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.
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.
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 firstname.lastname@example.org
Ole Kristian Hermansen email@example.com
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, MBA
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.
Co-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.
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.
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.
Kris 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
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.
Care pathway were originally used in (acute) hospitals. Currently there is an increasing interest in developing care pathways in other health care settings. Sabine Van Houdt, research fellow, Academic Center for General Practice, KULeuven – University of Leuven studied the effect of care pathways across boundaries of health care settings. Below is the abstract of her PhD dissertation.
Background: Patients with complex chronic conditions often require care coordination to ensure a good quality of care. Strategies to improve care coordination do not always have the desired results. This is partly due to incomplete understanding of the key concepts of care coordination. The lack of clarity is a result of multiple existing definitions and theoretical frameworks for the study of care coordination, each with a different emphasis. In 2007, the Agency for Healthcare Research and Quality defined care coordination as “the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care.” A uniform, comprehensive theoretical framework for the study of care coordination is needed to provide us more insight in the key concepts and the links between these key concepts. This insight is important when developing, implementing and evaluating strategies to improve care coordination.
Aim: This dissertation aims to gain more insight in care coordination by exploring key concepts of care coordination and the links between these key concepts. The secondary aim is to inquire care pathways as a possible strategy to improve care coordination in primary care and to bridge primary and hospital care.
These objectives are translated into the following research questions:
- What key concepts of care coordination and links between these key concepts can be identified in international literature and in daily experiences of patients and healthcare professionals?
- To which extent can care pathways support or create elements necessary to improve care coordination across boundaries of primary and hospital care and in primary care leading to more quality of care?
Methods: First, existing theoretical frameworks for the study of care coordination were identified through a literature review. An in-depth analysis of these theoretical frameworks was performed to identify key concepts of care coordination and links between these key concepts. Second, key concepts of care coordination and links between these key concepts were further explored in patients’ and primary healthcare professionals’ experiences of care coordination. A qualitative research design was used. Twenty-two patients who had breast cancer surgery were selected in three hospitals in Flanders (Belgium) and interviewed. Primary healthcare professionals involved in the care of these patients were invited to participate in a focus group. Six focus groups were organized. Data were analyzed using constant comparative analysis. Third, an in-depth analysis of multiple cases developing a new or evaluating an already existing care pathway was performed to assess to which extent key concepts of care coordination are supported or created by care pathways. Data were gathered using mixed methods, including structured face-to-face interviews, participant observations, documentation and a focus group. Multiple cases were analyzed performing a cross case synthesis to strengthen the results. Finally, an exploratory trial was performed to explore whether revising an existing care pathway would improve quality of care enhancing patient outcomes. A pre-post intervention postal survey was used. Quality of care was translated into process and outcome indicators. These indicators were measured in two groups receiving a postal questionnaire: one group before (pre-intervention) and another group after implementation of a revised care pathway (post-intervention).
Results: The in-depth analysis identified 14 key concepts of care coordination and links between these key concepts. Nine of the fourteen key concepts were further explored in patients’ experiences of care coordination. “Roles” and “quality of relationship” were identified as core key concepts. “Quality of relationship” was extended to “quality of relationship” with the patient. “Patient’s related factors ” was newly identified. These 15 key concepts of care coordination were found and further explored in healthcare professionals’ experiences. Links between these 15 concepts were identified, including 9 newly identified links.
The development of a care pathway across the primary-hospital care continuum, supported by a step-by-step scenario, enhanced existing and newly constructed structures, knowledge and information technology, administrative operational processes, defining and knowing each other’s roles, building qualitative relationships, exchanging information and formulating and sharing goals. Observed improvement in information towards patients, communication between healthcare professionals, coordination, patients consultation of a physiotherapist who is specialised in pelvic floor muscle exercise training and patient outcomes after implementing a revised care pathway were not statistically significant after correcting for multiple testing. Quality improvement is a continuous process. Therefor the hospital takes further initiatives together with patient associations to improve well-being of patients.
Conclusions: A comprehensive theoretical framework emerges bringing all results together. The developed theoretical framework emphasizes the importance of relational coordination when developing effective coordination strategies. Relational coordination refers to clearly defined roles, knowing and respecting each other’s roles, collaboration, the bond with and trust of the patient, communication and shared goals. External factors and (inter)organizational mechanisms should enhance these aspects of relational coordination. The developed theoretical framework also emphasizes that patient’s related factors influence care coordination affecting quality outcomes.
Care pathways across the primary-hospital care continuum enhance components of care coordination when certain pre-conditions are met.
Sabine Van Houdt – Project manager quality of care and primary care, Flemish Patient Platform firstname.lastname@example.org
The winding down and withdrawal of the Liverpool Care Pathway (LCP) following the Neuberger Report has been met with mixed reviews. It appears that responsibility for failures of clinical care has been laid at the feet of a care pathway rather than the practitioners who used it, a rather curious
outcome given that the LCP was primarily a system of documentation, a tool with no intrinsic therapeutic properties. The Neubergerinquiry was the result of persistent and repeated reports of poor-quality end-of-life care associated with the use of the LCP. There were indeed problems with the LCP regarding the process of diagnosing dying and its approach to supportive care, particularly artificial nutrition and hydration. Some of the problems were the product of personal or professional ideology influencing goals of care rather than patient-centred considerations.
These problems were not insurmountable, however, and were being addressed by the organisation responsible for the LCP. With the removal of the LCP, we are left with no bench mark for end-of-life care, only aspirational goals for individualised care plans. It seems unlikely that practitioners who could not provide appropriate care with the LCP will do so without it.
D. MacKinthosh – JME Online First, published on January 20, 2015 as 10.1136/medethics-2014-102424
From September 8 – 10 E-P-A organised a three day Master Class on Care Pathways and the Organisation of Care Processes. 35 delegates from 14 countries met with the 4 E-P-A teachers from Belgium, Italy and the Netherlands. It was a truly international event! As in previous master classes and summer schools, there was room for teaching sessions, small group work and a simulation / business game. Our motto: All teach, All learn!
On day 1 we discussed the history of care pathways and our view on care pathways as a complex intervention. Care pathways are a methodology consisting of multiple ‘active ingredients’ or building blocks. These are: 1) feedback on your actual / as-is care process, the current state; 2) evidence based key interventions and indicators; 3) teamwork; and 4) a development and implementation strategy.
I valued the Master Class very much. It offered me a platform to learn the methodology of building and implementing care pathways. Also it enabled me to view care pathways from various perspective such as definition, evaluation of evidence, change management and the broader organizational picture. Ultimately I was able to spar with colleagues and build my network. Considering the stage we are in I believe it is important to keep in touch with colleagues in different countries and learn from their experience.
Pieter Bocken, Sr. Consultant, Medtronic Hospital Solutions, the Netherlands
The first day’s activity included looking at the effect of care pathways as described in literature. Although there are a number of good studies, showing positive effects of care pathways, we are cautious in interpreting the results. Because a Care Pathway is a complex intervention, it is very hard to study! There is still a lot of work to do. Finally we discussed the 7 phase model for the development and implementation of Care Pathways, E-P-A’s preferred method to developing Care Pathways. Care pathways are flexible, but the method is a systematic approach.
The International master class has improved the knowledge about clinical pathway developing process. The team explained whole implementation process step by step. So every details about each step we got. Now everything is more explicit for me, so that I can work for my pathway project systematically. EPA team was excellent, highly competent and all instructor were specialist in the pathway field.
Ayda Kebapçı, Instructor, Koç University School of Nursing
On day 2 we discussed the four building blocks of care pathways. As part of the European Quality of Care Pathway study, E-P-A developed a stepwise approach to identifying and selecting the clinical content of a Care Pathway: key interventions and indicators. Although suitable for scientific research, it may be too complex for a local project. Rather than using the Delphi method, a local expert group can play an important role in defining the evidence based content.
An important part of the Care Pathway methodology is to measure the ‘as is’ performance and give feedback based on these measurements. The goal of this step is ‘awakening’. Where are we doing well and what should we improve?
We discussed teamwork and leadership; both big concepts and we could have organised separate three days Master Class on both topics! We tied both concepts to Care Pathways, meaning that teamwork is the silo crossing, or the horizontal team, and the leader does not always have hierarchical power.
The second day concluded with a short theoretical introduction to Lean management in health care, followed by a very interactive business game. The delegates simulated a care process with the outcome of showing a change to improvement using Lean thinking.
Stine Lundstroem Kamionka, Research assistant in the Centre for Global Health / the Migrant Health Clinic, University of Southern Denmark
The final day saw the group being divided into groups focussing on a) practical examples and cases, and b) focussing on evaluation of Care Pathways.
For evaluation of Care Pathways the formative or summative evaluation paradigm can be used. Formative evaluation is used to provide feedback to people who are trying to improve something. providing analyses of the process of implementation. It is used continuously, using quantitative and qualitative methods. Summative evaluation is used to determine the effectiveness of an intervention. It is used in a limited time frame, using predominantly quantitative methods.
For me it was the first introduction to clinical/care pathways and I am very grateful that I got this opportunity. In three days, I learned so much and it motivates me to work with CP’s in the future. I have a general overview of what it is and want to learn more about it.
Ellen Coeckelberghs, Researcher, Health Services Research Group, KULeuven, Belgium
We thank all delegates for their active involvement and are looking forward to organising a next Master Class!
International Master Class on Care Pathways and the organisation of care processes – double interview with Sandra Buttigieg and Kris Vanhaecht
This September, the European Pathway Association (E-P-A), organised a three-day master class on pathways. E-P-A invited EHMA to delegate a member to the master class. Sandra Buttigieg, Associate Professor in Health Services Management, University of Malta was asked to join the master class. After three days of interactive ‘all teach, all learn’ course we asked her and Kris Vanhaecht, E-P-A’s Secretary General, about their experiences.
1. What was your most important lessons during the master class?
Sandra: I have gained a great deal of knowledge and skills in patient care pathways. The hospital where I work has been developing Clinical guidelines, protocols and standard operating procedures without going through all the steps identified so clearly in the Master Class. Therefore one crucial lesson is that if one wants to use care pathway methodology, all the steps need to be undertaken. Additionally, as part of the seven steps identified, we need to close the loop in proper evaluation of the care pathways. The second lesson is that using steps similar to what clinicians use when managing patients, namely history, differential diagnosis, investigations, diagnosis and treatment into similar steps for care pathways, will stand a better chance to get physician buy-in. The third lesson is the importance of effective leadership and well-structured interdisciplinary teams for being successful in implementing care pathways.
Kris adds: Off course it was a privilege to teach care pathways to a group of experts from 14 different countries. The fact that all these clinicians, managers and researchers were willing to share their knowledge was also this time for me the most important fact. We found out that even in 2014 we all have the same challenges and find the same bottlenecks on the organization of care. Knowledge sharing is the number one priority of our European Pathway Association and I think it will stay our n°1 for the next years.
2. How can care pathways help in improving healthcare services?
Sandra: Care pathways help to scrutinize in detail all the processes involved in patient care and relate these to patient outcomes. Care pathways help to identify roles of clinicians involved as well as empower patients to be part of care pathways. Clarity in leadership, roles and responsibilities of team members is important. Care pathways also help to identify critical points during which measurement (identification of clear KPIs) can take place. The use of care pathways will help to improve quality of care delivery, reduce errors, improve staff and patient satisfaction and reduce costs through lean management concepts.
Kris: If I look at the recent research studies I am involved in, I see that pathways can improve the organization of care and more specifically the compliance to the evidence. Not all pathways will lead to improved patient outcomes but if we can improve knowledge sharing among team members and enhance the standardization, I think we can improve the outcomes for our customer. Pathways are for me the method that can bring all the separate pieces of the complex puzzle together. It takes time, resources, willingness and creativity of everyone involved, but finally we all get better from these initiatives.
3. Both EHMA and E-P-A focus on improving (quality of) health care. How can we help each other?
Sandra: I believe that the two bodies have one major aim, namely that of improving the quality of health systems in Europe, through the improvement of healthcare services and management. The use of care pathways and more importantly using simple and effective means to implement care pathways should be encouraged by EHMA. Using the expertise provided by EPA will put care pathways on a much more solid platform.
Kris: Care pathways is about care “management” so a link with EHMA seems logical. That is why E-P-A offered a scholarship to EHMA and that they could appoint a free delegate to our master class. I think E-P-A has a proven methodology and EHMA has a great network, so let’s share knowledge and inform each other about innovative things, conferences and opportunities. I hereby would like to thank the EHMA staff, and especially Mr. Paul Giepmans, for the excellent collaboration ! I look forward to a bright future!
Associate Professor in Health Services Management
Room 7, Department of Health Services Management
Faculty of Health Sciences
University of Malta
Mater Dei Hospital
Msida, MSD 2090
KU Leuven Department of Public Health & Primary Care
Department of Quality Management, University Hospitals Leuven
Kapucijnenvoer 35 blok D bus 7001
The European Pathway Association (E-P-A) is an international not for profit association of Clinical/Care Pathway networks, user groups, academic institutions, supporting organisations and individuals who want to support the development, implementation and evaluation of Care Pathways. The association has an international network of more than 1100 pathway facilitators, researchers and managers from more than 50 countries. More information can be found at www.E-P-A.org.
The European Health Management Association (EHMA) is a membership organisation that aims to build the capacity and raise the quality of health management in Europe. Our 170 members bring together the research, policy and management communities. EHMA membership is open to all organisations or individuals committed to improving health and healthcare in Europe by raising standards of health management. More information can be found at www.ehma.org.
From Monday 8 – Wednesday 10 September we organised the international Master Class on care pathways and the organisation of care processes. 34 delegates from 14 countries met in Leuven to learn and teach about care pathways. Topics of the Master Class followed the logic of care pathways as a complex intervention:
- introduction to care pathways – care pathways as a complex intervention
- the 7 phase appraoch to care pathways
- feedback on current care process and performance
- Evaluation of care pathways
Here are some inputs from delegates and teachers that we’re posted on Twitter:
daan aeyels @daanaeyels · Sep 8
daan aeyels @daanaeyels · Sep 8
Kris Vanhaecht @krisvanhaecht · Sep 8
@IlseWeeghmans Sep 9
daan aeyels @daanaeyels · Sep 9
Cluster randomized trials (CRT) are increasingly being used in healthcare evaluation to show the effectiveness of a clinical pathways. In CRTs, patients are nested within clusters such as hospitals and interventions are applied at cluster levels but outcomes are measured at the individual level. It is expected that individuals in the same cluster e.g. hospital, would have more similarities compared to individuals in different clusters. Intraclass correlation coefficient (ICC) is used to determine the degree of within-cluster dependence and it plays an important role in estimating sample size for cluster randomized trials. ICC takes value between 0 and 1. Higher ICC means higher within group similarities compared to between groups similarities. To perform a well-designed cluster randomized trial, the ICC should be available before conducting a trial to estimate the required sample size. The degree of the increase in sample size is a function of both ICC and cluster sizes where generally a greater ICC requires enrollment of a greater number of patients in the trial. In recent years, the need to have published ICCs from different CRTs was put forward to help planning future studies. We are happy to inform you that the first study to present ICC estimates for a cluster randomized trial of care pathway are recently available1.
1 Kul S, Vanhaecht K, Panella M. Intraclass correlation coefficients for cluster randomized trials in care pathways and usual care: hospital treatment for heart failure.BMC Health Serv Res. 2014 Feb 24;14(1):84. [Epub ahead of print]
Assoc. Prof. Dr. Seval Kul
Gaziantep University Faculty of Medicine, Department of Biostatistics, Gaziantep, Turkey