The care for patients undergoing surgery because of a tumor in the colon or rectum, has shifted to a more standardized approach over the last decades. These evidence based standardized programs aim to reduce the risk of complications and enhance the patients postoperative recovery. Despite the growing evidence for the usefulness of these programs, it is very difficult to implement the programs in daily practice, and to adhere to the programs.
Both healthcare professionals and policy makers are looking for ways to provide high quality and efficient health care. To achieve this, care programs such as the programs for patients with a tumor in colon or rectum, are implemented using so called care pathways, also known as clinical pathways. Care pathways aim to organize care processes around patient needs and to structure care processes. Recent studies show that care pathways help to improve quality of care; they can support professionals in adhering to evidence based programs. But little is known about the implementation process. This study has two aims: (1) to perform a quality improvement initiative in 12 hospitals in four European countries, and (2) to evaluate the implementation process of a care pathway.
The study is performed in three hospitals in four countries (Belgium, France, Germany and the Netherlands) totaling 12 hospitals. First, a model pathway describing the recommended care for patients undergoing surgery for colorectal cancer, was developed based on an extensive literature review. This model pathway contains 33 interventions for the care of patients pre- and postoperatively.
Next, a baseline measurement was performed in the participating hospitals to assess the level of protocol adherence and a number of outcomes, including length of stay, morbidity. Twenty patients per hospital were included in this study (in one hospital only 10 patients were included), 230 patients were included in total. These patients received on average 44% of the recommended care (a protocol adherence of 44%).
Following the baseline measurement, the participating teams received feedback on their current performance, followed by an on-site session to discuss their results and the introduction of the model pathway. The teams then implemented the care pathway. After six months we performed a qualitative evaluation, capturing the experience of the involved professionals, and a quantitative effect measurement, in 10 of the original 12 hospitals. Factors such as teamwork, availability of resources, leadership and the effect of feedback were reported as important factors in the implementation process. The quantitative measurement showed that the implementation of the care pathway reduced the mean length of stay with 2 days, and improved protocol adherence from 56 to 62%.
Finally, the results from the qualitative evaluation and the effect measurement were combined. The hospitals were ranked based on after-implementation performance. Two high and three low performing cases were included and compared with each other. Factors explaining the differences in pre- and post-implementation performance were: the level of integration of the care pathway, the experience and support of the improvement team in care pathway methodology, the motivation of the team, shared goals, level of management support and finally the participation of relevant disciplines, most noticeably the physician.
Overall, we concluded that this international quality improvement initiative was successful in reducing mean length of stay with almost two days. Protocol adherence improved overall to a median of 62%, with great variability between the hospitals. These outcomes are statistically significant, but can be considered modest. Despite the improved protocol adherence, our results suggest that a large proportion of patients is still at risk for under-use of care.
We propose a model for the implementation of care pathways. The implementation and normalization of care pathways asks for the contribution of multiple involved professionals at organizational, team and individual level. Both the capability of the care pathway as well as the context, described in terms of potential (to follow care pathway methodology) and capacity (to cooperate and coordinate actions) influence the implementation and vice versa. But it is contribution that leads to outcomes: success of care pathway implementation depends on the activities people do to implement it.