Master Class on care pathways – first impressions

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
  • teamwork
  • 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

introduces the team work aspects of care pathways


daan aeyels @daanaeyels  ·  Sep 8

introduces the team work aspects of care pathways

Kris Vanhaecht @krisvanhaecht  ·  Sep 8

Prof Panella discussing the (possible) effect of … What about publication bias?


ilse weeghmans ‏@IlseWeeghmans Sep 9

How about an information pathway: which member of the team informs patients about what and when?

daan aeyels @daanaeyels  ·  Sep 9

The game in masterclass

The Importance of Intraclass Correlation Coefficient for Clinical Pathways

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

Care Pathways for Acute Coronary Syndrome

A quality improvement research project

Cardiovascular diseases are the leading cause of death globally. In Europe, half of the acute myocardial infarctions hospitalizations are due to ST elevated myocardial Infarction (STEMI). Optimal treatment for STEMI has been published and disseminated through decades of (inter)national guidelines. Despite the availability of these guidelines, adherence to evidence on STEMI care varies greatly between hospitals, systems of care and time.

The Care Pathways for Acute Coronary Syndrome (CP4ACS) Quality Improvement Research Project was set up by the European Pathway Association to evaluate and improve the care process and the quality of care for adult patients with STEMI in 16 Belgian hospitals. The project started in May 2013 as a collaboration between the European Pathway Association, the Health Services Research Group of the Department of Public Health & Primary Care, KU Leuven and the Department of Cardiology of the University Hospitals Leuven. The 3-year project is funded by an unrestricted Grant from Astra Zeneca.

CP4ACS uses an interrupted time series design with one retrospective and two prospective measurements on quality of care (both on patient as hospital level). Providing feedback on the actual organization of the care process, informing the teams on the available evidence, enhancing the teamwork and using quality improvement strategies are used as a complex intervention in the participating hospitals. Variables were selected by a RAND modified Delphi method and cover under-, over- and misuse of care. Specific attention to STEMI process improvement will be on time intervals (i.e. door to balloon time) and life style changes (i.e. smoking cessation, nutritional advice and activity level).

ImageProf. dr. Peter Sinnaeve (Department of Cardiology, University Hospitals Leuven): “CP4ACS succeeded to set up a bottom – up research project which enables STEMI teams to improve quality of care by providing evidence, benchmarking and tailored quality improvement interventions. As such it prepares STEMI teams for public reporting.”

Dr. Kris Vanhaecht ( together with prof. dr. Peter Sinnaeve ( are the principal investigators of the CP4ACS project. The project builds on previous EPA research experience on care pathways for hip fracture and COPD.

Daan Aeyels ( or +32 475298377) is the dedicated research fellow and Phd student for the CP4ACS project.

Dr. Kris Vanhaecht, secretary general, E-P-A

Update Scottish National Section

The Scottish Pathway Association

The Scottish Pathway Association (SPA) continues to grow in strength and numbers since hosting the European Care Pathways Conference in Glasgow last year.  The national group now has dual representation from almost all NHS Boards in Scotland covering General and Mental Health specialities.  SPA continues to work closely with industry partners in providing a platform of support, education and information sharing with regards to pathway developments and implementation.

This year we have supported the development of pathways in Blood Borne Virus/HIV, Diabetes, Epilepsy and Podiatry as well as the ongoing national mental health work led by Healthcare Improvement Scotland.  We have reviewed our process for accessing support from the SPA by inviting anyone who requires assistance to attend our national group meetings and present/discuss their work. This approach allows us to tailor support by aligning SPA members with the most appropriate expertise to contribute as required.

Building on relationships from the E-P-A international conference and ISQua 2013 (Edinburgh) where the work and profile of SPA and the E-P-A were well promoted, we have now provided support as far afield as Australia providing information and guidance for developments in Cancer care pathways.

We are in the process of updating our online resource –  and welcome any contact from those interested in care pathways.  We would like to thank everyone who participated and contributed the highly successful conference in June last year.

Update Spanish National Section

The Spanish section of the EPA organized a seminar with last year Degree students and second year students of the Master in Nursing Science at the Faculty of Nursing in the University of Huelva. The aim of the seminar was to provide an overview to Nursing Degree and Master´ students about the use of care pathways from an international perspective and to raise awareness within future healthcare professionals of its benefits from an organizational and clinical level. The session took place the 20th of November was coordinated by Rafaela Camacho, and prof. Mariscal and prof. Merino, both lectures and members of the Spanish section, also participated. The seminar was divided into three sessions, the first one was an introduction to care pathways and presentation of the European Pathway Association, the second one was focused on the design and development of care pathways in Andalucia and the third one was orientated towards the evaluation of care pathways. A total of 60 students attended and provided a very positive feedback about the sessions.

Care Pathways for Quality Improvement; conference report

Care Pathways for Quality Improvement – Learning from the Liverpool Care Pathway

On Wednesday February 12, delegates met in London to consider the impact of the Liverpool Care Pathway, and recent national review on pathways more generally. The conference was chaired by Ruben van Zelm, E-P-A secretary. In his Welcome and opening, Ruben highlighted the importance of definitions and terminology regarding care pathways. He explained the E-P-A definition, focusing on the concept of ‘complex interventions’. A care pathway is more than a piece of paper!

Highlights from Rubens presentation available here

Next speaker was Deborah Murphy, Directorate Manager & National Lead Nurse- LCP Royal Liverpool & Broadgreen University Hospitals NHS Trust and Associate Director of the Marie Curie Palliative Care Institute Liverpool (MCPCIL), University of Liverpool. She explained the history of the Liverpool Care Pathway. Developed as a local pathway, to support health care professionals in delivering high quality and respectful care for the dying, the LCP became a national and even international care pathway. In it’s original, local setting, a number of conditions were set and met before implementation of the pathway. With the spread of the document to other regions and hospitals, these conditions were not always met, resulting in poor implementation. This is supported by the Neuberger Inquiry and report. Of the 44 recommendations in the report, only 2 focus on the LCP as tool (definition / name). The other recommendations are aimed at the care process.

Information on Deborah’s speech is available here

The next speakers presented examples of care pathway work, not only for the dying, or end of life phase, but for other clinical areas as well. Dianne Tetley and Martin Vokes, Lincolnshire Partnership NHS Foundation Trust, showed an example of a Single Point Access for mental health. Single Point Access can only work if care pathways are in place to provide transparency for both care professionals and users.

Helen Mitchell, Betsi Cadwaladr University Health Board, and Marlise Poolman, Bangor University, explained the Wales perspective of using an ICP for the last days of life. They have combined the care pathway, audits, variance tracking and analysis, and benchmarking into a working quality system. The care pathway is not used as a means in itself, but as a tool to achieve goals.

Information on the Welsh session here

Mark Flemming, Healthcare Improvement Scotland, presented the Scottish approach to developing national condition specific standards for care pathways. Rather than developing national pathways, national standard for pathways are developed, leaving room for local adaptation.

Highlights from Marks session:

A care pathway for an acute condition, Paracetamol poisoning, was showed by Janice Pettie. After an initial successful implementation, Janice was forced to de-implement the pathway. The guidelines regarding paracetamol poisoning had changed, and these changes needed to be incorporated in the care pathways. As Janice put is, many nurses felt that their ‘comfort blanket’ was taken away. Only for a short period; the update care pathway is now been used again.

Jonathan Webster, CWHHE CCGs Commissioning Collaborative, and Rob Sainsbury, Hammersmith & Fulham CCG showed the development of care pathways for frail elderly. These generic pathways use whole system approach to plan and deliver Out of Hospital care for frail elderly. The pathways do not focus on a specific condition or procedure, but on more generic aspects of care.

The conference yielded some good learning points. First, care pathway development and implementation is never just about content, the context (culture, politics, …) is equally important. Second, there is still a lot of misunderstanding regarding terminology. There are many definitions, and we tend to forget that healthcare workers might have a different understanding of the term ‘pathway’ than service users. Third, the successful examples in today’s conference all had in common that the project lead or care pathway facilitator really connected with the intended users. First hear, then speak. Finally, there was concern that the recommendation of the Neuberger Inquiry that the Liverpool Care Pathway should be replaced, will lead to ‘losing the comfort blanket’ as one of the delegates quoted Janice Pettie. The LCP is still regarded as a good tool, but it was the implementation was problematic in some cases.

A number of the presentations is available via: