The 600 Pathways Yale New Haven Health Takes to Improved Care Delivery

Yale New Haven Health launched a major initiative four years ago to reduce variation in care at the health system's four acute-care hospitals and outpatient sites.

Yale New Haven Health is seeking to reduce variation in the delivery of care with the health system's Care Signature Initiative.

Decreasing variation has been a central goal of quality improvement since W. Edwards Deming pioneered the concept in the Toyota Production System in the 1970s. In care delivery, research has shown the consequences of inappropriate variation include underusing needed services, overusing unwarranted services, higher costs, and worse clinical outcomes.

Yale New Haven Health launched its Care Signature Initiative in late 2019 and early 2020, says Chief Clinical Officer Thomas Balcezak, MD, MPH.

"The intent was based on the idea that variation is bad and that we should develop a clinical consensus on how specific conditions should be evaluated, diagnosed, and treated," he says.

The initiative has developed more than 600 Care Signature Pathways that are used thousands of times per week. The first Care Signature Pathway that the health system developed was for COVID-19, Balcezak says.

"We updated the Care Signature Pathway for COVID-19 every time a new therapy was determined to be effective, or an old therapy was determined not to be effective," he says. "As it worked out, we were updating that Care Signature Pathway practically every other day."

The impact of that pathway, Balcezak says, was profound.

"Our mortality was not only among the lowest in the country but also no different if you were in our smallest hospital in Westerly, Rhode Island, or at our academic medical center," he says. "We were able to achieve good outcomes at all of our hospitals because no matter which facility patients touched, they got the same care delivered in the same way."

Care Signature Pathways are developed by Care Signature Councils, which consist of representatives from all of the disciplines involved in the care for a particular condition. Those councils also update pathways as new medical knowledge arises.

"We give the council space and time to drive to consensus around the appropriate diagnostic work-up tests and the appropriate therapeutics for a particular medical condition," Balcezak says.

Once a pathway is developed, it is integrated into the health system's Epic EHR. Once a pathway is available on Epic, clinicians can populate care plans for patients automatically.

"We can make physicians' jobs easier by using technology to deliver recommendations," Balcezak says. "For example, if they are trying to treat pneumonia, we have a Care Signature Pathway for that condition, and they can click on a button in the EHR that populates the order set."

Thomas Balcezak, MD, MPH, is chief clinical officer of Yale New Haven Health. Photo courtesy of Yale New Haven Health.

Generating results

Balcezak says the initiative has produced positive results.

"We have gotten to a reduction in variation that has been a bedrock of quality improvement for years," he says.

For example:

• Alcohol use disorder: The health system's Care Signature Pathway for alcohol use disorder recommends a treatment plan and gives the physician a recommended order set. Before Care Signature Pathways were created, only about 14% of the patients received proper treatment; now roughly 85% of patients are getting that recommended treatment.
   
• High-sensitivity troponin test: In February 2023, a new high-sensitivity troponin test became available. Troponin is an enzyme that is released by heart tissue when it is injured, so testing for troponin in patients who present with chest pain in the emergency department can determine whether they are having a heart attack. The health system has a Care Signature Pathway for the high-sensitivity troponin test that includes the level of troponin that prompts a cardiology consult and the level of troponin that allows a patient to go home safely. The pathway has led to significant reductions in emergency department length of stay and hospital admissions.
   
• Blood cultures: On June 28, Becton, Dickinson, and Company informed Yale New Haven Health of a shortage of blood culture bottles, forcing the health system to reduce blood culture testing. The health system created a Care Signature Pathway to address the variation in stewardship for blood cultures, including appropriate reasons to do blood cultures, appropriate intervals for blood cultures, and protocols for conducting blood cultures such as the amount of blood required. Within three days, the health system reduced blood culture utilization by 65%.

Implementing Care Signature Pathways

When a Care Signature Pathway is developed, the primary goals of the health system for introducing them to clinicians are to achieve rapid change in clinician behavior and rapidly institute standardized practice to improve operations, throughput, quality, and safety, Balcezak says.

"Each one of those factors is intimately integrated with one another," he says. "You don't get high-quality and safe care without efficient, streamlined, and standardized operations. They go hand-in-glove."

Clinician adoption has a generational element, Balcezak says.

"Clinicians have changed over time," he says. "Today's generation of clinicians is much more likely to accept suggestions and Care Signature Pathways. In the 1990s, you would hear clinicians say, 'I do not accept cookbook medicine.' Today's physicians realize that standardization is not cookbook medicine—it is best practice."

The potential to make the lives of clinicians easier is a powerful incentive for clinicians to adopt the pathways, Balcezak adds.

"Clinicians are much more likely to accept a Care Signature Pathway because it gives them answers right at the time they are seeing patients, and pathways make it easier to do the right thing and harder to do the wrong thing," he says.