Optimization of Care Pathways Through Technological,Clinical,Organizational and Social Innovations: A Qualitative Study

Background

Many calls have been made over the past 20 years to improve the organization and quality of care in countries such as Canada ¹ and the United States,^2-4 as well as internationally by the World Health Organization.^5,6 However, suboptimal performance and inadequate use of resources persist.^7-9 These problems seem to stem largely from persistent organizational, professional and data silos, ¹⁰ leading to disruptions in the continuity of health services, ¹¹ unnecessary waiting times,^12,13 defects in the flow of information between episodes, ¹⁴ and the performance of examinations that may be unnecessary. ¹⁵ They come also from difficulties in innovating and integrating evidenced-based knowledge into routine clinical practice. ¹⁶ Thus, the need to improve the quality of care has led to interest in initiatives to redesign the provision of care and give greater social value. ¹⁷ Indeed, modern systems that can integrate innovation and knowledge in daily care have the potential to better contain costs and improve population health. ¹⁸

Since the emergence of the concept, care pathways have been intended to improve outcomes by providing a mechanism to coordinate care and reduce fragmentation and ultimately costs. ¹⁹ Many efforts have already been developed to better define and characterize the concept.^20-23 Although encouraging results have been shown recently, ¹² the results of care pathway optimization projects remain variable and sometimes disappointing in relation to the resources invested. ⁸ This variability in results leads experts to view these programmes as complex interventions in complex systems. ²³ This is why it seemed appropriate to redefine and characterize the concept. This new definition, simplified here, considers the care pathway as ‘a long-term and complex managerial intervention adopting a systemic approach, for a well-defined group of patients who journey across the entire continuum of care, from prevention and screening to recovery or palliative care’. ²²

From there, it becomes necessary to test this approach in a pilot project to verify the relevance of such a framework that considers operational, organizational and social realities. In addition, most studies are still designed and implemented to respond to local realities, highlighting possible weaknesses in spreading.^24,25

Based on an in-depth analysis of a care pathway optimization pilot study in Quebec, the aim of this article is to develop a model for the optimization of care pathways which integrates favourable factors, challenges and barriers to implementation.

Methods

We opted for an emergent study design in healthcare combining action research and grounded theory methodology.^26,27 An action research project ²⁸ was carried out collaboratively between a specialized healthcare organization and the research team. As further described in the action research project section, a group of multidisciplinary researchers and stakeholders of the organization managed a care pathway implementation project and researchers explored and analysed the process guided by grounded theory methodology.^29-32

Participants and data collection

In line with the grounded theory approach,^30-32 we used a strongly inductive process, to mobilize comparison and continuous theoretical sampling in order to produce theories. ³² Forty-two interviews were conducted throughout the project, 18 with actors involved in the steering of the project and 24 with voluntary staff to understand the enabling factors and barriers to implementation in each phase. The semi-structured interviews were conducted by the first author using interview guides and lasted between 45 minutes and 1 hour and 15 minutes. To ensure anonymity, an interview code was given, from 01 to 42 followed by 2 letters for the stakeholder’s role. Participant observations were made by the 2 authors throughout the project, including, but not limited to, 60 participant observations at meetings, workshops and field observations representing over 150 hours of observation. The investigators kept logbooks and recorded field notes. These 2 materials included activity calendars and reflections. ²⁸ Additional File 1 provides questions included in the different semi-structured interview guides. See Table 1 for a complete overview of data collection.

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Table 1.

Overview of the data collection in the project.

Data types	Description of the content and source of the data	Sampling details
Semi-structured interviews	Forty-two semi-structured interviews were conducted throughout the project. Eighteen of these interviews were with actors involved in the governance of the project. The remaining twenty-four interviews were conducted with professionals and managers in the field. The interviews were all recorded and transcribed before being uploaded to Nvivo (version 12).	• Steering of the project - Six researchers - Five managers - Two patient partners - Two physicians - Two representatives of the decision-makers - A representative of the private partner • Field professionals - Eleven nurses - Six operational managers - Two physicians - One care advisor - One occupational therapist, - One physiotherapist - One Nutritionist - One respiratory therapist
Participatory observations	The authors were directly involved in the whole project and all meetings. Thus, participant observation includes, but is not limited to sixty meetings, several workshops and field observations, representing over 400 h. Field observations were patient shadowing and observation and questions to professionals during their work. The field notes and logbook have been uploaded to Nvivo (version 12).	• Logbook and field notes - The logbook contains summaries and methodological and analytical notes of over 60 meetings and workshops. - The field notes include operating procedures descriptions, analytical notes and reflective notes on observation afterwards.

Results

The in-depth analysis of this case study has enabled us to develop a detailed understanding of enabling factors, challenges and barriers to the implementation of care pathways. Thus, a first model for the implementation of care pathway optimization is emerging (see Figure 1). As indicated in each title, all categories of the conceptual model include several subcategories. The detailed results are based on the different data sources. The narrative includes some quotes from participants. Additional File 2 provides further examples of quotes, as well as the types of actors who raised the concept.

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Figure 1.

Conceptual model of the enablers, challenges and barriers to implementing innovations in care pathways.

Discussion

This article presents an implementation pilot project of care pathways in a specialized healthcare organization in the province of Quebec, Canada. The generated conceptual model illuminates the new approach of care pathways as complex managerial interventions ²² that were tested and analysed in this pilot project with a focus on the enablers, challenges and barriers. As this process, to our knowledge, has never been explained before for this approach, the results provide a new understanding that may be useful in future implementation processes.

The conceptual model was generated from empirical findings but resonates well with existing implementation frameworks. For example, some points are in line with the CFIR framework proposed and improved by Damschroder et al^37-39 In particular, it strengthens the recent adjustments, emphasizing the need to pay attention to the needs of the actors receiving the innovations and to ensure their commitment. ³⁹ However, certain key points of our model stand out. Firstly, the conceptual framework is specific to healthcare research in the context of care pathway interventions and stands out for the role and place of patients as partners in data collection and analysis, then in the prioritization of solutions and the co-construction of solutions and innovations. Secondly, it stands out for the importance of involving multidisciplinary researchers in applied health. Finally, it stands out for the involvement of stakeholders in the field in formulating proposals and co-constructing innovative solutions. Similarly, our model joins several works in spread and scaling science, in demonstrating a need to consider the social approach, ²⁴ but also the importance of anticipating scaling, from the design phase of the pilot project. ⁴⁰

Considered as a complex intervention, ²³ a care pathway is indeed a long-term managerial intervention mobilizing many multidisciplinary skills and resources. However, this pilot project has identified and characterized favourable conditions for the emergence of innovation adoption. These conditions should not be neglected, as the absence of one of them can be problematic. Consistent with other studies, the presence of a supportive receiving environment with an awareness of suboptimal practices ³⁹ is crucial for the adherence of staff and the adoption of the innovations. Similarly, the implementation team should not only be multidisciplinary, ⁴¹ but also contain key implementation science skills. Through the implementation process, there must be a mobilizing shared objective, capable of transcending professional perspectives. This social approach to transformation is too often forgotten in technical approaches. ⁴¹ This is why it is essential to focus on the actors, capitalizing on their motivation and willingness to act and mobilizing research methods of participation and co-construction such as interviews, observation and co-construction workshops. Ensuring the involvement in decisions is often a requirement for success.^37,42 Similarly, the receiving environment must be able to mobilize its champions at all levels with strong leadership, enabling the generation of collective leadership. ⁴³ These 2 favourable factors are widely shared in the literature.^39,41

However, implementation is far from being a smooth ride. Many issues were a source of constant negotiation and adaptation. Indeed, over the nearly 2 years of the project, it was difficult to maintain a constant and effective level of communication, which is recommended, ³⁹ but not always easy. Similarly, the availability of the various actors, depending on expected and unexpected constraints and the pace of the project seemed to be a challenge. Finally, demonstrating value to all stakeholders is not straightforward, as each stakeholder has their own ways of valuing. This point remains underdeveloped in the literature. The present findings also further illustrate that inadequate computerization is a barrier to pathway implementation,^39,44 as found in other empirical studies. ⁴⁵ Finally, although the involvement of patients as consumers of care is common in implementation science, the involvement of patients as partners, both in the collection of data and in its analysis and decision-making throughout the project, seems to be novel in the implementation science literature. This brings a new vision of care pathways and helps to avoid the pitfall of an approach based only on the professionals’ perspective, which is intrinsically incomplete. They also serve as a constant reminder that changes are made primarily to improve patient experience and outcomes. They embody and strengthen the mobilizing shared objective and ensure that the validations and solutions adopted are in the right direction.

With a view to future spread and scaling, the various points raised in our study do not contradict the literature; thus it seems essential to anticipate spread and scaling up, ⁴⁰ both on the part of the decision-makers and the research team, insofar as methodological skills and knowledge must be shared^46,47 and disseminated in order to allow for scaling up. ⁴⁷

The limitations of our findings lie in the fact that they are based on a single case study and only consider the perspective of the willing participants. Thus, it is possible that the staff who were most resistant to the optimization project and less likely to participate, may have had a more negative perception of the change. Finally, this study focussed on the process, so, as is frequently the case at this evaluative stage (process evaluation) of an implementation project,^27,44 the impact on health outcomes and patient experience (outcome evaluation) were beyond the present scope.

Conclusions

The present model explains in a new way, the factors that positively or negatively influence the implementation of innovations in care pathways. The model represents interactions between facilitating factors, favourable conditions for the emergence of innovation adoption, implementation process enablers and challenges or barriers including those related specifically to the local context. What seems to be totally new is the embodiment of the mobilizing shared objective of active patient-partner participation in decision-making, data analysis and solution building. This allows, in our opinion, to transcend professional perspectives for the benefit of patient-oriented results. However, this needs to be further analysed. Finally, the pilot project has created expectations in terms of spread and scaling, which are relevant premises in the event of scaling up.

Future research on innovation implementation in care pathways should go further in the evaluation of the multifactorial impacts of the redesign and the enabling and disabling factors for spread and scaling up. In addition, it would be interesting to develop a methodological framework of care pathway implementation as the only existing proposition ⁴¹ seems limited by not integrating the social perspective. Furthermore, from a social science perspective, it would be interesting to analyse the modes of social valuation of different actors to understand what allows the transformation of collective action.

Supplemental Material

Supplemental Material