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 Bikash Kendra at 14MCHs






















Working Paper-2

Clinical Management Protocol


Clinical Management Protocol is a set of directions or principles to assist the health care provider with patient care decisions about appropriate diagnostic, therapeutic, or other clinical procedures for specific clinical circumstances.
Clinical Management Protocol based care enables hospital service provider to put evidence into practice by addressing the key questions of what should be done, when, where and by whom at a local level.  It provides a framework for working in multi-disciplinary teams.  This standardization of practice reduces variation in the treatment of patients and improves the Quality of care
Clinical Management protocols are the descriptions of the steps taken to care for and treat a patient. They are sometimes called the ‘integrated care pathway’ and are designed to:

Determine care provision by using the best available evidence (National Health care standards are not available).

Developed by multi-disciplinary teams, protocols reflect local services and staffing arrangements. They identify who carries out key parts of the care or treatment and where they should be delivered.

It  usually include decision support systems to help make decisions about appropriate care for specific clinical circumstances and may form all, or part of the record of care.

Protocol based care can help reduce unnecessary variations in treatment and outcomes, but shouldn’t constrain clinical freedom. Variations between planned and actual care may still occur as clinical judgments vary to meet the needs of patients. These variations should be noted so that there is a record of what happens in practice.


When does it work best?

The standardization of clinical management reduces variation in the treatment of patients on the same pathways. Working to stipulated protocols also provides the opportunity for redesigning and extending roles

Protocol based care optimizes patient flow by examining what should be done, when and by whom, thereby reducing delays for patients.

How to use it

When should I use protocols? 

It should develop local protocols in response to the service improvement priorities have been identified e.g. pathways with a high variation.

Try looking for these characteristics when selecting service improvement priorities:

The condition or disease follows a relatively predictable course and the process of care is relatively standardized

Large numbers of people require care for the condition or disease

The procedure is high cost

The area represents a high risk to the organization

Hospital Service Management considerations indicate that action is necessary 


Suggestive modality to develop the protocol:

The multi-disciplinary team first needs to establish and confirm the objectives. The most successful protocols are simple documents that guide staff through the process, not those which describe how each procedure is delivered to the patient:


1. Select and prioritize topics that are important for our perspective.

2. Set up a multi-disciplinary team, including representatives of all clinical departments
3. Involve patient, service users and careers and ensure they actively participate in the decision making process.( Optional)

4. Agree objectives that are specific, measurable and have targets for achievement.

5. Build awareness and commitment within the organization. We need high level support to successfully implement the protocol.

6. Gather information to underpin the protocol development, including:

·    Published evidence of good practice

·    Other organizations’ experiences and protocols

·    The views of patients and users. 

7. Perform a baseline assessment to determine current performance. 
8. Produce the protocol which should be a simple document that guides staff through the process.

9. Pilot the protocol to address any operational problems and amend if necessary. Use the PDCA cycle to test your protocol.

10. Implement the protocol: It may need to support this with training and written instructions. Aim for the protocol to become an integrated part of daily practice.

11. Monitor variation from the protocol to help establish what actually happens in practice.

12. Review the protocol to ensure that it continues to be safe, appropriate, based on up-to-date evidence of effectiveness, and measures and quantifies benefits for patients and staff. 

Draft Action Plan

 Activities name



























Core Committee formation





















Core committee meeting





















Finalization of  TOR & working modalities of  the Core committee





















Selection of the areas for clinical management protocol





















Perform baseline assessment





















Development of protocol by holding series of workshop





















Piloting of the protocol





















Implement the protocol





















 Monitoring & Evaluation





















Review the protocol