How to Redesign an Acute Medical Pathway: A Practical Guide for NHS Teams

Why this topic matters

The pressures on acute medical units (AMUs), emergency departments (EDs), and wider hospital resources are immense and well-documented. Suboptimal pathways can lead to delays in assessment and treatment, increased lengths of stay, patient dissatisfaction, and staff burnout. Conversely, a well-designed pathway can significantly improve patient flow, reduce avoidable harm, enhance staff morale, and sometimes release capacity, contributing to a more sustainable healthcare system.

National initiatives, such as the GIRFT programme and NHS England's focus on urgent and emergency care recovery, consistently highlight that pathway optimisation is crucial for meeting performance targets and delivering high-quality care. Effective redesign is a continuous process, not a one-off event.

Practical explanation

Pathway redesign involves a critical review and subsequent restructuring of processes within a specific patient journey. For acute medical pathways, this typically includes:

• Patient Triage and Initial Assessment: How patients are first seen, assessed, and streamed.
• Diagnostic Timelines: Ensuring timely access to necessary investigations (e.g., blood tests, imaging).
• Decision-Making and Treatment Initiation: Prompt and appropriate medical review and commencement of treatment.
• In-hospital Flow: Movement between different clinical areas (e.g., ED to AMU, AMU to ward).
• Discharge Planning and Processes: Early and effective planning for safe discharge or transfer of care.
• Post-discharge Support: Ensuring appropriate follow-up and community links.

Successful redesign relies on understanding the 'as-is' state, identifying bottlenecks, designing a 'to-be' state, implementing changes, and continuously monitoring their impact. It is inherently multidisciplinary, requiring input from medical, nursing, allied health professionals, pharmacy, social care, and operational teams.

Common pitfalls

Redesigning complex pathways is challenging, and several common pitfalls can derail efforts:

• Lack of multidisciplinary buy-in: Changes imposed top-down without involvement from those who deliver the care are rarely successful or sustainable.
• Insufficient data analysis: Relying on anecdotal evidence rather than robust data to identify problems and measure improvements.
• Focusing on symptoms, not root causes: Addressing superficial issues without understanding the underlying systemic problems.
• Failure to define clear objectives: Without specific, measurable, achievable, relevant, and time-bound (SMART) goals, it's difficult to gauge success.
• Poor communication: Inadequate communication throughout the process can lead to resistance, misunderstanding, and missed opportunities.
• Underestimating implementation challenges: Not allocating sufficient resources, training, or time for changes to embed.
• Lack of sustained monitoring: Implementing a change and assuming it will remain effective without ongoing review and adjustment.
• Ignoring the human factor: Changes to processes invariably affect staff workload, roles, and morale. These considerations must be integral to the design.

Step-by-step approach to acute medical pathway redesign

This structured approach supports a robust and sustainable redesign process:

Step 1: Define the Scope and Objectives

• Identify the specific pathway: What patient cohort or journey are you focusing on (e.g., frail elderly admissions, sepsis pathway, acute respiratory pathway)?
• Establish a steering group: Include key stakeholders from all relevant disciplines and departments (medical, nursing, therapy, pharmacy, ED, AMU, ward, mental health, social care, management, patient representatives).
• Define SMART objectives: What specific improvements do you aim to achieve? (e.g., 'Reduce average length of stay for condition X by 1 day within 6 months', 'Increase proportion of patients seen by a consultant within 14 hours new target'.)
• Allocate resources: Identify project leads, dedicated time, and any necessary budget.

Step 2: Understand the 'As-Is' State (Current Pathway Analysis)

• Process mapping: Visually map the current patient journey, identifying every step, decision point, and handoff. Involve frontline staff in this.
• Data collection and analysis: Gather quantitative data (e.g., length of stay, referral times, readmission rates, time to consultant review, investigation turnaround times) and qualitative data (e.g., staff feedback, patient experience surveys, incident reports).
• Identify bottlenecks and pain points: Where do delays occur? Where are there handoff failures or communication gaps? Use tools like fishbone diagrams or '5 Whys' to explore root causes.
• Benchmark: Compare your current performance against national standards, GIRFT recommendations, or other similar units.

Step 3: Design the 'To-Be' State (New Pathway Development)

• Brainstorm solutions: Facilitate workshops with the multidisciplinary team to generate innovative ideas for improving each identified bottleneck.
• Consider best practice: Research national guidance (e.g., NICE, Royal Colleges), GIRFT reports, and examples of successful pathways from other trusts.
• Develop the 'to-be' process map: Illustrate the ideal patient journey, incorporating proposed changes. Ensure clarity on revised roles, responsibilities, and communication protocols.
• Modelling and simulation (if feasible): For complex changes, consider using simulation tools to predict the impact of changes before full implementation.
• Pilot small: If possible, test key elements of the new pathway in a controlled environment or with a small patient cohort.

Step 4: Plan for Implementation

• Develop a detailed implementation plan: Outline specific tasks, timelines, responsibilities, and success metrics.
• Communication strategy: Clearly articulate the rationale for change, the new processes, and expected benefits to all affected staff and patients.
• Training and education: Provide comprehensive training for all staff on new protocols, technologies, or roles. Address potential skill gaps.
• Governance and clinical safety: Ensure the new pathway adheres to all clinical safety and governance requirements. This includes seeking approval from relevant committees.

Step 5: Implement and Monitor

• Go-live: Launch the new pathway according to the implementation plan.
• Continuous monitoring: Regularly collect data on key performance indicators (KPIs) identified in Step 1. Use control charts or run charts to track progress over time.
• Regular review meetings: Schedule frequent meetings with the steering group and frontline staff to review progress, identify new issues, and make real-time adjustments.
• Capture feedback: Actively solicit feedback from staff and patients on how the new pathway is working.

Step 6: Sustain and Embed

• Standardisation: Formalise new processes into standard operating procedures (SOPs) or clinical guidelines.
• Audit and review: Establish a regular audit cycle to ensure adherence to the new pathway and to identify further opportunities for improvement.
• Share learning: Disseminate successful outcomes and lessons learned within the organisation and beyond.
• Culture of continuous improvement: Foster an environment where staff are empowered to identify and propose further enhancements.

Example in clinical practice: Redesigning an Acute Kidney Injury (AKI) Pathway

An acute hospital recognised a higher-than-average incidence of hospital-acquired AKI and delays in appropriate management. Their redesign process involved:

1. Scope and Objectives: Target all adult inpatients with AKI. Objective: Reduce hospital-acquired AKI staging progression by 20% and time to specialist review for Stage 2/3 AKI by 30% within 12 months.
2. 'As-Is' Analysis: Process mapping revealed delayed recognition of AKI, inconsistent fluid management, and slow referral to nephrology. Data showed significant variation in time from AKI alert to medication review and consultant input. Staff surveys highlighted a lack of clarity on AKI roles and responsibilities.
3. 'To-Be' Design: Proposed changes included an automated electronic alert system for AKI detection; a standardized 'AKI bundle' of care (fluid assessment, medication review, avoiding nephrotoxic drugs); a dedicated AKI nurse specialist role for early intervention and education; and a clearer referral pathway to nephrology with defined response times.
4. Implementation Plan: Included comprehensive training for all medical and nursing staff on the AKI bundle, clear communication about the new nurse specialist role, and integration of the electronic alert with the existing EPR system.
5. Monitoring: Monthly data dashboards tracked AKI stage progression, time to nurse review, time to nephrology referral, and length of stay for AKI patients. Regular multidisciplinary meetings reviewed progress and addressed emergent issues.
6. Sustaining: The AKI bundle became embedded in ward-based teaching and induction for new staff. The electronic alert system was refined based on user feedback. Quarterly audits ensured compliance and identified areas for further refinement.

This sustained effort led to a significant reduction in severe AKI progression and improved patient outcomes, demonstrating the power of a systematic redesign approach.

How Lazomis can help

Lazomis provides a suite of tools that can significantly support each stage of your acute medical pathway redesign journey:

• Lazomis QI Project Setup: Helps define your project scope, objectives (SMART goals), and team roles, providing a structured starting point.
• Lazomis Data Collection & Analysis: Facilitates systematic collection and analysis of quantitative and qualitative data for both 'as-is' and 'to-be' states, allowing you to identify bottlenecks and measure impact effectively.
• Lazomis Process Mapping: Offers intuitive tools to map current (as-is) and proposed (to-be) pathways, making complex processes clear and highlighting areas for improvement.
• Lazomis Dashboards: Provides real-time visibility of your KPIs, allowing continuous monitoring of the pathway's performance post-implementation and enabling data-driven adjustments.
• Lazomis Communication Hub: Supports effective communication across your multidisciplinary team, ensuring everyone is informed and engaged throughout the redesign process.

By leveraging these tools, NHS teams can streamline their redesign efforts, ensuring a more data-driven, collaborative, and ultimately successful outcome.

This resource supports, but does not replace, clinical judgement. Local policy, formulary and specialist advice should be followed.