Project update: Care Pathways for Nutrition problems in surgical patients with Gastro Intestinal Cancer (CP4NutriGICan)

In E-P-A newsletter Issue 12, November 2013, we informed you of a project aimed at developing and implementing care pathways for nutrition problems. It is now time to give you a quick update. The project, supported by an unconditional educational grant by Baxter, is executed in 3 hospitals in Belgium, France, Germany and The Netherlands, and is a good example of working with a care pathway as a complex intervention. A complex intervention is always a combination of several ‘active ingredients’. In the case of care pathways these ingredients are: 1) the evidcence based key interventions and indicators for the target group; 2) feedback on the current care process on the basis of the key indicators; and 3) an improvement strategy to improve the care process.

So far, we have produced an overview of evidence based interventions and indicators by performing a systematic review. An international expert panel validated the output. A formal publication of the systematic review is under review with in the research team.

The 12 participating hospitals have performed a retrospective patient record analysis to provide data on the current care process. This has resulted in a 140 page feedback report, which can be used as a benchmark. We have organized feedback sessions per country for the participating teams, where we shared the results. Some of the results, such as time between decision for surgery and surgery, or number of patients that where screened for malnutrition, were real eye-openers for the teams, indicating room for improvement.

The next phase of the project is the quality improvement strategy (active ingredient #3) which is planned for the next few months. After this, the teams will perform a prospective analysis, to see if their performance has improved.

We will keep you posted!

The CP4NutriGICan research team,
Ruben van Zelm, MSc; Prof. Kris Vanhaecht (principal investigator); Ellen Coeckelberghs, PhD; Prof. Massimiliano Panella; Prof. Walter Sermeus

Lead contact person for Baxter: mrs. L. Nonneman

Research into STEMI care pathways: Online Survey

ST- Elevation Myocardial infarction (STEMI) is one of the most common  disease in our aging world that leads to mortality due to its time sensitivity characteristics. The promises by clinical pathway in  controlling the cost, time and quality of patient care has encouraged the use of clinical pathway in STEMI care. However, it is still not clear what are the the most optimal clinical pathway components that will suit the STEMI patients and will make the use of the clinical pathway more practical?. Hence, in this study a survey was designed to answer the aforementioned  question.

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New National Section: Italy

Following the successful International Care Pathway Conference 2015 in Reggio Emilia last October, E-P-A has a new National Section in Italy. Any country with more than 20 members can form a National Section. There are more than 20 individual E-P-A members in Italy, and there are two volunteers to lead the section. We introduce the Chair and Co-Chair of the Italian Section.

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ICPC2015 Patient experience

During the Round Table session on the final day of the ICPC2015, ms. G. Gelosini told the audience a very personal story from her perspective as a patient. She encountered negative and positive experiences during her illness. Among the negative experiences were not being taken serious by professionals and a fragmented care process. The positive experience were summarized in 7 positive aspects about care pathways:

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ICPC2015 Closing remarks

At the closing of the ICPC2015, prof. Sermeus gave an overview of developments and challenges, and E-P-A’s role in advancing care pathways. He used the model for managing complex change by T. Knoster as structure:

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Personalized Patient Care: Continuous improvement in Integrated Care Pathway for Stroke patients

In 2013, the Stroke care team from the region Roosendaal / Moerdijk, the Netherlands, was awarded for their achievements in improving patient care. They were awarded with the first prize of the Belgian-Dutch Clinical Pathway Network biannual competition for best care pathway project. One of the elements of this prize is presenting the project at the International E-P-A conference. Unfortunately, the team representatives are unable to attend ICPC2015. E-P-A still wants to share the project, a short overview of the project and lessons learned is published in this article.

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Care pathways and business process management (BPM)

Espen Salthaug

Espen Salthaug

As a part of our master’s degree in economics and administration at the Norwegian School of Economics (NHH), we wrote our

master’s thesis in the spring of 2014 on the topic of care pathways. We conducted a qualitative study on the management and development of care pathways at two Norwegian hospitals, both having several Care Pathway projects at the time. The purpose was to investigate the differences in how Norwegian hospitals practice business process management (BPM) when developing and managing care pathways, and elucidate the benefits and drawbacks that the different approaches provide. BPM is a holistic discipline for managing the organization’s critical processes. Care pathways, being one of the hospital’s critical processes, perfectly fits the scope of BPM, and should be seen as a more than just a way of organizing a treatment within a department.

Ole Hermansen

Ole Hermansen

In Norway, where the healthcare system is 90 % public, several hospitals have started care pathway initiatives. Like in other Western countries, care pathways, quality improvement and collaboration across services have been on the political agenda of Norway for some years. However, the extent to which care pathways have been used as a means for quality improvement is still limited, and care pathways have not been sufficiently defined and described, or they have not been consistent with any theoretically and empirically supported care pathway approach.

“the concept of care pathways is inconsistently understood”

Our master thesis confirmed that the concept of care pathways is inconsistently understood among Norwegian health care professionals, and that the implementation process may be rudimentary or lack the necessary ingredients in terms of management and the resources allocated for the work developing care pathways. Hospital A approached the work with care pathways through process management. The hospital management had allocated resources to actively build process management capacity. They had a clear methodology for conducting care pathway- projects and the cross functional team conducting the work were supported by process supervisors to implement the care pathways. Thus, a system was in place to successfully create care pathways. Hospital B had access to a methodology for developing care pathways, however this was not actively used. The total responsibility for care pathways was delegated to departmental level, lacking foundation at management level and resources were hardly allocated to the wok. The result of this approach was that several initiatives stranded during development. Thus, successful creation of care pathways was mainly down to committed individuals. On the other hand, both hospitals experienced a descriptive decrease in length of stay and decreased mortality compared to pre-implementation in some successfully implemented care pathways.

“hospitals need to view care pathways as processes and control and manage them accordingly”

To increase successful development and implementation of care pathways, hospitals need to view care pathways as processes and control and manage them accordingly. This means involving management and allocating necessary resources, and using recognized methodology, i.e. the 7-phase approach described by Vanhaecht et al. (2012). Further, BPM can provide a systematic approach for developing and managing care pathways.  We recommend that Norwegian authorities should make an effort to inform healthcare professionals about care pathways according to E-P-As definition (or similar approaches), and leaders, staff, and other stakeholders should try to learn more about care pathways before attempting to plan and implement them.

Espen Gilhuus Salthaug      espen.salthaug@vivento.no
Ole Kristian Hermansen     okh@capgemini.com

New National Section: Canada

From May 1st, E-P-A has a new National Section in Canada. Any country with more than 20 members can form a National Section. There are more than 20 individual E-P-A members in Canada, and there are two volunteers to lead the section.

Chair: Ms. Saima Awan, MBASaima
Ms. Awan is a Senior Manager of the Integrated Care Pathways program at the Centre for Addiction and Mental Health. CAMH is Canada’s leading mental health hospital and the largest academic health science centre in the country focused on mental illness. Prior to this role, she has successfully implemented innovative and sustainable solutions to enhance clinical processes, patient care and overall clinical efficiency. In her current role she has designed and utilized the methodology of developing Integrated Care Pathways for Mental Health and Addictions. This work has been recognized by peer hospitals and provincial health agencies. She has build internal and external collaborations across the institution with Clinical Programs, Research, Education and works closely with clinical leadership, managers, frontline clinicians and physicians. Ms. Awan received her MBA from Queens University (Canada), she also holds certifications in LEAN/Six Sigma Black Belt, Project Management Professional and Quality Improvement/Patient Safety. Ms. Awan serves on a number of hospital committees and is a champion for integrating care.

AndriyCo-Chair: Dr. Andriy V. Samokhvalov, MD, PhD
Dr. Samokhvalov is a Staff Psychiatrist and Clinician-Scientist at the Centre for Addiction and Mental Health (CAMH) and an Assistant Professor at the Department of Psychiatry of University of Toronto. Dr. Samokhvalov serves on a number of hospital committees including Pharmacy and Therapeutics subcommittee of the Medical Advisory Committee. Dr. Samokhvalov has taken an active part in development of CAMH Integrated Care Pathway for Major Depressive Disorder and Alcohol Dependence. He has an excellent track record of formal or informal implementation activities that range from implementation of new treatment approaches in his clinical practice. Dr. Samokhvalov completed his MD and PhD at Kharkiv National Medical University (Ukraine). He has 12 years of clinical experience as a psychiatrist in Canada and internationally. He has also been a Principal, Co-investigator, key collaborator and consultant on multiple research projects and grant proposals and authored 63 published works with the main focus on addictions and concurrent disorders. In 2014 Dr. Samokhvalov was the recipient of the Physician of Year Award at CAMH.

Future plans
Ms. Awan and Dr. Samokhvalov are delighted to be the inaugural chair and co-chair of the Canadian Section of the European Pathway Association. We are excited to officially start collaborations with our Canadian members and colleagues internationally with a common goal of improving the quality of care through the implementation of the ICP paradigm. We are both passionate about Integrated Care Pathways and have recently received a grant to disseminate one of our CAMH ICPs at eight other health facilities within the province of Ontario, Canada. This will allow us to work with specialists across multiple disciplines and variety of settings. Our primary goals for the Canadian Section of the European Pathways Association are to increase awareness about Integrated Care Pathways across Canada and to engage more specialists within the Canadian Section. We also look forward to continue spreading the ICP knowledge through presentations at scientific forums, nationally and internationally, as well as to host gatherings for our members in Canada.

100th Care pathway conference in Japan

Japanese translation of E-P-A definition of care pathway

Japanese translation of E-P-A definition of care pathway

Dr. Hidehisa Soejima, president of the Japanese Society on Clinical Pathways, invited Prof. Kris Vanhaecht, secretary general of E-P-A, to give the key note lecture during the 100th Care Pathway Conference in the Saiseikai Kumamoto Hospital in Japan. E-P-A and the Japanese Society have a long-lasting partnership and have been sharing knowledge during E-P-A summer schools, masterclasses and 7 years ago, also our president Prof. Panella already was invited to Japan.

JCPAKris had the opportunity to visit the Saiseikai Kumamoto Hospital and meet the Total Quality Management department and Care Pathway team. Dr. Soejima presented the new ICT support system for Care Pathways that was recently updated and that can both support the organization of the care process and provide online state of the art feedback to the clinicians and managers. Not only length of stay and cost data are included in the feedback loop but also data on the variance tracking. Based on this information the daily organization of the care process and the care pathway templates can be updated and revised. During the weekly Total Quality Management team meeting, the data are discussed and improvement projects are launched.

It was interesting to see that this hospital which is accredited by the Joint Commission International included the care pathway projects as strategic pillars in the overall quality improvement system. It was surprising for Kris to see that for example the compliance to the WHO Surgical Safety Checklist was 100%, not the type of result we see in other countries or hospitals. When Kris asked how this is possible, the answer was very clear: “Rule number one in Japan is: You break no rules!”. 

More than 300 people participated to the 100th Care Pathway Conference in the Kumamoto Hospital. More than 170 people came from all over Japan to participate to this meeting. Dr. Machida, Vice President of the Kumamoto Hospital and alumni of the E-P-A masterclass, chaired this conference. Dr. Soejima presented the relation between working with Care Pathways and

Dr. Soejima

Dr. Soejima

the leadership strategies and pros & cons of the Japanese culture. After these presentations a multidisciplinary team presented their care pathway for hip fracture. Seven team members each presented their role in this pathway and all of these mini-presentations were supported with up to date data on their improvement (kaizen) cycles. As last speaker of the day, Kris presented his experience and view on the role of care pathways in hospital management and the challenges for the future regarding the relation between pathways and outcome indicators.

E-P-A hereby thanks the Japanese Society for the ongoing friendship and look forward to future opportunities to share knowledge and expertise.

Dr. Machida and prof. Vanhaecht

Prof. Vanhaecht and dr. Machida