Relational coordination: important element in care coordination across the continuum of care

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:

  1. 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?
  2. 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?
Prof. J. De Lepeleire (promotor) and S. Van Houdt, PhD

Prof. J. De Lepeleire (promotor) and S. Van Houdt, PhD

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

Demise of the LCP: villain or scapegoat? – abstract

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

Report of the International Master Class on Care Pathways

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.

KebapciThe 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.

Thank you so much for some very interesting days! I bring home a lot of useful information which I am looking forward to share with my colleagues.lundstroem

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.

coekelberghsFor 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!

Interview Sandra Buttigieg and Kris Vanhaecht

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.

Group Picture

The group of teachers and delegates, E-P-A master class 2014

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!

Contact details:

Prof. Sandra C. BUTTIGIEG Buttigiegl

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

Prof. Kris VANHAECHT Vanhaecht

KU Leuven Department of Public Health & Primary Care
Department of Quality Management, University Hospitals Leuven
Kapucijnenvoer 35 blok D bus 7001
3000 Leuven



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

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


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: