General Pathways Education Workshop (click to go to the desired section)

1. General PathwaysEducation Workshop (click to go to the desired section) Introduction to Workshop/Instructions Evidence-Based Care Program General Pathways Workshop

2. Next Back Introduction • This is a web-based workshop, and thus has links throughout each page to enable you to move throughout the workshop. Whenever you see words underlined like this, you can click on that area to go to another section or to find more information on a topic. • At the bottom of each page are navigational buttons to help you move through the workshop. • You can go through as much or as little of the workshop as you like at a time. • If you have any questions about how to use this workshop or the individual pathways, feel free to ask your Site Champion. Back to Start of Workshop

3. Next Back Evidence-Based Care Program These pathways have been developed as a part of the Evidence-Based Care Program, which is Schedule 6 in the agreement of the Grey Bruce Health Network. The intent is to develop regional pathways and other evidence-based tools that flow across all hospitals and community services in Grey and Bruce (including Grey Bruce Health Services, Hanover and District Hospital, South Bruce Grey Health Centre, the Community Care Access Centre and Grey Bruce Health Unit). It is hoped that these pathways will improve: • Coordination of care through more communication across professions; • Continuity of care, through increased linkages among hospitals and the CCAC; • Clinical outcomes, through increased usage of best practices; and • Patient satisfaction, through linked expectations and increased patient teaching at our agencies. Back to Start of Workshop

4. Next Back Components of a Pathway Package • All pathways developed for the Network have been developed using the same template. Each pathway package contains the following: • Clinical Practice Guideline • Pre-Printed Orders • Acute Stage Clinical Pathway • Patient Pathway • Patient Education Materials • Community Care Stage Clinical Pathway (if applicable) Back to Start of Workshop

5. Next Back Clinical Practice Guideline • The Clinical Practice Guideline is a collection of the evidence used in the development of the pathway • It can be used as a reference if you have any questions about the content of the pathway • It can be found on the GBHN website at www.gbhn.ca Back to Pathway Components Back to Start of Workshop

6. Next Back Pre-Printed Orders • This is an order set to be used by physicians for the patients that fit the inclusion criteria for the pathway. (see sample) • It should be located in an easy to find place for physicians to fill out where they assess this patient population (i.e. emergency, doctor’s office, unit, etc.). • Find out where to find the orders on your unit from your manager. • Physicians should cross out any orders that do not apply to the patient due to patient complications, individuality, etc; and add any orders that are not on the sheet, either on the same sheet, or using an additional order sheet. Back to Pathway Components Back to Start of Workshop

7. Next Back Acute Stage Clinical Pathway • This is the in-hospital multi-disciplinary documentation tool used by all health care professionals who care for the patient on the pathway. • It can be found on your unit and should be placed on the chart and used in place of other charting forms (i.e. flow sheets, see your Site Champion for details) while documenting care for the patient. • Find out from your manager where to find the clinical pathway, and where to put the pathway on the chart. • Each pathway template looks and works the same. The first page contains some basic instructions for use, and a master signature sheet for all professionals to sign (unless you have one for your facility, then this portion will not be there) if they are using the pathway. • There are two types of formats of pathways – a day format and a phase format. The Total Hip Replacement is a day format, and the Community-Acquired Pneumonia pathway is a phase format. Each looks similar, but works a little differently. Back to Pathway Components Back to Start of Workshop

8. Next Back Day - Type Clinical Pathway • The Total Hip Replacement pathway is formatted as a day-type pathway. On the Day format pathway, each page of the pathway corresponds to a day. See sample. • On each pathway, we track “Performance Indicators”. • Performance Indicators are goals we are hoping we as health care providers will achieve in a day. • These indicators are to be tracked using the Variance Record, which is the last page in the pathway. Back to Pathway Components Back to Start of Workshop

9. Next Back Day – Type Clinical Pathway • The additional rows below the indicators are tasks to be done for the day. They have been separated into different types of tasks, i.e. assessments, treatments, etc. • On the right hand side are columns– they correspond to the number of shifts in a day. Each day starts at the beginning of your day shift. • Be sure you write in the time frame that you are working. • As each task is complete, initial in the time frame you did it. If a task does not apply to that patient, or has already been done and does not need to be done again that day, indicate “N/A” and initial the box. • At the end of your shift, no boxes should be left blank. Back to Pathway Components Back to Start of Workshop

10. Next Back Day - Type Clinical Pathway • The Total Hip Replacement pathway has a recommended length of stay of five days post-op. Thus, there are five pages, one for each day, to document tasks. See sample. • After the fourth day on the pathway, there is a phase for ongoing post-op care, if the patient requires care beyond the 5 days. • Following this, you will find a page of Discharge Criteria. • This page is a list of goals the patient needs to achieve before going home. Thus, if the patient has achieved all the Discharge Criteria, he/she should be able to be discharged. If not, he/she should stay until the Discharge Criteria have been met. • The patient is discharged from the pathway by filling out the Discharge Summary on the Variance Record. Back to Pathway Components Back to Start of Workshop

11. Next Back Phase - Type Clinical Pathway • The other type of clinical pathway is a Phase-Type clinical pathway. Click here to see the Congestive Heart Failure pathway. It has two phases. The first phase is anticipated to be two days. • The patient moves from one phase to the next by achieving the Patient Outcomes at the top of the page. Once these are achieved, the patient can move to the next phase. • A new blank page of the pathway page can be photocopied, and the patient stays in this phase until the outcomes have been met. In the odd case, an outcome will never be met, due to patient complications or comorbidities, and it is the health care provider’s judgment call to move a patient to the next phase without achieving all of the outcomes. Back to Pathway Components Back to Start of Workshop

12. Next Back Phase - Type Clinical Pathway • Again, once Phases are all complete, there will be a set of Discharge Criteria to meet before the patient can be discharged home. • When the Discharge Criteria have been met, the patient is discharged from the pathway, by filling out the Discharge Summary on the Variance Record. If the Discharge Criteria have not been met, the patient remains in hospital until they have been met. Back to Pathway Components Back to Start of Workshop

13. Next Back Variance Record • This is a record we are using to track how well we are meeting our goals on the pathway, to see if we need to change the pathway or identify gaps in the health care system. • Each indicator needs to be inputted into the Variance Record to indicate whether it has been met or not met. • The Record has several columns that need to be filled out for each indicator. It is easiest for everyone if this is filled out on a just-in-time basis, i.e. as variances happen, rather than trying to do this at patient discharge. See sample. • To the right of each indicator you check whether the indicator has been met or not met. Then date and initial. If the indicator has not been met, then the rest of the columns need to be filled in. If it has been met, this part of the Variance Record is completed. Back to Pathway Components Back to Start of Workshop

14. Next Back Variance Record • The next column is the Code. The Codes are found on the back of the Variance Record. There are three types of codes, and it is the health care provider’s judgment call as to the reason for the variance. • Some variances can be resolved, others cannot. If it can be resolved, indicate the plan for action in the next column. If the variance cannot be resolved, then indicate “N/A”. • When a variance has been resolved, the health care provider will indicate the date/time and initial it. Back to Pathway Components Back to Start of Workshop

15. Next Back Variance Record • If a patient is transferred to another hospital, the Variance Record should be copied and sent to the receiving hospital for them to continue with the pathway. The original of the Variance Record should be treated as if the patient is discharged (see below). On the back of the Variance Record is a list of other documentation that should go with the patient. • At patient discharge, the Discharge Summary on the Variance Record should be filled in. • This summary includes important information needed to help us track achievement of our goals on the pathway. • Once this is complete, take the Variance Record off the chart and give it to your Site Champion. It will then be forwarded to the Evidence-Based Care Program Coordinator for evaluation purposes. Back to Pathway Components Back to Start of Workshop

16. Next Back Patient Pathway • Each pathway package will include a patient pathway, which mirrors the clinical pathway but is worded in lay terms. • It is a large 11X17 page, folded in half, that covers each day or phase of the pathway. • It should be given to the patient early in the hospital stay and referred to throughout the length of stay to help the patient understand what is happening to him/her and become a partner in care. Back to Pathway Components Back to Start of Workshop

17. Next Back Patient Education Materials • Each pathway will include materials for the patient that include information about his/her condition or procedure. These should be given to the patient early in the hospital stay. • These can be used as a guide by healthcare professionals when teaching to ensure consistent teaching. • The patient can take these materials home with him/her to aid in self care and to be used by any community or outpatient providers in continuing care. Back to Pathway Components Back to Start of Workshop

18. Next Back Teaching Checklist • The teaching checklist is used by the healthcare team to aid in patient teaching. It will provide a guideline for teaching, and has references to the patient education materials. • It should be placed on the chart and referred to when teaching to reduce redundancies in teaching and ensure all topics are covered before discharge. Back to Pathway Components Back to Start of Workshop

19. Back Community Care Stage Pathway • In some cases, care for a patient often flows into either outpatient services or CCAC home care services. • In order to aid in continuity of care and ensure transfer of appropriate information, in these cases we will develop a Community Care Stage of a pathway. • This stage is for staff caring for patients in an outpatient or CCAC provider setting, and will help provide a guideline for care as well as allow us to evaluate care in those settings. Back to Pathway Components Back to Start of Workshop Begin Quiz

20. Back General Pathway Information Quiz • Where do I find the electronic pathway package and education materials on my unit? • What is the Clinical Practice Guideline? a) What is it used for? b) Where can I find it? • Where do I find Pre-Printed Orders? • Where do I find the Clinical Pathway? a) Where does it go on the chart? b) What is the difference between a Day-type pathway and a Phase-type pathway? c) What are patient outcome indicators? What are performance indicators? • What are the Discharge Criteria? • What is the Variance Record used for? a) What is done with the Variance Record when it is complete (patient is discharged vs. transferred) • Where do I find the patient pathway? a) What do I do with it? • Where do I find the patient education materials? a) What do I do with them? • Where do I find the teaching checklist? • What do I do with it? • Where do I put it? Back to Start of Workshop Answers

21. Next Back Answers to General Pathway Quiz • Where do I find the electronic version of the pathways and education materials on my unit? This is found on the GBHN website at www.gbhn.ca • What is the Clinical Practice Guideline? This is a summary of the evidence used in the development of the pathway. • What is it used for? It is used for reference if you have questions about the content of the pathway. • Where can I find it? It is found on the GBHN website at www.gbhn.ca • Where do I find Pre-Printed Orders? These can be found ___ (ask your site champion) • Where do I find the Clinical Pathway? This will be found as a package, including the pathway, the patient pathway, the patient education materials, and the teaching checklist ___ (ask your site champion) • Where does it go on the chart? ___(ask your site champion) • What is the difference between a Day-type pathway and a Phase-type pathway? A Day-type pathway has only one day per page. A phase-type pathway may have less than a day, or more than a day, but a patient moves from one phase to the next by achieving the patient outcomes. • What are performance indicators? Performance indicators are goals we would like to achieve as health care providers within the time period specified on the pathway page. • What are the Discharge Criteria? Discharge Criteria are the goals we would like the patient to achieve before being discharged home. • What do I do with the Discharge Criteria? Each day, you should be checking the Discharge Criteria to see if any of the criteria have been met. Once all the criteria have been met, the patient should be ready to go home. Back to Start of Workshop

22. Back Answers to General Pathway Quiz • What is the Variance Record used for? This is a record of any performance indicators and whether they were met or not met in the desired time frame. It used for evaluation purposes. a) What is done with the Variance Record when it is complete (patient is discharged vs. transferred) • Patient Discharged – take the Variance Record off of the chart and give to your site champion to be sent to the Evidence-Based Care program Coordinator • Patient Transferred – take the Variance Record off of the chart, make a copy of it, send copy to transferring hospital, and original to site champion to be sent to Evidence-Based Care program Coordinator. Other documentation is listed on the back of the Variance Record that should also go with the patient to the receiving hospital. • Patient to CCAC – hospital case manager will send the appropriate forms to provider agency. If there is no hospital case manager working that day, the discharging nurse should fax the forms listed on the back of the variance record to Intake and Referral. 6. Where do I find the patient pathway? It should be found in the pathway package. a) What do I do with it? Give it to the patient and refer to it throughout the hospital stay to help the patient understand what is happening each day or phase of the pathway. 7. Where do I find the patient education materials? These should be found in the pathway package a) What do I do with them? Give them to the patient and refer to them while teaching the patient. 8. Where do I find the teaching checklist? It should be found in the pathway package. a) What do I do with it? Put it on the chart in __(ask your site champion) section, indicate on it when any of the topics have been covered to allow other health care professionals to know what has been taught and what is left to teach, along with any comments you have. If you have had difficulty with any of these questions, go back through the information in the preceding sections, or ask your Site Champion any additional questions you may have. Back to Start of Workshop