The role and impact of information exchange on the performance of clinical pathways

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The role and impact of information exchange on the performance of

clinical pathways

Double degree MSc Technology & Operations Management Newcastle University Business School

University of Groningen

Supervisor Groningen: prof. dr. J. de Vries Supervisor Newcastle: dr. G. Heron Supervisor UMCG: dr. D.P. Allersma

Paul Oosterhuis S2017660 B150607283

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i Abstract

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1. Introduction

The healthcare sector is forced to look for ways to improve the quality of care. Quality of care is defined by the Institute of Medicine (2001) as

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the degree to which healthcare services for individuals and populations increase the likelihood of desired outcomes and are consistent with current professional knowledge” (p.44). The current professional knowledge is developing fast as more and more is known about the human body and medical innovations are constantly renewing. The healthcare sector benefits directly from advancements in medical knowledge by being able to provide patients with better treatments, which in turn increases the quality of care. The advancements in knowledge of other sectors, such as the information technology sector or the industrial sector, can in turn be beneficial to the healthcare sector as well.

Hospitals deal with some similar concepts as businesses in an industrial setting, such as material flow, stock management, human resource planning and information management. The body of knowledge regarding some of these processes in the industrial sector is larger in comparison to the same processes in hospitals, even though the basic principles are the same. This means that the healthcare sector can learn from knowledge gained in industrial processes. Particularly supply chain management is an industrial phenomenon from which the healthcare sector can learn during the management of certain procedures. A flow of patients with the same illness are treated with the same chain of procedures. Such a chain of procedures is called a clinical pathway (European Pathway Association, 2016). Supply chains and clinical pathways are most definitely not synonymous, but they have some similarities that can be used to one’s advantage when managing clinical pathways (Hummel, de Meer, de Vries, & Otter, 2009).

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(Drupsteen, van der Vaart, & van Donk, 2013). The lack of integration and communication often hinders the performance of clinical pathways and therefore leaves room for improvement in the exchange of information. Grasping the improvement opportunities regarding the exchange of information in clinical pathways may possibly result in a better performance of clinical pathways and ultimately a better quality of care.

The aim of this study is to examine the influence of information exchange on the performance of clinical pathways. Underlying mechanisms regarding communication and the exchange of information will be revealed. Naming both communication and information exchange is important as the exchange of information in clinical pathways is inseparable from the way stakeholders communicate with each other. This study will thereby contribute to the body of knowledge regarding information exchange processes in clinical pathways. The gained insights show the importance of information exchange in clinical pathways and the effect it has on the performance of clinical pathways and the quality of care.

This study is a combination of action research and a case study. The oncological clinical pathway of a Dutch university hospital was found to be a suitable study object. It embodies the make-to-order system of the cytostatic drugs provided to a certain group of patients diagnosed with cancer. This clinical pathway consists of multiple departments and stakeholders, thereby representing the multidisciplinary and complex features of a clinical pathway and making it suitable for this study. De Vries (2007) developed an approach that can be used to support the assessment of supply chains by taking a multidisciplinary perspective. It covers the decision areas physical infrastructure, planning structure, information architecture and the organizational embedding. This model will be changed to hospital standards by adding patient behavior to the four decision areas and it will be used to assess the clinical pathway. The output is a thorough understanding of the clinical pathway and its current performance (de Vries, 2007). This study focusses on one decision area; the information architecture which covers the exchange of information. The other decision areas need to be considered as well as they are closely connected to the exchange of information.

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2. Background

Clinical pathways

Clinical pathways originate from Boston (USA) where it was introduced in 1985 at the New England Medical Center by Zander, Etheredge and Bower (1987). The phenomenon then spread across the world, resulting in different interpretations and definitions. De Luc et al. (2001) found 17 terms all describing the concept of clinical pathways. The most used terms are clinical pathway, care pathway, integrated care pathway, care map and critical pathway. De Bleser et al. (2006) found 84 definitions describing the concept of clinical pathways, of which 37 were stated as primary definitions. This abundance in terms and definitions results in different ways in which clinical pathways are put into practice.

To understand the true meaning of the term clinical pathway it is broken up into individual parts. A distinction is made between clinical pathway, standards, guidelines and protocols (Kerstens, 2015; Kinsman, Rotter, James, Snow, & Willis, 2010; Lawal et al., 2016). Standards, guidelines and protocols are all part of clinical pathways and can be ranked according their generalizability, which means that one arises from the other. A guideline is a document which indicates the best care for a group of patients and is both evidence and practice based (Kerstens, 2015). It is an advisory document with a high level of abstraction describing the ‘what’, ‘when’ and ‘why’ of the care. This guideline can be translated into a protocol (Campbell, Hotchkiss, Bradshaw, & Porteous, 1998). A protocol describes the ‘how’ of care by giving the exact steps of a certain treatment. A standard describes the preconditions to which the treatment must comply for it to function.

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the patient through the clinical pathway. Through standardization, care becomes more predictable, transparent and of higher quality (Kerstens, 2015). Information exchange in this sense gives insights into the different steps of the clinical pathway and thereby enables the standardization of these steps. This study will provide insight into the influence of information exchange on the performance of clinical pathways. This is relevant as the departmental design of clinical pathways hinders the communication between departments and communication is a prerequisite for successful information exchange (Arora, 2003). Defining clinical pathways regarding the use and exchange of information in clinical pathways is important for this study as there are numerous interpretations and definitions of clinical pathways. This study follows the definition of the European Pathway Association (2016) and defines clinical pathways as “a complex intervention for the mutual decision making and organization of care processes for a well-defined group of patients during a well-defined period.”

This definition needs to be broken down to fully understand its meaning for this study. Three parts are important regarding the exchange of information and will be explained in more detail, these are: complex, mutual decision making, and organization of care.

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is completed. The responsibilities of the stakeholders at the different steps need to be clear to ensure the stakeholder knows what information to exchange and with whom.

Multiple facets of clinical pathways become clear relative to the exchange of information. First it is important to determine from what perspective the clinical pathway is operated as this has certain implications for the exchange of information. Next the level of complexity, the way information exchange is facilitated and the organization of care in the clinical pathway need to be assessed. Different characteristics unique to the healthcare sector need to be studied before the given facets can be evaluated. This is necessary as these characteristics influence the information exchange in clinical pathways.

Healthcare characteristics influencing information exchange in clinical pathways

Complexity as defined earlier is a recurring subject when studying clinical pathways. It is caused by different characteristics of clinical pathways, and the healthcare sector in general. The healthcare sector is characterized by a strong departmental design (Vissers et al., 2001) and little integration and communication between these departments (Drupsteen et al., 2013). Most patients treated at hospitals are dependent on multiple departments during their clinical pathway, resulting in a high departmental interdependence. This interdependence is not always acknowledged by the departments, resulting in a lack of information exchange between departments. Departments operating solely for their own interests hinder performance (Everard, 2001). This becomes visible when looking at the departments from a chain perspective. Departments can successfully execute their own routines while the overall performance is low, implying that improvement opportunities will only become visible when looking past departmental boundaries and thinking in terms of the entire pathway. This lack of interconnectedness among the hospital departments can lead to problems in clinical pathways (Tucker, Heisler, Janisse, & Richter, 2014).

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advantage (Buchanan & Badham, 1999). Powerful stakeholders can force others what, when, how and with whom to exchange information. It is often seen in hospitals that there is a power balance between different groups of stakeholders and that these stakeholders will try to get their way (de Vries, 2011; Lega & DePietro, 2005). Interest or perceived interest is the extent to which an entity believes it benefits from a project or the entire clinical pathway (Boonstra & de Vries, 2005). When a stakeholder believes he/she will not benefit from the exchange of information the interest will be low and no information will be exchanged.

The departmental design, the need for a multidisciplinary perspective and the power and interests of stakeholders are added to the earlier defined facets of clinical pathways. Determining these concepts per clinical pathway with regard to their influence on the information exchange can be done with the use of the model formulated by de Vries (2007).

Evaluation of clinical pathways

De Vries (2007) developed an approach that can be used to evaluate a clinical pathway. It results in an overview of the clinical pathway together with a detailed insight in the improvement opportunities. This approach The approach of de Vries (2007) covers four main decision areas: physical infrastructure, planning structure, information architecture, and organizational embedding. Multiple studies proved the usefulness of the approach of de Vries (2007) by incorporating multiple dimensions (Fahmy Salama, Luzzatto, Sianesi, & Towill, 2009; Kekale, Spens, & Phusavat, 2010). This study alters the approach to make it more suitable. ‘Patient behavior’ has a strong influence on clinical pathways and is therefore added to the four decision areas. The importance of adding patient behavior to the model is found by a study that assessed the usability of the model in a healthcare setting. This study will be introduced in the methodology section.

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Figure 2.1: Diagnosing the clinical pathway

During step 3 an in-depth analysis is conducted in the five decision areas. The physical infrastructure is concerned with the production and distribution of goods (de Vries, 2007). The planning structure defines the planning and control of patients together with the resources needed during the different steps of the pathway. It gives answers to the questions how many patients are planned when and where. These questions are answered by making use of a control framework. The framework encompasses the underlying rational of the planning. It is used to plan and prioritize patients and needed resources (de Vries, 2007). Making use of a control framework during the planning is important in the healthcare sector as patients demand short waiting times and emergency patients must get priority over other patients. The information architecture refers to the information technologies being used as well as to the way communication, operations and management processes are supported (de Vries, 2007). It encompasses the way stakeholders within the clinical pathway exchange information through formal and informal channels. The organizational embedding is divided into two dimensions: the superstructure and the structure of positions. The superstructure consists of group planning and control activities into organizational units, this is the formal structure of a hospital. The structure of positions refers to the power balance within the clinical pathway, stakeholders, and the requirements needed to hold a position (de Vries, 2007; Mintzberg, 1979). Patient behavior has an extensive influence on the clinical pathway and is therefore added to this model, it refers to the process-steps and the decisions made by the patient.

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However, the different decision areas are intertwined due to the complex nature of clinical pathways. This means that the other decision areas may need to be analyzed in order to gain full insight into the complexity of the clinical pathway, the facilitation of information exchange, the organization of care, and the perspective from which the clinical pathway is operated.

Information exchange

The concept of information exchange needs deepening since it is an umbrella term that has a different meaning depending on its context. Placing it in the context of clinical pathways it can be referred to as activities of distributing useful information among stakeholders of the clinical pathway in an open environment (Sun & Yen, 2005). Information exchange is therefore a means to a collaborative clinical pathway in which the stakeholders strive for the same goals.

However, information exchange in the context of clinical pathways also means dealing with powerful stakeholders, a departmental design and a multidisciplinary perspective. These characteristics unique to the healthcare sector can result in little to no exchange of information between departments in clinical pathways. Mapping the exchange of information will deal with questions as the ‘how’, ‘when’, ‘what’ and ‘why’ of information exchange. Information exchange in clinical pathways encompasses operational information as well as patient information.

Literature provides potential factors that influence the exchange of information, these are trust, mutuality, commitment, shared vision, and information technology (Barratt, 2004; Kang & Moon, 2016; Li & Lin, 2006). This list is not exhaustive but gives the most important factors. Trust positively influences the exchange of information (Li & Lin, 2006). The benefits of exchanging information must be mutual; it must create a win-win situation (Ireland & Bruce, 2000). A shared vision of stakeholders of the clinical pathway, and commitment to this vision, will foster the exchange of information (Ireland & Bruce, 2000; Li & Lin, 2006). Information technology is an enabler for the exchange of information (Li & Lin, 2006). Not meeting these preconditions will lead in many cases to poor information exchange. Poor information exchange may influence the performance of the clinical pathway and the quality of care. Clinical pathways need to be tested on these preconditions before the performance of clinical pathways can be linked to the exchange of information.

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will therefore focus on the operational processes of exchanging information and not on the actual content of the exchanged information. Timeliness, accuracy and completeness are important when exchanging information (Moberg, Cutler, Gross, & Speh, 2002). This determines the quality and usability of the exchanged information. Information exchange is a vastly studied subject in the field of supply chain management. Clinical pathway management can benefit from these studies in information exchange due to the similarities between the two.

Learn from the industrial sector

A supply chain consists of at least three entities which are involved in the up- and downstream flow of products and information (Mentzer et al., 2001). It is successful if all the entities have the same goal and focus on serving the customer (La Londe & Masters, 1994). Supply chain management is the process of managing product flow, information flow, and relationships between the different entities to deliver enhanced customer service and economic value through synchronized management of the flow of physical goods and associated information from sourcing to consumption (La Londe, 1997). Supply chains and clinical pathways are both a chain of entities. These entities work for a common goal and they need to exchange information beyond their own boundaries to accomplish this common goal. The chain needs to avoid sub-optimizations if it hinders the performance of the entire chain. One can only know if their own sub-optimizations hinder the performance of the entire chain if there is exchange of information in the chain.

Transferring knowledge from supply chain management practice to hospitals, and the management of clinical pathways in particular, can be a challenge due to the existence of multiple stakeholders, the distinctive characteristics of healthcare operations, and a dynamic internal and external environment (de Vries & Huijsman, 2011). Adding to this complexity is the complicated and strict regulatory system in hospitals (HFMA, 2008). However, the multidisciplinary structure of supply chain management suits the multidisciplinary nature of hospitals (Croom, Romano, & Giannakis, 2000), and it is this multidisciplinary perspective that links supply chain management to clinical pathway management. The existence of multiple stakeholders results in processes that are inseparable from organizational aspects like the allocation of responsibilities and authority, building relationships, and interface problems (de Vries & Huijsman, 2011).

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pathway management. First of all, a clinical pathway is a complex structure which is formed over a long period of time. It encompasses the development of relationships and networks and the development is therefore shaped as a development path. Moberg et al. (2002) identified that the commitment to these relationships is strongly related to the exchange of information. Second, information technology plays an important role. It enables smooth communication between stakeholders. Advancements in information technology can improve the information exchange and the communication between stakeholders (Wu, Yeniyurt, Kim, & Cavusgil, 2006). This means that integrating information in clinical pathways by making use of information and communication technologies help to improve the internal and external performance of the pathway (de Vries & Huijsman, 2011). Third, there is a need for alignment and integration of organizational aspects. The multidimensional character of clinical pathways calls for a systematic integration of information exchange processes. Fourth, clinical pathways are an organizational innovation. Departments enter into long term inter-departmental relationships based on mutual trust. Frequent meetings between stakeholders can have a positive influence on the exchange of information (Müller & Gaudig, 2010) These lessons learned from the industrial sector emphasize certain aspects of information exchange which need to be considered when conducting research in information exchange. The development of relationships between stakeholders takes time but is important as these relationships influence the exchange of information. Information technology can play an important role in forming and maintaining the relationships. Management of clinical pathways can look for reasons why their performance is negatively influenced by the exchange of information in these four lessons.

Conceptual model

The above given information shows that there are numerous factors influencing information exchange in clinical pathways. The most important factors are summarized here and are subsequently visually represented in a conceptual model.

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to their own advantage, disregarding the overall interests of the clinical pathway. To what extent this will happen depends on the commitment of the stakeholder to the clinical pathway. The information technologies used by the stakeholders can foster the exchange of information.

The influence of information exchange on the performance of clinical pathways has not been studied before. Therefore, nothing can be concluded yet on the importance of an efficient information exchange and if clinical pathways must invest resources in improving the exchange of information. Information exchange is itself influenced by multiple factors, these factors are introduced above. This means that the performance of clinical pathways can indirectly be influenced by the factors influencing the exchange of information. Improvements regarding the exchange of information must be made before it can be assessed if the way of exchanging information in a clinical pathway influences the performance of that clinical pathway. The conceptual model displaying the relationships between the concepts is represented in figure 2.2.

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3. Methodology

This study aimed to show the role and influence of information exchange on the performance of clinical pathways as depicted in figure 2.2. The different factors in figure 2.2 and the relationships between them are studied by using a case study. The unit of analysis in this case study was the clinical pathway oncology in the University Medical Center Groningen.

An explorative case study resulted in an overview of a clinical pathway and the way information was exchanged in this clinical pathway (Karlsson, 2009; Yin, 1994). Besides this, a case study was suitable to show the relationships between the concepts shown in figure 2.2 (Voss, Tsikriktsis, & Frohlich, 2002). Active participation of the researcher was needed to fully understand the clinical pathway and the way the exchange of information took place. This made the study a combination of participative action research and an explorative case study. Action research is a participative approach that uses multiple sources of knowledge and it has led to implications for the involved clinical pathway passed beyond this research (Saunders, Lewis, & Thornhill, 2012). Due to the scope of the study and time constraints, only a single case study was conducted. A single case study was chosen over a multiple case study due to the fact that a single case study leads to a more thorough understanding of the studied case (Karlsson, 2009). Adding to this, the clinical pathway oncology is unique and it can therefore not be replicated by other cases (Saunders et al., 2012). Reassuring validity and reliability is important when conducting a case study. Finding ways to deal with these concepts are based on Karlsson (2009) and Saunders et al. (2012). How the validity and reliability are reassured becomes clear in this chapter and is summarized in table 3.1.

Test Tactic

Construct validity - Chain of evidence

- Discuss results with key stakeholders Internal validity - Data triangulation

- Method triangulation External validity - Random sampling

Reliability - Detailed description of methodology Theoretical

validity

- Collecting clinical pathway data over an extended period of time - Theory triangulation

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13 University Medical Centre Groningen

The University Medical Centre Groningen (UMCG) is with 30.000 infusions per year home of the largest oncology center in the north of the Netherlands. Being a university hospital in this case means that it treats the most complex forms of cancer and it is often the last resort for cancer patients. The clinical pathway oncology in the UMCG starts when patients do a blood test at the laboratory and ends when the cytostatic drug is given to the patient. Various variations are possible within this process. This clinical pathway consists of multiple departments and stakeholders. It therefore represents the complexity of healthcare processes and is suitable to study the influence of information exchange on the performance of clinical pathways. One of the main problems of the clinical pathway oncology is the low service rate of the pharmacy. A low service rate results in longer patient waiting times, patient dissatisfaction and in turn a low perceived quality of care. Increasing the service rate was the main reason for the clinical pathway oncology to cooperate in this study.

A study in this clinical pathway ended in June 2015. Results of this study were used in the current study. The study of 2015 will be referred to as the 2015 study and the current study will be referred to as the 2016 study to prevent any confusion.

The 2015 study showed that the model of de Vries (2007) is useful in a hospital setting when patient behavior is added. The 2016 study also uses de model of de Vries (2007) meaning that certain aspects of both studies can be compared to each other. Specific aspects that were compared are the overview of the clinical pathway, information exchange and the performance. A similar overview of the clinical pathway in 2015 and in 2016 showed that changes in the performance are due to improvements regarding the information exchanged and not to other factors. This adds to the construct validity of the 2016 study (Saunders et al., 2012).

Ethics and requirements

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14 Data collection

The data collection of the 2016 study had multiple goals: determine the current performance of the clinical pathway, evaluate the information exchange in the clinical pathway, assess the power and interests of the involved stakeholders, determine the used information technology and assess the commitment of the stakeholders.

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15 Figure 3.1: Methodology

Diagnostic tool

The diagnostic tool is shown in figure 2.1. The different steps of the tool and its corresponding deliverables are explained here. The stepwise approach of this model led to a deeper understanding of the clinical pathway after every step. Data gathered during the first three steps cover the concepts depicted in figure 2.2. and will be displayed in the results chapter. The improvement opportunities give insights into the exchange of information and the performance of the clinical pathway oncology but they were not implemented during this study. The improvement opportunities are discussed in the managerial implications in chapter 6.

Step 1: Create overview clinical pathway oncology

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pharmacy there were four other departments involved in this clinical pathway, namely the laboratory, the outpatient clinic, the internal day care center, and the central planning department oncology. The laboratory is part of the clinical pathway but could not be observed due to ethical reasons. All the other departments were observed by the researcher. These observations had two functions, firstly to give the researcher a deeper understanding of the clinical pathway together with the stakeholders involved and secondly to inform the involved stakeholders that a study was conducted in the clinical pathway. Semi-structured and informal interviews were used to create a feeling of how the stakeholders perceived the clinical pathway. The interview script is provided in appendix A. The trail of information was followed. This resulted in a complete overview of the involved departments and stakeholders, the information technologies used by these stakeholders, and a first insight into the exchange of information in the clinical pathway oncology.

Step 2: Determine performance

The performance is the process time of the different steps taken by the patient. The process times may be influenced by the information exchange in the clinical pathway. The current performance of the clinical pathway was determined using a quantitative analysis. A dataset of 103 patients was randomly selected from requests for cytostatic drugs at the pharmacy. Randomization results in a small sample from a larger population and this sample can be used to make generalizations about the population (Karlsson, 2009; Saunders et al., 2012). The sample provided the time a request was send to the pharmacy, the time the drug had to be administered to the patient at the day care center and the time the drug was send to the day care center. From this data set, the delivery time and production time was derived.

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The dataset of 103 patients was used to derive the performance, rather than the dataset of 55 patients, since in general the larger the sample group the better it represents the entire patient population in the clinical pathway (Karlsson, 2009). The time between the blood test and the start of the consult and the duration of the consult derived from the dataset of 55 patients is compared to a dataset of 475 patients to assess if the dataset of 55 patients represents the entire population of patients. Step 3: Analysis

Data collected during the interviews of step 1 was enlarged with observations and interviews focusing on the planning structure, the information architecture, the physical infrastructure, the organizational embedding, and patient behavior. Interview questions asked during this step are shown in appendix B. Answers of interviewees indicating improvement opportunities regarding the exchange of information were used as input for step 4.

The outcomes of the interviews performed on the different decision areas were comparable with the outcomes of the observations done at step 1, this increases the reliability of the observations (Voss et al., 2002). Closed questions were asked to test the insights gained during step 1. Open questions were used to look for new influencing factors and to enrich the data. Each stakeholder was interviewed in the same way, this strategy allowed the researcher to compare the answers of the different stakeholders leading to increased reliability (Yin, 1994). Knowledge gained during this step added to the knowledge gained in step 1 and step 2. In every step the researcher got a deeper understanding of the clinical pathway, highlighting the exploratory approach of this study.

A survey was used to analyze the power of stakeholders, the information technology and the commitment of stakeholders. The questions asked together with its targeted information are given in appendix C. This survey used a combination of open questions, closed questions, and closed questions with a 7 point Likert-scale ranging from strongly disagree to strongly agree. Different types of questions are used to distinguish between facts and opinions. Results showed the influences of the different factors as depicted in figure 2.2.

Step 4: Improvement opportunities

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specifically the exchange of information. Insights in improvement opportunities in the other decision areas showed whether improvement opportunities in the information exchange and improvement opportunities in other decision areas overlap. Overlaps between decision areas implies that these opportunities had to be taken care of simultaneously.

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4. Results

This chapter describes the results of this study. The results are displayed regarding the concepts of figure 2.2. It is descriptive as it states the findings of the study in a fact-based manner and will serve as the input for the analysis. It starts with an overview of the clinical pathway together with its stakeholders and the planning rules used in the clinical pathway. This will give insights into how things are done in the clinical pathway and by whom. Next, the current performance will be studied in terms of process times of the different steps of the clinical pathway. The performance of the 2016 study is compared to the performance of the 2015 study. This chapter ends with an overview of the information exchange.

Clinical pathway oncology

The clinical pathway oncology provides patients with individualized cytostatic drugs. This process consists of the same series of steps for each patient. The study focusses on patients who get their blood tested at the same day as the cytostatic drug is provided. There are five entities operating in this clinical pathway, namely: the laboratory, the outpatient clinic, the day care center, the oncology planning unit, and the pharmaceutical department. This is not an isolated clinical pathway; the involved departments operate in other processes and pathways as well.

The clinical pathway oncology starts when a patient gets a blood test at the internal laboratory. The results of this blood test are discussed with a physician at the outpatient clinic. A request form for the cytostatic drug is filled in by the physician if the results of the blood test are sufficient. This request form is faxed to the pharmaceutical department by an administrative assistant. The pharmaceutical department receives and processes the request after which it starts producing the drug. The cytostatic drug is sent to the day care center where it will be administered to the patient. The planning unit schedules patients at the outpatient clinic and at the day care center. The clinical pathway oncology is schematized in figure 4.1 and appendix D.

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The process times between the completion and start of subsequent steps determine the overall performance of the clinical pathway. The planning unit oncology uses multiple planning rules to plan patients at the outpatient clinic and the day care center. These planning rules have certain implications for the entire clinical pathway which will become more apparent during the analysis of the results. The patients’ blood test is planned 30 minutes before the appointment with the physician at the outpatient clinic. The appointment at the day care center is scheduled 90 minutes after the appointment at the outpatient clinic. 15 Minutes are planned for the appointment at the physician. These times are summarized in figure 4.2.

Figure 4.2: Timeline planned process times

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results in a bureaucratic structure of the clinical pathway which is acknowledged by the survey respondents with a Likert-scale score of 4.6 out of 7 on question 24.

The most important results found in creating the overview of the clinical pathway are that the clinical pathway oncology operates in the same manner as during the 2015 study. This means that results of both studies can be compared. Besides this, there are only a few stakeholders that possess power in the clinical pathway and the clinical pathway has a bureaucratic way of operating within a strict hierarchical structure.

Performance clinical pathway oncology

Performance is defined as the process times of the different steps as depicted in figure 4.1 and thus ultimately as the total time a patient spends in the hospital. Various information exchange processes are used in the clinical pathway which may influence the process times of the different steps. Administering the cytostatic drug is the last step in the clinical pathway as can be seen in figure 4.1. Delivery of the cytostatic drug has a big influence on the amount of time a patient must spend in the hospital as it determines the timing of the administration, which is either on time or too late. An important factor is the time at which an order for cytostatic drugs is send to the pharmacy. A distinction can be made between the kind of cytostatic drug produced by the pharmacy, which is either study related or non-study related. Delivery time is the time between when an order is received by the pharmacy and the time when the order must be administered to the patient. Production time is the time between when an order is received by the pharmacy and the time when an order is delivered. When the production time exceeds the delivery time, the drug will be administered too late. The performance related information regarding the production of cytostatic drugs is shown in tables 4.1, 4.2 and 4.3.

Delivery time Production time ∆

Overall average (min) 52:39 48:19 04:20

Delivered on time (min) 61:01 42:53 18:08

Delivered too late (min) 39:31 56:50 -17:19

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Overall average (min) 33:23 58:00 -24:37

Delivered on time (min) 44:36 35:48 08:48

Delivered too late (min) 23:27 63:53 -40:26

Table 4.2: Study related

Table 2.3: Service rate

The given information in tables 4.1, 4.2 and 4.3 are based on a dataset of 90 non-study related patients and 13 study related patients. Table 4.3 shows the service rate of the pharmacy. The total duration of the clinical pathway enlarges when orders are delivered too late.

Figure 4.3 shows the average times of the 55 patients at each step of the clinical pathway.

Figure 4.3: Timeline real process times

The dataset of 55 patients is compared to a dataset of 475 patients on the time between the blood test and the start of the appointment, and the duration of the appointment. It is found that the time between the blood test and the start of the appointment of the dataset of 55 patients has a 5% deviation of the dataset containing 475 patients. The deviation in the duration of the appointment is 4%. These deviations show that the dataset of 55 patients represents the population of patients.

Total On time Too late % on time

Non-study related definition 90 55 35 61.11%

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Performance changes from the 2015 study to the 2016 study

The 2015 study identified the delivery time and the production time of non-study related requests for cytostatic drugs in a similar way as the 2016 study. The cytostatic drug is on time when it is delivered to the day care center before the time set for the drug to be administered to the patient. The comparison between the performance of the 2015 study and the 2016 study is summarized in table 4.4 and table 4.5.

Overall average 2015 (min) 59:00 70:00 -11:00

Overall average 2016 (min) 52:39 48:19 04:20

∆ ∆

-06:21 -21:41

Table 4.4: Performance changes non-study related

Total On time Too late % On time

Non-study related 2015 124 47 77 37.90%

Non-study related 2016 90 55 35 61.11%

∆ 23.21% Table 4.5: Changes service rate

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24 Information exchange

The following actions of information exchange are present in the clinical pathway oncology: the blood test results are send to the physician, the request form for cytostatic drugs is faxed to the pharmacy and the day care center, and the patient planning is faxed to the pharmacy on a daily basis. This pathway is supported by various information exchange processes. General patient information is stored in PoliPlus, an information system accessible for all hospital departments. The physician fills in a request form that is faxed to the pharmaceutical department and to the day care center. This request form is then digitized by a pharmaceutical technician, he/she transfers the information from the request form into the order system of the pharmaceutical department called Cato. A pharmacist has to approve the request in Cato before it can be produced. Cairo is in use as a track and trace system and is accessible for all departments. The oncology planning unit makes use of X-care to plan the patients at the outpatient clinic and the day care center.

The pharmacy uses a policy that every study related order for cytostatic drugs must be delivered within 120 minutes. Every non-study related order for cytostatic drugs must be delivered within 90 minutes. This policy is communicated to other hospital departments in a policy form. A policy form is thus a way of information exchange in the clinical pathway. However, the planning unit oncology is not aware of this policy or does not take the policy of the pharmacy into account. Adding to this, the planning unit does distinguish between study related and non-study related drugs. This means that for both kinds of drugs the planned delivery time is 75 minutes as can be seen in figure 4.2, and not the 120 minutes for study related drugs and 90 minutes for non-study related drugs.

Errors occur in the exchange of information. Examples of errors are a request form being filled in incorrectly by the physician or stakeholders calling the pharmaceutical technician to ask for delivery information. Stakeholders call each other to resolve errors. The information technology used by the different departments, the policy form, and the phone calls to resolve errors are all the information exchange processes present between the involved departments in the clinical pathway oncology. The different stakeholders do not have meetings to discuss aspects regarding the clinical pathway. Information exchange changes from the 2015 study to the 2016 study

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Requests waiting for approval increased the average production time and result in peaks during the workday. Currently, the pharmacist is always available to approve requests. This change dealt with the peaks and took the waiting time of the request out of the production time. Second, less information is asked from the pharmaceutical technician by other entities in the clinical pathway. They now search for the information in the available information systems. The pharmaceutical technician can therefore focus on his/her own tasks.

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5. Analysis

The results are analyzed here to evaluate the influence of information exchange on the performance of clinical pathways. The results show the power, interests and the commitment of stakeholders in chapter 4.1, the used information technologies are given in chapter 4.3. Analyzing these results will give insight into the relationship between these factors and the exchange of information. This analysis is guided by the conceptual model shown in figure 2.2. Findings of this analysis will be underpinned with examples of the studied case and literature defined during the background. First, the relationship between the power of stakeholders, the exchange of information and the performance of clinical pathways will be analyzed. Then the concepts of information technology and commitment will be analyzed in a similar way.

Power of stakeholders

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meetings have a positive influence on the exchange of information (Kang & Moon, 2016; Li & Lin, 2006).

Information technology

There are multiple information technologies in use. However, there is a lack in digitization in the clinical pathway in the sense that there is not one information system connecting the entire clinical pathway. This is a problem from an information exchange standpoint as information technologies are an enabler for the exchange of information and it helps to build lasting relationships between stakeholders which can improve the performance of clinical pathways (de Vries & Huijsman, 2011; Li & Lin, 2006; Wu et al., 2006). The information systems are currently used within the boundaries of the departments and they therefore do not foster the exchange of information. Certain information exchanged between departments is done via a fax machine. This results in high amount of paperwork, the risk of data getting lost and low quality of information.

Commitment

There is a lack of commitment of stakeholders to the clinical pathway oncology. This is illustrated by questions 11 and 12 of the survey. Stakeholders know what their own tasks are in the clinical pathway, but they do not know what the tasks are of other stakeholders. This is due to the departmental design of clinical pathways and hospitals in general (Vissers et al., 2001). This lack in alignment leads to misunderstandings and has a negative effect on the information exchange. The example of the power possessed by physicians shows that some information exchanged is incomplete and therefore of low quality (Moberg et al., 2002). This also illustrates the lack of commitment of the physicians to the clinical pathway. The physician does not see the added value of filling in the request form correctly. However, the phone call the pharmaceutical technician makes to collect all the information needed takes time and is therefore of bad influence for the performance of the clinical pathway. One stakeholder noted that “people are only aware of and interested in their own jobs, they do not focus on others and they most definitely do not look beyond the department they work in.”

Information exchange and clinical pathway performance

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meetings between the stakeholders of the different departments is an indication for the lack of information exchange. This lack of information exchange results in information asymmetries and other errors. These will be analyzed by means of examples.

There are two definitions of ‘on time’ present in the clinical pathway oncology. The day care center defines on time as prior to the moment the drug is supposed to be administered to the patient, thus before the end of the delivery time. However, the pharmacy defines on time as when the cytostatic drugs are sent to the day care center 30 min before the drugs are administered to the patient. This definition results in a planned delivery time of 45 min for both the study related and non-study related cytostatic drugs, as can be seen in figure 5.1.

Figure 5.1: Timeline planned process times with definitions of on time

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Table 5.1: Service rate

This table illustrates the effect of the information asymmetries and the impact it has on the performance of the clinical pathway. This information asymmetry is due to the lack of commitment. Meetings in which stakeholders explain their processes help to provide insights in the processes and will prevent these kinds of asymmetries. Asymmetries are also the result of the abundance of information technologies in use, stakeholders simply do not know where to look for information. One stakeholder said: “I know there is a system in use in which I can find delivery information of cytostatic drugs but I do not exactly know how it works, so it is easier for me to call the pharmaceutical technician and let them check the system.” This quote illustrates that certain stakeholders need schooling in the information technologies available. This is suggested by stakeholders, but the UMCG seems to be bureaucratic. Meaning that new initiatives must pass numerous stakeholders before it reaches the right powerful stakeholders and it can be approved. Getting approval for new initiatives is therefore a long process. Too long for certain stakeholders, preventing them from suggesting new initiatives even though they are not fully satisfied with the clinical pathway.

Results of the 2015 study confronted stakeholders with their way of information exchange and the consequences this had for other stakeholders in the clinical pathway. This confrontation has led to the fact that stakeholders took responsibility for their own actions. A quote from a stakeholder illustrates this: “The nurses of the day care center do not call us (the pharmacy) as often as they did before the research, some still call but it is noticeably less.” Thus, some stakeholders did not call the pharmacy as much as they used to but they now look up the information in the available information systems. The pharmaceutical technician can therefore focus on his/her own tasks. From interviews, it was found that this had a positive influence on the exchange of information. At first the pharmaceutical technician was called many times a day for information This had a negative effect on their willingness to help the one who was calling. They did not trust the one who was calling and felt used. The pharmaceutical technician is still called, but not as often as before. They are now more willing to help the ones calling.

Total On time Too late % On time

Non-study related definition day care center 90 55 35 61.11% Non-study related definition pharmacy 90 11 79 12.22% Study related definition day care center 13 4 9 13.77%

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6. Discussion

Interpretations

The results and the analysis of the results show some interesting findings. The influence of information exchange on the performance of clinical pathways is found. Improvements in the information exchange of the clinical pathway oncology proved to positively influence the performance of the clinical pathway. The increase in the service rate of the pharmacy of 23.21% means that the cytostatic drugs is more often delivered on time. Delays occur less often and this results in a higher performance. However, the service rate is still only 61.11%, implying there is still room for improvement. Multiple factors in the exchange of information can be seen as a reason for this.

Stakeholders not mentioning suggestions for improvements is a missed opportunity. Especially when it involves suggestions regarding information technology as advancements in information technology have a positive effect on the exchange of information (Wu et al., 2006). The power balance between stakeholders as defined by Lega and DePietro (2005) and de Vries (2011) is also found in the clinical pathway oncology. This power balance negatively influences the exchange of information and in turn the performance of the clinical pathway. Certain medical professions have the capacity to exert their will over others, without considering consequences for others (Buchanan & Badham, 1999; de Vries, 2011). Physicians have a powerful position in the clinical pathway, as well as policy makers. Decisions made by these stakeholders can negatively influence the exchange of information and the performance. Another important factor present in the clinical pathway oncology that negatively influences the exchange of information is the lack of commitment stakeholders have to the clinical pathway. This is due to the strong departmental design of hospitals (Vissers et al., 2001). The current information exchange in the clinical pathway is characterized by little to no communication between the departments due to this departmental design. The departments focus too much on their own interests instead of focusing on the performance of the clinical pathway, which in turn hinders the performance of the clinical pathway oncology (Everard, 2001).

Limitations

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differently when observed, which is known as the Hawthorne effect (Mayo, 1949). Examples of this are not showing certain mistakes, altering processes, and adapting behavior. The influence of the researcher on the observed stakeholders was dealt with by observing multiple stakeholders at different moments in time. Subjectivity of the researcher may have been a limitation, using multiple sources of data was a way of coping with this issue.

Limitations of this study also resulted from the interpretations of the results. It is shown that the identified factors do influence the exchange of information and in turn the performance of clinical pathways. However, the relationship between the different factors is not tested, meaning that it can be possible that there is no direct link between one of the factors and information exchange. The following example illustrates this limitation. The power of stakeholders influences the commitment to the clinical pathway, and the commitment influences the information exchange. In this hypothetical example there is no direct link between the power of stakeholders and information exchange. However, there is an indirect link via the commitment of the stakeholders to the clinical pathway. For this study, it was sufficient to have either a direct or indirect link as they both show a positive change in performance when improved.

Other limitations are caused by the set-up of this study. Only one clinical pathway is studied. For future research, more clinical pathways need to be studied before the results can be generalized. Improvement results are only partially available The results would have been stronger if all the effects of improvements in the exchange of information were available for analysis.

Theoretical implications

Current literature on clinical pathways pays little attention to the link between information exchange in clinical pathways and the performance of that clinical pathway. This study showed that there is a link between performance and information exchange. It then takes this implication one step further and studies which factors influence the information exchange.

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This study has some implications for the management of clinical pathways. The influence of information exchange is a relationship that is to be taken into account from the design phase of a clinical pathway. Managers know, as is proven in this study, that improvements in the exchange of information will result in a higher performance. However, ethical issues must be considered before making improvements. Working with patients means that there sometimes exists a trade-off between the care for a patient and the performance measured. Some processes might not be suitable for improvements as it is the care for patients that always has the highest priority.

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7. Conclusion

The aim of this research was to study the influence of information exchange on the performance of clinical pathways. It can be concluded that this influence is present in clinical pathways. The power balance in the clinical pathway, the availability and use of information technologies and the commitment of stakeholders affect the exchange of information in clinical pathways. This relationship is presented in figure 2.2.

Problems in the exchange of information will negatively influence the performance of clinical pathways. On the other hand, the performance of clinical pathways will improve when improvements are made in the exchange of information. In short this means that when two department unit-heads in the clinical pathway, who previously never had meetings, now will meet on a regular basis, this will improve the performance. This is only a practical example, the possibilities for improvements in the exchange of information, and thus in the performance of clinical pathways, will differ per hospital and per clinical pathway. However, General healthcare characteristics found at most hospitals such as the departmental design and powerful stakeholders are also found in clinical pathways and these characteristics influence the exchange of information. Further research must be done to map the exact relationship between the different factors and the information exchange. There may be more factors influencing the exchange of information. These must be identified in future research to create a complete picture of the factors directly influencing information exchange.

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Reference list

Aeyels, D., & van der Veken, L. (2016). 7-Fasenmodel voor de ontwikkeling, implementatie, evaluatie en continue opvolging van zorgpaden. Netwerk Klinische Paden.

Arora, N. (2003). Interacting with cancer patients: the significance. Social Science & Medicine, 57, 791–806.

Boonstra, A., & de Vries, J. (2005). Analyzing inter-organizational systems from a power and interest perspective. International Journal of Information Management, 25, 485–501. Buchanan, D., & Badham, R. (1999). Politics and Organizational Change: The lived Experience.

Human Relations, 52(5), 928–940.

Campbell, H., Hotchkiss, R., Bradshaw, N., & Porteous, M. (1998). Integrated care pathways. BMJ (Clinical Research Ed.), 316(7125), 133–7.

Croom, S., Romano, P., & Giannakis, M. (2000). Supply chain management: an analytical framework for critical literature review. European Journal of Purchasing & Supply Management, 6(1), 67–83.

de Bleser, L., Depreitere, R., de Waele, K., Vanhaecht, K., Vlayen, J., & Sermeus, W. (2006). Defining pathways. Journal of Nursing Management, (July), 553–563.

de Luc, K., Kitchiner, D., Layton, A., Morris, E., Murray, Y., & Overill, S. (2001). Developing Care Pathways: the Handbook. Oxon: Radcliffe Medical Press.

de Vries, J. (2007). Diagnosing inventory management systems: An empirical evaluation of a conceptual approach. International Journal of Production Economics, 108(1–2), 63–73. de Vries, J. (2011). The shaping of inventory systems in health services: A stakeholder analysis.

International Journal of Production Economics, 133(1), 60–69.

de Vries, J., & Huijsman, R. (2011). Supply chain management in health services: an overview. Supply Chain Management-an International Journal, 16(3), 159–165.

Drupsteen, J., van der Vaart, T., & van Donk, D. P. (2013). Integrative practices in hospitals and their impact on patient flow. Journal of Small Business and Enterprise Development, 33(7), 912–933.

European Pathway Association. (2016). Care Pathways. Retrieved September 18, 2016, from http://e-p-a.org/care-pathways/

Everard, L. (2001). Blueprint for an Efficient Health Care Supply Chain. White Paper, 1–34. Fahmy Salama, K., Luzzatto, D., Sianesi, A., & Towill, D. R. (2009). The value of auditing supply

chains. International Journal of Production Economics, 119(1), 34–45.

HFMA. (2008). Opportunities for supply chain improvement. Healthcare Financial Management : Journal of the Healthcare Financial Management Association, 62(5), 1–8.

Hummel, H., de Meer, J. P., de Vries, J., & Otter, R. (2009). Integrale oncologische zorgpaden. Assen: Van Gorcum.

(40)

35

century. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National academy press.

Ireland, R., & Bruce, R. (2000). CPFR - Only the beginning of collaboration. Supply Chain Management Review, 80–88.

Kang, S., & Moon, T. (2016). Impact of Information Exchange and Supply Chain Integration on Supply Chain Performance. International Journal of U- and E- Service, Science and Technology, 9(7), 237–246.

Karlsson, C. (2009). Researching Operations Management. New York: Routledge.

Kekale, T., Spens, K., & Phusavat, K. (2010). Understanding the human factor: the key to process improvement in service operations. Int. J. of Services, Economics and Management, 181–190. Kerstens, J. A. M. (2015). Zorgpaden. BijZijn-XL, (8), 12–18.

Kinsman, L., Rotter, T., James, E., Snow, P., & Willis, J. (2010). What is a clinical pathway? Development of a definition to inform the debate. BMC Medicine, 8, 31.

La Londe, B. J. (1997). Supply Chain Management: Myth or Reality? Supply Chain Management Review, 1, 6–7.

La Londe, B. J., & Masters, J. M. (1994). Emerging Logistics Strategies: Blueprints for the Next Century. International Journal of Physical Distribution & Logistics Management, 24(7), 35– 47.

Lambert, D. M., Cooper, M. C., & Pagh, J. D. (1998). Supply Chain Management: Implementation Issues and Research Opportunities. The International Journal of Logistics Management, 9(2), 1–20.

Lawal, A. K., Rotter, T., Kinsman, L., Machotta, A., Ronellenfitsch, U., Scott, S. D., … Groot, G. (2016). What is a clinical pathway? Refinement of an operational definition to identify clinical pathway studies for a Cochrane systematic review. BMC Medicine, 14, 35. Lega, F., & DePietro, C. (2005). Converging patterns in hospital organization: Beyond the

professional bureaucracy. Health Policy, 74(3), 261–281.

Li, S., & Lin, B. (2006). Accessing information sharing and information quality in supply chain management. Decision Support Systems, 42(3), 1641–1656.

Mayo, E. (1949). Hawthorne and the Western Electric Company: The social problems of an industrial civilization. London: Routledge.

Mentzer, J. J. T., Dewitt, W., Keebler, J. J. S., Min, S., Nix, N. W., Smith, C. D., & Zacharia, Z. G. (2001). Defining supply chain management. Journal of Business Logistics, 22(2), 1–25. Mintzberg, H. (1979). The Structuring of Organizations: A Synthesis of Research. Prentice-Hall,

Inc. Englewood Cliffs.

Moberg, C. R., Cutler, B. D., Gross, A., & Speh, T. W. (2002). Identifying antecedents of

(41)

36

Müller, M., & Gaudig, S. (2010). An empirical investigation of antecedents to information exchange in supply chains. International Journal of Production Research, 49(6), 1531. Page, S. E. (2010). Diversity and complexity. New Jersey: Princeton University Press. Saunders, M., Lewis, P., & Thornhill, A. (2012). Research Methods for Business Students.

Business (Vol. 5th).

Sun, S., & Yen, J. (2005). Information Supply Chain : A Unified Framework for Information-Sharing. Springer-Verlag, 422–428.

Tucker, A. L., Heisler, W. S., Janisse, L. D., & Richter, C. (2014). Designed for Workarounds: A Qualitative Study of Hospitals’ Internal Supply Chains. The Permanente Journal.

Vanhaecht, K., De Witte, K., Depreitere, R., & Sermeus, W. (2006). Clinical pathway audit tools: A systematic review. Journal of Nursing Management.

Vissers, J. M. H., Bertrand, J. W. M., & de Vries, G. (2001). A framework for production control in health care organizations. Production Planning & Control, 12(6), 591–604.

Voss, C., Tsikriktsis, N., & Frohlich, M. (2002). Case research in operations management. International Journal of Operations and Production Management, 22(2), 195–219.

Wu, F., Yeniyurt, S., Kim, D., & Cavusgil, S. T. (2006). The impact of information technology on supply chain capabilities and firm performance: A resource-based view. Industrial Marketing Management, 35(4), 493–504.

Yin, R. K. (1994). Case Study Research: Design and Methods - Second Edition. Applied Social Research Methods Series (Vol. 5).

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Appendix A: Interview script overview clinical pathway

Question Targeted information

 At which department do you work? Background interviewee  What is your job title?

 What is your job description?

 Are you familiar with the clinical pathway oncology? (If no, explain and see if they recognize it)

o If yes, what does it do?

o Name the departments involved

o What is the order in which patients visit the departments?

o Would you describe the pathway as ‘complex’?

o Do you share a goal with other departments in the clinical pathway?

o Do you feel responsible for results of the clinical pathway?

Overview clinical pathway

Commitment and performance  How do you send/receive information? Information technology

 What kind of information systems do you use?

 What information do you receive? Information exchange  From whom do you receive information?

 Is the information you receive always complete? o If no, what do you do in such a case?  What do you do with the received information?  To whom do you send information?

o Do you get requests for additional information?

 If yes, could you have prevented this?  Do you create new information?

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Appendix B: Interview script in-depth analysis

Question Targeted information

How do patients influence the processes of the clinical pathway?

Patient behavior How often does this occur?

What are the planning rules used by the planning unit?

Planning structure Are you aware of any informational asymmetries? Information architecture Would you describe the UMCG and the clinical

pathway as bureaucratic?

Organizational embedding Is there an open culture where you can share ideas

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Appendix C: Survey questions

Question Type Information targeted

1. The clinical pathway results in cost reductions Likert scale Performance 2. The clinical pathway contributes to the quality

of care

Likert scale Performance 3. The clinical pathway optimizes the speed of the

care processes

Likert scale Performance 4. The clinical pathway contributes to flexibility Likert scale Performance 5. I can rely on everybody working in the clinical

pathway

Likert scale Performance 6. I know which departments are part of the

clinical pathway

Closed Commitment 7. Which departments are part of the clinical

pathway?

Open Commitment

8. I know which processes of other departments are relevant for the clinical pathway

Closed Commitment 9. I can do a better job due to the clinical pathway Closed Commitment 10. Others can do a better job due to the clinical

pathway

Closed Commitment 11. I know what my tasks are in the clinical

pathway

Likert scale Commitment 12. I know what the tasks of others are in the

clinical pathway

Likert scale Commitment 13. I know what information to exchange in the

clinical pathway

Likert scale Information exchange 14. I know with whom to exchange information in

the clinical pathway

Likert scale Information exchange 15. I know how to exchange information in the

clinical pathway

Likert scale Information exchange 16. I know when to exchange information in the

clinical pathway

Likert scale Information exchange 17. I always exchange relevant information Likert scale Commitment

18. I only exchange relevant information when I am asked to do so

Likert scale Commitment 19. I can trust others working in the clinical

pathway to handle information in a right way

Likert scale Information exchange 20. I am satisfied with the clinical pathway Likert scale Commitment

21. I speak up when I am not satisfied Closed Information exchange 22. I am not satisfied about: Open Information exchange 23. Everybody in the clinical pathway benefits

from a shared information system

Closed Information exchange 24. The clinical pathway is bureaucratic Likert scale Power

25. Important decisions in the clinical pathway are made by one person

Likert scale Power 26. My suggestions for improvements are

considered

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pathway is

Closed Power

28. The process owner is: Open Power

29. What are the opening hours of the blood collection department? (prikpoli)

Open Information exchange 30. What are the opening hours of the day care

center?

Open Information exchange 31. What are the opening hours of the pharmacy? Open Information exchange 32. What are the opening hours of the outpatient

clinic?

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The role and impact of information exchange on the performance of clinical pathways