronchiolitis; reducing use of broad-spectrum antibiotics for acute otitis media and community-acquired pneumonia; reducing the number of unnecessary urethral catheterization in young febrile children; and reducing unnecessary admissions for anaphylaxis Through our efforts over the past decade and a half, we have found this work to be rewarding; it engages clinicians to be curious about their current practices Additionally, sharing what we have learned with our colleagues has sparked interest in pathways-based quality improvement at our own institution as well as at hospitals around the world The Children’s Hospital of Philadelphia pathways are available at https://www.chop.edu/pathways Suggested Readings and Key References Adegboyega KL, Rotter T, Kinsman L, et al What is a clinical pathway? Refinement of an operational definition to identify clinical pathway studies for a Cochrane systematic review BMC Medicine 2016;14:45 Berwick DM The science of improvement JAMA 2008;299:1182–1184 Buchert AR, Butler GA Clinical pathways: driving high-reliability and high-value care Pediatr Clin N Am 2016;63:317–328 Dona D, Baraldi M, Brigadoi G, et al The impact of clinical pathways on antibiotic prescribing for acute otitis media and pharyngitis in the emergency department Pediatr Infect Dis J 2018;37:901–907 Finebery HV A successful and sustainable health system—how to get there from here N Engl J Med 2012;366:1020–1027 Flores EJ, Mull NK, Lavenberg JG, et al Using a 10-step framework to support the implementation of an evidenced-based clinical pathways programme BMJ Qual Saf 2019;28:476–485 Florin TA, Byczkowski T, Ruddy RM, et al Variation in the management of infants hospitalized for bronchiolitis persists after the 2006 American Academy of Pediatrics bronchiolitis guidelines J Pediatr 2014;165(4):786–92.e1 Florin TA, French B, Zorc JJ, et al Variation in emergency department diagnostic testing and disposition outcomes in pneumonia Pediatrics 2013;132(2):237–244 Hipp R, Abel E, Weber RJ A primer on clinical pathways Hosp Pharm 2016;51:416–421 Institute of Medicine 2011 Clinical Practice Guidelines We Can Trust Washington, DC: The National Academies Press; 2011 Institute of Medicine Best Care at Lower Cost: the Path to Continuously Learning Health Care in America Washington: National Academies Press; 2012 Jha A, Pronovost P Toward a safer health care system: the critical need to improve measurement JAMA 2016;315(17):1831–1832 Kaiser SV, Rodean J, Bekmezian A, et al Effectiveness of pediatric asthma pathways for hospitalized children: a multicenter, national analysis J Pediatr 2018;197:165–171.e2 Lashoher A, Pronovost P Creating a more efficient healthcare knowledge market: using communities of practice to create a checklist Qual Saf Health Care 2010;19:471–472 Lavelle JM, Blackstone MM, Funari MK, et al Two-step process for ED UTI screening in febrile young children: reducing catheterization rates Pediatr 2016;138:e20153023 Lee KH Developing a measure of value in healthcare Value in Health 2016;19:323–328 Marshall M, Pronovost P, Dixon-Woods M Promotion of improvement as a science Lancet 2013;381:419–421 Pascale C Human factors system approach to healthcare quality and patient safety Appl Ergon 2014;45:14 Pronovost P Enhancing physician’s use of clinical guidelines JAMA 2013;310(23):2501–2502 ... persists after the 2006 American Academy of Pediatrics bronchiolitis guidelines J Pediatr 2014;165(4):786–92.e1 Florin TA, French B, Zorc JJ, et al Variation in emergency department diagnostic testing... disposition outcomes in pneumonia Pediatrics 2013;132(2):237–244 Hipp R, Abel E, Weber RJ A primer on clinical pathways Hosp Pharm 2016;51:416–421 Institute of Medicine 2011 Clinical Practice... operational definition to identify clinical pathway studies for a Cochrane systematic review BMC Medicine 2016;14:45 Berwick DM The science of improvement JAMA 2008;299:1182–1184 Buchert AR, Butler