Involving physicians in clinical pathways: an example for perioperative knee arthroplasty.

Background: At Stanford University Hospital, attempts to improve the case management program led to the development of clinical paths, a multidisciplinary case management tool. Successful design and implementation of clinical paths depend on physician leadership. However, since physicians are trained to function independently and to treat each clinical problem as unique, they tend to resist attempts to have them follow clinical paths. Strategies to get physicians who perform the same clinical procedure to agree with each other on a sequence of common interventions had to be developed. Clinical paths define the expected processes of care and therefore allow for the introduction of continuous quality improvement (CQI) into the clinical arena. A structure had to be developed for the effective use of pathways in a CQI framework, and physicians had to be encouraged to function as CQI leaders.

Example: Description of the design of a perioperative knee arthroplasty pathway demonstrates the steps needed for successful physician involvement in pathway design and its integration into clinical CQI.

Conclusions: With sensitive facilitation, physicians can become productive leaders of the design of clinical paths, and when they learn the benefits of improved efficiency, outcomes, and costs their involvement becomes self-sustaining. A quality improvement group led by physicians to develop the pathway after implementation can mark the beginning of clinical CQI implementation.