DESIGNING A CLINICAL PATHWAY: A
STAKEHOLDER PERSPECTIVE
A multiple case study in Dutch healthcare institutions
M. C. Monster
Msc. Technology & Operations Management University of Groningen, Faculty of Economics and Business Supervisor: prof. dr. J. (Jan) de Vries
Student nr. s2003724 m.c.monster@student.rug.nl
Msc. Supply Chain & Operations Management Newcastle University Business School
Supervisor: dr. G. (Graeme) Heron Student nr. B4062592
A B S T R A C T
Nowadays, clinical pathways are used all over the world to improve the efficiency and quality of hospital care. For pathways to be successful, many authors stress the importance of involving stakeholders in the design, implementation and evaluation of clinical pathways. However, very little is known about the effects different stakeholders have on the final design of clinical pathways, while this can help to understand the lack of high-quality designs and why pathway projects fail to achieve project goals. This research indicates that the final design of a clinical pathway can be explained by the involvement of different stakeholders. The relationship between the stakeholders’ perspective and influence, and the final design was explored in depth by a multiple-case study among several healthcare institutions in the Netherlands. This research found that the involvement of mainly medical professions in the design process resulted in a design that is more focused on standardised protocols whereas cases which involved a mixed composition of an (operations) manager and medical professions, the design tends to focus more on achieving outcomes. A contribution is made where literature lacks an explanation on how the final design of a clinical path relates to the involvement of stakeholders in the design phase of a clinical pathway.
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ACKNOWLEDGEMENTS
This research has been written as the final chapter of my Double Degree master program in Operations Management at the University of Groningen and the Newcastle University. It has been a challenging journey, which I could not have been completed without the help and support of the following people.
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TABLE OF CONTENTS
A B S T R A C T ... 1
ACKNOWLEDGEMENTS ... 3
TABLE OF CONTENTS ... 4
LIST OF FIGURES ... 7
LIST OF TABLES ... 7
1. INTRODUCTION ... 8
2. THEORETICAL BACKGROUND ... 10
2.1 Clinical Pathways ... 102.2 The Design of a Clinical Pathway ... 11
2.3 Stakeholders in the Design Phase ... 12
2.3.1 Stakeholder Perspective ... 14
2.3.2 Stakeholder Attributes ... 14
2.3.3 Stakeholder Actions, Attitudes and Interaction ... 16
2.4 Conceptual Model ... 16
3. METHODOLOGY ... 17
3.1 Case Selection ... 17 3.2 Data Collection ... 18 3.3 Data Analysis ... 234. CASE FINDINGS ... 24
4.1 Case A ... 24 4.2 Case B ... 28 4.3 Case C ... 29 4.4 Cross-Case Findings ... 325. DISCUSSION ... 34
5.1 Stakeholder perspective in the design process ... 34
5.2 Stakeholder influence in the design process ... 35
5.3 Final design ... 36
5.4 Performance of a pathway ... 38
6. CONCLUSION ... 40
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6.2 Limitations and suggestions for further research ... 41
REFERENCES ... 43
APPENDIX A: INTERVIEW PROTOCOL ... 47
APPENDIX B: ONLINE SURVEY ... 53
APPENDIX C: STAKEHOLDER PERSPECTIVE ... 56
APPENDIX D: EXTRACT CODING PROCESS ... 59
APPENDIX E: FOCUS FINAL DESIGN ... 61
APPENDIX F: CASE FINDINGS ... 62
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LIST OF FIGURES
Figure 2.1 Conceptual Model ... 17
Figure 4.1 Focus of final design per case ... 32
Figure 4.2 Stakeholder influence per case ... 32
Figure 5.1 Causal map ... 40
LIST OF TABLES
Table 2.1 7-phase method by Vanhaecht et al. (2012b) ... 12Table 2.2 Different types of stakeholders (Mitchell et al. 1997) ... 15
Table 3.1 Case overview ... 19
Table 3.2 Operationalised variables in categories and subcategories ... 20
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1. INTRODUCTION
Within the Dutch and international healthcare sector, hospitals must ensure their services while demand for care is growing, more and more constraints on available budgets and resources rise and pressure from the government increases to reduce costs (Shahin & Matta, 2015). Factors including an aging population, increasing regulatory demands on stakeholders, inefficiencies in delivery, and out-dated information technologies raise the costs of healthcare (Feinberg et al., 2012) what demands for healthcare innovations that organise healthcare in more efficient and effective ways. Nowadays, clinical pathways are used all over the world to systematically plan and follow up a focused patient or client care programme (EPA, 2015).
Although these pathways have been used since the 1980s and have become popular in political and policy statements, there remain several important misunderstandings about their use and potential (Vanhaecht et al., 2012a). Moreover, increasing debate surrounds the different definitions that exist of pathways, the impact on resources and patient outcomes and its effectiveness (Barbieri et al., 2009; de Bleser et al., 2006; Kinsman et al., 2010; Vanhaecht et al., 2007). De Bleser et al., (2006) devoted an extensive research on defining and deriving key characteristics of a clinical pathway and found 84 different definitions all describing clinical pathways slightly different. For some institutions clinical paths can be seen as a translation of standardised care protocols into staff roles (van Citters et al., 2014) while for others they represent guidelines (de Bleser et al., 2006) or a structured multidisciplinary care plan (Campbell et al., 1998). This can be attributed to the confusion for both researchers and healthcare workers regarding what constitutes a clinical pathway (Kinsman et al., 2010).
For pathways to be successful, many authors emphasize the importance of involving stakeholders in the design, implementation and evaluation of clinical pathways (De Allegri et al., 2011; Evans-Lacko et al., 2010; Feinberg et al., 2012). Interestingly, only a limited number of empirical studies is available that elaborate on involvement of stakeholders in the design phase of clinical pathways. Feinberg et al., (2012) demonstrate how physicians play an important role in developing oncology pathways. Furthermore, the research of Knai et al., (2013) identifies the key actors involved in the development of a clinical pathway. However, none of these studies describe the influence these stakeholders have on the pathway projects. A study of shaping inventory systems in a healthcare setting demonstrates that stakeholders can have a strong influence on outcomes of the projects (de Vries, 2011). Therefore, it seems interesting to investigate the influence different stakeholders have on the final design of a clinical pathway. Moreover, this provides a deeper understanding of how the process of designing a clinical pathway takes place and to what extend this can be affected by the involved stakeholders.
9 systems can often be explained by the actions and attitudes of the stakeholders involved (Boonstra 2006; Coakes & Elliman 1999). Hence, it is reasonable to assume that in shaping a clinical pathway, among the stakeholders involved, different perceptions exist and stakeholders will attempt to shape the design according to their own perspective. This implies that the outcome of a pathway project can be related to the actions and attitudes of stakeholders in the design process of a clinical pathway. By taking into account the stakeholder salience theory, which considers stakeholders to possess power, legitimacy and/or urgency that enable them to affect the outcomes of a change project to a certain degree (Mitchell et al. 1997), the influence different stakeholders have during- and on the outcome of pathway projects can be identified. Consequently, whether the actions and attitudes of stakeholders in the design process will be effective, may depend on the amount of influence one has in the design process.
Since clinical pathways are likely to differ from one another not only in their design and content but also in their effectiveness (Rotter et al. 2013; CPA, 2014), it seems of significant importance to understand what characteristics determine the design of a pathway and who is involved in these desicions. Being able to comprehend the differences in design, can allow to differentiate aspects of the final design of a pathway and relate these to the involvement of stakeholders and possibly the performance of a pathway.
The aim of this research is to explore the effect different stakeholders have on the design of a clinical pathway. By focusing on the perspectives and attributes of the stakeholders involved in the design process, it might be possible to find out to what extent these relate to the final design of a clinical pathway. By viewing the design phase from different stakeholder perspectives, it can be understood why pathways have differences in designs. As a result, aspects can be identified that could determine the performance of a clinical path. A contribution can be made where literature lacks an explanation on how the final design of clinical pathways is affected by the stakeholders involved in the design process.
This research aims to explore to what extent different stakeholders’ perspectives and attributes affect the design process
and thereby the final design of a clinical pathway. Additional sub-questions are:
o Who are the main stakeholders involved in the design process?
o How do these stakeholders interpret the definition and objectives of a clinical pathway? o How do these stakeholders interact in the design process of a clinical pathway?
o What are the aspects that determine the performance of the final design of clinical pathway?
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2. THEORETICAL BACKGROUND
2.1 Clinical Pathways
Clinical pathways originate from the US, were in the 1980s a response to the escalating costs of healthcare and served as a framework for balancing costs and quality (de Bleser et al., 2006). In the early 1990s, clinical pathways were introduced in the UK, not only to increase efficiency but also to expand the use of guidelines in daily practice for clinical governance (Vanhaecht, 2012a). Since then, pathways are used all over the world. Besides the international differences that exist in the objectives and implementation of pathways, many alternative terms can be found. Clinical pathways, critical pathways, care pathways, care paths, integrated care pathways, case management plans, clinical care pathways or care maps, are all used to systematically plan and follow up a patient focused care program (EPA, 2015). De Bleser et al., (2006) devoted an extensive research on defining and deriving key characteristics of a clinical pathway and found 84 different definitions all describing clinical pathways slightly different. Being unable to universally define a clinical pathway influences the competences to empirically test the evidence base and compromises planning, development and implementation of pathways (Kinsman et al., 2010). Notwithstanding the variety in pathway manifestations, De Bleser et al., (2006) revealed a set of broad and uniformly accepted similarities of a clinical path. So in general, a clinical pathway is characterised by:
» the coordination of interventions of a homogeneous patient group; » the involvement of multiple medical disciplines;
» the focus on achieving optimal efficiency and improving the quality of care; » the statement and achievement of predefined goals and outcomes.
Besides these different characteristics, many different goals exist that need to be achieved when implementing these pathways. The underlying meaning of a clinical pathway is that by intensive and well-structured alignment of different actors involved in the healthcare process, significant improvements can be realised for a homogeneous group of patients (Hummel et al., 2009).So in general, the goal of a clinical pathway is on improving the quality of care. However, a wide variety of alternative goals exist: ranging from a focus on improving risk-adjusted patient outcomes and maximize effectiveness and efficiency (Dautremont et al., 2013; Vanhaecht et al., 2012a) to improved documentation, improved decision-making and reducing variation in practice (Allen et al., 2009; Faber et al., 2014; Kwan et al., 2004).
11 record; they are a way to organize multidisciplinary, patient-focused care. Therefore, this research adopts the definition of the European Pathway Association: clinical pathways are “a complex intervention for the mutual decision-making and organization of care processes for a well-defined group of patients during a well-defined period” (EPA, 2015).
Since a clinical pathway does not have a universally accepted definition, has various characteristics and serves multiple goals, it is not surprising that various perspectives exist in approaching a clinical pathway. For example, pathways can be seen as a translation of prescribed guidelines into practical, local protocols (Campbell et al., 1998; Faber et al., 2014; Rotter et al., 2013). The protocol provides a detailed description of the course of the diagnostic, treatment and care process based on evidence-based medicine. This perspective stresses the steps that need to be carried out based on the available guideline of a pathology. Also, clinical pathways can be seen as a care process on its own (Vanhaecht et al., 2010). From this perspective, the expected care journey of a patient is described by coordinating the roles and sequencing the activities of the multidisciplinary team. This emphasizes the arrangement and planning of processes, multidisciplinarity and crosses organisational boundaries. This perspective results in a more integrative approach which is in line with lean thinking, which aims at the improvement of processes and service delivery (Joosten et al., 2009; Robinson et al., 2012).
2.2 The Design of a Clinical Pathway
When developing a pathway for homogeneous patient groups, one needs to take into account the evidence-based key interventions, the interdisciplinary teamwork, the patient involvement and the available resources (Vanhaecht et al., 2007). Although evidence-based guidelines are usually developed in a top-down way, clinical pathways are more often derived from the bottom-up (Evans-Lacko et al., 2010). They are specifically tailored to the local structures, needs, systems and time-frames used and consequently, are likely to differ from one another not only in their content but also in their effectiveness (Rotter et al., 2013; CPA, 2014). So, what works for one organization may not work for another, because of subtle differences in processes and bottlenecks (Vanhaecht et al., 2012a). Therefore, it is not possible to generalize conclusions regarding the use and effectiveness of a pathway: performance of a pathway will differ among and even within healthcare institutions.
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continuous succession of clinical pathways and is based on the Deming cycle, better known as the “plan-do-study-act” (PDSA) cycle. This method aims to offer a systematic approach to support a multidisciplinary team that is developing a new pathway or aims to improve an existing pathway. An overview of the objectives and activities of this method is shown in Table 2.1. The first four phases, screening, project management, diagnose and objectification, and development are part of the design phase. By following these steps, at the end of this phase the pathway gets not only designed, but also practically developed and made visual. Based on the defining characteristics of a clinical pathway as described by de Bleser et al., (2006), it is possible to derive four different focusses in the final design of a clinical pathway. Moreover, the final design of a clinical pathway can have a focus on: 1) improving communication; 2) integrating care processes; 3) outcomes; and/or 4) standardised care protocols.
2.3 Stakeholders in the Design Phase
Evans-Lacko et al., (2010) describe facilitators and barriers in the design phase of a clinical pathway, of which most are related to involvement of individuals, often working in a (multidisciplinary) team. These individuals can be seen as the stakeholders of the clinical pathway. Freeman (2010, p.46) defines stakeholders as “any group or individual who can affect or is affected by the achievement of the organization’s objectives”.
Phase Objective Activities
Screening Determine whether a care pathway is the appropriate method to improve the care process
Assemble and analyse information on: o Ownership, teamwork, stakeholders
o The actual care process (readily available information) Project Management o Define the care process for which
the care pathway is developed o Assemble the working group /
core team
o Define patient group
o Define start and endpoint of care pathway o Set up project plan, incl. milestones Diagnose and
Objectification Evaluate the current (as is) care process from four perspectives: a. Organization and team b. Patient
c. Evidence and legislation d. External partners
Analyse the sequence and timing of the care process from these four perspectives:
o Measurements of indicators, questionnaires, process mapping
o Patient surveys, interviews, shadowing of walkthroughs o Use of guidelines, clinical algorithms, etc.
Development Development of the care pathway based on information from the previous phases
o Define inclusion and exclusion criteria for the patient group
o Define evidence based key interventions
o Practical organization of the care process (resources, staff, training etc.)
Implementation Prepare the actual implementation, test the pathway and implement the pathway
o Informing and / or training of all team members o Develop implementation plan
o Pilot testing of (elements of) the care pathway o Adjusting the care pathway based on the test o Implementation
Evaluation Determine the effect and usability of
the care pathway o o Effect measurement Measurement of adherence to the pathway o Adjust care pathway if necessary
o Develop ‘dashboard’ for continuous follow up
Continuous follow up Keeping the pathway alive and up to
date o o Use of indicators (dashboard) Establish ownership o Variance analyses
o Every six months’ substantive discussion in core team o Objective measurement at least once a year
13 For a pathway to be successful, many authors have emphasised the involvement of these stakeholders in the design phase (Castillo et al., 2015; De Allegri et al., 2011; Evans-Lacko et al., 2010; Vanhaecht et al., 2012b). Clinical paths are often developed for and by several stakeholders that work together in multidisciplinary teams (Vanhaecht et al., 2006). This team is broadly defined and consists of ‘teams of nurses, physicians, therapists and pharmacists’, and ‘other various professions’ (de Bleser et al., 2006). For example, Citters et al., (2014) developed a clinical pathway for patients undergoing total joint arthroplasty. They convened a multi-stakeholder panel based on several specialists, lean production managers, nurses and program directors for reviewing and refining a preliminary design of the clinical pathway to finally come to an optimal design. Pathways are multidisciplinary in design and should thus reflect all aspects of treatment provided by each discipline involved. Hence, in this research, stakeholders are those who can affect or are affected by the design of clinical pathways and thus can be seen as those individuals involved in the multidisciplinary team.
Since a multidisciplinary team is broadly defined, not all stakeholders are the same for each team. One fundamental member of a team is the medical specialist: without these physicians involved, it is doomed to fail (Vanhaecht et al., 2012b). They do not only possess the required expertise but also the daily responsibility of care processes. Also, a survey in collaboration with the European Pathway Association revealed that medical specialists and nurses were those most frequently identified as being involved in the development of clinical pathways (Knai et al., 2013). Another stakeholder identified as important in the process of pathway development is the management. Moreover, more and more articles stress the involvement of (operations) managers from outside the hospital setting in order to improve care processes (Castillo et al., 2015; van Citters et al., 2014; Dahlgaard et al., 2011). The importance of operations management for the healthcare in general is obvious; health care systems are faced with a growing demand for care and higher expectations for improved service delivery with more and more constraints on available budget and resources (Sahin & Matta, 2015). Also, in operations management literature the operational nature of pathways is emphasised: “the patient flow is considered similar to process throughput and is
a key measure of efficiency in hospital operations. Process bottlenecks in clinical and administrative tasks can delay patient discharges and lead to lower quality and higher costs” (Devaraj et al., 2013 p.182; Hyer et al.,2009). Moreover,
clinical pathways provide detailed operational procedures within a specific organization, and can therefore be referred to as standardised, typically evidence based, health care processes (van de Klundert et al., 2010). Notwithstanding that this perspective can be of significant importance to the development of a clinical pathway it has not yet been accepted that models should be developed by considering clinical as well as operational aspects (Langabeer et al., 2015; Parnaby & Towill, 2009).
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can often be explained by the actions and attitudes of the stakeholders involved (de Vries 2011). Additionally, project management literature states that stakeholders often affect project management processes (Olander, 2007). Therefore, it is likely that the design of a clinical pathway can be related to the involvement of stakeholders in the design phase in of a clinical pathway. By taking a stakeholder perspective, it may be possible to clarify why certain pathways are designed as, for example, a protocol or a multidisciplinary care plan (Campbell et al., 1998; Faber et al., 2014; Rotter et al., 2013).
2.3.1 Stakeholder Perspective
Although clinical pathways are widely used in Dutch healthcare institutions (CBO, 2015), the design (process) often varies among and even within these organizations. This is not surprising given the lack of agreement of both researchers and healthcare professionals regarding the definition of a clinical pathway (Kinsman et al., 2010). Moreover, it is well known that different groups of stakeholders in organisations can have different perceptions and expectations of management systems and project outcomes (Bourne & Walker, 2006; Coakes & Elliman, 1999). These different perspectives and expectations between healthcare professionals make it more difficult to develop, implement and evaluate pathways (van Gerven et al., 2010). Additionally, a study on ERP projects, Boonstra (2006) shows how stakeholders act by influencing the projects, through altering the design in ways that are more consistent with their own interpretations of the system. Therefore, it is reasonable to assume that different stakeholders in healthcare institutions may have different perspectives with respect to the definition, objectives and outcomes of a clinical pathway and consequently will shape the design according to their own perspective. For example, according to Porter and Teisberg (2007), effective care for a medical condition and added value for patients usually requires the combined and coordinated efforts of multiple physicians and other health professionals. From a management perspective, this seems rather obvious whereas from a medical perspective, this seems unreasonable since physicians tend to define their activities by their specialty rather than organizing care around medical conditions (Porter & Teisberg, 2007). Therefore, it seems to be worthwhile to study the influence of different stakeholders during the design process of a clinical pathway, since the design of a clinical pathway may be related to the perspective of stakeholders.
2.3.2 Stakeholder Attributes
15 » Power. Power is the (potential) ability of stakeholders to impose their will on a given relationship
through coercive, utilitarian, or normative means. Control based on application of physical means, such as the use of a gun, whip or lock, is ascribed as coercive power. The use of material means for control purposes, such as material rewards consist of goods and services, constitutes utilitarian power. The use of symbols for control purposes, such as prestige, esteem or acceptance, is referred to as normative power (Etzioni, 1964).
» Legitimacy. A legitimate stakeholder is one whose actions and claims are seen as appropriate,
proper, and desirable in the context of the social system (Suchman, 1995). The social system within which legitimacy is achieved, is a system with multiple levels of analysis, the most common of which are the individual, organizational, and societal levels of analysis (Wood, 1991).
» Urgency. Urgency refers to the degree to which stakeholder claims call for immediate attention
and is based on time sensitivity and criticality (Mitchell et al., 1997). Time sensitivity is the degree to which managerial delay in attending to the claim or relationship is unacceptable to the stakeholder, and criticality is the importance of the claim or the relationship to the stakeholder.
Power, legitimacy and urgency interact and when combined, create different types of stakeholders with different expected behavioural patterns regarding the healthcare institution (Mitchell et al., 1997). The stakeholder classes that result from these combinations of these attributes are described in Table 2.2
Table 2.2 Different types of stakeholders (Mitchell et al. 1997)
Nr. Typology Description
1 Dormant stakeholder
They possess power to impose their will on a firm, but do not have a legitimate relationship or an urgent claim. Their power remains unused and they have little or no interaction with the firm.
2 Discretionary stakeholder
They possess the attribute of legitimacy, but they have no power to influence the firm and no urgent claims. There is absolutely no pressure on managers to engage in an active relationship.
3 Demanding stakeholder
They possess an urgent claim, but have no power or legitimate relation- ship. This is bothersome, but does not warrant more than passing management attention.
4 Dominant stakeholder
They are both powerful and legitimate. It seems clear that the expectations of any stakeholders perceived by managers to have power and legitimacy will matter. Combined to create authority.
5 Dangerous stakeholder
They lack legitimacy, but possess power and urgency. They will be coercive and possibly violent, making the stakeholder ‘dangerous’ to the firm.
6 Dependent stakeholder
They have urgent and legitimate claims, but possess no power. These stakeholders depend upon others for the power necessary to carry out their will.
7 Definitive stakeholder
They possess both power and legitimacy. They will already be members of an organization’s dominant coalition. When such a stakeholder’s claim is urgent, managers have a clear and immediate mandate to attend to and give priority to that claim.
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2.3.3 Stakeholder Actions, Attitudes and Interaction
Clinical pathways are interdisciplinary: different disciplines need to interact and decide how they will organize the care process and who is responsible and will take the lead in which part (Vanhaecht et al., 2010). An example adapted from Boonstra (2006): in designing a clinical pathway, one stakeholder initiates and constructs a design according to priorities and expectations. Later, stakeholders of the multidisciplinary team react in different ways, based on their perspectives. In doing so, they construct the design in the sense that these reactions may become features of the final design. This continuing interaction means that the results eventually obtained can be different from those, which were originally expected. This illustrates that stakeholders influence each other by acting based on their perspective and interact in order to obtain changes in favour of their perspective. Moreover, the same author found that the design of inventory systems can often be explained by the actions and attitudes of the stakeholders involved. This implies that the outcome of a pathway project could be related to the actions, attitudes and interaction of stakeholders in the design process of a clinical pathway.
2.4 Conceptual Model
17 Figure 2.1 Conceptual Model
3. METHODOLOGY
In order to explore to what extent the design of a clinical path is affected by the perspective and influence of different stakeholders involved in the design process of clinical pathways, a multiple case study was conducted. Since a profound understanding on how the process of designing a clinical pathway takes place is needed, case studies are especially valuable as they provide the opportunity to describe a real life phenomena surrounding a specific case in an in-depth manner (Yin, 2013). Since little research was done on determining the effect stakeholders have on the design of a clinical pathway, a case study approach enables to gather rich knowledge of the specific context. Moreover, since the design of clinical pathways differs per healthcare institution, a multiple case study will provide insights from multiple perspectives what allows a more objective dataset for augmented external validity (Voss, 2009). When this approach is applied correctly, it becomes a valuable method for health science research to develop theory, evaluate programs, and develop interventions (Baxter & Jack, 2008).
3.1 Case Selection
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suitability of pathways for complex, unpredictable conditions, where care exhibits variability, is less certain (Currie & Harvey, 2000). Probably, the involvement of clinical judgement varies among those different types of pathways. Therefore, it can be possible that the influences of stakeholders involved differs in the different types of pathways. Consequently, in this research the emphasis is on those pathways with a moderate – high standardised and moderate – low complex designs. Paths that are highly complex with a low to moderate degree of standardization are very unique cases which rarely suit the pathway approach (Jones, 1999) and are therefore are out of scope in this research.
The three mini-cases were selected based on the same criteria as the main three cases. These mini-cases followed the replication logic aiming at producing similar results compared to the in-depth exploratory case studies (Yin, 1994). In total, two paths were developed in an academic hospital whilst the remaining four paths were developed in a regional (non-academic) hospital. The selected cases, their characteristics and types of retrieved data are shown in Table 3.1. Due to privacy reasons, cases are named as A, B, C and the mini-cases are named d, e and f. Those stakeholders that have supportive tasks and/or have been involved or consulted only for their ‘one-way’ input, not for their opinion about how to shape a pathway, are not seen as the main stakeholders of a pathway. Those who are seen as the main stakeholders are those who can affect the design of clinical pathways by their actions, attitudes and interaction, and are involved multiple times.
3.2 Data Collection
Table 3.1 Case overview
Case Hospital Stakeholders Type Pathway
Additional information
Documents Observations Characteristics
A Regional Project leader * Physician A * Physician B + Physician-assistant A* Physician-assistant B Nurse High standardised Low complex Quality coordinator * o PowerPoint kick-off o Clinical Pathway document o Patient Path
o Internal building blocks for good care
Way of working and registration tasks of nurses of a similar pathway. Example of how it will look like.
o Top down introduced to improve efficiency and way of working.
o Currently in design / implementation phase
B Regional Project leader *+
Physician Nurse A + Nurse B + High standardised Low complex
- o Clinical pathway document o Brochure for patients o Project evaluation document
Way of working within the system, by nurses and physician.
o Introduced by project leader to improve quality of care, efficiency and to start working according to the method of the Dutch Institute for Healthcare Improvement (CBO).
o Currently in evaluation phase C Academic Project leader *
Physician A Physician B Physician-assistant A Physician-assistant B Consultant * Nurse * Moderate standardised Moderate complex Project owner/ lean consultant /department leader *
o Article that introduced this pathway o Example pathway, a 47 paged document of
a similar pathway as pathway C. What it will look like.
o The guidelines developed by the involved physicians for this pathology
o Print screens of digital pathway
- o Introduced as a result of the changing strategies of the hospital. First introduced pathway according to the new principles.
o Currently in implementation phase
d Regional Project Leader * Physician A * Physician B + Physician C Physician-assistant + Nurse + Moderate standardised Low complex Hospital manager *
o Brochure for patients o General pathway document
o Surgeon pathway (translated) document
- o In a very short time period, forcedly introduced to engage in a quality certification.
o Currently in redesign phase
e Regional Project Leader * +
Physician A + Physician B + Physician-assistant Nurse High standardised Low complex Hospital manager *
o Brochure for patients
o document of the clinical pathway, o Agreements and guidelines of this path
- o Introduced by surgeons since they were not working according to national guidelines.
o Currently in implementation phase
f Academic Project Leader Physician A Physician B Physician C Physician D Physician-assistant * + Consultant * + Moderate standardised Moderate complex Managing consultant*
o Clinical Pathway document o Achievements after implementing o Development approach / program focus
when developing a pathway.
- o Introduced to integrate two different treatments for the same group of patients.
o Currently in implementation/evaluation phase
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Since the operationalization of constructs is one of the challenges of a case study, variables were carefully derived from the presented literature in chapter 2. Also, data based on multiple indicators of a variables were identified and collected so the true value of the variable could be captured, since all those indicators “point in the same direction” for that variable (Bennett, 2004). The operationalised variables are shown in Table 3.2.
During the semi-structured interviews, data was gathered regarding the stakeholder’s perspective, in terms of their definition and objective of a clinical path in general. In this way, it was possible to see from what perspective these stakeholders were reasoning. Also, data was collected concerning the interviewees’ and its team members’ possession of the attributes. Each interviewee identified the (main) stakeholders and rated them in terms of (perceived) power, legitimacy, or urgency. By comparing the
Categories and subcategories
Discipline of stakeholder Project leader, physician, physician-assistant, nurse, consultant, hospital manager, phycologist, physiotherapist or secretary
Stakeholder Influence
§ Power The degree to which a stakeholder is perceived as having the ability to bring about the outcomes they desire; the degree to which stakeholders had access to, influence on or the ability to impact the healthcare institution; and the degree to which a stakeholder enforces claims during meetings. § Legitimacy The degree to which the claims of particular stakeholders are viewed as legitimate; the degree to which
the project leader believes that the claims of a stakeholder were not proper or appropriate; and the degree to which the claims of a stakeholder were legitimate in the eyes of the project leader. § Urgency The degree to which stakeholders exhibited urgency in its relationship with the healthcare institution;
degree to which the stakeholder actively sought for the attention of the project leader; and the degree to which a stakeholder urgently communicated its claims to the healthcare institution.
Stakeholder Perspective
§ Definition Interpretation, perception, analysis, reasoning, of a clinical pathway, its definition in general. § Objectives Interpretation, perception, analysis, reasoning of the aims of a clinical pathway, in general. Design process
§ Attitudes The behaviour, belief, mind-set or opinion towards shaping the design during the design phase. § Actions The activities, movements, response or reaction towards shaping the design during the design phase. § Interaction The interaction, communication, cooperation, interplay between two or more stakeholders that has
an effect upon one another. Focus design
§ Communication Facilitate, assist, expedite the communication among the team members; facilitate, assist, expedite the communication with patients and families.
§ Process Integration Coordination, planning of the care process by coordinating the roles and sequencing the activities of the multidisciplinary care team; coordination, planning of the care process by coordinating the roles and sequencing the activities patients and their relatives.
§ Outcomes The documentation, monitoring, and evaluation of variances and outcomes
§ Standardised Protocols Translation of existing (national) guidelines into local protocols, tasks, actions and/or events; Integration of protocols into tasks, actions and/or events.
21 answers of the interviewees per team, a valid conclusion could be drawn from the possession of attributes of the stakeholders involved. Additionally, by identifying the stakeholder attributes, the amount of influence could be determined one had in the design process. In the first part of the interview, questions were asked for which the attributes were not specifically mentioned. Later, after providing a definition and example of power, legitimacy and urgency, similar questions with the words ‘power’, ‘legitimacy’ and ‘urgency’ were asked to confirm the possession and use of the attributes. This was done since the use of these words might have deterred stakeholders. Furthermore, to be able to (re)construct the design process, questions were asked about the attitudes and actions of themselves plus the stakeholders involved, and regarding the collaboration with others in the team. Lastly, data was gathered related to the interaction between stakeholders and the stakeholders view regarding the final design of the pathway. The latter was done to find out how they perceive the pathway and whether their perspective was similar to that of others involved. This was found out by asking them for a description of the pathway they were involved in and what aspects and descriptive characteristics were emphasised. Besides, information regarding the performance of the pathway, was shared, if possible. By gathering this kind of data, it was able to create a detailed and in-depth assessment of the cases.
Semi-structured interviews were chosen because this offers sufficient flexibility to approach different respondents differently while still covering the same areas of data collection (Noor, 2008). Consent was provided prior to the interviews and anonymity and confidentiality were guaranteed. The questions asked during the interviews were set up according to an interview protocol which is presented in Appendix A. The questions were consciously not presented in advance since that could have caused a response bias regarding stakeholder attributes. The interviews were recorded to facilitate the note-taking, to avoid losing data and to contribute towards reduction of observer bias. To prevent miscommunication, incomplete answers and to generate as complete and in-depth data as possible, the interviews were conducted in Dutch. The recordings, detailed interview notes and impressions were transcribed and completed within one day of the interview as suggested by Eisenhardt (1989). Important data used for further analysis was carefully translated into English. In order to ensure construct validity, all interviewees had the opportunity to commend on the transcripts of their interviews and confirmed that it was correctly documented.
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provide their consent. Open questions were asked regarding the stakeholder perspective. The attributes of the stakeholders were determined based on the same strategy as interviews. However, in determining the attributes per stakeholder within the team, a pre-determined list of stakeholders was provided that may have added bias by including unnecessary stakeholders or excluding important stakeholders. This was not assumed since careful attention was drawn to the identification of the main stakeholders per case in the initial interviews. By adding the possibility to answer the questions more anonymously, individuals were more open and answered more honest whereas in interviews, answers often were more nuanced towards the attitudes and actions of other stakeholders in the design process. In order to encourage accurate and honest answers and prevent confusion or unclear questions, the survey consisted of a limited number of questions. Extensive information was provided per question and the relevance of this research was explained in the survey and by the managers of the stakeholders, who distributed the survey among the team members. The survey questions are presented in Appendix B.
Additional information was derived from available documents and observations. In some cases, the final design represents a document whereas for other cases a (complementary) system is used. Therefore, observations were done when possible. Documents regarding the preparations, development approaches, review of the pathway project and final design were collected so evidence gathered from other sources could be confirmed. Hence, a clearer representation of the design process, the final design, its focusses was provided. The validity of the documents was carefully reviewed to avoid incorrect data included in the analysis. In analysing the documents, emphasis was on whether one or more of the subcategories of the design focus were present, in any form, and how these were used, described, operationalised, integrated and/or visualised. In some cases, the way of working of nurses in the electronic system was observed. In doing so, there was a focus on the four different focuses of the final design of a pathway. What was emphasised in the system, rather tasks or registering outcomes? So by observing, also the practical focus of the path could be analysed.
The primary data collected for the mini-cases was done in the same way as with the three main cases, only more condensed and with a limited amount of sources. The three mini-case studies included in total eight interviews, ranging from one to three interviews per case. Data from five additional stakeholders was gathered from the online survey. Furthermore, some interesting documents were studied. An overview of the sources of evidence and retrieved data is shown in Table 3.1.
23 related to other stakeholders’ behaviour, it was endeavoured to fill this gap. Ultimately, the use of multiple measures drawn from different data sources aids in improving both the validity and reliability of the case study findings (Voss, 2009).
3.3 Data Analysis
The collected data was analysed by following the proposed steps of Miles and Huberman (1994), data reduction, data display and conclusion-drawing/verification. Data was reduced through selecting the relevant quotes of the transcribed interviews and translate them into English. These quotes were coded using a deductive approach by using the coding software ATLAS.ti. The codes were derived from research questions, key concepts and/or important themes within this research (Miles and Huberman, 1994). By comparing each quote with previous quotes in the same category, theoretical properties of categories and the subcategories of these properties were developed (Voss, 2009). An overview of the used (sub)categories is provided in Table 3.2. Firstly, codes were related to the (sub)categories of stakeholder disciplines and perspectives. From each quote it could be derived to which disciplines of the stakeholders it was related. In order to determine the degree of influence different disciplines had in the design process, codes were related to the different subcategories of stakeholder influence. An overview of the types of stakeholders involved per case and the retrieved stakeholder perspectives is shown in Appendix C. Whether these stakeholders tried to influence the design process based on their perspective, was determined by relating these to the subcategories of the design process and the stakeholder perspectives. In this way, it becomes clear which stakeholders tried to influence the design process by actions, attitudes and/or interaction related to their perspective. So, data was put together in new ways by regrouping and linking categories with each other. An extract of this coding process is shown in Appendix D, showing how different aspects of stakeholders impact the design process.
The focus of the design of a clinical pathway was determined by analysing the coded interviews, data from the surveys and observations –if possible, and the documents. Since the analysed documents often provide a more objective overview of the pathway, more value was on these documents. The relative frequency of occurrence of one of the four subcategories of final design in either of the sources of evidence determined the degree of focus. Since all cases show some focus to either one or more of the subcategories of the design focus, it was chosen to allocate a –low, moderate, high- degree to the presence of the subcategories. The allocation of L, M or H is based on the relative frequency of occurrence. An example of this process can be found in Appendix E.
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stakeholder involvement in one overview, the focus of the designs and the perspective of the stakeholders were compared. If similarities occurred/presented itself, it was reviewed whether this stakeholder had a certain degree of influence in the design process. Also, in order to determine the relation between the final design and the stakeholder involvement, a comparison was made between the old- and new way of working. Consequently, it was possible to see what aspects of which stakeholder were reflected in the final design. For example, if a stakeholder viewed a pathway as a translation of protocols, is a definitive stakeholder and the final design reflects the use of protocols, it is reasonable to assume that this stakeholder influenced the design process according to his or her perspective. The performance of the pathway was described in the results, when possible. Since some pathways are not yet implemented, it was not possible to determine its effectiveness. If anything was unclear or information was not complete, a skype or telephone call was conducted with the respondent to fill this gap and provide clarity on the particular concern. Consequently, the reliability of data was increased.
After the within-case analysis, a cross-case analysis was done which helped to understand how processes are bent by specific local contextual variations. By comparing cases, it was possible to establish the range of generality of a finding or explanation, and at the same time, pin down the conditions under which that finding will occur (Miles and Huberman, 1994). The cases, varying in the stakeholders involved in the design process, were compared and slight differences could be discovered in the focus of the design. In order to be able to display the relation between the final design and the involvement of stakeholders in the design process of a clinical pathway in one overview, a degree of presence (high, moderate, low) was allocated to each of the four subcategories of final design. Furthermore, a comparison was made with the involvement of different types of stakeholders, their influence and the focus of the final design to be able to draw conclusions whether the involvement of different disciplines resulted in a different focus of design.
4. CASE FINDINGS
Table 4.1 represents an overview of the results of the three main- and three mini-cases in terms of their type of hospital, type design, the main stakeholders involved in the design process, type of stakeholders, the project goals and results, as well as the focus of the final design of the clinical pathways. In addition to this table, the three main case findings will be described briefly in the following sections. A description of the three mini-cases is provided in Appendix G. Ultimately, this chapter will end with cross-case findings.
4.1 Case A
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Table 4.1 Overview of pathway projects, stakeholders involved and project goals results (continues on next page)
Case Hospital Stakeholders Goals Changes/Results Focus design
Type Pathway Discipline Type (degree) (degree)
A Regional
High standardised, Low complex
Project leader Dependent (M) - Improve quality of care, patient satisfaction and safety
- Optimize outcomes (length of stay, mortality, (re)hospitalisation.
- Based on evidence and best practice, uniform policies, efficiency and patient focus - Evaluation of this path 10 months after the
project has initiated. Specific goals:
100% of the patients with this pathology: - started its treatment by calculating indexes; - started antibiotics according to protocols; - was switched to oral when all criteria are met.
- The design process was finished 12 months after the first meeting, design not ready to be implemented. Only document available, no system.
- Project leader is now working towards kick-off, presenting the pathway design 13 months after the first meeting.
- Design only shows structured tasks, focussed and based on protocols.
- Instead of two separate, different policies, now one aligned policy available for the hospitalisation of patients with this pathology. Communication (M) Integration (H) Outcomes (L) Protocols (H) Physician A Definitive (H) Physician B Definitive (H) Physician-assistant A Dependent (M) Physician-assistant B Dependent (M) Nurse Discretionary (L) B Regional High standardised Low complex Project leader Physician Nurse A Nurse B Definitive (H) Definitive (H) Dependent (M) Dependent (M)
- Clinical goals: less visitations, waiting times and referral to treatment time.
- Process goals: Improve the efficiency by less lead-times, better coordination and aligning of disciplines
- Increase patient- and job satisfaction; - Clear agreements about the roles and
responsibilities of the team.
- Reduce costs by efficient and effective use of resources.
- Overall goal: The comprehensive state of health of the individual patients with this pathology will be improved on four domains: dysfunction – complaints – limitations - quality of life.
- Guidelines according to standards are translated into a pathway. This pathway, including guidelines, are implemented within the EPD.
- Multidisciplinary agreements were made based on what suits which discipline best, time wise.
- Not yet possible to evaluate the clinical goals; - Patient satisfaction is increased;
- Financial goals are met based on the use of the EPD parallel to the pathway;
- Processes are mapped well and the way of working is efficient and effectively related to the different disciplines so individual qualities are optimally used;
- It seems that a better description of the process (with clear insights and arrangements about who does what) has a positive impact on the team;
- Changed from “because it works that way” towards “Why do we work that way? Possible to different, better, more patient friendly?”
- Patient is placed in the centre, everything evolved around the patient
- Changed from a supply-driven to a demand- driven clinic. - Nominated as most promising pathways developed in 2015
26 C Academic Moderate standardised, Moderate complex Project leader Physician A Physician B Physician-assistant A Physician-assistant B Consultant Nurse Dependent (M) Definitive (H) Discretionary (L) Definitive (H) Dependent (M) Dependent (M) Definitive (H)
- Improve the quality of care; - Provide patient focused care;
- Measure and improve outcomes for patients - Obtain maximal results with the treatments - Focus on efficiency, maybe decreased costs as
a result?
- Every step in the care process should add value to the patient
- Balance registration burden and information gains
- Make care within this department more transparent by measuring outcomes.
- The guidelines are translated into the pathway and in the EPD, in which now variances and outcomes are measured and monitored
- More registering of actions
- Patient needs are assessed beforehand based on a questionnaire, so hospital visits will connect better to the patient, its condition and personal needs.
- Equality within the team is emphasised, everyone is able to speak their mind and concerns during weekly meetings; - Improved efficiency of care processes;
- Meeting every 3 months to evaluate outcomes, way of working and tasks of disciplines
- Increased collaboration within the team - Clear responsibilities and tasks
Communication (M) Integration (H) Outcomes (H) Protocols (M) d Regional Moderate standardised Low complex Project Leader Physician A Physician B Physician C Physician-assistant Nurse Definitive (H) Definitive (H) Definitive (H) Definitive (H) Dependent (M) Discretionary (L)
No goals were set beforehand, they just wanted to make as many adaptions as possible that are necessary to meet the quality standards so accreditation is obtained.
- Desired situation is described;
- Especially surgeons added desired conditions;
- Clear division of tasks and roles and important decisions were put on paper;
- Guidelines were translated into protocols so it was made sure all disciplines were working according to the prescribed guidelines. Communication (M) Integration (H) Outcomes (L) Protocols (H) e Regional High standardised Low complex Project Leader Physician A Physician B Physician-assistant Nurse Dependent (M) Definitive (H) Dominant (M) Dependent (M) Discretionary (L)
- Provide a framework for the treatment around this pathology in offering organising, structure, processes and content.
- Alignment of the procedures and improve way of working of surgeons.
- Start working according to the national guidelines
- Improve communication among medical specialists
- Introduce this pathway in three hospitals
- Agreements for all stakeholders involved about who provides which information, when;
- Information transmission between professionals and patients is set.
- Guidelines are always available and up-to-date
- The design is available in a document, still an agreement is required between two types of physicians regarding certain protocols before implementation is possible;
- Working according prescribed, national guidelines. - Introduction of this pathway planned in one hospital
Communication (H) Integration (H) Outcomes (M) Protocols (H) f Academic Moderate standardised Moderate complex Project Leader Physician A Physician B Physician C Physician D Physician-assistant Consultant Dependent (M) Definitive (H) Definitive (H) Definitive (H) Definitive (H) Dependent (M) Dominant (M)
- Integrate the hospitalization process of two different departments into one general treatment.
- Increase the efficiency by integrating and coordination of tasks and roles
- Decrease the referral-to-treatment time - Improve communication among and within
members of the different departments - Make outcomes more transparent to improve
the position of the hospital with respect to the healthcare insurances
- Integrated use of clinical guidelines and evidence-based care into daily practice;
- Streamlining care delivery and optimised clinician time - Improved communication within the team.
- System introduced that aids in communication and tasks of stakeholders.
- Continuous performance management and assessment of clinical practices;
- Reduced variations in clinical and operational practices, enabling improved clinical outcomes, increased patient satisfaction and cost optimization.
- Reduced waiting times, reduced hospitalisation stay, shorter waiting lists, decreased referral to treatment time (13 to 4 weeks) and avoidance of diagnostic test duplication.
Communication (M) Integration (H) Outcomes (H) Protocols (M)
27 Over 5000 employees work in this hospital and there are in total 850 beds. In aiming to continuously improve the quality of care, they introduced several clinical pathways for various pathologies. Pathway A is designed in 2014 and is not yet in use. The main reason for initiating this pathway project was based on the need to organise care around this pathology: patients were hospitalised in two different departments, both departments having different policies. For this pathology, the process of care is predictable and it is clear what procedures need to be standardised and therefore has a high standard – low complex design. The team with which this pathway was designed consisted out of two physicians, two physician-assistant, a nurse and the project leader. The project leader defines a clinical pathway as a standardised process based on patient needs and evidence-based practice to improve patient care by improving actions and communication of all disciplines. She had urgent and legitimate claims but possessed no power and has a moderate degree of influence. The project leader had difficulties in leading this team since she was also participating as a project leader in other pathway projects. Consequently, other disciplines could see she was struggling with her task as project leader: “I can imagine a
consultant/manager as a project leader because our current project leader had obvious difficulties… I can imagine that she, with a nursing background, has a different perspective than someone who is trained to do this.” The project leader felt
like she had to make sure the nursing perspective was taken into account. In doing so, she was not objective in constructing the design. Physician A views a pathway as a translation of protocols into daily practice: a clear vision of what has to happen, when and by whom, and aims to improve the quality of care. This physician was perceived as a dominant stakeholder in the design process since he pushed his claims, took over the lead in some meetings and wanted to agree on certain actions behind the back of the team. He influenced the design process by trying to convince involved stakeholders and by pushing his arguments based on his perspective, with and sometimes even without full consent of the team. Physician B perceived a pathway as a description of an idealistic program, developed around a pathology to increase the quality of care based on clear division of responsibilities of roles. Both physicians possess the power to impose their will, the legitimacy because of their medical profession and the urgency to determine what is critical and crucial. The physician-assistant’s perspective regarding a pathway is that it offers guidance to disciplines in the process around the hospitalisation of a patient aiming to realise quality and efficiency improvements in actions and treatments. She only had legitimate claims, based on the experience of practice. The physicians and physician-assistant did not perceive the nurse as a stakeholder with much influence since she did not have much knowledge. The demand of the project leader to involve other stakeholders (physiotherapist, dietician) was not necessary according to the physicians: “nurses are able to perform those tasks as well”.
During meetings, that often were not fully attended, more value was placed on those with more knowledge. Therefore, knowledge was an obvious form of power. When the team sat together, physicians delivered the content and the project leader decided what was included in the design. “The
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meant it, if everything was complete and clear, and if it was workable/manageable for us.” So, the final design of this
clinical pathway is mainly based on the input from the physicians and project leader: both stakeholders were able to alter the design in ways more consistent with their own perspective. Overall, the stakeholders did not feel responsible for the development of this path, which highly frustrated the project leader. As the physician-assistant shared: “I personally did not want to accomplish anything with this clinical path,
I just thought it was interesting to see how such a process happens.”
At the start of this project it was stated that the care towards patients needed to be more transparent and a check was necessary whether nation guidelines were followed within the treatments. During the design process three main aspects of the desired pathway were central to the development: the design should contain: medical (protocols); logistical and communication (towards the patient) aspects. What changed compared to the old way of working is that the tasks within the final design of this pathway are based on the available guidelines and protocols for this pathology and provides an aligned way of working for the two departments. Furthermore, within the design, there is a clear division of tasks for the nurse and physician-assistant. Only a paper document is available, no possibility to monitor and assess variances within a system is available (yet).
4.2 Case B
29 possesses the power, legitimacy and urgency to in- or exclude certain actions in the design and can determine priorities, necessities and requirements, all since she works as the coordinator of this department and has a medical profession. During meetings, the project leader was influenced by the opinion of the physician and valued his opinion most: “He is the final one responsible for the care
provided and we will follow him as a team.” Nurse A states that pathways are used to name a process in which the care around a group of patients is described from beginning to end with the integration and optimization of care for a patient group. Nurse B defines a clinical pathway as a dynamic document that shows the shared agreements about care for a patient. Both nurses were legitimate based on their medical profession and possessed urgency based on their ability to determine the necessity and criticality of actions.
The design process was based on short and concise meetings with the project leader and those who were most affected by the decision. If needed, she convinced the nurses in taking these decisions. The project leader recognised there were different perspectives of the pathway and solved this by making sure everyone could speak their mind and shared their ideas. During the shaping of the design, not many disagreements or discussions were present since everyone spoke their minds and felt listened to. All stakeholders involved felt responsible and worked well together to develop this path. Ultimately, the project leader was the one who constructed the pathway in its current form.
The research conducted before starting this project revealed that different disciplines did not know what to expect from each other and the same disciplines used different methods and procedures which made care not transparent towards patients, its family and external partners. Appointments were not structured and thereby quality of disciplines was not fully utilised. Also, guidelines according to the care standards were unknown and barely used. So there were possibilities to increase the potential of involved disciplines, and activities could be structured more efficiently and effectively. What has changed compared to the old situation is that now: guidelines according to standards are translated into pathway B, and this pathway, including guidelines, is implemented within the EPD; multidisciplinary agreements were made based on what suits which discipline best, time wise; patient satisfaction is increased; processes are structurally mapped and the way of working is efficient and effectively related to the different disciplines so individual qualities are optimally used. Finally, it seems that a better description of the process (with clear insights and arrangements about who does what) has a positive impact on the team. However, it was not yet possible to evaluate the clinical goals, related to the visits, waiting times and self-management. Pathway B was nominated as most promising pathways developed in 2015.
4.3 Case C
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basis, almost 13.000 employees are committed to provide care, perform research or teach. This hospital has 51 departments and over 1300 beds and aspires to pioneer, push boundaries and lead, in research education and care. Within this hospital, projects are developed based on the value based healthcare principle that emphasizes working more efficiently in focussing on outcomes, so it becomes clear what kind of value is added for patients and professionals. Pathways are used as a tool to deliver outcomes of care processes. Pathway C is introduced as one of the first value based healthcare projects in this hospital and is developed because hospital C wanted to know how they were performing within this department. The team with which this pathway is developed consisted of a project leader, two physicians, two physician-assistants, consultant and a nurse. The project leader’s perspective is based on the view that a clinical pathway is a process; who does what on what moment and what care is provided by which discipline aiming to provide insights in treatments for disciplines and patients. Based on her background as a quality advisor, she does have the legitimacy and is able to determine what is necessary and urgent for this group of patients. She was responsible for the IT-system surrounding the pathway and the daily way of working with this pathway. The consultant defines a clinical path as a description of a process in which all actors are mentioned and integrated that intervene with a patient. It is used to measure outcomes by clarifying mutual relations and to organise events efficiently. The consultant had an advisory and guiding role and made the value based principle practical and workable based on urgent and legitimate claims. She kept an eye on all stakeholders and made sure all elements were covered, if not, she mentioned and discussed this. For example: “In designing a clinical pathway there are certain parts that
a physician should not be worried about and should not focus on. A consultant/manager should be able to provide a physician the important elements for succeeding in designing a clinical pathway.”. She had in-depth knowledge regarding
Lean techniques and made use of this during the design process: for example, in showing that better outcomes of the pathway can be obtained by performing specific tasks one rather than multiple times (out of insecurity or nurses), the consultant offered an efficiency perspective to the nurse. Also, the consultant showed the possibility of cost-efficiency gains to the physicians.
