Clarification of Care Pathways and related terms?

It is Saturday evening and I am trying to sort out in my mind a set of related concepts that appear to be near the heart of how ACOs will hopefully help reduce costs and improve outcomes. It appears that a number of terms (clinical pathways, care pathways, integrated care pathways and care maps) are all used more or less interchangably. If so, there appears to be a need to sort out these terms and to use them more precisely. I think a "clinical pathway" refers to an evidence-based approach to addressing one patient's one specific apparent need. But, what of the needs of a patient with multiple medical conditions? And what of the need to do aspects of planning that are not clinical in nature, such as discharge planning and financial planning? The idea to rationalize care in a larger context than is possible with our presently fragmented ecology of providers.

Elderly patients are likely to have multiple chronic conditions. Does "integrated care pathway" mean a customized clinical pathway that includes one patient's multiple conditions? Will there be computer applications such that one patient's mutliple conditions are input and the computer produces an integrated clinical pathway that seeks collapse multiple parallel pathways into one sequence of events for that specific patient? There are complex relationships among the many subsystems of the human body and individual differences among patients with similar combinations of conditions. Any attempt to optimize the way care is provided as related to multiple medical subsystems is going to require monitoring and real-time adjustment.

I am presently reading a book titled, Joint Cognitive Systems: Foundations of Cognitive Systems Engineering by Hollnagel and Woods. The book is about cognitive networks that include both artificial and natural intelligence. When humans attempt to control a complex system they must be able to anticipate the "behaviors" of the various "agents" within the system. When some of the agents are computer programs that include artificial intelligence the ability to anticipate the behaviors of those agents can be difficult or impossible. Intelligence (artificial or natural) produces emergent behaviors, especially if the computer programming includes some generation of probability distributions, as when simulation software is used to control real systems. Not even computer programmers can fully anticipate emergent behavior and as a result "bugs" are sometimes defined to be unanticipated "features" of the software.

My conclusion at the moment is that we need to clarify terms like, "care pathway" so as to be more explicit regarding how ACOs are going to constrain costs and improve outcomes. The political case against the recent health care reform legislation was expressed as "bureaucrats" standing between physicians and patients. It seems to me that another aspect of concern is the prospective substitution of joint cognitive systems for the professional discretion of individual physicians. Is the phrase, "evidence-based" serving to help us feel more comfortable with a shifting from natural intelligence to artificial intelligence as we prepare to scale up our nation's healthcare delivery system? And how can accountability be assigned when care implementation is defined by joint cognitive systems including artificial intelligence? If the entire system is sufficiently complex, no part of it can be held responsible for adverse system outcomes.

The Roles and Responsibilities of Managers

Our reading assignments this week in the class at Georgia Health Sciences University regard the role of managers in healthcare organizations, including aspects of control, design, professional integration, adaptation and accountability. One of the points made by the authors of our textbook (Kovner, McAlearney and Neuhauser) is that the measurement of aspects of processes and outcomes is important in assessing quality of care provided. I have no doubt that Lean Six Sigma, the Toyota Way, balanced scorecard and other similar management tools are valuable. But there is also a lot to be said for just good old common sense. I wonder if managers don't sometimes become so detached from what is really happening in the organization that they miss the obvious. Bureaucratic and highly regulated organizations can create people so fixated on rules and procedures that they can miss what is obvious and common sense.

I am remembering the statement of "Dr. Leonard McCoy" in Star Trek IV: The Voyage Home as the crew is pondering what their next ship will be. "The bureaucratic mentality is the only constant in the universe. We'll get a freighter." My point is that the foundation of good management is good sense. If someone steps forward and identifies a problem or an opportunity there are probably many others who share the observation and for whatever reason have not expressed the obvious. In my opinion, good managers do not thrive on rules. Over time, they shape the culture of an organization in such a way that that common sense and shared values reduce the dependence on rules.

There is a Taco Bell store in Albany that I like. The people are friendly and the food is good. But there is one light fixture that customers are always bumping into. Its placement is a design flaw. It is suspended at a height of less than six feet. It is in the exact location that people walk to get to a table and then to place used cups and papers in the waste can. Many people bump into it. It is so obvious that it needs to be either raised or removed! There is no need for a customer satisfaction survey asking whether you enjoyed bumping your head into a light fixture today. I have asked managers at the Taco Bell store at least five times to either raise or remove the light. I have sent e-mail to "Taco Central" with the same plea. Nothing happens. Either the local managers don't care or they are powerless to take such a radical initiative as to raise a lighting fixture.

I bet there are plenty of situations like that in hospitals that managers miss because they are watching the numbers rather than looking up and seeing the obvious.