Clinical Pathway for Improving Quality Service and Cost Containtment in Hospital

Abstract

The explanation begins with the Clinical Pathway in Hospital which describes how the Clinical Pathway is used in relation to 2 things: Components-Linkages and Step-Problems-Optimal Solution, followed by Linkages Clinical Pathway with Quality Improvement and Cost Containment, which describes the relationship of each. Followed by the Clinical Pathway for Service Quality: which consists of: (1) Clinical Pathway for Service Quality, (2) Patient Safety for Service Quality Improvement, (3) The role of alogarithm, thereby clarifying the form of clinical pathways in quality improvement efforts that ensure service improvement by still maintain the quality that is maintained during the cost containment. The Clinical Pathway in Cost Containment describes the roles of: (1) Link of Components, (2) Procedure, (3) Unit Cost, so that cost containment efforts can be made in the form of cost containment optimally while maintaining quality does not need to decrease. Clinical Pathway in New Era is a newly developed algorithm related to current and future conditions. This is related to: (1) New Era in Pandemic Covid-19, (2) Clinical Pathway in Non Curative Service, (3) Clinical Pathway in Technology Services, (4) Clinical Pathway in Technological Rerelated while continuing to carry out quality improvement and cost containment simultaneously. Concluton: clinical pathway in hospital can be used as a system for Quality Improvement and Cost Containment, related to New Era in Pandemic Covid-19, Non Curative Service, Technology Services and Technological Rerelated.

1. Introduction

1.1 Clinical pathway in hospital

Clinical Pathway [1] is an effort made in order to:

1. Outlines the steps in detail:

2. Outlines the important steps that must be taken;

3. Describe services to patients;

4. Estimate possible clinical problems.

The description above provides directions to make it easier to discuss and try to get the same understanding, thus further formulation can be carried out to find clinical problems that may occur and provide directions for possible solutions, so that optimal conditions or the best conditions can be considered in existing conditions. This will be important for the following 3 things:

1. Provide an overview of the optimal service quality conditions;

2. Linkage with the best activity steps of cost-related services;

3. Clear activity as part of the steps that an algorithm can make, so that software can be made for computer or smartphone applicants.

Now with more advanced and superior computerization advancements, help simplify the complex problems of the Clinical Pathway, thus providing a discussion space for clinicians and hospital management to:

1. The use of the Clinical Pathway, its components and relationships that are clinically correct and in optimal management, an understanding that has often become difficult;

2. Provide steps, problems and optimal solutions, so that cost calculations can be carried out and rationally accepted.

The following are examples related to the role of clinical pathways in effectiveness [2]: clarity of admission, interventions, comparison of old and new therapies and clearer outcomes of clinical pathways. In this condition, the use of computerization makes it easier to explain and simulate events. The relationship of the above becomes clearer as described, as follows.

1. Components-relation to clinical pathway

   Components in the right and correct clinical pathway are important, because it determines the appropriate diagnosis and is associated with appropriate clinical reasoning [3], otherwise it will be very dangerous related to misdiagnosis. The existence of various components that can be replaced or substituted is a challenge to keep choosing the right and right choice, as well as linkages that remain in the right and precise order according to Clinical Resioning while still guided by the flow of diagnosis as well as the correct therapy. Any mistake in the association will be dangerous to diagnosis and therapy, which can be dangerous for the patient. In the use of algorithms in the use of information systems in the Clinical Pathway, components and relationships play an important role in maintaining compatibility between clinical Reasioning and computational logic. The role of the fields of Information Technology, Medical and Medical Informatics is to jointly guard the condition of the components and their activities correctly and correctly.

2. Step-problem-optimal solution

   Actually the best is the ideal or maximum, this is one that is intact from the world of medicine which is classified as an art, although some things have been replaced by tools and computerization. Determination of Step-Problem-Solution requires clinical reasoning, judgment, and experience so it is necessary to have an alternative companion, including still considering any possible side effects. Again, the role of Medical, Information Technology and Medical Informatics [4] or Information System experts is important to guard not only accuracy-truth, also Step-Problem-Solution, it is also necessary to consider the existence of patient safety [5].

1.2 Linkages clinical pathway with quality improvement and cost containment

The existence of Component-Linkage and Step-Problem-Solution is a necessity that needs to be considered in order to achieve an optimal Clinical Pathway, so the importance of being considered is related to things like the following.

1. Quality Improvement [6] is the existence of service conditions related to the ideal or optimal quality that can be achieved, or meets the minimum or optimal quality standard requirements, thus it must be protected from decreasing quality or achieving low quality of service.

2. Cost Containment [7] must actually consider services that remain of quality, should not decrease below the minimum standard required, so it is important that Cost Containment can be carried out while maintaining the quality that does not decline. 3. Adequacy of Quality Improvement and Cost Containment in Clinical pathway, must be pursued with repeated simulations, which will be facilitated by the use of software or smartphone applications using appropriate and supportive algorithms.

It is important to note things like the following:

(1) It is necessary to pay attention to and select the quality that can be improved, related to examination, diagnosis and therapy as well as rehabilitation, in real terms with scientific developments, technology and community development, (2) so that components and steps that lead to costs are selected, and can be carried out without reducing the quality of service, related to science and technology, as well as the substitution and new sophisticated equipment at a higher or lower cost.

Thus the selection must be carried out by means of a formal and written review, so that the success rate can be measured. Described as follows, Figure 1.

Figure 1.

Linkages clinical pathway with quality improvement and cost Cotnaimnent.

In computerized technology, software development [8] and mobile phone applications [9] have many sophisticated technologies and procedures, but there is still a need for close cooperation between medical, information technology, hospital management and medical infromatics in order to manufacture form algorithm [10], so that it can be made faster and in accordance with the integrity and in harmony with the use of the application in the field with optimal results that can be achieved while still being used easily, simply and user friendly.

2. Clinical pathway for services quality improvement

2.1 Clinical pathway for service quality

The example of the Clinical Pathway algorithm for the management of malnourished patients in elderly patients, shows: clarity of steps, clarity of risk, clarity of size, clarity of time, which allows clinicians to collaborate with management; has demonstrated one quality improvement strategy [11]. Examples of the effectiveness of clinical pathways in infection disease [12], algorithms on diagnosis and therapy provide good pathways for quality improvement and also cost savings, because there are:

1. Clear and measurable steps, diagnostic steps that show a basis for the diagnosis accompanied by a measure of the likelihood of that basis;

2. Stages from beginning to end, this stage is important to develop clinical reasoning that is important in the algorithm for clinical pathways, this is important for improving service quality;

3. There are types and doses of drugs, which can be selected on the basis of the level of the type of diagnosis, in this case the therapy becomes a clear choice and can be calculated the cost burden, so at the same time cost containment efforts can be carried out.

The 3 important things above provide evidence that a Clinical Pathway can provide simultaneous direction between:

1. Quality, between components-linkages and Step-Problem-Solution, which will specifically differ for each disease diagnosis, which needs to be considered in order to maintain the quality;

2. Quality Improvement, which is the hope of the clinician, management is the patient, because it will provide improvements in the efficiency and patient satisfaction.

The relationship between Clinical Pathway and Quality Improvement [13], with its accompanying components, is illustrated as follows, Figure 2.

Figure 2.

Clinical pathway for quality improvement.

The figure above shows:

1. Related to Quality and Quality Standard [14], which will provide an overview of the extent to which must be done and especially services that meet the minimum and optimal standards;

2. Related to procedures [15] that must be carried out and the most important thing is related to patient safety, because it will allow services that save the patient, it will include simultaneously saving doctors and hospitals;

3. Prioritization in order to improve can be done simultaneously, but the fulfillment of patient safety first and then the quality standard;

4. Quality Improvement so that it is endeavored simultaneously with different levels and simultaneously achieving an optimal level.

2.2 Patient safety for service quality improvement

One of the ways of Service Quality Improvement is to use accreditation, accreditation is an effort to periodically assess the Quality Standard as the highest reference, so that our achievement is assessed against that standard. Service Quality Improvement which is important and must be a concern is Patient Safety [16], because it is one of the main goals of health services. Patient safety which is important in the hospital is the expected outcome as follows:

1. Significantly increased patient safety;

2. There is a reduction in risk and accidents;

3. There are health outcomes that are better than before;

4. There is an improved patient experience.

   The four things above are related to the Quality Improvent of the service so that it will be clear what processes, outputs and outcomes will be achieved, and this effort needs to be carried out continuously and continuously, and is always a fun daily activity.

5. Optimal cost, in connection with this the existence of Cost Containment is required, it is proposed to do the following:

   1. Create a clear clinical pathway component-Linkage and Step-Problem-Optimal Solution, and can be tracked for costs;

   2. Make efforts to carry out a clear and directed Quality Improvement towards the expected quality standard;

   3. Work on Cost Containment which takes into account the quality of service, service procedures, unit costs which are simultaneously reviewed in order to create an optimal cost condition without reducing the specified quality.

2.3 Algorithm usage

The following is an example of an algorithm, which is the basis for making diagnosis and therapy, with this algorithm it can be used as a software or smartphone application. Like the following example, Figure 3.

Figure 3.

Example of algorithm [17].

The figure below shows:

1. The existence of certain steps in accordance with the direction of the signs and symptoms, in this case Heat in Adults;

2. There is a Differential Diagnosis guide;

3. There is a flow for yes and no choices;

4. If the yes path is selected it will lead to the further path-Tets-Diagnosis-Therapy.

This simple algorithm image will provide an opportunity for programmers to create software and smartphone applications, which can then be developed to examine in each of the steps which allows for quality improvement, so that it is easier to analyze shortcomings and their relationship with other steps to be improved.

Research process in the context of making APSIS (Aplikasi Pembelajaran Alur Diagnosis dan Terapi Kedokteran = Learning Application Flowchart of Medical Diagnosis and Therapy) in Smartphone Application, related to algorithm development can be sown as above Figure 4.

Figure 4.

Flowchart of APSIS [17].

The figure above shows:

1. There is direction about the beginning of the start,

2. There is a division of groups which contains relatively similar indicators,

3. There are continuous steps in the form of a flowchart,

4. Provide a final description of the series, in the form of tests, diagnosis and therapy.

3. Clinical pathway in cost containment

3.1 Link of components

Cost Containment is done by maintaining the quality of service, because that is the first and important value of medical services, so the thought of costs is the next thing to consider, not the other way around. This effort can be done in terms of: [18].

1. Rates that reflect costs, with the help of Clinical Pathway and software algorithms, will easily provide remedial options, and better still provide easy possibilities for simulations by performing simulation at various costs, so that lower costs will be found while still maintain quality;

2. On investment, tools and instruments can now be selected which results in an easier and cheaper basis for diagnosis and therapy.

Described as follows, Figure 5.

Figure 5.

Link of component in cost containment.

3.2 Prosedure

Procedure is a series of activities that have been directed and specific in order to carry out the service, so that the service achieves the objectives as determined, in accordance with the competence of the specified executor, as Figure 6.

Figure 6.

Link of procedure for cost containment.

The figure below shows:

1. Procedure, will be related to equipment, material and infrastructure so as to enable services to run smoothly;

2. Related to operations, namely: time, schedule and service implementation, as well as operators to enable services to run according to their destination and time;

3. The existence of certain service specifications, which are related to available funds and determined service rates, are considered in the context of cost containment.

The 3 things above must be considered with the standard of optimal cost, and the quality of service still occurs without a decrease in quality, this is a characteristic of cost containment that is carried out properly.

3.3 Unit cost

Description related to Unit Cost [19] which is the basis for Cost Containment, related to Billing for existing Services in accordance with Quality Standards and Coding in Clinical Pathways. The figure is as below, Figure 7.

Figure 7.

Link of unit cost for cost containment.

Furthermore, the Unit Cost, as a breakdown of Cost in accordance with the required cost details, will be the basis for determining the tariff and the charging of investment, so that a complete loading will occur; thus the optimal efficiency conditions will be calculated. In this case, it will be a part that provides a limitation so that the Quality Standard does not decrease by keeping the Unit Cost from decreasing drastically which causes the Quality Standard also decline too.

4. Clinical pathway in new era

4.1 New era in pandemic Covid-19

There are 4 important things related to the Covid-19 Era Pandemic: [20]

1. Pandemic atmosphere, anxious atmosphere, lots of information circulating and often confusing, mainstay information centers are often late in reporting, so there is an atmosphere that is at least unsettled and unpleasant.

2. Daily behavior, work and trying behavior are limited and there is a health protocol, providing a new, limited atmosphere and additional rules.

3. Patients with chronic diseases, such as hypertension, diabetes, chronic lung disease and others are known as comorbid people, a label that is very susceptible to infection, so there must be special protection and treatment.

4. This is invisible to the eye, the prominent patient being treated is only limited stress [21] which can be handled alone, an iceberg phenomenon that requires special treatment which currently only focuses on physical activities. The proof is that the health protocol is very difficult to implement, it must be violent until the threat of punishment, it does not develop automatic and natural awareness.

In connection with the matters above, how is the condition of the hospital: [22]

1. Outpatient visits decreased dramatically, so admissions were reduced;

2. Additional costs for the implementation of the health protocol, required immediately and cannot be delayed,

3. Protection for medical personnel, paramedics and other personnel related to hospital services, requires extra efforts to maintain a balance of quality services with protection of health workers so that they do not become infected.

Throughout the current journey, no hospital has gone bankrupt, apart from being supported by the government with social assistance, also because the hospital can make good adjustments, or postpone the burden into the future. In this connection:

1. There is an effort to maintain quality, it remains an important task that must be carried out without adjustments that can reduce quality;

2. The existence of cost containment is an option that must be done, with all the risks and consequences, which must be done right now;

3. There is an effort to give a big role to clinical pathways and the use of computerized analysis [23] to simplify complex problems and prepare new efforts quickly and easily, in this case when normal is only an option for later, then now inevitably have to be selected and worked on now, using computerized assistance.

There are 3 important things that will immediately be used as important references in ministry in the new era, as below:

1. Clinical Pathway in Non Curative Service [24], is a service that needs attention, as part of reducing contact and cost containment, which is promoted as a service that tries to reduce curative services which are usually more expensive, which of course can only be done at certain diseases and stages of therapy only;

2. Clinical Pathway in Technology Services [25], services designed with the support of mechanical technology and information systems, thereby reducing doctor-patient contact and providing better accuracy, which may be lacking in compassionate contact;

3. Clinical Pathway in Technological Related [26], is a service that from the beginning relied on technology as a mainstay, thus the presence of doctors will be made more efficient and on matters that are important and that are not harmful.

4.2 Clinical pathway in non curative service

The application of the Clinical Pathway now and in the future requires adjustments related to earlier approaches and prevention, not just therapy, because technological advances and awareness of healthy living are being promoted. Advance clinic and treatment to an earlier direction, such as Promotive, Preventive and Rehabilitation which is more aggressive and earlier.

An example is illustrated as follows as Figure 8.

Figure 8.

Clinical pathway in non curative service.

The current palliative approach still needs to be developed towards older and more productive patients who can still enjoy an optimal quality of life, requiring hard work and continued development.

The next explanation is as follows.

1. Promotive [27] is an effort to increase knowledge and behavior in order to have a basic knowledge in dealing with disease with 3 main activities:

   1. Awareness, is an effort to make people aware, especially those who are still healthy or slightly ill, have an awareness of the dangers that lead to disease;

   2. Health education, which aims to increase knowledge and society or prospective patients, or have become patients so that the prevention is more severe;

   3. Education, is an effort to encourage the community or patients to improve their abilities that previously could not be, bad behavior becomes good;

   4. Consulting, is an effort to help the community or patients to be able to solve existing problems, and together find solutions.

   This condition is often mixed up so that efforts do not produce optimal results, the best way to suggest is to select the required picture, then adjust the handling according to need.

2. Preventive [28] is an effort to prevent the disease from occurring, not getting worse, not getting worse, a common example is the use of immunization. This effort will be calculated the value of the cost that is cheaper when compared to treatment.

3. Rehabilitation [29] is an effort to make improvements to a condition that is already damaged or there is already an abnormality, so that as much as possible it can be restored as before. The current rehabilitation, many use tools and some are computerized, what is needed is a careful study so that it is sorted according to needs and the use of cost containment can be done.

4.3 Clinical pathway in technology services

The era of Telemedicine [30], with the Covid-19 Pandemic, the need to maintain distance makes it imperative to use more massive telemedicine, it is necessary to develop algorithms that are in accordance with the following: (1) there is a standard procedure and still meets clinical reasoning, (2) services that can be carried out gradually Quality Improvement, (3) services that can be simultaneously carried out cost Contaiment optimally but reduce quality. This presents a challenge, not only for doctors, hospitals, Information Communication Technology and Medical Informatics experts, to collectively achieve the above expectations.

The robotic era [31] will be greatly stimulated by the Covid-19 Pandemic by trying to avoid contact between doctors and patients in order to prevent transmission. The differences that occur are: (1) the procedure will be relatively the same, dealing with the patient is a robot, (2) the doctor controls the robot, not the instrument, also the time and sequence will be clear and can be calculated. Increasingly sophisticated computer performance with large capacities, supported by Artificial Intelligent, provides challenges, and at the same time, care must be taken with regard to patient safety, not according to good tools, still violating the patient safety principle.

The era of the Internet of Things [32] is a challenge now in various countries with a large number of elderly people, several countries have happened, some countries are not less than 10 years old will be a heavy burden. Thus the use of: Clinical Pathway, Quality Improvement, Cost Contaiment and the Internet of Things will be the way out that is needed. An example illustration is as follows as Figure 9.

Figure 9.

Clinical pathway in technology services.

The description above provides options and accelerates the use of advanced technology and with large capacities more quickly and relatively forced, due to the Covid-19 Pandemic which requires maintaining distance, avoiding contact and avoiding relatively long trips. Anticipation must be developed immediately with the following standards:

1. Keep following Clinical Reasoning and Clinical Pathway which are based on service quality standards;

2. Developing Quality Improvement and Cost Containment that are relevant and balanced, so that the perspective is accepted by doctors, hospitals, patients and insurers.

4.4 Clinical pathway in technological related

1. Heath Electronic Record (HER) or Medical Record (MR) [33] related to electronic medical records, which is getting more and more advanced with regard to voice recognition which provides direct recording of the history, and video recognition which records examination conditions using video in an integrated manner. The importance of an integrated and electronically based Medical Record (MR) provides:

   1. Higher speed;

   2. Clearer accuracy, greater capacity and high access, also with completeness, will help Quality Improvement;

   3. Conditions that will impose large costs, which require Cost Contaiment to achieve optimal efficiency and cost load; with the Direct Consultation tool, the patient can consult a doctor or a robot, for several diseases that have been standardized first.

   4. Tele-device [34], is a device that can be controlled remotely, or performs remote inspection, so that examinations that use certain tools do not need people to come from a distant city, just at the initial place, the results of the examination can be sent including the description. This is important for reference and preparedness in the context of Covid-19.

   5. Self Service [35] with a standardized algorithm, a Guidance Commission Support System can be used to make diagnosis and therapy of diseases. In this case, Quality Improvement and Cost Contaiment is important in giving choices, because the decision is made by the patient, it may need to be limited to chronic disease and regular control and options that are not feasible.

   6. A simple example illustration as follows as Figure 10.

Figure 10.

Clinical pathway in technological related.

The above description is broader as below.

1. Consultations, with real doctors, with robots that use voice or video can be carried out, which requires an unbeatable Clinical Pathway Algorithm, so the Quality Improvement role is very important and must be made from the time the services and software are used.

2. Examinations such as laboratories, methods, reagents and result criteria must be clear about the normal and maximum or minimum standards that apply, this is related to so that patients do not need to think a lot and do not need to learn clinical reasoning, but precisely in a safe corridor. This Cost Containment becomes important, especially in choosing a relatively cheap and safe examination.

3. Self-medicating, determining the usual diagnosis and therapy and in a safe category, can be done as long as it is normally done, without complications and there are new diagnoses and therapies. Quality Improvement and Cost Containment simultaneously to ensure high quality at optimal cost.

5. Conclution

Clinical pathway in hospital is an effort made in order to: outlines the steps in detail, outlines the important steps that must be taken, describe services to patients and estimate possible clinical problems; it can be used as a system for Quality Improvement and Cost Containment. The effectiveness of clinical pathways in algorithms on diagnosis and therapy provide good pathways for quality improvement and also cost savings. Cost Containment is done by maintaining the quality of service, because that is the first and important value of medical services, so the thought of costs is the next thing to consider, not the other way around. The Cost Containment effort can be done in terms of rates that reflect costs, with the help of Clinical Pathway that lower costs will be found while still maintain quality. Clinical Pathway that is used on investment, tools and instruments can now be selected which results cheaper basis for diagnosis and therapy. There are important things that will immediately be used as references in the new era that related to New Era in Pandemic Covid-19, Non Curative Service, Technology Services and Technological Rerelated, biside that Clinical Pathway will be made more efficient and on matters that are important and that are not harmful.