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Gartner JB, Côté A. Optimization of Care Pathways Through Technological, Clinical, Organizational and Social Innovations: A Qualitative Study. Health Serv Insights 2023; 16:11786329231211096. [PMID: 37953914 PMCID: PMC10637140 DOI: 10.1177/11786329231211096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 10/12/2023] [Indexed: 11/14/2023] Open
Abstract
Numerous calls at national and international level are leading some countries to seek to redesign the provision of healthcare and services. Care pathways have the potential to improve outcomes by providing a mechanism to coordinate care and reduce fragmentation and ultimately costs. However, their implementation still shows variable results, resulting in them being considered as complex interventions in complex systems. By mobilizing an emerging approach combining action research and grounded theory methodology, we conducted a pilot project on care pathways. We used a strongly inductive process, to mobilize comparison and continuous theoretical sampling to produce theories. Forty-two interviews were conducted, and participant observations were made throughout the project, including 60 participant observations at meetings, workshops and field observations. The investigators kept logbooks and recorded field notes. Thematic analysis was used with an inductive approach. The present model explains the factors that positively or negatively influence the implementation of innovations in care pathways. The model represents interactions between facilitating factors, favourable conditions for the emergence of innovation adoption, implementation process enablers and challenges or barriers including those related specifically to the local context. What seems to be totally new is the embodiment of the mobilizing shared objective of active patient-partner participation in decision-making, data collection and analysis and solution building. This allows, in our opinion, to transcend professional perspectives for the benefit of patient-oriented results. Finally, the pilot project has created expectations in terms of spread and scaling. Future research on care pathway implementation should go further in the evaluation of the multifactorial impacts and develop a methodological framework of care pathway implementation, as the only existing proposition seems limited. Furthermore, from a social science perspective, it would be interesting to analyse the modes of social valuation of the different actors to understand what allows the transformation of collective action.
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Affiliation(s)
- Jean-Baptiste Gartner
- Département de management, Faculté des sciences de l’administration, Université Laval, Québec, QC, Canada
- Centre de recherche en gestion des services de santé, Université Laval, Québec, QC, Canada
- Centre de recherche du CHU de Québec, Université Laval, Québec, QC, Canada
- Centre de recherche du CISSS de Chaudière-Appalaches, Québec, QC, Canada
- VITAM, Centre de recherche en santé durable, Université Laval, Québec, QC, Canada
- Centre de recherche de l’Institut Universitaire de Cardio-Pneumologie de Québec, Université Laval, Québec, QC, Canada
| | - André Côté
- Département de management, Faculté des sciences de l’administration, Université Laval, Québec, QC, Canada
- Centre de recherche en gestion des services de santé, Université Laval, Québec, QC, Canada
- Centre de recherche du CHU de Québec, Université Laval, Québec, QC, Canada
- Centre de recherche du CISSS de Chaudière-Appalaches, Québec, QC, Canada
- VITAM, Centre de recherche en santé durable, Université Laval, Québec, QC, Canada
- Centre de recherche de l’Institut Universitaire de Cardio-Pneumologie de Québec, Université Laval, Québec, QC, Canada
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Roodbari H, Axtell C, Nielsen K, Sorensen G. Organisational interventions to improve employees' health and wellbeing: A realist synthesis. APPLIED PSYCHOLOGY-AN INTERNATIONAL REVIEW-PSYCHOLOGIE APPLIQUEE-REVUE INTERNATIONALE 2021. [DOI: 10.1111/apps.12346] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Hamid Roodbari
- Institute for Work Psychology, Sheffield University Management School University of Sheffield Sheffield UK
| | - Carolyn Axtell
- Institute for Work Psychology, Sheffield University Management School University of Sheffield Sheffield UK
| | - Karina Nielsen
- Institute for Work Psychology, Sheffield University Management School University of Sheffield Sheffield UK
| | - Glorian Sorensen
- Department of Social and Behavioral Sciences Harvard T.H. Chan School of Public Health Boston Massachusetts USA
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Wainwright TW, McDonald D. A hospital-based mixed-methods observational study to evaluate a hip and knee replacement quality improvement project. TQM JOURNAL 2021. [DOI: 10.1108/tqm-12-2020-0301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeHealth services continue to face economic and capacity challenges. Quality improvement (QI) methods that can improve clinical care processes are therefore needed. However, the successful use of current QI methods within hospital settings remains a challenge. There is considerable scope for improvement of elective clinical pathways, such as hip and knee replacement, and so the use and study of QI methods in such settings is warranted.Design/methodology/approachA model to manage variability was adapted for use as a QI method and deployed to improve a hip and knee replacement surgical pathway. A prospective observational study, with a mixed-methods sequential explanatory design (quantitative emphasised) that consisted of two distinct phases, was used to assess its effectiveness.FindingsFollowing the use of the novel QI method and the subsequent changes to care processes, the length of hospital stay was reduced by 18%. However, the interventions to improve care process highlighted by the QI method were not fully implemented. The qualitative data revealed that staff thought the new QI method (the model to manage variability) was simple, effective, offered advantages over other QI methods and had highlighted the correct changes to make. However, they felt that contextual factors around leadership, staffing and organisational issues had prevented changes being implemented and a greater improvement being made.Originality/valueThe quality of QI reporting in surgery has previously been highlighted as poor and lacking in prospective and comprehensively reported mixed-methods evaluations. This study therefore not only describes and presents the results of using a novel QI method but also provides new insights in regard to important contextual factors that may influence the success of QI methods and efforts.
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van Zelm R, Coeckelberghs E, Sermeus W, Wolthuis A, Bruyneel L, Panella M, Vanhaecht K. A mixed methods multiple case study to evaluate the implementation of a care pathway for colorectal cancer surgery using extended normalization process theory. BMC Health Serv Res 2021; 21:11. [PMID: 33397382 PMCID: PMC7784254 DOI: 10.1186/s12913-020-06011-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 12/10/2020] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Specific factors that facilitate or prevent the implementation of enhanced recovery protocols for colorectal cancer surgery have been described in previous qualitative studies. This study aims to perform a concurrent qualitative and quantitative evaluation of factors associated with successful implementation of a care pathway (CP) for patients undergoing surgery for colorectal cancer. METHODS This comparative mixed methods multiple case study was based on a sample of 10 hospitals in 4 European countries that implemented a specific CP and performed pre- and post-implementation measurements. In-depth post-implementation interviews were conducted with healthcare professionals who were directly involved. Primary outcomes included protocol adherence and improvement rate. Secondary outcomes included length of stay (LOS) and self-rated protocol adherence. The hospitals were ranked based on these quantitative findings, and those with the highest and lowest scores were included in this study. Qualitative data were summarized on a per-case basis using extended Normalization Process Theory (eNPT) as theoretical framework. The data were then combined and analyzed using joint display methodology. RESULTS Data from 381 patients and 30 healthcare professionals were included. Mean protocol adherence rate increased from 56 to 62% and mean LOS decreased by 2.1 days. Both measures varied greatly between hospitals. The two highest-ranking hospitals and the three lowest-ranking hospitals were included as cases. Factors which could explain the differences in pre- and post-implementation performance included the degree to which the CP was integrated into daily practice, the level of experience and support for CP methodology provided to the improvement team, the intrinsic motivation of the team, shared goals and the degree of management support, alignment of CP development and hospital strategy, and participation of relevant disciplines, most notably, physicians. CONCLUSIONS Overall improvement was achieved but was highly variable among the 5 hospitals evaluated. Specific factors involved in the implementation process that may be contributing to these differences were conceptualized using eNPT. Multidisciplinary teams intending to implement a CP should invest in shared goals and teamwork and focus on integration of the CP into daily processes. Support from hospital management directed specifically at quality improvement including audit may likewise facilitate the implementation process. TRIAL REGISTRATION NCT02965794 . US National Library of Medicine, ClinicalTrials.gov . Registered 4 August 2014.
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Affiliation(s)
- R van Zelm
- Leuven Institute for Healthcare Policy, Katholieke Universiteit Leuven, Leuven, Belgium.
| | - E Coeckelberghs
- Leuven Institute for Healthcare Policy, Katholieke Universiteit Leuven, Leuven, Belgium
| | - W Sermeus
- Depertment of Abdominal Surgery, University Hospital Leuven, Leuven, Belgium
| | - A Wolthuis
- Depertment of Abdominal Surgery, University Hospital Leuven, Leuven, Belgium
| | - L Bruyneel
- Leuven Institute for Healthcare Policy, Katholieke Universiteit Leuven, Leuven, Belgium
| | - M Panella
- Department of Translational Medicine, University of Eastern Piemonte (UPO), Novarra, Italy
| | - K Vanhaecht
- Leuven Institute for Healthcare Policy, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Quality, Academic Policy Advisor, University Hospital Leuven, Leuven, Belgium
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Improving the Patient Experience Following Total Knee and Total Hip Arthroplasty: A Practice Development Project. J Nurs Care Qual 2019; 35:171-176. [PMID: 31219900 DOI: 10.1097/ncq.0000000000000420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The paradigm shift that has occurred for patients with total hip (THA) and knee (TKA) arthroplasty through enhanced recovery programs underscores the need for redesigning care provision. LOCAL PROBLEM In this hospital, the patient outcomes and experience anticipated from the implementation of enhanced recovery medical protocols were not fully realized. METHODS The Practice Development in Nursing and Healthcare model guided this project. INTERVENTIONS A nurse-led team designed a new care delivery model with patient/family-centered interventions based on the best evidence. RESULTS Outcomes included an increase in discharges of postoperative day 1 or less of 154% THA and 41.8% TKA and an increase in discharge to home by 24.6% THA and 18.7% TKA. In addition, 90-day readmissions were reduced for both patient groups. CONCLUSIONS An interprofessional team of clinicians made sustainable improvements in the experience and outcomes for the surgical patients with THA and TKA.
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Bjurling-Sjöberg P, Wadensten B, Pöder U, Jansson I, Nordgren L. Struggling for a feasible tool - the process of implementing a clinical pathway in intensive care: a grounded theory study. BMC Health Serv Res 2018; 18:831. [PMID: 30400985 PMCID: PMC6219016 DOI: 10.1186/s12913-018-3629-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 10/16/2018] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Clinical pathways can enhance care quality, promote patient safety and optimize resource utilization. However, they are infrequently utilized in intensive care. This study aimed to explain the implementation process of a clinical pathway based on a bottom-up approach in an intensive care context. METHODS The setting was an 11-bed general intensive care unit in Sweden. An action research project was conducted to implement a clinical pathway for patients on mechanical ventilation. The project was managed by a local interprofessional core group and was externally facilitated by two researchers. Grounded theory was used by the researchers to explain the implementation process. The sampling in the study was purposeful and theoretical and included registered nurses (n31), assistant nurses (n26), anesthesiologists (n11), a physiotherapist (n1), first- and second-line managers (n2), and health records from patients on mechanical ventilation (n136). Data were collected from 2011 to 2016 through questionnaires, repeated focus groups, individual interviews, logbooks/field notes and health records. Constant comparative analysis was conducted, including both qualitative data and descriptive statistics from the quantitative data. RESULTS A conceptual model of the clinical pathway implementation process emerged, and a central phenomenon, which was conceptualized as 'Struggling for a feasible tool,' was the core category that linked all categories. The phenomenon evolved from the 'Triggers' ('Perceiving suboptimal practice' and 'Receiving external inspiration and support'), pervaded the 'Implementation process' ('Contextual circumstances,' 'Processual circumstances' and 'Negotiating to achieve progress'), and led to the process 'Output' ('Varying utilization' and 'Improvements in understanding and practice'). The categories included both facilitating and impeding factors that made the implementation process tentative and prolonged but also educational. CONCLUSIONS The findings provide a novel understanding of a bottom-up implementation of a clinical pathway in an intensive care context. Despite resonating well with existing implementation frameworks/theories, the conceptual model further illuminates the complex interaction between different circumstances and negotiations and how this interplay has consequences for the implementation process and output. The findings advocate a bottom-up approach but also emphasize the need for strategic priority, interprofessional participation, skilled facilitators and further collaboration.
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Affiliation(s)
- Petronella Bjurling-Sjöberg
- Department of Public Health and Caring Sciences, Caring Science, Uppsala University, Box 564, 751 22, Uppsala, Sweden. .,Centre for Clinical Research Sörmland, Uppsala University, Kungsgatan 41, 631 88, Eskilstuna, Sweden. .,Department of Patient safety, Mälar Hospital, 631 88, Eskilstuna, Sweden.
| | - Barbro Wadensten
- Department of Public Health and Caring Sciences, Caring Science, Uppsala University, Box 564, 751 22, Uppsala, Sweden
| | - Ulrika Pöder
- Department of Public Health and Caring Sciences, Caring Science, Uppsala University, Box 564, 751 22, Uppsala, Sweden
| | - Inger Jansson
- Institute of Health and Caring Sciences, University of Gothenburg, Box 457, 405 30, Gothenburg, Sweden
| | - Lena Nordgren
- Department of Public Health and Caring Sciences, Caring Science, Uppsala University, Box 564, 751 22, Uppsala, Sweden.,Centre for Clinical Research Sörmland, Uppsala University, Kungsgatan 41, 631 88, Eskilstuna, Sweden
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Byrnes A, Young A, Mudge A, Banks M, Clark D, Bauer J. Prospective application of an implementation framework to improve postoperative nutrition care processes: Evaluation of a mixed methods implementation study. Nutr Diet 2018; 75:353-362. [DOI: 10.1111/1747-0080.12464] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 07/03/2018] [Accepted: 07/05/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Angela Byrnes
- Centre for Dietetics Research, School of Human Movement and Nutrition Sciences; University of Queensland (UQ); St Lucia Queensland Australia
- Nutrition and Dietetics Department; Royal Brisbane and Women's Hospital (RBWH); Brisbane Queensland Australia
| | - Adrienne Young
- Nutrition and Dietetics Department; Royal Brisbane and Women's Hospital (RBWH); Brisbane Queensland Australia
- School of Exercise and Nutrition Sciences; Brisbane Queensland Australia
| | - Alison Mudge
- Internal Medicine and Aged Care Department; Royal Brisbane and Women's Hospital (RBWH); Brisbane Queensland Australia
- Institute for Health and Biomedical Innovation, Queensland University of Technology (QUT); Brisbane Queensland Australia
- School of Medicine; University of Queensland (UQ); St Lucia Queensland Australia
| | - Merrilyn Banks
- Nutrition and Dietetics Department; Royal Brisbane and Women's Hospital (RBWH); Brisbane Queensland Australia
- School of Exercise and Nutrition Sciences; Brisbane Queensland Australia
| | - David Clark
- School of Medicine; University of Queensland (UQ); St Lucia Queensland Australia
- Surgical and Perioperative Services; Royal Brisbane and Women's Hospital (RBWH); Brisbane Queensland Australia
| | - Judy Bauer
- Centre for Dietetics Research, School of Human Movement and Nutrition Sciences; University of Queensland (UQ); St Lucia Queensland Australia
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