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Importance-Performance-Analysis: setting improvement priorities in care pathway development and implementation

Care pathways are tools to coordinate and organize care processes. All care pathways consist of multiple interventions, and combine the clinical perspective (optimal care) with the management perspective (optimal organization of care). The use of care pathways can generate insight in several challenges that healthcare teams face in practice:

Management challenges:

  •  Providing objective data / feedback on current process
  • Variation between patients and between hospitals
  • Optimal utilization of resources
  • Setting priorities for quality improvement

Research challenges:

  • Dealing with different levels of evidence for interventions
  • Putting evidence into practice
  • Identification of key interventions and quality indicators
  • Setting priorities

An Importance-Performance-Analysis (IPA) helps to set the improvement priorities for multi professional teams working with care pathways. This post shows the concept of IPA, illustrated with results from care pathway research projects on COPD and colorectal cancer surgery, supported by the European Pathway Association.

In an IPA, all interventions which are listed in the care pathway are mapped in a matrix. The importance dimension of each intervention is showed on the Y-axis. In the COPD study the Y-axis was based on international guidelines and validated by an expert panel. This resulted in a continuous range from 0 – 100%. In the colorectal cancer study, the importance was defined by the strength of the recommendation of each intervention based on the international ERAS® protocol, ranging from 1-5.

The performance dimension, on the X-axis, is defined by the adherence rate: in which percentage of patients is the intervention actually performed? This results in a 2-by-2 matrix, in which each intervention from the care pathway is represented by a dot. The top-right quadrant shows interventions that are important and have a high adherence. The bottom-left quadrant shows interventions that are less important with a low adherence. This could be interventions with an individual indication for specific patients. The bottom-right quadrant shows interventions with high adherence, but low importance. This could be overtreatment, but this can also be new interventions with a low level of evidence because research is still in progress. The top-left quadrant shows the ‘room for improvement’: these are interventions that are important, but have a low adherence.

Example IPAs

Importance-Performance-Analysis provides an intuitive way to visualize ‘missed care’, and helps in making teams aware of their performance and room for improvement. Setting the cut-off points in IPA can be challenging; in the colorectal surgery study, a 70% cut-off was based on previous studies, showing increased patient outcomes with adherence rates ≥70%. The other cut-off points are based on discussion, and can be somewhat arbitrary.

This text is based on a poster presentation at the International Conference on Integrated Care 2019 (Van Zelm et al., 2019).

Seys, D., Bruyneel, L., Decramer, M., Lodewijckx, C., Panella, M., Sermeus, W., … & Vanhaecht, K. (2017). An international study of adherence to guidelines for patients hospitalised with a COPD exacerbation. COPD: Journal of Chronic Obstructive Pulmonary Disease14(2), 156-163.

Van Zelm, R., Sermeus, W., Coeckelberghs, E., Seys, D., Panella, M., & Vanhaecht, K. (2019). Setting improvement priorities: Importance-Performance-Analysis in care pathways for integrated care. International Journal of Integrated Care, 19(4).

Van Zelm, R., Coeckelberghs, E., Sermeus, W., van Overstraeten, A. D. B., Weimann, A., Seys, D., … & Vanhaecht, K. (2017). Variation in care for surgical patients with colorectal cancer: protocol adherence in 12 European hospitals. International journal of colorectal disease32(10), 1471-1478.