Increased integration of care pathways and its effect on healthcare efficiency

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Increased integration of care pathways and

its effect on healthcare efficiency

A case study at a hospital in the Netherlands

Thu Dao t.k.t.dao@student.rug.nl

S2974983

Supervisors Dr. M.J. Land Prof. dr. J.T. van der Vaart

Master thesis

Msc. Business Administration Health University of Groningen Faculty of Economics and Business

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Abstract

As healthcare expenditures have been growing in the past years, it is increasingly important for hospitals to search for ways to increase efficiency. Past research found that efficiency can be improved by increased integration. The aim of this research is to investigate the effect of integration of care pathways on efficiency and which integrative elements and efforts are important in order to increase efficiency. The study is based on three care pathways of the oncology department and two care pathways of the gastroenterology and liver department of a hospital in the northern part of the Netherlands. Based on the care pathways that were

examined, it was found that communication, collaboration, and coordination are important for increased efficiency. The following elements and efforts stand out: a timely and developed information system, frequent meetings and engagement in activities, evaluation of which service is provided by who and how, and what should be done to improve service provision together. Furthermore, being committed to the overall care process instead of only their own responsibilities, and coordination of tasks and processes make departments more aware of service duplication. However, the integration of care pathways can be hampered by a higher variety in patient groups and a lower level of complexity of the patient group’s care needs.

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1. Introduction

In the past years, healthcare expenditures have grown while public funding has decreased. This makes it increasingly important for hospitals to search for ways to increase efficiency (Chernew & Newhouse, 2011; Tiemann and Schreyögg, 2012). Increasing efficiency can be considered crucial as it enables efficient use of resources and the provision of more services without diminishing quality of care (Lo Storto & Goncharuk, 2017; Rosko et al., 2007). Past research has generally found that efficiency and performance can be improved by increased integration (Van der Vaart and van Donk, 2008; Barki and Pinsonneault, 2005; Pagell, 2004; Huckman, 2006). Integration considers the activities and mechanisms to reach harmonizing efforts across hospital departments and how tightly coordinated these activities are (Bazzoli et al., 1999; Barki and Pinsonneault, 2005). In this research, the focus will be on the integration of care pathways and its effect on efficiency.

In a situation with care pathways that are little integrated, the several hospital departments involved in the different steps of a care pathway mostly operate independently and focus on their own internal processes and costs. So generally, the activities of the departments are not coordinated with other departments involved in the care pathway. As a result, the different processes of a care pathway are not aligned, leading to a lower productivity and decreased patient satisfaction (Drupsteen et al., 2013).

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al., 2009; Minkman, 2011). On top of that, it also requires significant implementation efforts, commitment, and investment (Eljiz et al., 2019; Leuschner et al., 2013). This makes it challenging to determine which elements are essential for integrating care pathways to realize efficiency gains (Minkman et al., 2009a). Up till now, it remains unclear which elements essentially should be implemented for integration of care pathways. Therefore, the main purpose of this research is to examine which elements should be integrated that will contribute to efficiency. The following research question will guide this research:

What are essential elements for integrated care pathways to pursue efficiency gains?

To answer the research question, an exploratory single-case study at a hospital in the northern of the Netherlands has been conducted. The main data source for establishing a greater understanding of which set of elements are essential for integrated care pathways in order to realize efficiency gains were in-depth semi-structured interviews with nursing consultants and a head of unit of care pathways. This research will contribute to a better understanding of the elements that are relevant for the integration of care pathways to increase efficiency, which is also the contribution to practical relevance.

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2. Theoretical background

This section provides an overview of the theoretical background of three subjects. The first subject concerns healthcare efficiency. The second subject discusses integration and the classification of integration to understand the specific integration efforts. Lastly, the relationship between integration and efficiency is discussed.

2.1 Efficiency

Healthcare expenditures are one of the largest spending categories of the government and the expectation is that it will keep growing due to population aging and inefficiencies in healthcare delivery (Mastromarco et al., 2019; Tiemann & Schreyögg, 2012; Hall, 2006). To keep the provision of care affordable while maintaining or improving quality of care, enhancing healthcare efficiency is an important goal (Rosko et al., 2007; Kodner, 2009; Lo Storto and Goncharuk, 2017).

In the healthcare context, efficiency has been defined in multiple ways. As a result, there is no consensus on how efficiency should be measured and what should be included (Ding, 2014; Greenberg & Champion, 2006). Overall, efficiency considers the transformation of hospital inputs, such as capital and staff, into better outputs as the quality of care and patient outcomes (Lo Storto, 2017; Ibewuike and Weeks, 2014; Greenberg & Champion, 2006). In other words, efficiency measures whether healthcare resources are being used to get the best value (Palmer & Torgerson, 1999). Improved efficiency enables more or the same level of services to be provided with fewer resources while sustaining the same quality of care (Rosko et al., 2007; Ibewuike and Weeks, 2014).

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To improve efficiency, one important method that could be taken into consideration is increasing integration of care pathways (Minkman et al., 2011). In the following part, this method will be further explained.

2.2 Integration

Integration has been diversely understood and defined in a number of different but interrelated ways across disciplines. Each discipline has its own perspective on the concept and there is no generally accepted definition of integration (Barki and Pinsonneault, 2005; Pagell, 2004). The lack of explicitness and clarity in defining integration has hampered the understanding and implementation in practice (Kodner, 2009). However, integration is generally defined in line with several concepts such as interaction, collaboration, and cooperation (Drupsteen et al., 2013).

In a healthcare context, integration considers the activities and mechanisms to reach harmonizing efforts across different hospital departments and how tightly coordinated these activities are (Bazzoli et al., 1999; Barki and Pinsonneault, 2005). A more concrete definition of integration was given by Pagell (2004):

‘A process of interaction and collaboration in which units work together in a cooperative manner to arrive at mutually acceptable outcomes for the organization.’

In this thesis, the focus is on the integration of care pathways. A care pathway is a multidisciplinary care plan that outlines the essential steps in a care process for patients with similar characteristics such as disease or diagnosis (Campbell et al., 1998; Zonderland et al., 2015). It organizes multidisciplinary care and routes patients along a predefined path of providers, facilities, and departments (Zonderland et al., 2015).

In a situation with little integration, hospital departments operate independently and focus on their own specialization, internal processes, and outcomes to achieve their own goals. This complicates the collaboration with other departments and the coordination of the activities involved in a care pathway. As a result, this may lead to poorly streamlined patient flows and lower productivity (Drupsteen et al., 2013; Barki and Pinsonneault, 2005).

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while delivering high-quality care is a complex process in which multiple elements must be implemented and several domains are involved, including management, functions, strategies, and information systems (Barki and Pinsonneault, 2005; Minkman et al., 2009b). Significant implementation efforts, commitment and capabilities are required to coordinate people, processes, structures, and resources (Chen et al., 2009; Minkman, 2011; Eljiz et al., 2019; Leuschner et al., 2013).

For the characterization and measurement of integration, Alfalla-Luque et al. (2013) noted that a wide range of different studies on integration have used a great variety of variables and scales. There are also no general accepted variables and scales for integration. For this research, integration will be evaluated by looking at the level, intensity, and dimensions of integration as proposed by Pagell (2004), Van der Vaart and Van Donk (2004), and Leuschner et al., (2013), respectively. The level of integration considers the different levels of integration a care pathway can be in, from no integration to full integration (Pagell, 2004). The intensity of integration looks at what has been implemented to increase the intensity of integration, for example, information systems or an integrative planning (Van der Vaart and Van Donk, 2004). The dimensions of integration concern the specific activities and efforts that departments engage in to increase integration, such as information and data sharing and collaboration in developing activities (Leuschner et al., 2013; Barki and Pinsonneault, 2005). By determining the level, intensity and dimensions of integration, a clearer picture will be outlined of the extent to which a care pathway is integrated and the integration efforts the departments are engaged in. This classification will be further elaborated below. Some elements of the literature are adapted to fit the context of this research.

2.2.1 Level of integration

Most research on integration has been based on the supposition that integration occurs in different levels (Pagell, 2004). With different levels of integration, as described by Pagell (2004), departments that are involved in the steps of a care pathway move through a set series of levels of integration, ranging from no integration, to some integration and finally to full integration.

1. No internal integration

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9 2. Some internal integration

There is some internal integration between departments that are involved in a care pathway when only some of the time or only within specific process steps they interact, collaborate with each other and work on reaching the same goals.

3. Full internal integration

When most of the time departments interact, collaborate and work towards achieving mutual goals, the level of integration can be considered as full internal integration. The care processes involves a seamless flow through the care pathway (Pagell, 2004).

2.2.2. Intensity of integration

The intensity of integration looks at what has been implemented to increase the intensity of integration. Each next stage means a higher intensity of integration, which indicates that departments involved in a care pathway are increasingly working towards sharing all information and eventually having an integrative planning (Van der Vaart and Van Donk, 2004). As the research of Van der Vaart & Van Donk (2004) evaluated integration in a supply chain context, the stages are adapted to fit in a healthcare context. Three stages can be distinguished:

1. The transparency stage

Departments involved in care processes of a care pathway share relevant information on for example planning, decisions and treatments. Information shared with other departments is without any commitment involved. In this stage, it is mostly the inappropriate information systems or absence of trust that hinders the intensity of integration (Van der Vaart & Van Donk, 2004).

2. The commitment and coordination stage

Departments share all relevant information with a form of commitment. Choices of departments have an impact on the other department and they may be bound by clauses defined in contracts on for example service level agreements or prioritization of patient groups. Clauses also have a coordination purpose and lead to more trust, as departments have a form of commitment (Van der Vaart & Van Donk, 2004). The other department will stand by its word and conform to the norms (Van der Vaart et al., 2012).

3. The integrative planning stage

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departments are linked. Also, major decisions are centralized (Van der Vaart & Van Donk, 2004).

2.2.3 Dimensions of integration

Several dimensions of integration have been distinguished in past research (Leuschner et al., 2013). Leuschner et al. (2013) developed a comprehensive set of dimensions of integration based on a composition of dimensions used in past research. The dimensions of integration describe the specific integration efforts and activities that departments involved in a care pathway are engaged in. The efforts and activities of the dimensions are classified as information, operational and relational integration. Each next stage indicates that departments are more engaged in integration efforts and activities.

1. Information integration

For efficient information integration, departments are willing to engage in information and data sharing and they work and communicate in a collaborative way (Van der Vaart et al., 2012). There are technologies or information systems available that support the key functions and information transfer is coordinated and integrated (Leuschner et al., 2013).

2. Operational integration

In addition to information and data sharing, management integrates activities. There is collaboration in developing activities, work processes and coordination of decision making between departments (Leuschner et al., 2013). Prior research has shown that organizations involved in joint decision making and integrative efforts to develop services are better able to adjust to changing conditions and technologies and develop activities in a shorter period of time. Consequently, significant cost and quality improvements are achieved (Thrasher et al., 2010)

3. Relational integration

After information sharing and operational integration, departments can have a more strategic relationship that is characterized by trust, commitment and long-term focus (Leuschner et al., 2013).

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11 2.3 Effect of integration on efficiency

So far, past research has mainly analyzed the effect of integration on efficiency and organizational performance. The results of these studies have shown mixed outcomes. Some studies found no direct relationship (Lee and Wan, 2002; Koufteros et al., 2007; Gimenez and Ventura, 2005), while other studies found a positive relationship between integration and performance or efficiency (Thrasher et al., 2010; Flynn et al., 2010; Saeed et al., 2005; Cho et al., 2014; Wan et al., 2002).

First of all, information technology (IT) integration positively affects efficiency and performance. According to Bates (2002), sharing knowledge, information, clinical results and making joint decisions is crucial for hospitals, as having access to knowledge when it is needed is essential for efficient and effective patient care. Integrating IT could enable and improve the coordination of information that is shared across departments (Bates, 2002; Thrasher et al., 2010). Furthermore, departments may get access to management expertise or specialized technologies through integration (Huckman, 2006). The research of Cho et al. (2014) and Thrasher et al. (2010) examined the effects of IT integration on hospital efficiency and performance outcomes. Cho et al. (2014) found a significant positive effect of IT integration on hospital efficiency. Similarly, in the research of Thrasher et al. (2011), the results show that IT integration leads to financial improvements by reduced clinical and administrative costs. Moreover, patient-centered outcomes, such as mortality and admissions, improved as a result of IT integration (Thrasher et al., 2010)

On the other hand, Lee and Wan (2002) investigated the effect of structural clinical integration on efficiency and patient outcomes. In this study, the structural aspects of hospitals are considered, not the coordination and integration of care processes. The authors measured the hospital efficiency by evaluating the care process with a cost-efficiency indicator, the average total costs per discharge. The expectation was that a higher structural clinical integration would lead to lower average total costs per discharge. However, the results indicate the opposite, as hospitals with high clinical integrated structures showed higher average total costs than hospitals with less integrated structures.

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management, hybrid physician-hospital integration, forward integration, backward integration, and high tech medical services. These mechanisms appear to be positively correlated with efficiency. So, this research shows that hospital can increase their efficiency by implementing these integration strategies.

While past research mostly focused on the effect of integration on efficiency or performance, little research is done about the integration of care pathways and the specific elements that must be integrated to positively affect efficiency. It remains unclear to what extent and which elements of integration lead to increased efficiency. Therefore, this research aims to contribute to the understanding of whether the integration of care pathways positively affect efficiency and what elements of integration are effective in increasing efficiency. More or less, this research considers the efforts, activities, and cooperation among departments to reach harmonizing collaboration and coordination of activities and their effects on efficiency.

The framework in figure 1 shows the proposed relationship between integration and efficiency. As it is generally acknowledged that increased integration of care is an approach to increase efficiency, the expectation is that increased integration of care pathways will also contribute to greater efficiency (Minkman et al., 2009a).

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3. Methodology

3.1 Research design

The initial aim of this research is to investigate how efficiency can be increased by considering the elements of integration and activities of care pathways. In care pathways, several departments, care providers of different disciplines, processes and resources are involved, so achieving or sustaining integration may be complex. To investigate the relationship between integration of care pathways and efficiency, an exploratory single-case study has been adopted. A case study is suited for this research because little research has been conducted on the essential elements that must be integrated to realize efficiency gains. A case study gives an in-depth understanding of a contemporary and complex phenomenon in an unfamiliar setting in order to build or enrich existing theory (Meredith, 1998). As this research aims to answer research questions of ‘what’, ‘why’, or ’how’, a case study methodology can be considered appropriate as well (Yin, 2009). The unit of analysis is care pathways, as this research looks at how efficiency can be increased by integrating care pathways efforts of departments. In the following paragraph, the case and the specific care pathways will be described.

3.2 Case description

This study has been conducted at the Medical Center Leeuwarden (MCL), a large non-university hospital in the northern part of the Netherlands. As health demands are growing, while the public budgets are decreasing, it is becoming more important for this hospital to find ways to design their health practices differently and achieve efficiency. With increased integration of care pathways, the hospital aims to decrease costs while sustaining the quality of care.

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integration of the care pathways for these patient groups. Analyzing care pathways with different levels of integration might give an understanding of its effect on efficiency.

Department Patient group Development care pathway

Gastroenterology and liver disorders

Inflammatory Bowel Disease

Not developed

Gastroenterology and liver disorders

Gastroenterology oncology

Developed

Oncology Pancreatic cancer Not Developed

Oncology Lung cancer Developed

Oncology Breast cancer Developed

Table 1. Studied care pathways and patient groups

3.3 Data collection

For this research, the main data source consists of in-depth semi-structured interviews with nursing consultants and a unit head. These employees are involved in the development or improvement of a care pathway or they oversee the processes and steps of a care pathway. They have a broad level of understanding and knowledge of the structure and the current state of integration of the care pathway.

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inefficiencies experienced in the current situation will be considered and what still could be done to improve integration. The specific interview questions that were asked can be found in Appendix 1 and 2. The interviews were all conducted by phone and it was recorded with the consent of the respondent.

3.4 Data analysis

After conducting the interviews, the interviews have been transcribed. Then, the collected data from the interviews were analyzed in Excel by using the phases of qualitative data analysis as proposed by Miles and Huberman (1994): data reduction, data display, and conclusion drawing and verification. These steps will be explained below.

Data reduction: In the first phase, data reduction, data from the interviews have been reduced by selecting, simplifying, and transforming data that is relevant for answering the research question. This data is related to the following variables: integration of care pathways, the level, intensity and dimension of integration specifically, the care pathways and the (in)efficiencies.

Data display: In the second phase, data display, the reduced data have been given descriptive codes and then are displayed in a way that provides arranging and thinking about the data. This could be, for example, in a diagram or matrix (Miles and Huberman, 1994). Moreover, the descriptive codes have been classified into themes that are relevant for the research. In this study, the themes were integration, information sharing and communication, collaboration, coordination, objective, and efficiency. This gives an overview of what and how much has been discussed about each theme. The coding scheme for the care pathway for patients with breast cancer is included in Appendix 3 as an example.

After classifying the data in the coding scheme, each variable has been analyzed. Also, the themes have been compared across the interviews to see whether there are relevant emerging patterns of similarities or differences.

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4. Findings

In this chapter, the findings of the analyzed care pathways are presented based on the interviews. First, some general findings on the care pathways will be given. Second, similarities in the integration of the care pathways will be given. Thirdly, findings on the care pathways, integration and efficiency of the care pathways are described. In the last subsection, all interviews and findings will be taken into account to explore the most important elements of integration that are commonly identified and its effect on efficiency will be discussed.

4.1 Care pathways

Developing or officially documenting a care pathway is generally perceived as important by the respondents. The respondents state that the documentation makes it clear which care processes or steps patients (may) take, which department or discipline should be involved in which processes and it is also indicated what the maximum lead time is. The departments may also agree upon having more uniform working methods and policies. Yet, in the pancreatic cancer and IBD care pathways that are not developed, it is also clear which steps the patient groups take and who is involved in each step.

The most important bottleneck for the development or improvement of care pathways is the availability of time, as mentioned by the nursing consultant of breast cancer, IBD and GE-oncology. Developing or improving a care pathway is time-consuming, because other disciplines and departments need to be involved and protocols have to be developed. Moreover, there may be people involved that respond very late, which could delay the development of a care pathway, as stated by the nursing consultant of breast cancer.

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17 4.2 Integration of care pathways

For all care pathways, except the IBD care pathway, the respondents state that the care processes can be seen as an integrated process instead of a collection of separately managed steps. It is clear how tasks are divided and who is responsible for which tasks. Furthermore, departments participate in a meeting that concerns the improvement of a care pathway.

Another similarity is that all care pathways use Epic, an information system that provides insight into the electronic health record (EHR) of the patient. This way, information about the patient can be accessed and updated by staff members that are involved in the patient’s care process. The information system also enables departments to send messages and information to each other. The unit head of pancreatic cancer explained the advantage of having an integrated information system: ‘It is mainly an improvement, because in the past we had an EHR, but the doctors were still working on a paper while the clinical file was in the EHR. That was not well integrated. What we have now is that the doctor can read the nursing record and the nurse can read the doctor’s record. That is quite optimized. If a nursing consultant has certain findings or thinks the surgeon still needs to do something, she can document this, which can be read by the surgeon. It works very well’.

Furthermore, all patient groups organize multidisciplinary meetings. The breast cancer care pathway has two meetings each week and the other care pathways have weekly meetings, except for IBD. For the IBD care pathway, there are less frequent meetings in which not all involved disciplines are present. In multidisciplinary meetings, the patient, their treatment plan and any other areas of concern are discussed. It is discussed what everyone is doing in the care pathway, why and processes can be coordinated. However, the different care processes are little coordinated in the GE-oncology and IBD care pathway in comparison to the care pathways for patients with breast cancer and lung cancer. The following paragraphs will elaborate on each care pathway.

4.3 Integration of care pathways and its effect on efficiency

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integration given a III. The values are added together to form a total score that indicates the extent of integration, ranging from three to nine. The table below shows an overview of the care pathways and the outcomes of the evaluation of integration. A complete and elaborate description of the evaluation of each care pathway can be found in Appendix 4.

IBD GE-Oncology Pancreatic cancer Lung cancer Breast cancer

Level of integration No internal integration (I) Some internal integration (II) Some internal integration (II) Some internal integration (II) Full internal integration (III) Intensity of integration Transparency stage (I) Commitment and coordination stage (II) Commitment and coordination stage (II) Commitment and coordination stage (II) Integrative planning stage (III) Dimension of integration Information integration (I) Information integration (I) Information integration (I) Relational integration (III) Relational integration (III) Total (range 3-9) 3 5 5 7 9

Table 2. Outcomes of integration of care pathways

Based on the evaluation of the care pathways and the interviews, the main findings on each care pathway, the integration and its effect on efficiency is presented below.

Care pathway 1: Inflammatory Bowel Disease (IBD)

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situation, it is sometimes the case that a patient is in our path, but when the patient goes to the surgeon, he will disappear from our view. That is quite unfortunate, because at some point the patient returns. Because if patients had surgery, they are not cured of their disease. That means they come back again, but there have actually been two separate paths, while it actually has to be a two-track path that comes together again later. But now there are still separate paths’. As departments do not coordinate their work and they do not directly communicate about what has been done, the same things may be done multiple times without the departments being aware of it.

Care pathway 2: Gastroenterology-oncology

In the GE-oncology care pathway, tasks and responsibilities are clearly divided. In the diagnostic phase, the GE-department is involved and responsible for the patient. Lead times are registered to monitor whether the standards are met. The GE-department refers the patient to the right department for the treatment phase and they will not be involved in the patient’s care process anymore. The department that the patient will be referred to is responsible for the patient’s treatment and they will be updated on the patient’s condition and the areas of concern by reading the patient’s files in the EHR. Departments do not directly communicate about what is already done for the patient and what still needs to be done to make sure that things that are done in the diagnostic phase will not be done in the treatment phase. As a result, it may not be a seamless process when patients go from the diagnostic phase to the treatment phase and services are duplicated.

Care pathway 3: Pancreatic cancer

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efforts: ‘Of course, you want to achieve coordination and that we are not doing too much. You do not want the physiotherapist to be involved at the beginning of the care pathway or only at the end. You want the right discipline involved at the right time, when it is necessary for the patient. Involve disciplines in the right processes. We do this by sitting down at the table and really discussing what the right steps are and which disciplines should join when’.

Even though tasks are divided and different disciplines are responsible for the patient in different steps, processes are coordinated and it is communicated which processes are necessary and what exactly is done in the care processes. Therefore, duplication of services is minimized and the right and only necessary services are provided.

Care pathway 4: Lung cancer

For the lung cancer care pathway, there is a long-term focus and departments trust each other. Departments are committed and feel responsible for doing their task as good as possible. The lines of communication are short and departments often communicate with each other.

Additionally, they frequently collaborate to improve services and care processes. The care pathway enables departments to have an optimized and uniform way of working and they work towards achieving a central objective. Furthermore, departments have to meet standards and guidelines, which are registered and monitored in a system, but this is rather focused on the effectiveness of care than efficiency.

Care pathway 5: Breast cancer

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possible time. Keeping the lead times as short as possible, in times of uncertainty for the patient’, and the following advantages were mentioned as a result of integration: ‘I think an important advantage is that you get a more uniform way of thinking and objectives are more aligned. Also, that you remove gaps for patients, inefficiencies, or doing things double’. This shows that care processes are structured, coordinated and services are not provided multiple times. Notable is that the patients’ perspective is very much emphasized in the integration of care pathways, as they are also considering removing gaps for patients or keeping lead time and waiting time as short as possible for patients, which does not necessarily improve efficiency.

Overall, the findings show that increased integration efforts and increased integration of care pathways have a positive effect on efficiency. However, a similar extent of integration does not necessarily imply that also a similar level of efficiencies are gained. The level of efficiencies depend on the activities and efforts that departments and disciplines are engaged in. Increased collaboration, communication and coordination seem to positively affect efficiency. Specifically, this concerns having frequent meetings with the involved disciplines, discussing which care processes are necessary for the patient and which not, what exactly is done in each care process and by who, discuss if there are any problems, and engage in activities to improve care processes. The efficiencies that are realized mostly concern the minimization of both service duplication and unnecessary service provision.

In care pathways that are less integrated and in which fewer efficiencies are gained, it is notable that there is little awareness of making sure that things are not done multiple times. Tasks are divided, but it is not directly communicated what exactly is done in care processes. Departments are usually only committed to their own tasks and processes are not coordinated. This leads to inefficiencies such as duplication of services and no uniform way of working or thinking. However, it is also a possibility that the extent of integration is influenced by other variables, which will be explained in the following paragraphs.

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very unpredictable disease, so a care pathway should be flexible in that sense. The main steps can be outlined and who is involved in that step, but often you will have to depart from this. This is interesting for efficiency, but it is complicated’. So, while the breast cancer patient group goes through similar care processes that are more predictable, there is a difference in the sequence of processes that IBD patients go through. The IBD patient group concerns a heterogeneous group with variation in the type and complexity of diseases that require different care needs. For some patients, it is necessary to see the rheumatologist or the dermatologist, while for other patients none of these disciplines are involved. As there are differences in the combination of processes and the disciplines that are involved in the patients’ care pathway, it costs more time and it may also be more difficult to coordinate or optimize care processes and integrate the care pathway. Consequently, this could contribute to the considerable lead times and a lower level of efficiency.

Another variable that may have an impact on the extent of integration is the level of complexity of the patient group’s care needs. For oncological patients, there is a higher level of complexity in care needs in which numerous disciplines are involved in comparison to the patient groups of the gastroenterology and liver department. Usually, this is also paired with higher urgency and it is strived to treat them within a predetermined period of time. Organizing care for complex and urgent patients requires good collaboration and coordination between the involved disciplines to make the care processes proceed as smoothly as possible. The urgency for oncological patients was stated by the unit head of pancreatic cancer: ‘It just has to go smoothly. You should not wait too long, you do not want that for any patient, but the oncological patient group has always had some kind of urgency label. So we do our best to ensure that everything runs smoothly and that it all works out’.

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care pathway, the lead times are registered and the standards are used to measure the effect of integration. The nursing consultant of IBD mentioned that the expectation is that a more integrated care pathway will lead to a decrease in the waiting times because arrangements on the standards of lead time will be in place. The standards and guidelines may improve effectiveness and quality of care as it ensures that several elements such as the waiting time and lead times are monitored and are maintained within a required level. However, this does not necessarily imply a higher level of efficiency if the input of resources remains the same.

4.4 Elements of integration and its effect on efficiency

In this subsection, the most important elements of integration that are commonly identified in the results will be discussed and its effect on efficiency will be taken into consideration.

First of all, there are differences regarding the development and documentation of a care pathway. The care pathway for IBD and pancreatic cancer do not have a care pathway documented. However, for the pancreatic cancer care pathway, there is a higher extent of integration and a higher level of efficiency than for the GE-oncology care pathway. The reason for this could be that the pancreatic cancer care pathway is more engaged in activities and efforts to improve services and processes, such as communication about services provided and coordination of these services, as described in the previous subsection. Therefore, the findings show that the official documentation of a care pathway does not necessarily have an effect on the level of efficiency, but it depends on the activities that care pathways are engaged in.

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of importance. So, multidisciplinary meetings do have a positive effect on efficiency, but the efficiency gains really depend on what is being discussed by the disciplines.

Having a uniform information system that is used by all involved disciplines facilitates communication and information sharing. As there is one information system used, all information is integrated into one system and will not get lost. Information is easily accessible and information transfer is supported. Information does not have to be sent to other disciplines or requested as they have access to the information, which saves time and energy and leads to a higher level of efficiency. Even though the information system can facilitate information transfer, communication and integration between disciplines, it is not a means to an end. It is still necessary for disciplines to engage in direct communication and other activities or efforts to increase the integration of care pathways.

Engaging in activities or efforts, in addition to having multidisciplinary meetings, can improve care processes, because departments may share information and knowledge, working methods and help each other to improve services or solve problems. Consequently, working methods and service provision will be optimized. A higher level of efficiency can be achieved as fewer resources are needed for the same outcomes or better outcomes are achieved with the same or even fewer resources. However, it is striking that the activities to improve care processes that disciplines are engaged in are also aiming to improve effectivity of patient outcomes. The following was stated by the nursing consultant about an activity or collaboration that the lung cancer care pathway is engaged in: ‘We are always working on improving services and processes, because new ideas are coming up (both national and international). For example, for patients that are facing surgery, it is expected that they will be in better condition if they exercise in advance, eat better and healthier food, stop smoking, initiatives like that. We are starting this up to draw up a plan of action for this. Patients will start four weeks in advance with proper nutrition and sports. We are very busy with such initiatives to improve care and patient outcomes’. This initiative is an example in which the care processes and patient outcomes are improved, but it does not consider improving efficiency.

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good manner. The processes should be coordinated and it requires collaboration in doing this in order to minimize doing things multiple times or missing important steps for the patient. For the care pathway of pancreatic cancer, attention has been paid to the coordination of processes to provide the services that are necessary for a patient. It is discussed what has been done for the patient and what still needs to be done. By doing this, doing unnecessary things or doing things multiple times will be minimized and thus more efficiency gains will be realized in comparison to the care pathway for IBD and GE-oncology patients. This shows that instead of only being committed to the tasks that you are responsible for, it is also important to have a broader view of the care pathway in order to provide only necessary services and let processes go as seamless as possible for the patient.

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5 Discussion and conclusion

The data was collected and analyzed with the aim to investigate how efficiency could be increased by increasing the integration of care pathways. The research question for this research was formulated as follows: ‘What are essential elements for integrated care pathways to pursue efficiency gains?’

The insights that were gained from the findings regarding the effect of integration of care pathways on efficiency and the elements that facilitate a higher level of efficiency will be discussed in this section. Furthermore, this section will link the findings to existing literature.

5.1 Integration of care pathways and its effect on efficiency

Based on prior research, it can be concluded that the integration has a positive effect on efficiency and performance (e.g. Thrasher et al., 2010; Flynn et al., 2010; Bates, 2002; Cho et al., 2014). In this research, the relationship between integrated care pathways and efficiency was analyzed and in line with past research, the findings point out there is a positive relationship. The level of efficiencies gained depend on the activities and efforts that departments are involved in. A higher level of efficiencies can be achieved if there is more collaboration and communication. More specifically, this concerns frequent meetings, evaluation of (which) services to provide and by who, and how it can be improved. The effect of increased communication and collaboration is in accordance with the research of Bates (2002), who found that sharing knowledge, information, clinical results and joint decision-making improves efficiency, as it enables departments to have access to information when it is needed. Additionally, it is in line with Thrasher et al., (2010), as the departments that are involved in integrative efforts to develop or improve processes also gained more efficiencies.

On the contrary, a lack of communication, collaboration and coordination lead to service duplication and working methods and care processes that are not optimized. The most important reasons that were leading to fewer efficiencies are if departments do not directly discuss what everyone exactly does and if departments were not or little aware of service duplication. Furthermore, being mostly committed to their own tasks instead of being committed to the progress the overall care process also negatively impacts efficiency.

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and thus a high variability in patient routings may make it harder to increase integration of the care pathway as the patient’s care pathway is more unpredictable. The research of Drupsteen et al. (2013) found that a lower routing variability has a positive relationship with integration. In the IBD care pathway, it concerns a patient group with higher routing variability and a low level of integration, which is the opposite of the research of Drupsteen et al. (2013). However, research on the effect of high routing variability on integration has not been conducted.

The level of complexity may also have an effect on the extent of integration. Oncological patients have a higher level of complexity and urgency in comparison to the patient groups of the gastroenterology and liver department. Good collaboration is necessary between the involved departments, which may have a positive impact on the extent of integration. This is in line with Leeftink et al. (2020), who argue that increased coordination of care between involved departments is needed for patients with more complex diseases.

While this research intended to study the effect of integration of care pathways on efficiency, the results showed that effectiveness of care is also considered important when integrating care pathways. Integration of care pathways then aims to improve patient outcomes, waiting times, lead times, which are all improvements from a patient’s perspective. These findings are in accordance with Drupsteen et al. (2013), as increased integrative efforts lead to improved lead time and patient flow performance.

5.2 Elements of integration and its effect on efficiency

The findings have shown that there are several elements that are important for the integration of care pathways that enable a higher level of efficiency.

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In addition to this, frequently having (multidisciplinary) meetings and engaging in activities or efforts will increase integration of care pathways and efficiency as there will be more communication and collaboration between departments. As stated by Meijboom et al. (2011), communication is of importance as it makes departments aware of what everyone is doing, how and why, and it is possible to coordinate the processes optimally. Pagell (2004) also found that communication channels and cross-functional teams can improve integration.

However, the official documentation of a care pathway does not necessarily have a positive effect on the level of efficiency. However, no research is done on this relationship, so it cannot be supported by prior research.

5.3 Theoretical implications

In prior studies, the effect of integration on efficiency and performance was found to be positive. However, little research was done about the integration of care pathways and its effect on efficiency. Furthermore, it remained unclear which specific elements and efforts should be implemented or performed to increase efficiency. The aim of this study was to fill the gap in the literature concerning which elements are essential for the integration of care pathways to pursue such efficiency gains. This research analyzed the integration of five care pathways of different patient groups and the efficiencies that were pursued. The main theoretical contribution of this research is that it identified which efforts and elements that departments should be engaged in to pursue efficiency gains. Furthermore, a positive relationship was found between integration of care pathways and efficiency, which is in line with the findings of prior research on integration and efficiency.

5.4 Managerial implications

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facilitated by the presence of information systems. On top of that, results showed that efficiency increases if tasks and processes are more coordinated. This will make departments more aware of service duplication and what care processes are necessary to provide.

The variety in patients’ needs, low level of complexity and low level of urgency may be factors that hamper the extent of integration.

5.5 Limitations and further research

This research was subject to several limitations. These can either be addressed in further research or should be considered in the interpretation of the research outcomes. First of all, the outcomes of this study are based on one single case study and it is unclear whether these results can be generalized to other hospitals. Further research is in other hospitals or a multiple case study is proposed to validate the research outcomes. The same holds for the generalizability of the outcomes to other care pathways within the hospital. In this research, only the oncology and gastroenterology and liver department were considered. Care pathways with different characteristics may lead to different outcomes. It is recommended for future research to analyze additional care pathways with different characteristics and patient groups or to quantitively test the effect of increased integration of care pathways on efficiency. This way, the generalizability and validity of the research outcomes increase.

Furthermore, during the data collection and analysis, it was found that variation and the level of complexity of the patient group are variables that may have an impact on the extent of integration, but they were not considered in the research. These variables or other characteristics of patient groups can be worth including in future research.

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6 Final conclusion

The purpose of this case study was to explore how care pathways are integrated and to determine by which integrative elements and efforts efficiency can be increased.

This research found that care pathways that are more engaged in integrative efforts and implemented more integrative elements have gained a higher level of efficiencies. Specifically important is the communication, collaboration, and coordination between the departments or disciplines that are involved in a care pathway. Increased communication and collaboration are facilitated by a timely and developed information system, but for increased integration to pursue efficiency gains, it is also necessary for departments to frequently meet and engage in activities, evaluate which services every department is providing and how and what could be done to improve service provision together. Besides, a higher efficiency level was achieved if departments are more committed to the overall care process instead of only their own tasks. The coordination of tasks and processes make departments more aware of who provides which services and how. As a result, service duplication will decrease.

However, this research also shows that there may be other variables that hamper the extent of integration of care pathways, namely a higher variety in patient groups, a lower level of complexity of the patient group’s care needs and a lower urgency.

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References

Alfalla-Luque, R., Medina-Lopez, C., & Dey, P.K. (2013). Supply chain integration framework using literature review. Production Planning & Control, 24(8-9), 800–817. Barki, H., & Pinsonneault, A. (2005). A model of organizational integration, implementation

effort, and performance. Organization Science, 16(2), pp. 165-179.

Bates, D.W. (2002), The quality case for information technology in health care, BMC Medical Informatics and Decision Making, 2(7), pp. 1–9.

Bazzoli, G., Shortell, S., Dubbs, N., Chan, C., & Kralovec, P. (1999). A taxonomy of health networks and systems: Bringing order out of chaos. Health Services Research, 33(6), 1683-717.

Campbell, H., Hotchkiss, R., Bradshaw, N., & Porteous, M. (1998). Integrated Care Pathways. BMJ: British Medical Journal, 316(7125), pp. 133-137.

Chen, H., Daugherty, P., & Landry, T. (2009). Supply chain process integration: a theoretical framework. Journal of Business Logistics, 30(2), pp. 27–46

Chernew, M., & Newhouse, J. (2011). Health care spending growth. Handbook of Health Economics, 2, pp. 1-43.

Cho, N.E., Chang, J., & Atems, B. (2014). The effects of health information technology adoption and hospital-physician integration on hospital efficiency. The American journal of managed care.

Conrad D.A. & Shortell S.M. (1996). Integrated health systems: promise and performance. Frontiers of Health Services Management ,13(1), pp. 3–40.

Ding, D.X. (2014). The effect of experience, ownership and focus on productive efficiency: A longitudinal study of US hospitals. Journal of Operations Management, 32(1-2), 1-14.

(32)

32

Eljiz, K., Greenfield, D., Derrett, A., & Radmore, S. (2019). Health system redesign:

Changing thoughts, values, and behaviours for the co-production of a safety culture. The International Journal of Health Planning and Management, 34(4), 1477-1484.

Flynn, B. B., Huo, B., & Zhao, X. (2010). The impact of supply chain integration on performance: A contingency and configuration approach. Journal of Operations

Management, 28(1), 58–71.

Gimenez, C. & Ventura, E. (2005). Logistics-production, logistics-marketing and external integration: their impact on performance. International Journal of Operations & Production Management, 25(1), 20–38.

Greenberg, L. & Campion, D., (2006). Efficiency in health care: what does it mean? How is it measured? How can it be used for value-based purchasing? Academy Health, AHRQ.

Hall, R. (2006). Patient flow: the new queuing theory for healthcare. OR/MS Today 33, pp. 36–40

Huckman, R.S. (2006). Hospital integration and vertical consolidation: An analysis of acquisitions in New York State. Journal of Health Economics, 25(1), pp. 58-80 Ibewuike, N.O. & Weeks, R. (2014), Healthcare Service Delivery Efficiency: Performance of

Gauteng Hospitals. INCOSE International Symposium, 24: 252-267. Ketikidis, P.H., Koh, S.L., Gunasekaran, A., Danas, K., & Roudsari, A. (2006). The

applicability of a multi‐attribute classification framework in the healthcare industry. Journal of Manufacturing Technology Management.

Kodner, D. (2009). All Together Now: A Conceptual Exploration of Integrated Care. Healthc Q.

Koufteros, X.A., Cheng, T.C.E. & Lai, K.H. (2007). Black-box and gray box supplier

(33)

33

Lee, K., & Wan, T.H. (2002). Effects of hospitals' structural clinical integration on efficiency and patient outcome. Health Services Management Research, 15(4), 234- 244.

Leeftink, A. G., Bikker, I. A., Boucherie, R. J., & Vliegen, I. M. H. (2018). Multi-disciplinary planning in health care: a review. Health Systems.

Leuschner, R., Rogers, D., & Charvet, F. (2013). A meta-analysis of supply chain integration and firm performance. Journal of Supply Chain Management, 49(2), pp. 34-57. Lo Storto, C. (2017). Performance analysis of healthcare systems in European countries.

Bulgarian Journal of Business Research.

Lo Storto, C., & Goncharuk, A.G. (2017). Efficiency vs effectiveness: a benchmarking study on European healthcare systems. Economics and Sociology, 10(3), pp. 102–115. Mastromarco, C., Stastna, L., & Votapkova, J. (2019). Efficiency of hospitals in the Czech

republic: Conditional efficiency approach. Journal of Productivity Analysis, 51(1), pp.73-89.

Meijboom, B.R., Bakx, S., & Westert, G.P. (2011). Supply chain management practices for improving patient-oriented care. Supply Chain Management: An International Journal, 16(3), pp. 166–175.

Meredith, J. (1998). Building operations management theory through case and field research, Journal of Operations Management, 16(4), pp. 441–454.

Miles, M.B., and Huberman, M.A. (1994). Qualitative Data Analysis, Saga Publications, London.

Minkman, M. (2012). Developing integrated care. Towards a development model for integrated care. International Journal of Integrated Care, 12(8).

(34)

34

Minkman, M., Ahaus, K., & Huijsman, R. (2009b). A four phase development model for integrated care services in the Netherlands. Bmc Health Services Research, 9(42).

Minkman, M., Vermeulen, R., Ahaus, C., & Huijsman, R. (2011). The implementation of integrated care: the empirical validation of the development model for integrated care. Bmc Health Services Research, 11(177).

Pagell, M. (2004). Understanding the factors that enable and inhibit the integration of operations, purchasing and logistics. Journal of Operations Management, 22(5), pp. 459-487

PAHO: Pan American Health Organization (2011). Integrated Health Service Delivery Networks: Concepts, Policy Options and a Road Map for Implementation in the Americas. SERIES: Renewing Primary Health Care in the Americas No.4

Palmer, S., & Torgerson, D. (1999). Economics Notes: Definitions of Efficiency. BMJ: British Medical Journal, 318(7191), 1136-1136.

Rosko, M., Proenca, J., Zinn, J., & Bazzoli, G. (2007). Hospital inefficiency: What is the impact of membership in different types of systems? Inquiry, 44(3), pp. 335-349. Saeed, K.A., Malhotra, M.K. & Grover, V. (2005). Examining the impact of

interorganizational systems on process efficiency and sourcing leverage in buyer– supplier dyads. Decision Sciences, 36(3), 365–396

Sarka, P., & Pavla, S. (2016). Horizontal Integration of Hospitals–Does it have an impact on their Effectiveness?. Procedia Economics and Finance, 39, pp. 553-561.

Severens, J.L. (2003). Value for money of changing healthcare services? Economic evaluation of quality improvement. BMJ Quality & Safety, 12(5), 366-371.

Tiemann, O., & Schreyögg, J. (2012). Changes in hospital efficiency after privatization. Health care management science, 15(4), pp. 310-326.

(35)

35

Van der Vaart, T., & van Donk, D. (2008). A critical review of survey-based research in supply chain integration. International Journal of Production Economics, 111(1), pp. 42–55.

Van der Vaart, T., & Van Donk, D. (2004). Buyer focus: Evaluation of a new concept for supply chain integration. International Journal of Production Economics, 92(1), pp. 21-30.

Van der Vaart, T., van Donk, D., Gimenez, C., & Sierra, V. (2012). Modelling the integration-performance relationship: Collaborative practices, enablers and contextual factors. International Journal of Operations and Production Management, 32(9), pp. 1043-1074.

Van Donk, D., & Van der Vaart, T. (2004). Business conditions, shared resources and integrative practices in the supply chain. Journal of Purchasing and Supply Management, 10(3), pp. 107-116.

Wait, S., Han, D., Muthu, V., Oliver, K., Chrostowski, S., Florindi, F., ... & Wierinck, L. (2017). Towards sustainable cancer care: Reducing inefficiencies, improving outcomes—A policy report from the All. Can initiative. Journal of Cancer Policy, 13, 47-64.

Wan, T.H., Lin, Y., & Ma, A. (2002). Integration Mechanisms and Hospital Efficiency in Integrated Health Care Delivery Systems. Journal Of Medical Systems, 26(2), 127 -143.

Yin, R.K. (2009). Case Study Research: Design and Methods, Essential guide to qualitative methods in organizational research, Sage Publications, London, Vol. 5.

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Appendices

Appendix 1: Interview questionnaire (Dutch)

Algemene vragen

• Wat is uw functie en wat zijn uw belangrijkste verantwoordelijkheden? Zorgpad

• Wat zijn de belangrijkste stappen van het zorgpad van patiënten met ____? • Wie is verantwoordelijk voor het zorgpad en de patiëntenstromen?

o Toezien op de stappen binnen een zorgpad en de patiëntenstromen, doet elke afdeling dat afzonderlijk of is er iemand die hierop toeziet?

• Wie houdt toezicht op het gehele zorgproces van een patiënt? Integratie

Algemeen

• Hoe zou u integratie van zorgpaden omschrijven?

• Hoe ziet een geïntegreerd zorgpad er uit en wanneer kan je daarvan spreken?

• Wordt het zorgproces van een patiënt gezien als een collectie van losse, individuele te managen stappen of als een geïntegreerd proces?

• In hoeverre is het ______ zorgpad geïntegreerd? o Welke elementen zijn gecoördineerd?

▪ 1: Vooral informatie delen en communiceren

▪ 2: Ook activiteiten/diensten (ontwikkelen), processen, beslissingen ▪ 3: Strategische relatie; vertrouwen, lange termijn focus

• Wie is verantwoordelijk voor het integreren van zorgpaden?

• Bij het integreren van zorgpaden, waar wordt vooral aandacht aan besteed?

o Hoe wordt ervoor gezorgd dat de integratie en samenwerking steeds verbetert? • Wat is het doel van het integreren van zorgpaden?

o In hoeverre is er overeenstemming tussen de doelen van afdelingen? • Wat zijn de barrières van het integreren van zorgpaden?

Samenwerking

• In hoeverre wordt er samengewerkt tussen afdelingen die betrokken zijn bij een zorgpad? o Hoe vaak wordt er samengewerkt met andere specialismen of afdelingen? Op wat

voor manier?

o Hoe zorg je ervoor dat er een goede multidisciplinaire samenwerking is? • Is er sprake van integratie en coördinatie van de patiëntenplanning?

o Is er afstemming met andere stappen of processen?

• Zijn er richtlijnen of protocollen die omschrijven hoe er moet worden samengewerkt of waar naar wordt gestreefd?

• Als je contact moet opnemen met een betrokken afdeling, is het duidelijk met wie je contact moet opnemen van andere afdelingen? Hoe?

• Als er zich een probleem voordoet binnen het zorgtraject, hoe wordt dit dan opgelost?

Informatie delen

• Wat voor informatie wordt gedeeld tussen de afdelingen?

o Is er bepaalde informatie die afdelingen verplicht moeten delen met elkaar?

▪ Is hiervoor een overeenkomst tussen de afdelingen waaraan zij zich dienen te houden?

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o In hoeverre zijn afdelingen vrij om informatie te delen met andere afdelingen? • Zijn er meetings tussen betrokken afdelingen om zorgprocessen / zorgpaden beter te

organiseren?

o Wat wordt hierin besproken? Effect van integratie

• Wordt integratie van zorgpaden gemeten en beoordeeld? Hoe?

• Welke voordelen heeft u gemerkt nadat zorgpaden meer zijn geïntegreerd? o Of: Welke voordelen verwacht u te behalen na de integratie?

• Hebben beslissingen die gemaakt worden door een bepaalde afdeling invloed op andere afdelingen?

• Is er een bepaalde bottleneck in het zorgpad? Wat de stroom eigenlijk ophoudt? • Wat kan verbeteren om de mate van integratie te vergroten?

o Welke initiatieven neemt het ziekenhuis om integratie te vergroten?

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Appendix 2: Interview questionnaire (English)

General questions

• What is your position and what are your main responsibilities? Care pathways

• What are the main steps of the care pathway for patients with ____? • Who is responsible for the care pathway and patient flows?

o Monitoring the steps within a care pathway and the patient flows, does each department do this individually or is there someone who monitors this? • Who monitors the entire care process of a patient?

Integration General

• How would you describe the integration of care pathways?

• What does an integrated care pathway look like and when would you speak of it? • Is the patients’ care process seen as a collection of steps to be managed individually or

as an integrated process?

• To what extent is the ______ care pathway integrated? o Which elements are coordinated?

▪ 1: Especially sharing and communicating information

▪ 2: Also activities / services (development), processes, decisions ▪ 3: Strategic relationship; trust, long term focus

• Who is responsible for integrating care pathways?

• When integrating care pathways, what is the main focus of attention?

o How is it ensured that integration and cooperation continue to improve? • What is the purpose of integrating care pathways?

o To what extent is there alignment between the goals of departments? • What are the barriers to integrating care pathways?

Cooperation

• To what extent is there cooperation between departments involved in a care pathway? o How often do you collaborate with other disciplines or departments? In what

way?

o How do you ensure that there is good multidisciplinary collaboration? • Is there integration and coordination of patient planning?

o Is there coordination with other steps or processes?

• Are there guidelines or protocols that describe how to collaborate or what to aim for? • If you need to contact a involved department, is it clear who to contact with from the

other departments? How?

• If a problem arises within the care process, how will it be solved?

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• What kind of information is shared between the departments?

o Is there certain information that departments are required to share with each other?

▪ Is there an agreement between the departments to which they must adhere?

o How does the current information system affect the exchange of information? o To what extent are departments free to share information with other

departments?

• Are there meetings between the departments involved to better organize care processes / care pathways?

o What is discussed in the meetings?

Effect of integration

• Is integration of care pathways measured and assessed? How?

• What benefits have you noticed after more integrated care pathways? o Or: What benefits do you expect to achieve after the integration? • Have decisions made by a particular department impact on other departments? • Is there a specific bottleneck in the care pathway? Which hinders the flow? • What can be improved to increase the extent of integration?

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Appendix 3: Coding scheme example

In the following table, the coding scheme of the breast cancer care pathway is shown as example.

Variable Data reduction Descriptive

code Theme

Level of integration

- Het zorgproces wordt meer gezien als een geïntegreerd proces.

Vind ik wel 100 procent geïntegreerd. Full integration Integration

- Eigenlijk kun je niet zonder elkaar. Wij hebben de röntgen nodig, wij hebben de OK nodig, wij hebben de radiotherapeut nodig, de nucleaire geneeskunde, dus je kunt eigenlijk niet zonder elkaar.

Mutual

dependency

- Alles heeft met alles te maken. Als ze bij radiologie onvoldoende personeel hebben, de wachttijd loopt op voor de MRI, dan kunnen wij misschien niet garanderen dat iemand binnen vijf weken geopereerd wordt. Die hele keten, je hebt een heel proces en als een schakel uitvalt, dan loopt de hele keten in de soep.

- Ik vind dat er veel samenwerking is tussen afdelingen. Collaboration Collaboration

-Iedereen die te maken heeft met de zorg voor patiënten voor die groep wil je eigenlijk ook betrokken hebben bij de ontwikkeling van zo een zorgpad.

Involving

parties Coordination

Intensity of integration

- Op patiëntniveau, wij werken met EPIC, dat is een geïntegreerd digitale patiëntendossier. Daarmee kan iedereen in elkaars dossier kijken. Information system Information sharing and communication

- Toen kon je niet bij elkaar in het dossier kijken, dan was er weer eens een dossier zoek, dan kun je je nu bijna niet meer

voorstellen, maar dat is nu echt een hele verbetering. Alle afdelingen maken gebruik van EPIC.

- of wanneer een operatietijd wat oploopt, daar hebben we elke week een planningsoverleg over

Communication

- En dan bespreken we zo iemand in het MDO, multidisciplinair overleg,

- of het niet te lang duurt en wanneer de patiënt aan de beurt is.

Dus dat gebeurt eigenlijk in gezamenlijkheid Collaboration Collaboration

Increased integration of care pathways and its effect on healthcare efficiency