About Integrated Care Pathways

In this section:


Introduction

One of the main challenges facing healthcare professionals, managers and administrators in the U.K. today, is trying to make the best use of limited resources, whilst providing high quality, timely, evidence-based, best practice. The ICP tool has much to offer, yet the many potential benefits often fail to be realised due to poor project planning and management.

"People and perfect processes make a quality health service - a poor quality service results from a badly designed and operated process, not from lazy or incompetent health care workers" John Ovretviet, Health Service Quality, 1992.

The ICP know-how information set out here aims to provide you with knowledge of the ICP Tool and the ICP Conceptual Framework, as well as access to further resources for ICP information, training and support.

Integrated Care Pathways - what are they?

ICPs are both a tool and a concept that embed guidelines, protocols and locally agreed, evidence-based, patient-centred, best practice, into everyday use for the individual patient.

In addition, and uniquely to ICPs, they record deviations from planned care in the form of variances.

An ICP aims to have...

  • the right people
  • doing the right things
  • in the right order
  • at the right time
  • in the right place
  • with the right outcome
  • all with attention to the patient experience

and to compare planned care with care actually given.

It is this last point that sets ICPs apart from the myriad of other tools supporting best practice.



The ICP Tool and Conceptual Model - Definitions

Concise Definition of an ICP (©Venture 2002)

An Integrated Care Pathway (ICP) is a document that describes a process within health and social care, and that collects variations between planned and actual care.

Comprehensive Definition of a Quality ICP (©Venture 2002)

An ICP is a document. However, it must be used within the ICP conceptual framework to realise its potential.

An ICP An ICP is a document that describes the process for a discreet element of service. It sets out anticipated, evidence-based, best practice and outcomes that are locally agreed and that that reflect a patient-centred, multi-disciplinary, multi-agency approach. The ICP document is structured around the unique ICP Variance Tracking tool. When used with a patient/client, the ICP document becomes all or part of the contemporaneous patient/client record, where both completed activities and outcomes, and variations between planned and actual activities and outcomes, are recorded at the point of delivery.

An ICP Framework An ICP framework incorporates a systematic cycle of activities based around the development and use of an ICP document to ensure continuous improvements to practice and outcome. These activities include selecting ICPs to use with patient/client groupings, developing ICP content and layout, using ICPs as the contemporaneous patient/client record, recording, analysing and comparing any variations from planned activity and outcome, and continuously updating practice as a result.

Other Definitions

A number of definitions of ICPs have been around since the late 1990’s. Some confusion has been created because they all link ICPs directly to patient groupings or case-types. A single ICP rarely covers the full span of a patient journey for a particular condition; the patient’s package of care is commonly built up from a group of ICPs, each of which describe a component/phase of the care e.g. an admission or assessment phase, a set of interventions, a discharge phase.

Other definitions commonly quoted include:

An ICP "amalgamates all the anticipated elements of care and treatment of all members of the multidisciplinary team, for a patient or client of a particular case-type or grouping within an agreed time frame, for the achievement of agreed outcomes. Any deviation from the plan is documented as a ‘variance’; the analysis of which provides information for the review of current practice." Johnson (1997) "Pathways of Care", Chap 2, pub. Blackwell Science

"An ICP determines locally agreed, multidisciplinary practice based on guidelines and evidence where available, for a specific patient/client group. It forms all or part of the clinical record, documents the care given and facilitates the evaluation of outcomes for continuous quality improvement". NPA (1998)

What may ICPs contain?

  • multi-disciplinary, multi-agency, clinical and administrative activities
  • evidence based, locally agreed, best practice
  • local and national standards
  • variance tracking (essential to all ICPs)
  • tests, charts, assessments, diagrams, letters, forms, information leaflets, satisfaction questionnaires etc
  • scales for measurement of clinical effectiveness
  • outcomes
  • freehand notes
  • ‘space’ to add activities or comments to a standard ICP to individualise care for a particular patient
  • Problem, Plan, Goal and Notes or similar structured freehand area (multi-disciplinary template for recording and variance tracking an individual patient’s problems, goals, plans and freehand notes)

ICPs always contain structured variance tracking.



Designing ICP Documentation

The answer to what ICPs look like is simply "anything that you would like them to look like". ICPS rarely look the same in any setting or between departments and organisations, in the same way as notes, assessments, charts etc are very different in different places. It is not the layout of the ICP document that is critical; rather that it makes sense and can be clearly followed by those using it.

Developing rules and guidance for ‘Corporate ICP Templates’ assists in standardising a corporate look within a particular organisation.

How the Variance Tracking and Continuous Improvements Framework is embedded within the ICP will be critical to the success of useful data capture and its subsequent analysis.

The layout of the Variance Tracking tool within the ICP will influence whether or not the users record variances as they occur. If variances are not recorded, there will be no information available to inform the multidisciplinary team as to whether or how activities were ‘unmet’.

The design of the Variance Tracking tool should be:

  • quick and easy to complete
  • intuitive
  • accessible
  • meaningful
  • part of the routine of clinical/administrative record keeping
  • clearly linked with the relevant activity by a unique identifier

It should not involve:

  • duplication of recording
  • searching for Variance Tracking sheets
  • searching for information on how to complete the record
  • having to describe the related activity longhand in order to identify it on the Variance Tracking sheet


Are ICPs and Protocols the same thing?

ICPs may go by many names, but there is only one way to be sure that a document is a true ICP - it will contain structured variance tracking.

An ICP is not:

  • a protocol
  • a flow chart of events
  • a care map
  • a process map
  • a decision tree
  • a guideline
  • a care plan

ICPs may contain protocols and guidelines and they may start their developmental histories as a process map, flow chart or decision tree, but unless they have a mechanism for recording variations/deviations from planned care/activities when used as the record of patient care, then they are not a true ICP.

Other names that are sometimes used to describe ICPs include:

  • Anticipated Recovery Pathways (ARPs)
  • Multidisciplinary Pathways of Care (MPCs)
  • Care Protocols
  • Critical Care Pathways
  • Pathways of Care
  • Care Packages
  • Collaborative Care Pathways
  • CareMaps®
  • Care Profiles

The genuine ICP is characterised by:

  • systematic action for consistent best practice, continuous improvements in patient care, all with attention to the patient experience
  • patient centred - built into packages of care for identified groupings
  • provides continuous feedback via variance tracking and analysis
  • multidisciplinary - based on roles, competence & responsibility rather than discipline alone
  • maps and models clinical and non-clinical care processes
  • incorporates order and priorities including guidelines and protocols
  • includes standards and outcomes


What is the difference between an ICP and a Package of Care?

Confusion often arises over the differences between ICPs and Packages of Care. This may have arisen because there has been, and still is, a tendency to call ICPs by the patient group they serve rather than by the service that they provide to that group.

ICPs are elements, or ‘bite-sized chunks’ of service or care. Each ‘bite-sized chunk of service’ is developed into an ICP, setting out detailed processes i.e. a collection of activities, done by a ‘role’, that uses one or more kinds of input, often in an order, and which creates an output that is of value to a patient/other.

A Package of Care (often called the ‘Patient Pathway’ or ‘Pathway of Care’) may contain one or more ICPs selected for a particular patient or target patient group. It describes the whole range of care given to that patient or patient group, usually for one episode of care. A Package of Care is also sometimes represented in the form of a flow chart, process map or decision tree. In this case, each item (or small group of items) in the map could represent a discrete ICP.

It is essential during the ICP project planning stage to define the scope of each ICP so that it has a clear start and finish point. Well-scoped ICPs will facilitate the building up of these ‘bite-sized chunks of service’ into seamless Packages of Care for each target patient group. Keeping the ICPs discrete also makes it possible to tailor care more closely to an individual patient by adding or removing ICPs from the patient’s anticipated Package of Care in response to their particular or changing needs. It also provides opportunities for including distinct Patient/Carer ICPs as part of the Package of Care.

In summary, this ‘bite-sized chunk’ approach:

  • enables the use of ICPs with complex patient groups
  • helps to avoid duplication of effort (such as when the same pre-admission process is written into numerous longer ICPs instead of being written once only and selected for each appropriate package of care)
  • enables tailoring of the Package of Care for individual patients by adding and removing ICPs
  • facilitates the development of Patient/Carer ICPs
  • supports a framework for the development of eICPs

Example of a Package of Care for one Target Patient Grouping:

Target Patient Group:

Autism

Mapping against ICD10, SnowMed, Read, HRG or other Codes

ICD10 Code: F84, Pervasive Developmental Disorder

Category(s) of Patient Group:

Age group - pre-school
Severity - severe

Package of Care:

  • Autistic Disorder Pre-Assessment (ICP)
  • Autistic / Asperger Syndrome Complex Assessment (ICP)
  • Social Development Team Treatment Programme for Children with Autism or Autistic-like Syndromes (ICP)
  • Consultation with other professionals / agencies - by telephone (ICP)
  • Network and Review Meeting - convened by the epartment - by telephone (ICP)
  • Medication and Supervision of Medication (ICP)
  • General Discharge Package (ICP)



The History and Spread of ICPs

Critical Path & Process Mapping methodology was used in industry, particularly in the filed of engineering from as early as the 1950s.

In the 1980’s, clinicians in the USA began to develop the pathway tool within Managed Care; they were re-defining the delivery of care and attempting to identify measurable outcomes. They were focusing on the patient rather than the system, but needed to demonstrate efficient processes in order to fulfil the requirements of the insurance industry.

In the early 1990’s the NHS in the U.K. funded a patient focused initiative to support organisational change. This resulted in the investigation and development of concepts such as pathways. In 1990 a team from the U.K. visited the USA to investigate the use of these pathways, or ‘Anticipated Recovery Pathways’ as they were then called.

As a result of this visit, 12 pilot sites for Pathways were set up in Northwest London in 1991-2. The West Midlands Pathway Development work also got underway.

By 1994, the Anticipated Recovery Pathway had evolved into the Integrated Care Pathway (ICP) in the U.K. ICPs were clinician led and driven, and had patients and locally agreed, best practice at their heart.

In response to demand for a coordinated ICP users group, the National Pathways User Group (later re-named the National Pathway Association) was set up in 1994. It finally folded in 2002.

The NeLH Pathways Database was launched in 2002 to enable the free sharing of ICPs and ICP Projects across the U.K.

The International Web Portal dedicated to ICPs was launched in 2002 to enable the free sharing of ICP information and to provide ICP user and developer forums for discussion and sharing of best practice and development skills. The International ICP Web Portal.

Since 1992 ICPs have been developed and implemented across all healthcare settings in the U.K. (acute, community, primary, mental health, private, independent, NHS).

ICPs are now used all around the world including the U.K., USA, Canada, New Zealand, Australia, Germany, Belgium, and the Netherlands.