introduce new treatment technologies or change how treatment were performed but it features were intended for: ?Standardization of procedures ?Time-line compress ?Reduction in variability between individual surgeons The main features of the care path and how it would improve on the current operation are below:

Current Operation Care Path Large variability in how the CABG procedure is performed Standardizing the operating procedure Relatively high length of stay and costs as compared to other hospitals Detecting diversions from the care path and alerting caregivers.

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Producing exception reports for analysis Poor cost accounting and no centralized documentation Improving record keeping for better patient records and cost analysis Poor communication between parties along the care path Improving the communication between various parties within the care path system In practice, the care path was applied to manage a process and improve patient care within the hospital.

There are some limitations to the care path method. One of the most important limitation was the fact that the care path did not dictate the medical treatment of a given patient (in case of the CABG). But only:

?Delt with some part or data of the patients as far as medical records. ?It is limited to build the scenarios for the future, because it is based on optimal or current practices. ?It implementation depended more so on changing behaviors and processes long-time established in healthcare sector. ?Time consuming and required a “buy in” for all departments and staff to success ?It main feature – standardized treatment – require physicians ethical and logical change in their routine or practices (limit in scope). 3. What are the most common causes of extended stay for CABG patients?

The most common causes of extended stay for Coronary artery bypass graft (CABG) patients at MGH were identify by the implementation team which was trying to find out areas of improvement using a healthcare industry widely used software.

This software helped identify patients receiving only treatment and did not require hospitalization. Among the causes of extended stay for CABG were: •CABG surgery is required to perform number of medical tests of patients, the day before the surgery that increases the length of stay due to delays in tests.

•The length of stay for CABG patients increases, because of limited resources at MGH that includes lack of staff in surgical intensive care unit (SICU) during weekends, limited availability of beds at recovery floor (Ellison 8), and no currently designed floor for patients overflow. •The delays in patient’s discharge due to lack of communication between the recovery staff of hospital and referring physicians, medical complaints, and lack of weekend admissions to rehab facilities are also responsible for increasing the length of stay for CABG patients.

4. What are some of the important steps the team took to develop the care path to make it acceptable to everyone involved? To make the care path acceptable to all, Drs. Bohmer and Torchiana put together a team of 25 people made of a cardiologist, a surgeon, an anesthesiologist, various residents, and staff from operating rooms, SICU (Surgical intensive care unit) staff, recovery staff (Ellison 8), social workers and other non-medical staff.

They put together a very comprehensive team because there were many important steps toward the implementation of the program. Here are some of the steps:

1. Educating the team about the care paths benefits, needs and how the program would improve CABG area of the hospital. 2. The production of a flow diagram of current CABG process (Case Exhibit 8) to structure and organize teams discussions; 3. The use of the flow diagram of current CABG process to identify problems in the current operating process; 4. The use of the software to find past trends in the medical record of CABG patients and finding out why the length of stay happen in the first place;

5. A closer look at the actual CABG methodologies and understanding current procedures; 6. Development of subgroups of operating room people, physical therapists and social workers who met on weekly basis to discuss progress. 5. What are the hazards of standardizing the process too rigorously?

The hazards of Standardizing the process too rigorously risks undermining other processes in the hospital operation as a whole. This would potentially affect the quality of CABG surgery. The other risk could be the shift in physician independent medical decisions on a case-by-case which could alter the care, physician performance and effectiveness.

But the most important hazard in my opinion have to do with how motivated the staff involve will be. There is potential for letdowns, resistance to change, for the staff of hospital if there is a rigorous attempt to standardize the process.

This could be the result of too much rigorousness in the standardization process because how important and crucial it is. A hard push to a standardization process by the teams could affect the implementation and other operations. 6. What are the dangers of allowing too much freedom to customize the process?

There are dangers, risks or negative effects of allowing too much freedom to customize the process. There is a specific guidelines and mode of operation in a hospital setting or healthcare sector, so too much freedom in customization of the process would potential change a few procedures which could increases costs (more pressures) and at the same time affecting any improvements overall.

But more importantly, there dangers of increasing a not so popular, sophisticated program as seen on the flow diagram of current CABG process with the freedom of adding more features.

Another danger with too much freedom to customize could be the difficulty to coordinate and communicate or explain the customized process. Minimal freedom would encourage participation and more “buy in” from staff. 7. Does every care path patient have to go through all the steps in the care path? What happens to patients who do not follow the path fully? The care path existed a checklist of what the patient had to go through the day before the surgery, the day of the surgery and on the post-surgery days (Case Exhibit 3).

With the new care path process, every patient had to go through all the steps of this process for the procedure to be a success. A patient on the care path would be expected to meet all the goals and be discharged by day 5 after the procedure. Otherwise, a patient would be deem “off the path” would be one would missed at least one steps of the process for any of the following reasons: systematic, social or medical.

The patients who do not follow the path fully, would be faced with: Lengthy of stay in the hospital, delay in the CABG surgery and increased costs, treatment risks for the patient. Reference Wheelwright, Steven C. , and James Weber. “Massachusetts General Hospital: CABG Surgery.