ED Clinical Pathways Improvement Evaluation in Saudi Arabia - Research Proposal Example

A Research Proposal on the Adherence of Emergency Department Physicians and Nurses to the Up d Clinical Pathways Table of Contents 0 Introduction 2 1.1 Background of the study 3 1.2 Statement of the problem 4 1.3 Research purpose 5 1.4 Research objective 5 1.5 Research questions 5 1.6 Research assumption 6 6 1.7 Significance of the study 6 2.0 Literature review 8 2.1 The development of clinical pathways 8 2.2 The extent of adherence of updated clinical pathways 9 2.3 Factors that influence the adoption of clinical pathways by physicians and nurses working at the emergency department 10 3.0 Research methodology 11 3.1. Research method 11 3.1.1 Quantitative method 11 3.1.2 Qualitative method 11 3.2 Ethical consideration 12 References 13 Alkhenizan, A. and Shaw, C. (2010). Assessment of the accreditation standards of the Central Board for Accreditation of Healthcare Institutions in Saudi Arabia against the principles of the International Society for Quality in Health Care (ISQua). Ann Saudi Med. 30(5): 386–389. 13 1.0 Introduction According to Ernst (2010), ever since the history of mankind it has widely been documented on the progressive steps that are normally undertaken in the medical field, which are in tandem with the development of new forms of diseases and injuries. This allude to that fact that the medical field in equal measures as the field of information communication and technology, as it continually undertakes research studies and development in order to improve service delivery that is aimed at improving the quality of life of patients with chronic illnesses and shorten the healing process of patients with treatable diseases and injuries. One such example that demonstrates how practitioners in the medical field work towards improving their service delivery is the through the clinical pathways, which is described by Poirrier and Oberleitner (1999) as “one of the main tools that are normally used in the healthcare sector to manage the quality of service delivery through standardization of medical care procedure and/ or processes.” With reference to the writings by Sorensen and Iedema (2011), clinical pathways have been referred to as medical guidelines of which when there are implemented in healthcare set-ups they normally lead to a reduction in the level of variability in clinical practices and they are capable of improving the quality of health, and hence the outcomes on patients’ recovery process. Snyder and Gauthier (2008) wrote that considering these pathways are developed and agreed upon by medical practitioners it means that they are able to promote organized and efficient healthcare practices that are based on evidence and validated outcomes. Lastly, Howick (2011) wrote that clinical pathways have been lauded for the fact that they optimize the outcomes in home care settings and even in acute care. It is important to note that normally these clinical pathways normally undergo periodic improvements or updates which most of the time reflect the advancements in the ICT sector, and they are normally designed to improve the quality of healthcare and the outcomes of the recovery process. This present paper seeks to propose a study that is focused on investigating the extent to which physicians and nurses who have been trained on the updated clinical pathways actually adhere to these pathways. 1.1 Background of the study Various practices such as accounting have laid down procedures and standards that accountants are expected to adhere to in order to maintain consistency in reports from all companies and to allow for easy comparison (Shamrock, 2012). For example, at the present moment media reports indicate that practicing accountants in the United States are expected to shift from using the Generally Accepted Accounting Principles to the International Financial Reporting Standards that has been widely in use in Europe in the past years (Shamrock, 2012). Since these new accounting standards are expected to create a significant change in the way accountants make records and compute accounting data, it will be easy to observe whether the accountants in the United States are adhering to these new standards or not since the financial reports of various companies will definitely expose this. Same as the accounting field, the medical field in the Kingdom of Saudi Arabia, has the Central Board of Accreditation for Healthcare Institution (CBAHI) which accredits hospitals in the country. Among the accrediting standards for this board is the MS.57 clinical practice guidelines that are used to guide the clinical care offered to patients and the ER 9.7, which provide protocols for some of the important and common emergencies such as stroke, chest pains, asthma, tetanus, and stroke, among others. Therefore, from the data held by CBAHI it is possible to establish the adherence of clinical pathways in the emergency departments with KSA (Alkhenizan and Shaw, 2010). However, it is important to note that data from the Ministry of Health showed that only 52 of the 272 hospitals in KSA have been accredited by CBAHI, and although CBAHI conducts training for people working in hospitals quality management department in order to prepare them for the survey, it only conducts training on clinical pathways to a few selected physicians and nurses (Alkhenizan and Shaw, 2010). 1.2 Statement of the problem If the level of adherence to clinical pathway is low as stated by Cabana et al (1999) who focused on establishing why physicians do not follow clinical practice guideline, it means that it will be practically impossible for practitioners working in different emergency departments to consult since they are not using the same clinical pathway. In a scenario whereby there is an assured high adherence of clinical pathways, then physicians and nurses can easily consult on matters pertaining to various clinical pathways that they are using. Secondly, the low levels of adherences reduces the chances that another physician and/ or nurse will be able to easily carry on with treating a patient who has been transferred from another emergency department where a different set of clinical pathways are been utilized. Thirdly, and most importantly, update clinical pathways ought to be the most effective forms of clinical practices that are assured of gaining the best outcomes within a shorter period. Therefore, if physicians and nurses working in the emergency room are not adhering to the update clinical pathways, it means that they are denying their patients an opportunity to have a better quality of life and/ or recover at a much faster pace. This is despite the fact that numerous research studies and testing are normally undertaken before a clinical pathway can be updated. 1.3 Research purpose The purpose of this proposed research study is to gauge the extent to which hospitals accredited with the Central Board of Accreditation for Healthcare Institution adhere to clinical pathways. In particular, the investigation will focus on physicians and nurses working in different emergency departments within various hospitals in the Kingdom of Saudi Arabia (KSA). 1.4 Research objective a) To establish the process involved in updating clinical pathways b) To establish the number of physicians and nurses who received training on clinical pathways c) To establish the extent to which trained physicians and nurses working in different emergency departments in hospitals in KSA adheres to update clinical pathways. d) To establish factors influencing the level of adherence of updated clinical pathways by physicians and nurses working in different emergency departments within hospitals in KSA 1.5 Research questions a) What is the process that is involved in updating clinical pathways? b) How many physicians and nurses normally receive training on updated clinical pathways? c) To what extent do trained physicians and nurses working in different emergency departments in hospitals within KSA adhere to updated clinical pathways? d) What are some of the factors that influence the level of adherence of update clinical pathways by physicians and nurses working in different emergency department within hospitals in KSA? 1.6 Research assumption This proposed research study will assume that there is normally an update on clinical pathways that is recommended for use by physicians and nurses working in emergency departments within hospitals that are in KSA. 1.7 Significance of the study This research study will be of significance to different groups of people as discussed below; Medical practitioners These comprises of every person engaging in different forms of medical practice. This research study will provide them with a clear measure of the level of adherence of the updated clinical pathway. Medical practitioners who are directly involved in devising clinical pathways will assess the impact of their work and whether or not their contribution are appreciated by their counterparts (Law and MacDermid, 2008). Medical regulatory bodies Bodies such as the Central Board of Accreditation for Healthcare Institution and the Ministry of Health will establish factors that influence the level of adherence of updated clinical pathway and thereby implement regulations that will aim at increasing the level of adherence, which will subsequently improve the quality of healthcare in KSA (Law and MacDermid, 2008). Academic circles In the academic circles, this proposed research study will fill a research gap that pre-existed. This research gap is whether updated clinical pathways have a direct impact on the improvement of healthcare services. If for instances, the study establishes that the level of adherence is low among trained physicians and nurses then it will mean adherence on clinical pathways does not have a major influence on the good service delivery at emergency departments and vice versa. 2.0 Literature review 2.1 The development of clinical pathways In the publication by the National and Gulf Center for Evidence Based Medicine (2008), clinical pathways was referred to as evidence-based clinical practice guidelines that have increasingly been utilized as tools that can enable clinical governance, which has a spiral effect of improving the quality of health care. The NGCEBM (2008) further added that clinical pathway help in devising strategies for preventing, diagnosing, treating, and managing diseases and injuring, and they are also used in the assessing the quality of healthcare. According to Field and Lohr (1992), the evidence –based clinical practice guidelines are statements that are used by medical practitioners as well as patients whilst making a decision on the appropriate healthcare practice that can be employed in a specific clinical scenario. In a simple perspective, the clinical pathways provide charted path, which organize and time the appropriate interventions that can be applied in a particular clinical scenario. In the Kingdom of Saudi Arabia as well as other Gulf countries, the National and Gulf Center for Evidence Based Medicine exists to assist the country in the development and implementation of evidence-based approach towards provision of health care. According to Field & Lohr (1992), this organization undertakes numerous studies and tests in order to come up with clinical pathway that has been validated to be effective by the numerous tests to conducted and hence there is evidence to show it is the best practice that can provide a positive outcome in a particular clinical scenario. It is important to note that in KSA, clinical pathways are customized for specific clinical circumstances for example; the Saudi Association for Pulmonary Hypertension periodically publishes updated guidelines on the diagnosis and management of pulmonary hypertension. Other examples of clinical pathways in the KSA include the Saudi guidelines for chronic obstructive pulmonary diseases and the Saudi guidelines for the diagnosis and management of asthma in adults and children. Practitioners in this field conduct specialized studies that first highlight on the drawbacks experience in the existing clinical pathways and following recommendations they conduct the tests to establish which pathway has enough evidence to warrant the updating of the existing pathway. 2.2 The extent of adherence of updated clinical pathways In a research study conducted by Al-Jahdali et al., (2004), they focused on investigating the extent to which the National Asthma Management Guidelines were been implemented in the emergency department. In particular, this research study sought to compare the actual service delivery within emergency departments with those that had been recommended under the national protocol for management that was published in 1995. This research study focused on four hospitals in KSA as the case studies and it conducted a retrospective analysis of 150 records from the emergency room pertaining to asthma patients. The retrospective analysis compared indices of severity, treatment administered, pre-discharge assessment as well as prescriptions issued to patients, with the guidelines that had been recommended in 1995. The results of this research study showed that there was a variance in the documented treatment offered to asthma patients with what was recommended, which means that asthma patients received inadequate care (Al-Jahdali et al., 2004). In a separate research study conducted by White et al., (2011), that sought to investigate the extent to which recommended clinical pathways were employed in the management of pain, sedation and neuromuscular blockade for mechanically ventilated patients at the emergency department. A retrospective analysis was also conducted in this study, which looked at the treatment documentation for the mechanically ventilated patients before and after the implementation of the clinical pathways. The result of this research study showed that there was only partial adoption of the recommended clinical pathway (White et al., 2011). This two research studies affirms that indeed, medical practitioners do not normally adopt updated clinical pathway in full. 2.3 Factors that influence the adoption of clinical pathways by physicians and nurses working at the emergency department In a research study, conducted by Carlfjord et al. (2010) on the factors influencing adoption of an innovation in primary health care it was noted that positive expectations of an innovation positively influence its adoption. Secondly, adoption was also positive influenced if there was a perception that the innovation will be compatible to the routines that are in place and it will bring about numerous advantages. Lastly, this study established that adoption was greatly influenced by the attitude on change as well as innovation by medical practitioners. In the studies conducted by Institute of Medicine (U.S.) and Graham (2011), it was noted that factors which determine the acceptance of clinical guidelines are normally cost involved in the adoption, attitude of medical practitioners, availability of support during adoption, patients’ attitude to use, legal and ethical issues, and credibility of evidence justifying the recommendation. The factors listed above could be among the factors that cause medical practitioners in KSA to fail in fully adopting updated clinical pathways. 3.0 Research methodology This section highlights on the research method and procedure that will be used to collect and analyze data that will be used to answer the research questions listed above. 3.1. Research method Considering that the CBAHI, has data that could demonstrate the level of adherence of clinical pathways among physicians and nurses, then it means that the best method applicable for this research study is the mixed method, which consist of both the quantitative and qualitative method (Kothari, 2004). 3.1.1 Quantitative method Under this method the research will use the CBAHI clinical pathways checklist to survey health the physicians and nurses who are involved in the implementation of clinical pathways. Based on the data obtained from the CBAHI, the researcher will seek to establish the number physicians and nurses who are working in emergency departments within hospitals in KSA who have received training on clinical pathways and those who have not. From the number of the trained physicians and nurses, the researcher will seek to establish the percentage of adherence i.e. the number of physicians who are adhering and those who are not. 3.1.2 Qualitative method Under the qualitative method, the researcher will use two focus groups. The first focus group will be mainly be composed of 6 physicians and 6 nurses while the second focus group will consist of 12 administrative managers of different hospitals in the KSA where the CBAHI has trained the personnel on clinical pathways. From these focus groups, the researcher will seek to establish factors that influence the level of adherence among physicians and nurses. 3.2 Ethical consideration First of all the researcher will seek to obtain consent from the management of the hospital targeted agreeing to be included in the proposed research study. Secondly, the researcher will not disclose confidential information obtained from the CBAHI records pertaining to adherence of clinical pathways. References Al-Jahdali, H. Al-Omar, A. Al-Moamary, M. Al-Duhaim, A. Al-Hodeib, A. Hassan, I. and Al- Rabegi, A. (2004). Implementation of the National Asthma Management Guidelines in the Emergency Department. Saudi Medicine Journal Vol. 25 (9): 1208-1211 Alkhenizan, A. and Shaw, C. (2010). Assessment of the accreditation standards of the Central Board for Accreditation of Healthcare Institutions in Saudi Arabia against the principles of the International Society for Quality in Health Care (ISQua). Ann Saudi Med. 30(5): 386–389. Cabana M, D., Rand C, S., Powe N, R., Wu A, W., Wilson M, H., Abboud P, A., and Rubin H, R. (1999). Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA, 282 (15): 1450-1465 Carlfjord, S. Lindberg, M. Bendtsen, P. Nilsen, P. and Andersson, A. (2010). Key factors influencing adoption of an innovation in primary health care: a qualitative study based on implementation theory. BMC Family Practice. Vol 11 (60) 1471 – 2296 Ernst, H. (2010). Progress of Medicine, 1850 – 1900: An Oration Delivered Before the Norfolk District Medical Society at the Celebration of the Semi-Centennial of its Org. Kessinger Publishing Field, M.J. & Lohr, K.N. (1992). Guidelines for Clinical Practice: from development to use. Institute of Medicine, National Academy Press, Washington, DC. Howick, J. (2011). The philosophy of evidence-based medicine. Chichester, West Sussex, UK: Wiley-Blackwell, BMJ Books. Institute of Medicine (U.S.)., & Graham, R. (2011). Clinical practice guidelines we can trust. Washington, D.C: National Academies Press. Kothari, C. (2004). Research Methodology: Methods and Techniques. New Delhi, India: New Age International Law, M. C., & MacDermid, J. (2008). Evidence-based rehabilitation: A guide to practice. Thorofare, NJ: Slack. National and Gulf Center for Evidence Based Medicine (2008). Guidance for Clinical Practice Guideline Development, Adaptation and Endorsement. NGCRBHC: CPG Development, Adapatation, and Endorsement Guidance Poirrier, G. P., & Oberleitner, M. G. (1999). Clinical pathways in nursing: A guide to managing care from hospital to home. Springhouse, Pa: Springhouse Corp Shamrock, S. E. (2012). IFRS and US GAAP: A comprehensive comparison. Hoboken, N.J: John Wiley. Snyder, J. E., & Gauthier, C. C. (2008). Evidence-based medical ethics: Cases for practice- based learning. Totowa, N.J: Humana Press. Sorensen, R. and Iedema, R. (2011). Managing Clinical Processes. London, UK: Elsevier Health Sciences White, K. Szumita, P. Gilboy, N. Keenan, H. and Arbelaez, C. (2011). Implementation of a guideline for the treatment of pain, sedation, agitation, and neuromuscular blockade in the mechanically ventilated adult patient in the emergency department. Open Access Emergency Medicine Vol 3. 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