Integrated Care Pathways - NHS Wales

1 National Leadershipand Innovation Agencyfor HealthcareAsiantaeth GenedlaetholArweiniad ac Arloesoldebdros Ofal IechydEdited by Nicola DavisIntegratedCare PathwaysA guide togood practicePublished by:National Leadership and InnovationAsiantaeth Genedlaethol Arweiniad acAgency for HealthcareArloesoldeb dros Ofal IechydInnovation HouseTy ArloeseddBridgend RoadFfordd PenybontLlanharanLlanharanCF72 9 RPCF72 9 RPWalesCymruPhone (+44) 1443 233 333Ff n (+44) 1443 233 1-905456-01-8 Crown Copyright 2005 Design: Ridler Webster Limited, SwanseaSeptember 20051 ForewordThe purpose of The Integrated care Pathways Guide to GoodPractice is to assist clinical teams with the implementation ofIntegrated care Pathways (ICPs) in Wales . This Guide is thelegacy of the ICP Network that was supported by Innovations inCare at the Welsh Assembly Government from June 2003 toOctober 2004.

2 The Network was widely attended byrepresentatives from across all NHS Trusts, Local Health Boardsand the wider health community. This Guide is intended toensure that there is equity in the development of ICPs acrossWales and gives the reader helpful suggestions to develop andestablish successful and sustainable for Life1has set the NHS some challenging targets for the next tenyears as we work to create world class health care and social services for development of Integrated care Pathways will be central to achieving thosetargets. AcknowledgementsWe would like to thank Allan Cumming (Associate Director for ServiceDevelopment, National Leadership and Innovation Agency for Healthcare) forhis support to the Network and the publication of this guide. We also thank theNetwork for their assistance in producing this ICP Good Practice Guide andJayne Gibbs for all the administrative support Authoring team Nicola Davis, ICP Development Manager, Swansea Local Health Board(formerly ICP Programme Lead, Innovations in care ) Grace Sansom, ICP Development Manager, Swansea NHS Trust Sian Jones, ICP Manager, Cardiff and Vale NHS Trust Kellie Jenkins, Deputy Clinical Governance Manager, Pontypridd andRhondda NHS Trust Lucy Roberts, ICP Co-ordinator,North East Wales NHS Trust and Wrexhamand Flintshire Local Health Boards Debbie Doig-Evans, ICP Facilitator, Conwy and Denbighshire NHS Trust.

3 Nia Richards, Sevice Development Manager, NLIAH1 Designed for Life: Creating World Class Healthand Social care for Wales in the 21st Century;Welsh Assembly Government, 20052 ContentsChapter 1:The Integrated care is an Integrated care Wales Integrated care pathway Network in the UK and USA and the Human Dimensions of Change 13 Chapter 2:Developing an Integrated care your Integrated care Four Meeting Model30 Chapter 3:Variances and Variance Tracking36 Chapter 4:Continuous Review and Future of Birmingham Integrated care pathway Appraisal Tool40 Appendix 1 Putting Patients at the Centre of Care43 Appendix 2 Recommendations for Design and Layout45 Appendix 3 ICP Timeline48 Appendix 4 The Venture Good Integrated care pathway Template Matrix50 Appendix 5 Impact Plan and Evaluation53 Appendix 6 Glossary54 Appendix 7 Useful Integrated care Pathway51 The Integrated care PathwayICPs come under the umbrella of a set of tools known as structured care methodologies ; tools that formalise knownpatterns of care processes, thus adding predictability andproviding the transfer of protocols, guidelines, algorithms and the problem orientated medicalrecord are all examples of structured care methodologies.

4 There have been numerous government documents and Welsh AssemblyGovernment revised documents which mention ICPs and patient journeys. Putting Patients First (1998) Quality care Clinical Excellence (1999) Improving Health in Wales : A plan for the NHS with its Partners (Feb 2001) Wanless - Review of Health and Social care in Wales (2004) Designed for Life: Creating World Class Health and Social care for Wales inthe 21st Century (2005)Emerging National Service Frameworks (NSFs) and National Institute of ClinicalExcellence (NICE) guidelines all support the developments of National Leadership and Innovation Agency for Healthcare in Wales (NLIAH) and the Clinical Support and Development Unit at the Welsh AssemblyGovernment are keen to support ICP development in of Developments1985 1986 Invented at New England Medical Centre, Boston.

5 Begun ascase managements plans then critical paths and evolved tocare map medical recordFirst Wave1986 1988US early adopters were hospitals in the States with highMedicare patient volume; Arizona, Florida, Rhode high Volume surgical populations such as orthopaedics,coronary artery bypass +Applications in Australia and UKSecond WaveMid 1990 Spain (Catalonia), New Zealand, South Africa and Saudi WaveBelgium, Japan, Singapore, GermanyFourth WaveKorea, ICP network ran from June 2003 until October 2004. The main aim of theprogramme was to influence the concept of ICPs as a way for Clinicians todeliver clinically effective care to support the Clinical Governance to the Chief Executives, Medical and Nurse Directors of Trusts and LocalHealth Boards around Wales to promote ICP concepts were received positively.

6 The initial Network meeting was formal and the audience widespread withspeakers such as Professor P Degeling and Dr B Ferguson, who haveundertaken research on the benefits of ICPs within Wales , Northern Englandand Australia. The subsequent Network meetings saw the numbers ofparticipating health communities rise and the number of ICP managersappointed in Wales increase until it became the way forward within the governance and modernisation teams in each health experience within the Network for advice and experience on ICPdevelopment was second to Integrated care is an Integrated care pathway ? is an Integrated CarePathway?An ICP is a document that describes a process within Healthand Social care . ICPs are both a tool and a concept whichembed guidelines, protocols and locally agreed, evidence-based, patient-centred, best practice into everyday use for theindividual patient.

7 Uniquely to ICPs they record variations fromplanned care in the form of variances .An ICP aims to have: The right people In the right order In the right place Doing the right thing In the right time With the right outcomes All with attention to the patient experienceAppendix 1 contains a diagram which explains how patients are put at thecentre of ICP is structured around the variance tracking tool (real time audit) and itdescribes a process for a discreet element of care , for example, primary care ,admission, acute care , rehabilitation or discharge. These elements buildtogether to construct a unique journey for each individual patient according totheir needs, based on professional judgement. For example, a diabetic journeymay include a Deep Vein Thrombosis (DVT) element where sets out anticipated, evidence-based, best practice and outcomes that arelocally agreed and that reflect a patient-centred, multi-disciplinary, multi-agency approach.

8 It must be noted that although certain elements of care canbe entirely unidisciplinary , they cannot be constructed without the knowledgeand input of the whole multidisciplinary team . The ICP document becomes all or part of the contemporaneous patient/clientrecord. Completed activities, outcomes and variations between planned andactual care are recorded at the point of is much evidence showing that ICPs have a positive affect on particularpatient conditions. Further UK research is needed to provide evidence that ICPsmake a difference in generic terms. There is work as yet unpublished in theEnglish language from the Belgian Dutch Clinical ICP Network which showsevidence that ICPs do make a difference. Even if the evidence to support the fact that ICPs do make a difference iscurrently limited, it is apparent that ICPs show their worth in enabling thesmooth implementation of current guidelines such as NSFs, NICE Guidelinesand health communities individual clinical governance guidelines.

9 ICPs cancertainly demonstrate their value by offering a continual, real time audit viavariance tracking which can contribute to all quality and effectiveness agendas. The development andimplementation ofICPs is an integral partof both Quality andModernisation agendasacross HealthCommunities. ICPs arekey to reducing thevariation in healthcare,which can lead to costsavings and lowerwaiting times. ICPs arecrucial to ensuring thedelivery of care that issafe, effective, patientcentred, timely,efficient and equitablein the NHS. Nicola Davis- Integrated CarePathway Wales Integrated care pathway Network Wales Integrated CarePathway Network StandardsThe term Integrated care pathway is often misused and thereare many so called ICPs being developed and implementedacross Wales with no uniformity. One objective of theInnovations in care ICP Programme was to develop the standardsfor the elements that make up an ICP.

10 These were drawn up notfor performance management purposes but to enable ameasurement guide to assist in the development of Gold Standard for development for ICPs as agreed by the ICP Network2003An ICP is anticipated care placed in an appropriate time frame, written andagreed by a multidisciplinary team . It has locally agreed standards based onevidence where available to help a patient with a specific condition ordiagnosis move progressively through the clinical experience. It forms part orall of the clinical record, documenting the care given. It facilitates anddemonstrates continuous quality improvement. It includes patient milestonesand clinical interventions noted on the day or stage that they are expected tooccur. It will include all of the following standards or show evidence that it isworking towards meeting these standards: Multidisciplinary Cross Boundaries Single Documentation Standard Format Use exception reporting Outcome orientated Variance analysis Built in audit Patient/user involvement Evidence based Monitoring of the utilisationInnovations in care , Welsh Assembly Government 2003 Common questionsWhy must ICPs be Multidisciplinary?