Abstract
Can pathways and clinical microsystems save us from the Bermuda triangle?
The vast majority of health-care organizations rely on care pathways to improve the quality of the care provided. Even if the use of care pathways still has some limitations, actual evidence shows an increasingly possible significant effectiveness of care pathways when applied in different conditions. However, it is not always easy to implement these pathways, as discussed in a recent review by Evans-Lacko et al. 1 We believe that a possible element of success could be that care pathways can enable professionals to form multidisciplinary teams that are dedicated to and focused on their own clinical microsystem. A clinical microsystem is a small organized group of clinicians and staff working together with a shared clinical purpose to provide care for a defined population.2,3 These microsystems can also be defined as ‘temporary firms’ that emerge and operate every time a patient with a specific condition is admitted to a hospital. 4 In this temporary firm, the team deliver a unique bundle of products and services, linked with a certain care process, to promote the patient's recovery. Due to the temporary and interactive nature of these work groups, communication, coordination and control over the process are challenging. As readers know, care pathways are complex interventions for the mutual decisionmaking and organization of care processes for a well-defined group of patients during a well-defined period5,6; therefore, there are obvious similarities between pathways and microsystems. According to Nelson et al., 3 a focus on microsystems allows for greater standardization of customized care for a patient population, greater analysis of information to support daily work, extensive teamwork across a microsystem's disciplines and specialities, and the opportunity to spread best practices. The analogies of this approach with the defining characteristics of effective care pathways are clear: (i) an explicit statement of the goals and key elements of care based on evidence, best practice, and patients’ expectations and their characteristics; (ii) the facilitation of communication among the team members and with patients and families; (iii) the coordination of the care process by coordinating the roles and sequencing the activities of the multidisciplinary care team, patients and their relatives; (iv) the documentation, monitoring, and evaluation of variances and outcomes; and (v) the identification of the appropriate resources.
As a matter of fact we believe that it is very difficult today to establish a borderline between the implementation of care pathways and the fostering processes of clinical microsystems: overlaps and links are clear and necessary. In a previous editorial 7 we outlined that ‘pathway development enables the breaking down of potential barriers to the integration of care between professionals and organizations’ and also that ‘pathways can furthermore be a building block to the enhancement of accountability in health-care organizations, a central element of an effective system of clinical governance’. 8 Therefore, we believe that care pathways can be a tool that can support clinical microsystems in becoming more effective by enhancing interprofessional teamwork, coordination and standardization of care. This would inevitably have an effect on quality of the care. Each clinical microsystem can have several care pathways running.
This does not mean that pathways are the ‘magic bullet’ that will solve all the problems of health-care organizations; but pathways can be of significant help, as their comprehensive approach facilitates health-care organizations to put together their initiatives of quality improvement in a coherent framework.
This is the reason why one of the areas of interest of the European Quality of Care Pathway (EQCP) Study will be the effect of pathways on multidisciplinary teamwork. 9 The PhD study by Deneckere et al. 10 will hopefully keep readers informed about this area of interest, and more information about this part of the EQCP study will be provided in the 2011 issues of this journal.
For the reasons mentioned above, we think that the International Journal of Care Pathways (IJCP) should look further afield, to the quality improvement initiatives and to present experiences that are not strictly limited to pathway applications. In fact, we believe that a pragmatic approach opened to study the possible links and interactions between pathways and other methodologies, approaches and initiatives can be of significant help to our readers and will also improve the readers’ understanding of care pathways.
In this journal, the European Pathway Association (www.E-P-A.org) suggested five main areas of work on pathways: (1) make pathways more evidence-based; (2) focus on disease-specific-oriented care; (3) invest in real teamwork; (4) develop the technical support for pathways; and (5) see patients as partners.11,12 In this issue of the journal, many of these areas have been addressed. The paper by Bengt Ahgren on dissolving the patient Bermuda triangle brings us directly into the danger zone: will pathways be able to help us in improving the different kinds of fragmentation, also due to the driving forces of professionalization and specialization? The role of the clinical microsystem will have to be further discussed. We hope that readers of this paper will send us their views and open the discussion on the possible relation between teams, pathways and triangles. Alongside the role of clinical teams, the challenges in care pathways for hospital governance are discussed in the paper by Van Gerven et al., who studied this question in 57 health-care organizations in Belgium. It is clear that these pathways will need the support of both the management and clinicians, but maybe this is also one of the reasons why pathways cannot be take from the shelf as discussed by Arthur Vleugels, also in this issue of the journal. One of the pieces of the future pathway puzzle is technological support, and information and communication technology will be one of the challenges. Wakamiya et al. present in their paper the Quantitative Evaluation Trial for Functions Included in Currently Available Electronic Clinical Pathways Products. Our Japanese colleagues have thus opened an important discussion that will hopefully contribute to our search for pathway excellence. An overview of the Care Pathways Conference 2010, held in London, UK, has been provided. Ruben van Zelm, Secretary of the E-P-A, has also contributed information regarding the Third International Summer School on Care Pathways, which was held at Lago Orta, Italy in September 2010. A selection of abstracts have been published in this issue to inform readers about the topics that were discussed at the Care Pathways Conference and the summer school.
As this is the last issue of 2010, we hope that the European Pathway Association and its official journal has been able to inform readers about the actual ‘hot’ items in the field of care pathways and care process organization. The need for international collaboration and international knowledge sharing will hopefully support both local projects and the international research community.