Clinical Standard Work (CSW) is the application of the principles of standardization and continuous improvement to patient care. Seattle Children’s providers and staff work with the Clinical Effectiveness program to create these pathways using existing evidence when available. When evidence is not available, it is determined by team consensus.
In 2010, Seattle Children’s began a hospital-wide initiative to develop and implement CSW pathways for a range of pediatric conditions. Since then, the hospital has implemented more than 50 pathways.
Last year, a team of Seattle Children’s doctors conducted a study to see what effect standardization had on the overall value of care. The results of the study were published March 21 in Pediatrics.
Two members of the team – Dr. Casey Lion, attending physician in General Pediatrics, and Dr. Rita Mangione-Smith, division chief, Division of General Pediatrics and Hospital Medicine – talk more about the study results and what they mean.
Tell me about the background of the study.
Lion: We began this study as part of a hospital-wide commitment to increase the value of care we provide. When you standardize care, you cut down on unwarranted variability. Sometimes variability is needed based on individual patient circumstances, but in order to improve patient outcomes and reduce unnecessary or unhelpful interventions, we we want to provide evidence-based care and standardize our methods as much as possible.
Mangione-Smith: The Seattle Children’s Hospital Board of Trustees made it a huge priority to improve clinical care using these CSW pathways. We created a pathway to standardize the treatment of asthma in 2002 and used that as a model to create pathways for treating other conditions.
Lion: We selected CSW pathways for 15 conditions children are commonly hospitalized for to see if standardizing our methods could improve patient care. At the same time, we wanted to understand whether we’re actually decreasing a patient’s length of stay or chances of re-admission, or reducing costs.
How did you decide which conditions to include in the study?
Lion: Seattle Children’s now has more than 50 pathways for different conditions. We decided to focus on conditions that are the most common causes of hospital admission. These are:
- Urinary tract infection
- Diabetes DKA
- Fractures: femur
- Fractures: supracondylar
- Neonatal jaundice
- Depressive disorders
- Pyloric stenosis
- Tonsillectomy and adenoidectomy
- Disruptive behavior disorders
- Diabetes non-DKA
- Neonatal fever
- Cellulitis and abscess
We studied more than 3,000 children who were treated for only one of these conditions and were otherwise healthy. Children who were treated for one of these conditions but had other health issues were not included.
Mangione-Smith: We conducted this as a retrospective cohort study, examining children admitted for one of the 15 general pediatric pathways between December 1, 2009, and March 30, 2014. We did not include admissions eligible for pathways that predated this time period because no pre-intervention data would be available. We also excluded children with complex, less common subspecialty conditions, such as inflammatory bowel disease. All of the included pathways were implemented during the study time period. We had 3,808 children in the group who were admitted before the pathways were implemented (pre-pathway) and 2,902 who were admitted after (post-pathway).
How did you measure the results?
Mangione-Smith: The main patient-level outcome measures we looked at were total hospital costs, length of stay (LOS) in the hospital, any unplanned 30-day hospital readmissions and physical functioning improvement after hospitalizations. We used hospital administrative data to determine the total charges per hospital stay (excluding physician fees), LOS and unplanned readmissions within 30 days of treatment.
To assess improvement in physical functioning, we used the Pediatric Quality of Life Inventory 4.0 Generic Core or Infant Scales (PedsQL) physical functioning subscale. At Seattle Children’s, we regularly administer the PedsQL survey to families and eligible patients within 72 hours of admission and again two to eight weeks after discharge. We talk to the family about the child when they first come to the hospital and then follow up after they go home to see how they’re doing.
What did the study determine?
Mangione-Smith: We were happy to find that post-pathway care showed a significant decrease in costs over the pre-pathway care – as much as $155 per patient, per month. It also showed a steady decrease in length of stay by about 43 minutes per admission, per month, or 8.6 hours per year. There weren’t major changes in the 30-day readmissions between pre-and post-pathway, but we did notice an increasing trend in the physical functioning improvement scores. Post-pathway, these scores increased by 6.0 points per year exceeding the minimal clinically important difference for PedsQL scores of 4.5 points.
Why are these results important?
Mangione-Smith: We’ve seen in other studies that clinical pathways provide varying degrees of improvement in clinical complications, physician documentation, LOS, and/or hospital costs, depending on the study. The difference is previous studies evaluated only one pathway at a time.
The evidence for the impact of a particular pathway was within a particular context. One of the strengths of our study is that we included patients who received care from a diverse range of pathways. This allowed us to evaluate the entire program of standardized pathway development and the implementation process itself, rather than the elements of a single diagnosis-specific pathway.
Our findings suggest that a process of pathway development, applied across a broad range of diagnoses, can increase the value of health care provided by improving or maintaining clinical outcomes while decreasing LOS and containing costs.
We work hard to keep improving the quality of care we provide to patients at Seattle Children’s. This study shows that using evidence-based, standardized pathways works. It’s a proven way to decrease the cost and length of stay without any negative effects to the patient.
Read the full study.