Process coordination in a
hospital setting
T
HE IMPACT OF CARE PATHWAYS
Master ThesisPROCESS COORDINATION IN A HOSPITAL SETTING The impact of care pathways
Master thesis (*CENSURED VERSION) Author: J.R. Pijlman (s1336088)
MSc Technology Management Faculty of Economics and Business University of Groningen
Supervised by:
Prof. dr. J. De Vries, University of Groningen Prof. dr. ir. C.T.B. Ahaus University of Groningen
Drs. T. Schrama Squarewise B.V.
May, 2009
A
CKNOWLEDGEMENTS
This report is not only the result of a case study research conducted among three Dutch hospitals regarding process-oriented approaches of organizing, it also represents the last piece of work of my academic career as a student. Looking back, my study period has been an extensive, adventurous and incredible journey which started in Peize in 2002, crossed multiple borders and ends here in Amsterdam, anno 2009. During this period, I have realized to the fullest extent that it was not the destination that made it all worthwhile. Rather, it was the journey itself that determined the true value. Luckily I did not travel alone, many people contributed in various ways to whom I would like to express my gratitude.
First, regarding this final research, I would like to express my sincere gratitude to my supervising committee. To my company supervisor; drs. Timo Schrama, thank you for challenging me and even though we did not always agree, I have learned enormously and will take your feedback with me in my personal development. To my first supervisor from the university; Prof. dr. Jan de Vries, thank you so much for your support, feedback and our inspiring discussions. Your enthusiasm has motivated me throughout the entire process. Also, my gratitude goes out to my co-assessor; Prof. dr. ir. Kees Ahaus for his feedback during the final phase of this report. Next to these people, this research would not have been possible without the cooperation of the participating hospitals. To all the involved people at the different hospitals, thank you. I sincerely hope my results will prove valuable to future implementations of process-oriented initiatives. Further, to my former colleagues at Squarewise, thank you for the valuable experience, feedback sessions and of course the fun times we shared during and after office hours.
Second, beside this research, there are some people and groups I would like to thank in particular for travelling along. I would like to thank my old friends from Peize; Erik, Egbert, Kasper and Jeroen for the good times we still share. From Groningen; Bas, Tim, Floris, Jonne and Tecla, all ISP participants and board members, my friends from TM, and Derk, my current roommate with whom I could happily share the last phase of my study. Thank you all, it has been a privilege. Last but all but least are the few special persons in my life who I need to thank. Writing this thesis has been rather intensive and sometimes kept me from devoting my time and attention to those who deserve it the most. I would like to thank my parents and younger brother for their unconditional support, love and belief in all my choices. They continue to inspire me to spread my wings and allow the ideas and dreams in my head to grow and develop without constraints. The last person I would like to thank is my girlfriend Marjon for her love, support and joy she brings to my life. I can only hope that we continue our adventure and fulfill our dreams to wherever it will take us.
S
UMMARY
This thesis approached the concept of process orientation within a hospital context. Induced by public pressures and macro-economic policy reforming, the Dutch healthcare sector seems to be in transition from a regulated- to a more liberalized system. These developments place new requirements on healthcare institutions in terms of efficiency, patient centeredness and medical effectiveness in order to adapt to the changing environment. It is argued that an integral approach is necessary for effective service improvement; this includes both internal- and inter-organizational adjustments. Regarding these two areas of improvement, this research focuses on the internal aspect within hospitals. Solutions seem to rely on forms of integrated care and shift from the traditional physicians-centered view towards organizing around care processes. As such, process orientation is becoming increasingly important within hospitals and a clear rationale is provided to find out how process orientation can be achieved and fostered within hospital organizations.
In order to assess how process orientation can be achieved, a cross-functional coordination perspective was taken. This perspective allowed us to address common cross-functional issues within hospital settings between departments or different medical groups. As this approach could not be found within current literature, providing insight on the relation between process orientation and cross-functional coordination is regarded as a research product on its own. Next to this, care pathways were selected as a case to assess current initiatives of achieving process orientation. The care pathway phenomenon is becoming increasingly popular and their implementation within hospital operations is often acknowledged as a major step regarding process orientation. However, other findings draw a more differentiated image regarding implementation, institutionalization and results. As such, care pathways provide a valuable case to assess how process orientation can be achieved in hospitals. By considering the above, two research objectives have been formulated:
1. To provide a theoretical contribution on the relation between process orientation and cross-functional coordination within a hospital setting.
2. To provide insight into the impact of care pathways on the transformation of hospitals towards more process-oriented organizations by analyzing changes in cross-functional coordination mechanisms within elective care settings.
process orientation is infeasible in situations characterized by low predictability. Formalization and standardization form the foundation of process management, however become ineffective in such situations, as such, other forms of orientation and coordination should be advised. Further, when process maturity within an organization increases, a dual effect is hypothesized from a coordination perspective. On the one hand, higher levels of process maturity relate to subtle mechanisms such as socialization and shared understanding as these are required to manage the often intensified interdependent relations between activities for instance through the removal of buffers or slack for logistics optimization. While on the other hand a more formalized approach seems required as the process scope broadens and more parties become involved requiring formalized approaches of coordination including a uniform information structure but also more formalized modes of control. As such, a balanced approach of coordination mechanisms is expected when process maturity increases which relates to Jaworski’s (1988) view on high management control as it combines both formal as informal mechanisms.
T
ABLE OF CONTENTS
ACKNOWLEDGEMENTS ... III SUMMARY ... IV TABLE OF CONTENTS ... VI LISTS OF TABLES AND FIGURES ... VIII DEFINITIONS OF FOCAL CONCEPTS ... IX RESEARCH PRINCIPAL ... X
1. INTRODUCTION ... 11
1.1 HEALTHCARE DYNAMICS IN THE NETHERLANDS ... 11
1.1.1 Reforming policies ... 11
1.1.2 DBC-system ... 12
1.2 RE-ORGANIZING CARE DELIVERY IN HOSPITALS ... 13
1.2.1 Recent initiatives ... 13
1.2.2 Redesigning hospitals ... 14
1.3 PROCESS-ORIENTATION ... 14
1.3.1 Process orientation and maturity ... 14
1.3.2 Process orientation and care pathways ... 15
1.4 REPORT STRUCTURE ... 16
2. RESEARCH DESIGN ... 17
2.1 CONCEPTUAL RESEARCH DESIGN ... 17
2.1.1 Problem definition ... 17
2.1.2 Research scope ... 17
2.1.3 Research objectives ... 20
2.1.4 Relevance & contribution ... 20
2.1.5 Research questions ... 21
2.1.6 Synthesizing the conceptual design ... 21
2.2 TECHNICAL RESEARCH DESIGN ... 22
2.2.1 Type of research & research approach ... 22
2.2.2 Case study ... 23
2.2.3 Sources and research techniques ... 24
2.2.4 Research structure ... 25
2.2.5 Research validity ... 25
2.2.6 Research constraints ... 26
2.2.7 Synthesizing the technical research design ... 27
3. A CLOSER LOOK ON CARE PATHWAYS, CARE PROCESSES AND PROCESS MANAGEMENT ... 28
3.1 THE ORIGIN AND DEVELOPMENT OF CARE PATHWAYS ... 28
3.2 PERSPECTIVES ON CARE PATHWAYS ... 29
3.2.1 Differences in terminology and evidence validity ... 29
3.2.2 Differences in purpose ... 30
3.2.3 Differences in organizational changes ... 30
3.3 CARE PATHWAYS AND ORGANIZATIONAL DEVELOPMENT ... 32
3.4 CARE PATHWAYS, PROCESSES AND PROCESS MANAGEMENT ... 33
3.4.1 Care pathways and care processes ... 33
3.4.2 Care pathways and process management ... 35
3.5 SYNTHESIZING FINDINGS ... 36
4. COORDINATION WITHIN PROCESSES ... 37
4.2 COORDINATION ... 38
4.2.1 Defining cross-functional coordination ... 38
4.2.2 Coordination and contingent factors ... 38
4.2.3 Coordination and social structures ... 40
4.3 COORDINATION MECHANISMS ... 40
4.3.1 Formalization and standardization ... 41
4.3.2 Planning and scheduling ... 42
4.3.3 Output & behavioral control ... 42
4.3.4 Information systems ... 43
4.3.5 Lateral mechanisms ... 43
4.3.6 Workplace rotation and interdisciplinary training ... 45
4.3.7 Socialization & incentive systems ... 45
4.4 REQUISITE COORDINATION ... 46
4.4.1 A variety of requisite factors ... 46
4.4.2 Complexity ... 46
4.4.3 Uncertainty ... 47
4.5 ACHIEVED COORDINATION ... 47
4.5.1 Achieved coordination perspectives ... 47
4.5.2 Achieved coordination and performance... 49
4.6 RELATING THE CONCEPTS ... 49
4.6.1 Synthesizing findings on coordination ... 49
4.6.2 Relating coordination mechanisms to achieved coordination constructs ... 50
4.6.3 Achieving fit between coordinating mechanism and requisite coordination ... 52
4.6.4 Combining coordination mechanisms, outcomes and process maturity ... 53
4.7 SYNTHESIZING FINDINGS ... 55
5. COORDINATION IN PRACTICE ... 56
5.1 CASE SELECTION ... 56
5.2 DATA COLLECTION ... 56
5.3 DATA STRUCTURING & PRESENTATION ... 57
5.4 FINDINGS PER CASE ... 57
5.5 CROSS-CASE FINDINGS ... 58
5.6 SYNTHESIZING FINDINGS ... 60
6. CONCLUSIONS & DISCUSSION ... 62
6.1 CONCLUSIONS ... 62
6.2 DISCUSSION ... 63
6.2.1 Process orientation and cross-functional coordination ... 63
6.2.2 Achieving process orientation within hospitals ... 64
6.2.3 Managerial recommendations ... 66
6.2.4 Academic recommendations ... 67
6.3 LIMITATIONS TO THE RESEARCH ... 67
7. REFERENCES ... 69
7.1 JOURNAL ARTICLES ... 69
7.2 BOOKS / BOOK SECTIONS ... 72
7.3 RESEARCH PAPERS, REPORTS AND OTHER ARTICLES ... 74
7.4 WEBSITES ... 74
L
ISTS OF TABLES AND FIGURES
*CENSURED
Table 1: Advantages of cross-functional coordination in a hospital context ... 18
Table 2: Data collection techniques per research question ... 24
Table 3: Stages in evolving towards a matrix- or project organization (from: Kolodny, 1979) ... 32
Table 4: Process maturity levels (from: McCormack & Johnson, 2001) ... 38
Table 5: Combining coordination mechanisms and process maturity ... 54
Table 10: Cross-case findings on process maturity ... 58
Table 11: Cross-case findings on barriers to coordination ... 59
Table 12: Cross-case findings on achieved coordination ... 60
Figure 1: Triangular market structure Dutch healthcare system (from: Van Montfort & Vandermeulen, 1997) ... 12
Figure 2: Process view of a hospital (from: Vera & Kuntz, 2007) ... 15
Figure 3: Classification of hospital care based on complexity and predictability (from: Blijham, 2005) ... 19
Figure 4: Research structure ... 25
Figure 5: Prevalence of care pathways -The Netherlands highlighted- (from: Vanhaecht, 2006) ... 29
Figure 6: Three perspectives on care pathways ... 31
Figure 8: Process hierarchy, care programmes and care pathways ... 34
Figure 9: Three dimensions of coordination ... 39
Figure 10: Coordination mechanisms... 41
Figure 11: Lateral coordination mechanisms (from: Galbraith, 1973) ... 44
Figure 12: Types of interdependence ... 47
Figure 13: Achieved coordination measures (from: Simatupang et. al., 2002 with modifications) ... 48
Figure 14: Theoretical framework on coordination. ... 50
D
EFINITIONS OF FOCAL CONCEPTS
Process orientation A process-oriented organization is an organization that, in all its thinking, emphasizes processes as opposed to hierarchies with a special emphasis on outcomes and customer satisfaction (McCormack & Johnson, 2001) Process management Process management refers to steering and controlling of
business processes. In general, process management entails three main activities; mapping processes, improving processes and ensuring adherence to changed processes respectively (Hardjono & Bakker, 2002; Benner & Tushman, 2002).
Process maturity Process maturity indicates the extent to which a process is explicitly defined, managed, measured, and controlled. It also implies growth in process capability, richness, and consistency across the entire organization (Dorfman, 1997). Cross-functional coordination Cross-functional coordination is the integration or linking
together of different interdependent but functionally separated activities in order to accomplish a collective set of tasks (Malone & Crowston, 1994; Van de Ven et. al. 1976) Coordination mechanism Any managerial tool for achieving coordination within an
organization (Galbraith, 1973; Martinez & Jarillo, 1989) Requisite coordination Requisite coordination refers to the requirements for
coordination efforts in an organization to achieve its goals after the division of tasks (Donaldson, 2001).
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ESEARCH PRINCIPAL
Squarewise
The principal company of this thesis is Squarewise BV. Squarewise is a strategic consultancy firm, specialized in strategy- and innovation management. Their consulting approach ranges from strategy consulting to practical implementation. Analysis, project- and program management are core activities. The company was founded in 2000 and is growing ever since, at the moment it employs about 25 consultants. The company is organized in three business units, each tailored for a specific target group of clients as described below;
1. Business Unit Profit; Multinationals, industrial companies, law firms 2. Business Unit Non-Profit; Ministries, local governments, NGO’s, foundations 3. Business Unit Healthcare; Healthcare institutions (e.g. hospitals), health
insurers, regional instances, IT companies Company motivation
1.
I
NTRODUCTION
In this chapter the context and motivation of the research is introduced. It was found that induced by public pressure and macro-economic policy reforming, the Dutch healthcare sector is currently transforming from a regulated- to a more liberalized system. Consequently, such developments place new requirements on healthcare institutions in order to adapt to the changing environment. It is argued that an integral approach is required for effective service improvement; this implies that both internal- and inter-organizational adjustments are required. By taking re-organizations within hospitals as the focal theme of this research, this research focuses on the internal aspect of improvement. Although best practices of horizontal approaches of organizational optimization are evident within the industrial sector, its application within hospitals is only just receiving academic and managerial attention. Within this context, the increasing popularity surrounding the adoption of care pathways provides this research with a valuable case to analyze improvements towards new approaches of hospital organizations. After outlining the context and motivation, chapter 2 continues by formulating the research goal and questions.
1.1 Healthcare dynamics in The Netherlands 1.1.1 Reforming policies
The Dutch healthcare sector is turbulently changing in the last decade. Recent policy reforms such as the liberalization of the market have resulted in fundamental changes for the parties involved. When viewed from a historic perspective, health policy reforms within OECD countries can commonly be described in three waves (Cutler, 2002). In the first wave (1) a healthcare system is built with equal access and universal coverage as the most important objectives of policy. Economical aspects such as efficiency are of no or little concern which leads to a rapid increase of the total costs. In response to these costs, most countries focus on regulatory limits and cost control. This forms the second wave of policy reforms (2). The introduced cost control leads to a limited use of resources but does not offer any incentive for efficiency. Subsequently, continuing inefficiency and rising waiting lists because of the limited resources lead to the third wave of policy reforms in healthcare (3). This third wave focuses on introducing an incentive based system such as market liberalization. By allowing healthcare providers to compete on price, health care providers are stimulated to increase their efficiency and drive down costs. Hence, when these general movements are compared to the Dutch situation it can be found that from the beginning of the 20th century until the 1960s healthcare
1.1.2 DBC-system
Nowadays, anno 2009, it is widely recognized that The Netherlands endorsed the third wave of healthcare policy reforms and is in transition from a regulated healthcare system towards a liberalized market system. This transition is supported by the recent introduction of a new reimbursement system based on diagnoses and treatment combinations (Dutch abbreviation: DBCs). A DBC includes all services and activities in a healthcare institution associated with the patient’s demand for care, covering the diagnosis, treatment and nursing functions involved. Healthcare institutions and health insurers have to negotiate about the price, quality and volume of these services and activities by which market incentives are created. Currently, about 66% of the diagnosis and treatment combinations are still financed by fixed tariffs set by the government (commonly addressed as segment A-DBCs), however an annually increasing amount of DBCs (currently 34%, commonly addressed as segment B-DBCs) has to be renegotiated with the health insurers.
Figure 1: Triangular market structure Dutch healthcare system (from: Van Montfort & Vandermeulen, 1997)
re-admission rates are not incentivized by the new payment mechanism. Further, the potential effect on patient centeredness, aimed at the identification of patient preferences, needs, and values and subsequent clinical decision-making based on these variables is potentially induced by the new reimbursement system as hospitals could attract patients by providing premium services and build up a good reputation within this dimension. Hence, when summarizing the findings above it becomes evident that the new payment mechanism offers incentives to improve the quality of healthcare in terms of efficiency and patient centeredness. Considering medical effectiveness, we find that this dimension is not directly impacted by the new system, however it can be stated that the dominant public trend towards transparency and public concerns on healthcare make it for healthcare institutions impossible to neglect the optimization of medical quality. As such, from a macro-perspective, incentives and pressures to improve healthcare on all three identified dimension seem to be present. These developments lead to an unknown level of dynamics within the sector by which it should be no surprise that healthcare institutions struggle with the changing demands of their surroundings. The multidisciplinary character and vast intertwinement of processes make management and (re)design of healthcare processes all but trivial (De Vries, 2009). As such, the next paragraph addresses some of the main initiatives taken to address the identified quality gaps. 1.2 Re-organizing care delivery in hospitals
1.2.1 Recent initiatives
professional and managerial culture by which professionals become engaged in managerial issues aligning their interests as much as possible with organizational goals (ibid.).
1.2.2 Redesigning hospitals
Through meta-analysis, Lega & DePietro further found that several studies have addressed inter-organizational studies (see: bridging) and behavioral interventions within hospitals (see: engaging), while surprisingly there seems to be a lack of interest among scholars on the second category, redesigning hospital organizations. This may be regarded odd by the fact that in contrary to the lack of academic studies, the redesign of hospitals seems to be a key focus for practitioners while their effectiveness in redesigning might be questioned. As Mintzberg (p.8, 1997) underlines: “Hospitals are constantly reorganizing, which means shuffling boxes around on pieces of paper. Somehow, it is believed that by rearranging authority relationships, problems will be solved. But all this may reflect none more than the frustration of managers in trying to effect real changes in clinical operations [..]”. These findings provide a strong rationale for this research to focus on how forms of integrated care establish themselves within hospitals. In this context, the shifting paradigm of hospitals transforming towards a care-focused organization (Lega & DePietro, 2005) plays a major role. The central idea behind this paradigm is that the earlier described industry dynamics drive the reshaping of hospital delivering processes around the needs of care processes and away from the traditional physicians-centered view, or as Mintzberg (1997) formulates: “the change in mindset from fragmentation to collaboration”. It is notable that industrial organizations experienced comparable developments during the 1990s. In this period, organizations were comparably faced with increasingly complex and dynamic environments, thereby adopting new management concepts such as business process reengineering (BPR) which aimed to shift the traditional focus on functional-like designs towards a focus on the core (business) processes of organizations. The transformations of these organizations were supported by the shared idea that process-oriented companies should be more focused on the needs of the customer and therefore be able to deliver better value in terms of end-to-end services (see: Porter, 1985). Although the radical character of the BPR approach has been heavily criticized over time and academic interest surrounding the concept has waned, the concept of process orientation has held up well to criticism and has become an integral element of other organization concepts such as modularization or supply chain management (Vera & Kuntz, 2007). In addition, Kaluzny (2000) argues that benefits of process-oriented organizations can also be applied to the hospital industry. Recent studies support these arguments by finding positive correlations between the level of process orientation and hospital performance (Vera & Kuntz, 2007). As such, induced by increasing dynamics and policy reforms, the momentum for hospitals to transform into more process-oriented organizations seems to be at hand and will be further discussed in the next paragraph.
1.3 Process-orientation
1.3.1 Process orientation and maturity
on care processes, we make use of a definition provided by Smith & Fingar (2003) on business processes in which coordination is regarded as an essential element: “A business process is the complete and dynamically coordinated set of collaborative and transactional activities that deliver value to customers”. When translated to a hospital setting, the definition can be reformulated as “A care process is the complete and dynamically coordinated set of collaborative and transactional activities that deliver value to patients”. In relation to this definition, a process-oriented organization is defined as: “an organization that, in all its thinking, emphasizes processes as opposed to hierarchies with a special emphasis on outcomes and customer satisfaction” (McCormack & Johnson, 2001). Garvin (1998) argues that in process-oriented organizations, processes are mapped so that task responsibilities are described with a focus on processes. This form of responsibilities exceeds the functional borders and encourages all members of the different departments to collaborate and achieve common goals. It also implies the use of process oriented performance indicators, obliging the members of an organization to work together as one group. Kai (1999) further denotes that a process-oriented organization should be distinguished from a process-based organizational structure concept. While process orientation represents the understanding of the business flow, it may be regarded as a first step towards such an organizational form. This evolutionary approach is supported by findings of a large survey among European companies which confirmed that more than 50% of the companies change their structure in the early stage of the implementation of business process management and that up to 70% do this in a well progressed stage (Armistead & Pritchard, 1999). On the other hand, process orientation can also be viewed as a broader term than the process organization, because an organization can reach a certain degree of process orientation maturity without formally being organized in a horizontal sense (Kai, 1999). The hereby mentioned maturity of a process-oriented organization thus proposes that a process has a lifecycle that is assessed by the extent to which the process is explicitly defined, managed, measured, and controlled. It also implies growth in process capability, richness, and consistency across the entire organization (Dorfman, 1997). As an organization increases its process maturity, institutionalization takes place via policies, standards and ultimately organizational structures (Hammer, 1996).
Figure 2: Process view of a hospital (from: Vera & Kuntz, 2007)
1.3.2 Process orientation and care pathways
encouraging more horizontal coordination between linked activities. In this context, the current manifestation of care pathways within hospitals around the world (including The Netherlands) provides a valuable case. Care pathways on the one hand aim to optimize care by means of intensive and well-structured coordination between the involved parties within the hospital and are considered as a major step in the process orientation of a hospital (Pischke-Winn, Wahlfeldt & Minnick, 1996; Vera & Kuntz, 2007), while on the other hand a rather differentiated perspective on aspects such as implementation, institutionalizing and results of care pathways is drawn by recent publications (Walldal et. al., 2002; Van Herck et. al., 2004). As Dy et. al. (p. 501, 2005) state: “Efficient investing in critical pathway programs would be facilitated by knowledge of why certain pathways in certain situations succeed, while others do not.” In addition, although Vanhaecht (2007) found a significant effect of care pathways on the coordination of care, he also concludes that one of the main challenges is to keep pathways ‘alive’ rather than leaving it a one-time improvement of the care process in hospitals. As such, initiated changes need to be embedded in hospital organizations so that care pathways continue to improve service delivery over time (ibid.). Taken all of the above into consideration, it can thus be questioned how and to what extent care pathways contribute to the transformation of hospitals towards more process-oriented organizations. More generic, it can be questioned how process orientation within hospitals can be achieved and institutionalized. Building on the work of various organizational scholars, these questions will be approached from a coordination perspective. This leads to a twofold research product; on the one hand practical insight is provided on care pathways and their application while on the other hand theoretical contributions are made on the relation between process orientation and coordination. This will be further elaborated in chapter 2 by which several research questions are formulated.
1.4 Report structure
2.
R
ESEARCH DESIGN
This chapter introduces the research design including the research goal and research questions. The research design consists out of a conceptual and technical part. Whereas the conceptual design constitutes what will be researched, the technical design constitutes how this will be done. Following the context and motivation as introduced in the previous chapter, the first part of this chapter addresses the conceptual design of the research and encompasses the formulation of the problem definition, the research scope, research objectives and research questions. Paragraph 2.2 continues with the technical design addressing the research approach, research strategy and ultimately research validity. After the research design has been determined, the following chapters start by answering the formulated research questions.
2.1 Conceptual research design 2.1.1 Problem definition
In the previous chapter the context and rationale for this research have already been discussed. It became clear that through recent macro-economic developments the need for service improvement within hospitals is becoming increasingly important. It is argued that solutions can be found in the concept of process orientation, however support for its effective application within hospitals is still relatively low. In this context, care pathways play an important role. On the one hand care pathways are regarded as an important first step towards process orientation while on the other hand a rather differentiated perspective on aspects such as implementation, institutionalizing and results of care pathways is drawn by recent publications. As such, multiple areas for research can be identified. First, generally, it can be questioned how process orientation can be achieved and institutionalized within hospitals. Second, given the mixed results found in literature, one might then question what care pathways are and how they contribute to process orientation within a hospital in relation to the first questioning. As these questions can be answered from a multitude of perspectives, the next paragraph addresses the scope and demarcation of the research.
2.1.2 Research scope Theoretical perspective
enacted mostly through hierarchical relations and vertical mechanisms supported by functional organization structures. However, through increasing dissatisfaction and problems associated to the established bureaucratic structures, organizational scholars shifted their attention to alternatives of organization design including horizontal coordination approaches (Gittell, 1995). Although the adoption by practitioners has been relatively slow, managers nowadays start to realize that they need to understand the tools and principles of designing organizations in order to be superior to their competitors (Galbraith 2002). Today, the discussion of organizations often centers on the difficulties in managing work across-functional barriers, problems related to the creation of “functional silos”, and the consequent cross-functional coordination challenge (Turkulainen, 2008). As the general shift towards process-oriented companies includes viewing processes as complete systems consisting out of interlinked activities and crossing functional boundaries (Benner & Tushman, 2002), we propose that cross-functional coordination is a vital component of process orientation and mechanisms to achieve cross-functional coordination can be used to support and foster process orientation. In essence, increasing attention towards cross-functional coordination and process orientation seem to go hand in hand. When reflected on hospital settings, the potential advantages of cross-functional coordination and similarly process orientation also become clear from the table below:
Advantages cross-functional coordination (Gittell, 1995) Examples of relevant issues in a hospital context The traditional functional structure breaks a natural process into
artificial categories and creates the need for administrative and managerial time to integrate it. Cross-functional coordination eliminates many of those reintegration tasks.
“As hospitals were historically considered as a collection of professional functions, it is not surprising that they were organized along functional departments characterized by specialization and centralization” (Gemmel, 2007). Cross-functional coordination can make an organization more of a
seamless web and easier to navigate from a customer’s point of view. This consideration is especially important for organizations that deliver services directly to the public.
“Patients often need to sort their own way through the system, receiving diagnoses and treatments from a loosely connected set of providers”
(Mintzberg, 1997). For firms that participate in a closely integrated supplier/customer
relationship and whose boundaries are permeable, the ability to coordinate across internal department boundaries might be translated into an ability to coordinate across inter-firm boundaries.
“Hospitals are often part of an integrated care network in which they closely cooperate with primary care instances (e.g. general practitioners) or with instances providing home- or nursery care after hospital visits” (Fabbricotti, 2007) The functional structure is costly because of the missed
opportunities for organizational learning that could improve both costs and quality. Functional structures motivate sub goal optimization and reduce the flow of information that would contribute to problem solving to blame avoidance.
“Professionals in hospitals can be characterized as multiple agents who have partial information, disparate (local) goals and limited communication capabilities" (Kumar et. al., 1993)
Table 1: Advantages of cross-functional coordination in a hospital context
Mintzberg, 1997). Therefore, we argue that research on cross-functional coordination within hospitals can also be applied between different professional medical groups. By integrating activities between disciplines, supporting professions and departments, both professional and organizational quality of the care process can be tackled (ibid.) This choice of scope is enforced by the notion that hospitals are service organizations by which the coordination between its frontline employees (disciplines and supporting departments) can be noticed and judged directly by its main customer, the patient.
Applicability of process orientation
Next to the theoretical perspective, this research is demarcated by the applicability of process-orientation within different hospital settings. Although many advantages on the subject are discussed and can further be extolled, organizations are viewed as open systems, and as such, contingent to their operating environment (Robbins, 1990). Implicitly, depending on contingent factors this also impacts the organization of care delivery. Blijham (2005) proposes a classification of hospital care based on the factors of complexity and predictability and orders these within four quadrants as illustrated below.
Figure 3: Classification of hospital care based on complexity and predictability (from: Blijham, 2005)
2.1.3 Research objectives
Based on all of the forgoing, the research objective of this research is twofold. The first research objective concerns to combine the general concepts of process orientation and coordination while the second research objective is specifically aimed at the impact of care pathways on cross-functional coordination within elective care settings. The objectives are formulated as follows:
1. The first research objective is to provide a theoretical contribution on the relation between process orientation and cross-functional coordination within a hospital setting.
2. The second research objective is to provide insight into the impact of care pathways on the transformation of hospitals towards more process-oriented organizations by analyzing changes in cross-functional coordination mechanisms within elective care settings.
It is noted that the objectives are mutually supportive as theoretical insights provided by fulfilling the first objective are a premise to fulfill the second research objective but also insights from care pathway experiences might contribute to verify or sharpen theoretical findings.
2.1.4 Relevance & contribution
The relevancy of a research can be expressed on both academic (or theoretical) and practical fields (De Leeuw, 1996). On an academic area, this research aims to contribute to academic literature by combining the concepts of process orientation and cross-functional coordination. Although analysis of cross-functional coordination and -control is a well-known area in scientific literature (Lawrence & Lorsch, 1967; Galbraith, 1973; Gittell, 1995, 2004), it is rather surprising that linkages with process oriented approaches of organizing are lacking or are just briefly mentioned (Barki, 2005). Instead, coordination mechanisms are more often assessed on inter-organizational or multinational levels (see: Grandori, 1997; Martinez & Jarillo, 1989). Moreover, process-oriented approaches of organizing within hospital settings are a relatively new field of research to which many contributions can be made (Vissers & De Vries, 2005; Van Merode, 2002; Young & Charns, 2004; Vera & Kuntz, 2007). Further, this research aims to build on previous academic research on care pathways. For example, whereas the dissertation of Vanhaecht (2007) already showed the effect of care pathways on the coordination of care, this research is more interested in how care pathways influence this increased level of coordination and thereby contributes to filling the lack of literature on the subject as addressed by Keen et. al. (p.317, 2006):
“There seems to have been remarkably little discussion of the nature of these co-ordination mechanisms, or of their relative merits, in the health services research literature to date. Our sense, based on some of our own work reported below, is that care pathways are hybrids, and where they work well they employ a range of different co-ordination mechanisms, involving both the exercise of authority and pure co-ordination”.
2.1.5 Research questions
Now that the problem definition, research scope, objectives and relevancy have become clear, this section addresses the research questions which need to be answered in order to fulfill the two research objectives. A main research question is formulated supported by multiple sub questions. Taken all of the forgoing into consideration, the following main research question can be formulated: “How can the level of process orientation within elective hospital settings be optimized from a cross-functional coordination perspective and how does the adoption of care pathways contribute to this process?”
To answer the main research question four sub questions are formulated:
1. What are care pathways and how are these implemented within hospitals?
So far, care pathways have been briefly introduced as methods to optimize the coordination of care throughout the hospital by introducing concepts of process orientation. However, to thoroughly assess how the adoption of care pathways impacts cross-functional coordination, a clear understanding of the concept is required. Therefore by answering this sub question more insight on the concept is provided which enables the selection of the right perspective given its ambiguous nature.
2. How can cross-functional coordination within elective care processes theoretically be optimized?
After providing insight in the concept of care pathways, this sub question addresses the theoretical relation between process orientation and cross-functional coordination within elective care processes. By answering this sub question a theoretical model is proposed. It covers the identification of various mechanisms to achieve cross-functional coordination given different contingent factors related to different levels of process orientation.
3. Given the theoretical model as proposed by answering the second sub question, which impact do care
pathways have on cross-functional coordination within elective care processes?
The third sub question covers the empirical part of the research and aims to determine how care pathways contribute to improved cross-functional coordination and process orientation. Based on different levels of process orientation and associated mechanisms identified by answering the second sub question, insight into practical applications and impacts of care pathways is retrieved from Dutch hospitals.
4. Given the findings on the second and third sub question, what recommendations can be done towards hospitals to further improve cross-functional coordination?
By answering the previous three sub questions, insight is retrieved in how process orientation can be achieved from a cross functional perspective, how care pathways have been approached and how they impact cross-functional coordination. Based on these findings, the final sub question addresses how hospitals can further increase the level of process orientation by use of cross-functional coordination mechanisms.
2.1.6 Synthesizing the conceptual design
some gaps in academic literature are addressed while insight into organization design might prove valuable for hospital managers to optimize internal processes. Whereas this section outlined what will be researched, the following technical design describes how this will be done.
2.2 Technical research design
This section covers the technical part of the research design which constitutes how the research will be performed. First the type and approach of the research are determined and discussed. Next the research strategy and methods and techniques used for answering the various research questions are explained, followed by criteria to justify the validity of the research.
2.2.1 Type of research & research approach
In order to formulate research methods the type of research needs to be determined. According to Malhotra (2006), a general research design may be broadly classified as exploratory or conclusive. The primary objective of exploratory research is to provide insights into, and an understanding of, the problem confronting the researcher. Exploratory research is used in cases when the problem needs to be defined more precisely, when relevant courses of action need to be identified, or when additional insights need to be gained before an approach can be developed. Conclusive research on the other hand, is based on analysis of large samples, and the data obtained are subjected to quantitative analysis aimed to establish law like patterns about the research object. As this research aims to retrieve deeper insight in how process orientation can be achieved within hospitals, it can be characterized as exploratory instead of conclusive. Closely related to the division between conclusive and explorative research is the division between qualitative and quantitative research methodologies. Whereas quantitative research is best suited for conclusive research, qualitative research seems best suited for explorative research given the rich nature required to provide new insights. Through thick and detailed descriptions focused on meaning of the observation, qualitative research can provide a researcher with a deep understanding of relationships, meanings and perceptions (Sandberg, 2005). Regarding care pathways, this latter approach is supported by Vanhaecht (ch.6, p.14; 2007) as he recommends for further research on care pathways: “Qualitative research methods, including interviews with (orthopedic) teams, could lead to a better understanding of what is exactly happening while care processes are undergoing improvement”. This deeper understanding in turn can be beneficiary to hospital managers to optimize their operations.
the solution is located somewhere in between. Related to processes and process orientation, this approach is supported by a study of Melao & Pidd (2000) who conceptualized various approaches on business processes. Based on their insights, Melao & Pidd state that: (p. 123) “business processes have a mixed and apparently conflicting nature. They have technical and social, tangible and intangible, objective and subjective, quantitative and qualitative dimensions”. This is supported by findings of a large scale survey of the implementation of BPR, which showed that business processes are best viewed as dynamic sociotechnical systems (ibid.). As will become clear from the literature review in chapter four, it was also found that recent insights on coordination place emphasis on the social structures next to the traditional deterministic approaches through which coordination can be enacted. As such, a research strategy in which both positivist and interpretivist approaches can be combined is preferred. Therefore a multiple case study approach is used, this is further discussed in the next section.
2.2.2 Case study
A case study can be characterized as a research strategy by which the researcher tries to gain a deep understanding of one or a few temporary objects or processes, which the researcher cannot influence (Verschuren & Doorewaard, 2007). Yin (2003) defines a case study as an empirical inquiry that investigates a contemporary phenomenon within its real-life context, especially when the boundaries between phenomenon and context are not clearly evident. Case studies can involve either single or multiple cases, and can contain numerous levels of analysis. Further, it is perceived as the most appropriate research strategy when three conditions are fulfilled: (1) a ‘how’ or ‘why’ question is being asked about (2) a contemporary set of events, (3) over which the researcher has little or no control (ibid.). Within this research, the main research question is clearly a ‘how’ question. Further, the researcher has practically no control over observed events and the research aim is of contemporary nature rather than historical. Regarding to the research approach (positivism vs. interpretivism) as addressed in the previous paragraph, Yin (2003) notes that case studies commonly rely on multiple sources of evidence, both quantitative as qualitative, by this enabling a combination of positivist and interpretivist approaches. Hence, based on all these points, the choice for a case study as a research strategy is justified.
2.2.3 Sources and research techniques
A major strength of the case study data collection is the opportunity to use many different sources of evidence. This offers the possibility to develop converging lines of inquiry, also named triangulation (Yin, 2003). Triangulation helps reduce the chances of coincidence in the research to a minimum, by using various sources of information and using several techniques to come to solid conclusions (Verschuren & Doorewaard, 2007). In the table below, an overview is given of the various data sources as used in this research. Below the table it is specified why and how the technique as noted in the table is used per sub question .
Table 2: Data collection techniques per research question
1. What are care pathways and how are these implemented within hospitals?
To assess how the introduction of care pathways impacts cross-functional coordination a clear understanding of the concept care pathways is required. As the researcher was relatively unfamiliar with the concept, a wide approach of data collection was used to retrieve a deep insight into the concept. First, professional and scientific literature was scanned to achieve a better understanding. Scientific literature was found by using (electronic) search registers and by tracing back references from useful literature, which is known as the snowball principle. The main search registers that are used include the catalogue of the University Library Groningen, EBSCO host (including Business Source Premier and Academic Search Premier), and Google scholar. Professional literature was further retrieved from websites of the NKP and the EPA and recent congresses on the subject. Next, experts in the field of care pathways, healthcare logistics or healthcare in general were interviewed either by telephone or unstructured interviews to provide the researcher with a rich amount of information on the context or concept of care pathways. An overview of the interviewed experts can be found in the appendix (8.1).
2. How can cross-functional coordination within elective care processes theoretically be optimized?
The aim of this sub question is to combine the theoretical constructs of process orientation and cross-functional coordination which leads to a theoretical model. The model is constructed primarily by analyzing literature. Similar to the first sub question, scientific literature was found through search registers and the snowball principle. Based on traditional organizational design theory (Lawrence & Lorsch, 1967; Mintzberg, 1979; Galbraith, 1973) as well as more modern approaches on coordination and control theory (Fenema, 2002; Gittell, 2002, 2004; Turkulainen, 2008) insights into various coordination mechanisms and outcomes are combined into a theoretical framework. Furthermore, by using the contingency approach a note is placed on the applicability of specific coordination mechanisms given different situations.
3. Given the theoretical model as proposed by answering the second sub question, which impact do care
pathways have on cross-functional coordination within elective care processes?
The third sub question covers the empirical part of this research. The theoretical framework on coordination is used to assess changes induced by implemented care pathways in Dutch
Chapter 3 4 5 6
Sub question 1 2 3 4
Personal Non- and semi-structured interviews √ √ √ Documents & process data Content analysis √
hospitals. More information on the case selection and data collection within these hospitals can be found in chapter 5.
4. Given the findings on the second and third sub question, what recommendations can be done towards hospitals to further improve cross-functional coordination?
The aim of the final sub question is to provide recommendations which can support hospitals to further improve process orientation and cross-functional coordination. Based on the knowledge obtained from sub questions 2 and 3 a discussion of the results, the applied perspective and recommendations for both hospital management and future research is provided.
2.2.4 Research structure
The structure of this research follows the first three stages of the regulative cycle of Van Strien (1975) consisting out of (1) the orientation phase (2) analysis and diagnosis phase and (3) the design phase. However, because of the time constraints the design phase is limited to recommendations for improvement. Based on the previous sections, the structure is illustrated in the figure below.
Figure 4: Research structure
2.2.5 Research validity
To establish the required quality of the case study research findings, Yin (2003) presents four commonly used criteria; construct validity, internal validity, external validity and reliability. Sandberg (2005) however argues that these criteria are mainly based on a positivist manner of thinking, and suggests that when conducting qualitative interpretative research, validity can be measured by communicative validity, pragmatic validity and transgressive validity. However, in our view, these criteria are mainly focused on how to retrieve ‘the truth’ by removing biases and contradictions from different respondents. Therefore, we view these aspects as part of reliability as identified by Yin (2003). By doing this, we combine the positivist and interpretivist approach as was discussed in the section research approach. We continue by addressing each criterion as identified by Yin.
Construct validity - For achieving construct validity, correct operational measurement concepts need to be developed to be able to objectively present findings. Construct validity can be achieved by (1) use of multiple sources of evidence, (2) a chain of evidence, and (3) by review of the draft case study (Yin, 2003). The first criterion is achieved in two ways, first by using a multiple case study among three hospitals in The Netherlands and second by using triangulation of sources including literature,
semi-structured interviews and process data. The second criterion is achieved by starting with a comprehensive, research design by which the research is guided and by use of the systematic way of conducting the research including the literature reviews and data collection procedures in the hospitals. The third criterion is achieved by reviews of the supervisors as presented on the front page of this report.
Internal validity - is concerned with establishing causal relationships and overall inferences made by the researcher (Yin, 2003). Yin shows that pattern matching, explanation building, addressing rival explanations and using logic models can contribute to the internal validity. Internal validity in this research is ensured by basing the theoretical model as presented in chapter 4 mainly on peer-reviewed organizational literature by renowned scholars like Galbraith (1973), Mintzberg (1979), Martinez & Jarillo (1989) and Gittell (2002, 2004). Further, the model is translated into a research protocol and for consistent data collection and rival findings to model are ultimately discussed to determine the limitations of the research.
External validity - deals with generalization of the research findings (Yin, 2003). As described in the case study section, a multiple case study instead of a single case study was used in this research to support external validity. Further, external validity is achieved by applying the discussed replication logic and analytical generalization, which according to Yin can be described as the act of the investigator striving to generalize a particular set of results to some broader theory, which in this case is generalizing results on care pathways on the theoretical linkage between process orientation and cross-functional coordination.
Reliability - is concerned with minimizing errors and biases in a study. When a research is repeated by another researcher, the research should provide the same findings and conclusions (Yin, 2003). As discussed, we hereby use the validity criteria communicative validity, pragmatic validity and transgressive validity as formulated by Sandberg (2005) to determine reliability. Communicative validity refers to which extent retrieved information through the form of communication reflects the empirical material. Pragmatic validity further checks if answers provided by respondents are in line with their actual behavior. However, the investigator might still overlook certain matters, therefore, transgressive validity aims to confront respondents with contradictions which might lead to different responses and insights. To achieve communicative validity, the held interviews with medical personnel were semi-structured and in the form of a dialogue. This enables the collection of rich data. Further, pragmatic validity was achieved by checking the responses of respondents with obtained process data and performance of the care process. If contradictions were found, explanations were asked, this provides this research with transgressive validity.
2.2.6 Research constraints
Alike any research, this research is constrained to some factors. One must be aware of constraints while reading the report, as such they are presented below:
This research is focused on hospitals located in The Netherlands. Insights from foreign countries will be used during literature studies as inspiration, but are further left out of focus of the thesis.
Given the education and background of the author (technology management), pure clinical considerations are left out of scope.
This research focuses on intramural care pathways, although the increasing popularity of transmural care pathways is recognized, these pathways are left out of scope because of the time constraints.
As will be explained in the beginning of chapter 5, the research is constrained to care pathways within oncological care settings.
Coordination is assessed on a micro-level and aimed at primary processes, thereby leaving strategic coordination (coordination of organizational strategy with its operations; see: Turkulainen, 2008) out of scope.
2.2.7 Synthesizing the technical research design
3.
A
CLOSER LOOK ON CARE PATHWAYS
,
CARE
PROCESSES AND PROCESS MANAGEMENT
In this chapter, based on literature reviews and preliminary expert interviews, a closer look on care pathways, care processes and process management in hospital settings is presented to answer the first sub question of this research. More insight into the care pathway concept and its relation to process orientation is vital to understand its all but univocal nature and ultimately to select an appropriate perspective. First, (international) developments on care pathways are discussed to give an impression of their development and current prevalence within healthcare. Second, different perspectives on care pathways are discussed and compared to achieve a better understanding of the concept. Third, based on the former literature review and in line with the internal organizational focus of the research, two specific approaches on care pathways are selected; care pathways as a form of organizational development and care pathways as a process management initiative respectively. The two perspectives offer a deep and relevant understanding of the concept which can be used as guidance for the empirical part of the research. Also, the selected perspectives serve as conceptual foundation for the theoretical framework as presented in chapter 4.
3.1 The origin and development of care pathways
be treated in a care pathway is estimated to be even higher (41-60%), however the actual development seems to be hampered by several interacting factors (Hindle et. al., 2005). In addition, within The Netherlands, organizations such as the NKP (Dutch abbreviation for: Belgian Dutch clinical pathway network) and CBO (Dutch abbreviation for: Dutch Institute for Healthcare Improvement) support hospitals to develop, implement and evaluate care pathways in their organizations. Nowadays approximately 20 Dutch hospitals are already associated to these organizations. Hence, although care pathways seem to be subject to increasing popularity, a note has to be placed on the terminology and definition of care pathways. So far, different terms such as critical pathway, clinical pathway, integrated care pathway (often used in the UK) and care pathway have been used interchangeably. Although all terms more or less seem to refer to the same concept, a clear understanding of the concept is required for this research as it seems that care pathways have evolved far from the original concepts of CPM and PERT. As such, the next paragraph will focus on the definitions and terminology surrounding care pathways.
Figure 5: Prevalence of care pathways -The Netherlands highlighted- (from: Vanhaecht, 2006)
3.2 Perspectives on care pathways
3.2.1 Differences in terminology and evidence validity
In this section, various approaches and terminology on care pathways are compared and discussed to derive a clear understanding of the concept of care pathways for this research. As became clear in the previous section, many terms are used when dealing with care pathways which causes confusion surrounding the concept. In literature, De Luc (2001) identified 17 different but equivalent terms and found that terms such as clinical pathway, critical pathway and (integrated) care pathway are most widely used in literature. Even more, many variations in definitions can be found. A recent literature review comprising data obtained from a Medline search for articles published from 2000 to 2003 identified no less than 84 different care pathway definitions (De Bleser et. al., 2006). Vanhaecht (2007) connects this confusion to the variety of outcomes on care pathway research. Researchers tend to label a variety of changes as the introduction of a care pathway; from implementing a new patient record with minor or no changes in clinical practice to totally redesigning care given by a multidisciplinary team, thereby clouding the true character and value of care pathways (ibid.). Also, El Baz et. al. (2007) argue that the majority of published articles on care pathway outcomes can be classified as low quality which raises questions about the validity of the evidence for the implementation of care pathways. In many cases, a clear selection bias seems to be present by which
overall results (e.g. effects on other patient groups) cannot be interpreted. Further, there seem to be multiple approaches on outcome measurements of care pathways, this is discussed in the next section.
3.2.2 Differences in purpose
Some authors seek to explain differences in care pathway outcomes by trying to classify them by care pathway purpose in some manner (e.g. Currie & Harvey, 1997; De Luc, 2000; De Luc & Currie, 1999). Based on the diverging ways in which care pathways developed themselves throughout the world, Currie & Harvey (1997) classified differences on a geographical level. They found that the way in which care pathways have been developed in the United Kingdom differ from that in the USA. While in the USA the global concept of care pathways was originally used as a framework for balancing costs and quality, in the United Kingdom care pathways are viewed as a way of achieving a continuum of care across care settings (ibid.). However, it is questionable to which extent geographically divided approaches cover true applications of care pathways and argue that this division might be too broad. On the other end of the spectrum we find Campbell et. al. (1998) who state that many researchers on care pathways “extol the flexibility of the concept, and advise that care pathways need to be adapted to local settings”. However, describing these differences simply in terms of the need for adaptability and to gain local ownership within the organization is insufficient according to De Luc (2000). She states that the current state of conceptualization on care pathways is inadequate by which many descriptions in literature mask important differences of care pathways. Based on findings of a survey among 100 healthcare organizations in the United Kingdom, De Luc & Currie (1999) provide another classification by subdividing care pathways into four different models: (1) Ensure continuity of care, (2) Clinical effectiveness, (3) Cost control/efficiency and (4) Patient focus. Each model refers to the possible perception of organizations on care pathways, what they are incorporating into them and to which uses care pathways have been put. In the view of De Luc & Currie, the models are intended to assist in the identification of the primary purpose of the care pathway that is in use which allows the care pathways to be evaluated on their actual effectiveness (ibid.). However, as they also acknowledge, the static impression of the model might be misleading. As argued in the introduction of this research, healthcare sectors in OECD countries (including the United Kingdom) have been subject to many changes. The possibility exists that different identified models merely reflect temporal changes occurring within healthcare and that slowly the combination of the four perspectives is again the primary purpose of a care pathway, making the identification of models obsolete. Therefore, it can be concluded that authors have yet to reach an agreement on the conceptualization of care pathways and their primary purpose; also, the suggestions of Campbell (1998) stating that care pathways and their purposes can not be conceptualized seem to be most likely so far, and most attempts to classify them leads only to even more confusion on the subject. Now that differences in both terminology and purposes have been discussed, the focus shifts towards perspectives on care pathways and organizational changes.
3.2.3 Differences in organizational changes
on internal changes enacted by implementing care pathways. In this perspective, Vanhaecht & Sermeus (2002) identify four possible perspectives on care pathways:
1. Concept – First, care pathways as a concept can be observed as a general tool to further enhance the patient (or care process) focus of the organization.
2. Process – Second, care pathways as a process refer to the intervention and team-building process when implementing care pathways.
3. Method – Third, care pathways as a method refer to the collection of methods and tools used to manage the care process.
4. Product – Fourth, care pathways as a product refer to all the documents used to support the care pathway method.
In this research, we correspond with Vanhaecht & Sermeus on the first concept (1) perspective. However, we do place a note on terminology of the process (2) and method (3) perspective. As the term ‘process’ can be easily mistaken by perceiving it as a care process (which a patient goes through), we propose to name this as a ‘care pathway intervention’ and relate it to a form of organizational development (see next section). Further, according to Vanhaecht & Sermeus the term ‘method’ encompasses all (organizational and clinical) methods and tools used in an expected care process given a specific set of patients. Through meta-analysis, De Bleser et. al. (2006) found the following non-contingent aspects of care pathways when viewed as methods: (a) a strong multidisciplinary character, (b) aimed at improving the quality and efficiency of care and (c) outlining the optimal sequence and timing of interventions. As such, they propose the following definition: “A care pathway is a method for the patient-care management of a well-defined group of patients during a well-defined period of time”. In this study, given the emphasis on management of multiple actors and activities over time surrounding the patient, we argue that this definition of a care pathway method is closely related to a form of process management for a selective group of patients within a hospital (see also: Eckardt, 2006; Smith & Fingar, 2003). As such, we view the method (3) perspective as a form of process management. The form and extent of applied process management activities are thereby a premise for achieving process orientation within organizations (McCormack & Johnson, 2001). Regarding the fourth and last perspective of Vanhaecht & Sermeus, viewing care pathways as a product, we refrain from viewing them as such as in our view documents are supportive and facilitating of nature and should not be named as a care pathway (product). As such, when summarizing three perspectives on care pathways are considered within this research: 1) care pathways as a concept, 2) care pathways as an intervention and 3) care pathways as a form of process management. The perspectives and underlying relations are illustrated in the figure below.
