Healthcare professionals' experiences of the implementation of integrated care pathways

Stakeholders' experiences and perception on transitional care initiatives within an integrated care project in Belgium: a qualitative interview study

BACKGROUND

In 2015, a plan for integrated care was launched by the Belgium government that resulted in the implementation of 12 integrated care pilot project across Belgium. The pilot project Zorgzaam Leuven consists of a multidisciplinary local consortium aiming to bring lasting change towards integrated care for the region of Leuven. This study aims to explore experiences and perceptions of stakeholders involved in four transitional care actions that are part of Zorgzaam Leuven.

METHODS

This qualitative case study is part of the European TRANS-SENIOR project. Four actions with a focus on improving transitional care were selected and stakeholders involved in those actions were identified using the snow-ball method. Fourteen semi-structured interviews were conducted and inductive thematic analysis was performed.

RESULTS

Professionals appreciated to be involved in the decision making early onwards either by proposing own initiatives or by providing their input in shaping actions. Improved team spirit and community feeling with other health care professionals (HCPs) was reported to reduce communication barriers and was perceived to benefit both patients and professionals. The actions provided supportive tools and various learning opportunities that participants acknowledged. Technical shortcomings (e.g. lack of integrated patient records) and financial and political support were identified as key challenges impeding the sustainable implementation of the transitional care actions.

CONCLUSION

The pilot project Zorgzaam Leuven created conditions that triggered work motivation for HCPs. It supported the development of multidisciplinary care partnerships at the local level that allowed early involvement and increased collaboration, which is crucial to successfully improve transitional care for vulnerable patients.

The Effect of Care Pathways on Coronary Care Nurses: A Preliminary Study

BACKGROUND AND OBJECTIVES

A care pathway is a structured care plan based on best clinical practice for a particular patient group. It reorganizes a complex process by providing structured, standardized care and supportive multidisciplinary teamwork. Although care pathways are used worldwide, the impact and benefit of a care pathway for coronary care practices have been minimally debated. This preliminary study aimed to examine the effect of a care pathway on the autonomy, teamwork, and burnout levels among coronary care nurses in a tertiary hospital.

METHODS

A preliminary study was conducted using a pre/posttest one-group quasi-experimental design. A self-administered questionnaire was provided to 37 registered nurses from the cardiac ward of a tertiary hospital. The care pathway was developed on the basis of the current literature, local guidelines, and expert panel advice. The autonomy, teamwork, and burnout levels at the beginning and 4 months after disseminating the care pathway were measured. Implementing the care pathway included educational sessions, training in using the care pathway, and site visits to monitor nursing practices.

RESULTS

Most of the respondents were female (94.6%; n = 35), the median age of the respondents was 26.5 years (interquartile range [IQR] = 23-31), and the median length of the clinical experience was 4 years (IQR = 2-8). A statistically significant reduction in the mean burnout score was observed (mean of 58.12 vs 52.69, P < .05). A slight improvement in autonomy level was found, although it was not statistically significant. No statistically significant improvement was found in the teamwork levels.

CONCLUSION

The care pathway was associated with reduced nurse burnout. The results showed a slight improvement in autonomy level among coronary care nurses after implementing the care pathway. From a practical viewpoint, the current study can help policy makers and managers reduce burnout. This study highlights the importance of using care pathways as a tool to reorganize the care process and improve the working environment. Managers must support nursing decisions and provide continuous education to enhance nurses' autonomy, which may increase understanding of respective roles, leading to higher levels of teamwork. However, with a small sample size, caution must be applied, as the findings might not be generalizable.

Team Members and Patients’ Views on Cost-effectiveness of (Integrated) Clinical Pathway

BACKGROUND: Integrated clinical pathways (ICPs), which have particularly enhanced existing clinical pathways (CPs) through the work of multifunctional teams, have become an important tool to enable informed decision-making and provide more efficient, cost-effective, and value-based care. AIM: In the absence of studies on the cost-effectiveness of ICPs, the aim of this study was to determine the opinion of team members treating patients with total hip arthroplasty and their patients on the practice of cost-effectiveness of the existing CP and ICP that might be introduced in the future. METHODS: A mixed descriptive quantitative and qualitative approach was used. A survey of 61 team members of CP for total hip arthroplasty was conducted, as well as in-depth interviews (n = 12) and focus groups (n = 11). In addition, in-depth interviews were performed with 20 patients who had undergone total hip arthroplasty at CP in a typical Slovenian general hospital. RESULTS: The results showed that participants occasionally prioritized cost-effectiveness over quality of health care. They frequently used CP to reduce the cost and time of patient care. Nurses with secondary education were statistically significantly more likely to prioritize cost-effectiveness of health care over quality of health care than nurses with higher education, physicians, and others. Team members and patients evaluated positively the cost-effectiveness of ICP for total hip arthroplasty, but patients also pointed out that staff, especially nurse had too little contact with patients. CONCLUSION: Both team members treating patients with total hip arthroplasty and their patients have a positive attitude toward the cost-effectiveness of ICP. The nursing staff has too little contact with the patients due to staff shortages.

Integrated Clinical Pathways: Communication and Participation in a Multidisciplinary Team

BACKGROUND: An integrated clinical pathway (ICP) is a key method for structuring or planning processes of care, enabling the modernization of health-care delivery and coordination of multiple roles, forming a complete, patient-centered multidisciplinary health-care team and establishing the sequence of activities, promoting individual and team communication, collaboration, networking, and transparency, and reducing the cost of care. AIM: As there is a research gap in the area of communication among members of a multidisciplinary team for the treatment of patients through an ICP, the aim of this study was to determine the impact of communication of a member of a multidisciplinary team on the active participation of an individual in this multidisciplinary team. METHODS: A cross-sectional study of three ICPs, forchronic kidney disease, stroke, and total hip arthroplasty was conducted in a typical Slovenian general hospital. RESULTS: The results show that in the analyzed hospital, two of the three clinical pathways are not yet fully integrated. CONCLUSION: There is a weak influence of staff communication within a multidisciplinary team on an individual’s participation in this multidisciplinary team, indicating the need for various activities to actually implement clinical pathway “integration,” and promote better communication within teams to strengthen participation in multidisciplinary patient care pathways.

Identification of quality indicators of public health nursing practice: "modified Delphi" approach

OBJECTIVE

Identify process indicators to measure public health nursing practice during first postnatal visits in Ireland.

DESIGN

Using a RAND/UCLA appropriateness- "modified Delphi" method, a two-round rating and ranking process was completed in 2016. Fifty-nine statements were reviewed for consensus and priority ranking.

SAMPLE

The sample comprised a panel of 21 national and international experts.

RESULTS

Fifty-nine indicators were identified and subsequently reduced across two rounds of consensus testing. Fifty-six indicators achieved consensus and priority ranking identified 13 indicators to measure care for mothers and 15 indicators to measure care for newborns resulting in 28 process indicators to enable Public Health Nurses (PHNs) to measure care during the first postnatal visit.

CONCLUSIONS

Measurement of care using quality indicators plays an integral role in quality improvement. Developing quality indicators is important in improving care outcomes. This two round "modified Delphi" study combined with literature and previous qualitative findings identified process indicators to measure public health nursing practice at first postnatal visits and enables benchmarking. Developing quality indicators for public health nursing practice using a "modified Delphi" technique has enabled a platform to provide consensus amongst a panel of experts and identified key processes of care by PHNs and mothers.

Evaluation of HealthPathways: an appraisal of usage, experiences and opinions of healthcare professionals in Australia and New Zealand

Objectives HealthPathways, pioneered in Canterbury, New Zealand, in 2008, is a web-based tool designed to promote health care integration and patient management in primary care and to reduce fragmentation in the delivery of health services. This cross-sectional study evaluated the utilisation and perceptions of this tool among health professionals in Australia and New Zealand. Methods A cross-sectional survey was administered online through Research Electronic Data Capture (REDCap) to general practitioners (GPs), practice nurses and managers, nurse practitioners, specialist and community nurses, hospital clinicians, nurses, managers, and allied health professionals between April and September 2018. The frequency of HealthPathways use in the previous month was modelled as an ordered response using an ordered logistic regression model after adjusting for the possible effects of sex, age, years in clinical practice, location and time spent in practice. Results Health professionals perceived HealthPathways to be useful in primary care management and referral, as well as in the prereferral treatment of patients. GPs in New Zealand, New South Wales and Victoria were 73%, 47% and 27% more likely to have used HealthPathways ≥10 times in the previous month respectively. Conclusion The results suggest that HealthPathways is having a positive effect on healthcare systems in New Zealand and Australia. However, differences in uptake suggests the need for focused implementation, integration into eReferral software and expanding the tool to medical students, registrars, allied health professionals and potentially patients to encourage behavioural change. What is known about the topic? Early evaluations suggest that HealthPathways is a useful tool for health professionals, although uptake and utilisation may be limited. However, there is no comparative evidence regarding uptake and implementation of the tool. What does the paper add? This study is among the first to provide a comparative narrative of the literature assessing the implementation and uptake of HealthPathways across Australia and New Zealand. It is also among the first to compare the perceptions of allied health professionals in the use of HealthPathways across Australia and New Zealand. What are the implications for practitioners? The results of this study suggest the need for focused implementation, integration into eReferral software and expanding the tool to medical students, registrars, allied health professionals and potentially patients to encourage behavioural change.

An integrative approach to improving patient care pathways

PURPOSE

Globally, healthcare managers continue to struggle with increasing demands for their services being delivered with limited or shrinking resources. It is, therefore, clear that systems, processes and practices need to change to meet these challenges. The purpose of this paper is to assess how integrating two improvement technologies, Lean and integrated care pathways (ICP) might help.

DESIGN/METHODOLOGY/APPROACH

Lean and ICP in healthcare provide a platform to develop conceptual frameworks for integrating two approaches.

FINDINGS

A conceptual integrated framework is provided to assist care pathway designers and implementers to consider the synergistic benefits of combining approaches to improvement.

RESEARCH LIMITATIONS/IMPLICATIONS

The authors provide a conceptual framework that requires empirically testing.

PRACTICAL IMPLICATIONS

This research provides a conceptual framework to aid practitioners to improve healthcare design and delivery.

ORIGINALITY/VALUE

For the first time, the authors bring together two approaches to improving patient care pathway design and consider how these are linked in relation to improving healthcare delivery.

Understanding new models of integrated care in developed countries: a systematic review

Background

The NHS has been challenged to adopt new integrated models of service delivery that are tailored to local populations. Evidence from the international literature is needed to support the development and implementation of these new models of care.

Objectives

The study aimed to carry out a systematic review of international evidence to enhance understanding of the mechanisms whereby new models of service delivery have an impact on health-care outcomes.

Design

The study combined rigorous and systematic methods for identification of literature, together with innovative methods for synthesis and presentation of findings.

Setting

Any setting.

Participants

Patients receiving a health-care service and/or staff delivering services.

Interventions

Changes to service delivery that increase integration and co-ordination of health and health-related services.

Main outcome measures

Outcomes related to the delivery of services, including the views and perceptions of patients/service users and staff.

Study design

Empirical work of a quantitative or qualitative design.

Data sources

We searched electronic databases (between October 2016 and March 2017) for research published from 2006 onwards in databases including MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Science Citation Index, Social Science Citation Index and The Cochrane Library. We also searched relevant websites, screened reference lists and citation searched on a previous review.

Review methods

The identified evidence was synthesised in three ways. First, data from included studies were used to develop an evidence-based logic model, and a narrative summary reports the elements of the pathway. Second, we examined the strength of evidence underpinning reported outcomes and impacts using a comparative four-item rating system. Third, we developed an applicability framework to further scrutinise and characterise the evidence.

Results

We included 267 studies in the review. The findings detail the complex pathway from new models to impacts, with evidence regarding elements of new models of integrated care, targets for change, process change, influencing factors, service-level outcomes and system-wide impacts. A number of positive outcomes were reported in the literature, with stronger evidence of perceived increased patient satisfaction and improved quality of care and access to care. There was stronger UK-only evidence of reduced outpatient appointments and waiting times. Evidence was inconsistent regarding other outcomes and system-wide impacts such as levels of activity and costs. There was an indication that new models have particular potential with patients who have complex needs.

Limitations

Defining new models of integrated care is challenging, and there is the potential that our study excluded potentially relevant literature. The review was extensive, with diverse study populations and interventions that precluded the statistical summary of effectiveness.

Conclusions

There is stronger evidence that new models of integrated care may enhance patient satisfaction and perceived quality and increase access; however, the evidence regarding other outcomes is unclear. The study recommends factors to be considered during the implementation of new models.

Future work

Links between elements of new models and outcomes require further study, together with research in a wider variety of populations.

Study registration

This study is registered as PROSPERO CRD37725.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Orthopaedic Surgery Under National Health Reform: An Analysis of Power, Process, Adaptation, and Leadership: AOA Critical Issues

Morrison argued that demography, economy, and technology drive the evolution of industries from a formative first-generation state ("First Curve") to a radically different way of doing things ("Second Curve") that is marked by new skills, strategies, and partners. The current health-reform movement in the United States reflects these three key evolutionary trends: surging medical needs of an aging population, dramatic expansion of Medicare spending, and care delivery systems optimized through powerful information technology. Successful transition from a formative first-generation state (First Curve) to a radically different way of doing things (Second Curve) will require new skills, strategies, and partners. In a new world that is value-driven, community-centric (versus hospital-centric), and prevention-focused, orthopaedic surgeons and health-care administrators must form new alliances to reduce the cost of care and improve durable outcomes for musculoskeletal problems. The greatest barrier to success in the Second Curve stems not from lack of empirical support for integrated models of care, but rather from resistance by those who would execute them. Porter's five forces of competitive strategy and the behavioral analysis of change provide insights into the predictable forms of resistance that undermine clinical and economic success in the new environment of care. This paper analyzes the components that will differentiate orthopaedic care provision for the Second Curve. It also provides recommendations for future-focused orthopaedic surgery and health-care administrative leaders to consider as they design newly adaptive, mutually reinforcing, and economically viable musculoskeletal care processes that drive the level of orthopaedic care that our nation deserves-at a cost that it can afford.

The media critique of the Liverpool Care Pathway: some implications for nursing education

End-of-life care pathways are championed around the globe as tools that might be used to enhance the quality of care at the very end of a person's life. This paper examines recent negative media discourse in the UK about the Liverpool Care Pathway for the Dying Patient (LCP). This media coverage may have had damaging effects, but it has also served to highlight inappropriate and even suboptimal end-of-life care. While recognising the pervading influence of organisational structures and cultures, some implications for initial and ongoing education of nurses are identified.

Overcoming resistance to implementation of integrated care pathways in orthopaedics

The future of orthopaedic surgery will be shaped by unprecedented demographic and economic challenges, necessitating movement to so-called "second curve" innovations in the delivery of care. Implementation of integrated care pathways (ICPs) may be one solution to imminent cost and access pressures facing orthopaedic patients in this era of health-care accountability and reform. ICPs can lower costs and the duration of hospital stay while facilitating better outcomes through enhanced interspecialty communication. As with any innovation at the crossroads of paradigm change, implementation of integrated care pathways for orthopaedics may elicit surgeons' concern on a variety of grounds and on levels ranging from casual questioning to vehement opposition. No single method is always effective in promoting cooperation and adoption, so a combination of strategies offers the best chance of success. With a special focus on total joint replacement, we consider general patterns of resistance to change, styles of conflict, and specific issues that may underlie orthopaedic surgeon resistance to implementation of integrated care pathways. Methods to facilitate and sustain orthopaedic surgeon engagement in implementation of such pathways are discussed.