Abstract
The development and implementation of a care pathway is a complex intervention. One of the goals is to standardize the interprofessional teamwork. During the development of the care pathway, the team can use the 3-blackboard method to systematically define the goals, describe the organization of the care process and develop a list of topics for further analysis. The 3-blackboard method is a consensus development exercise which can be used for pathway projects but also during other quality and patient safety improvement exercises.
Introduction
Care pathways are widely used, quality improvement strategies for organizing and reorganizing care processes. 1 The European Pathway Association defines a care pathway as ‘a complex intervention for the mutual decision making and organization of care for a well-defined group of patients during a well-defined period’. 2,3 Although literature suggests that pathways lead to positive outcomes, one needs to be careful with being too enthusiastic about their effect because pathways are complex interventions. 4 Complex interventions are those that have been built up of multiple components that both act independently and interdependently. 5–7 Care pathways are thus built up of a unique bundle of products and services to promote the patient's recovery. In addition, as a result of an increasingly complex, and knowledge-intensive work environment, requiring a wider skill base, health care organizations will more often need to employ interprofessional teams that can pool resources and skills, to deliver safe, high-quality patient care. 8 Therefore, to define all components of which a care pathway will be built up, will be a challenging process, requiring formal, standardized methods.
To support the process of effective decision-making in selecting pathway components, consensus-development methods can be used. These group-facilitation techniques are recommended in areas of knowledge where methodologically rigorous research evidence is limited and experts disagree on its interpretation, like health services research.
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Through their use, expert opinions are rigorously solicited and synthesized to transform individual opinions into group consensus.
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These consensus methods are based on the hypothesis that through expert interactions and shared knowledge, team performance will be greater than any individual part.
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One of these methods we will describe here is the 3-blackboard method. This method was developed at the Center for Case Management (CCM) in Boston (
Practical organization
The 3-blackboard method is being carried out by the project team during a consensus-development meeting. This project team consists of representatives of each professional group involved in patient care. When selecting participants, make sure that all professional groups are represented. The participants should have practical experience with the care process. Try to limit the number of participants. The effectiveness of these type of group-consensus meetings concerning the ideal number of participants, follows a reverse U-shaped curve. Effectiveness will decrease below or above a certain number of participants. Based on our experience, we believe that a range of 7–12 participants is ideal;
For this exercise you need:
Three large separate boards that are preferably erasable; A spacious room with tables in a U-shape so everyone can see the three boards; At least two hours of time in which the group cannot be disturbed;
The project manager leads this 3-blackboard exercise. Possibly an expert who is not part of the clinical team is invited to support the exercise. However, the clinical content is supplied by the actual clinicians of the project team and later on completed by other team members involved in patient care. Within the first exercise, only the most obvious topics will be discussed. Other members of the interprofessional team who cannot participate to this exercise can contribute later in follow-up sessions or via direct contact with the project leader.
Description of the three boards
The right board: the GOAL board
This board contains the goals of the care pathway implementation. The 3-blackboard method is based on the following saying: ‘You first have to identify your goals and then plan the activities to achieve those goals!’. Thus the first step will be to define the specific goals at the level of:
The care process: these are goals at the level of the patient group. These should contain at least the discharge criteria/transfer criteria the patient has to meet at the end of the care pathway. It should be emphasized that ‘the end’ of the care pathway is difficult to define. Think, for instance, of the patient's flow from the hospital to home care, or from home care to the rehabilitation centre. Also intermediary/interim goals are described objectively (for example if the patient is discharged at day 7 and has to be able to walk 100 meters at discharge, an intermediary goal could be the start of physiotherapy at day 2 after the operation, or to perform a mobility test at day 4); The project: these are targets one wants to achieve by the development and implementation of the care pathway or the revision of an existing clinical pathway. These goals are described on the basis of the five domains of the Care Pathway Compass
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: Clinical Domain, Service Domain, Team Domain, Process Domain, Financial Domain. A few examples: reduction of the infection ratio by 20% (clinical), 100% of the patients are able to walk for 100 meters at discharge (clinical), the variation in length of stay decreases (process + financial), all lab results (blood taking) of all patients are known before hospitalization, 100% of the patients return to our organization for another operation (service), the team working improves (team), etc.
The middle board: Time–Task Matrix
This board contains the activities that should be included in the care pathway in a later stage. At the stage of the 3-blackboard method, these activities should be restricted to the key interventions only. Key interventions are those activities that affect the effectiveness and efficiency of the care process set-up to promote the patients recovery and thus will have a direct impact on patient outcomes. This implies that, to keep the exercise workable, not all details of all possible activities are included in this time–task matrix when performing this 3-blackboard method. An example concerning medication: in the 3-blackboard method, the administering of antibiotics on day 2 after the operation will be included. Other information, needed in the final care pathway (type, concentration, way of administration, etc.) is not within the scope of the exercise and will be worked out later on.
Sometimes it is useful to work with a Goal Task Matrix and to start with defining the phases or targets. When does a patient pass/switch from one phase to another? By defining this, you can avoid discussions about which exact day exactly that certain things need to be done. The specific timetable can be added later on.
The left board: Bottlenecks and Question Marks
This board contains a list of bottlenecks or items about which there exists ambiguity. These items have to be cleared up or objectified later on. Methods like root cause analysis, patient record analysis, prospective measurement of process and outcome indictors, team surveys, patient satisfaction measurements, etc. are often used to further explore if the bottlenecks are real and if a change process needs to be launched to optimize the results. This list of bottlenecks or question marks will be continuously updated during the development process and continuous evaluation of the pathway. Bottlenecks or ambiguities that are cleared up are crossed off, others are added.
How is the 3-blackboard method carried out?
You start with noting down the time frame of the care pathway on the middle board (day 1, day 2, hour one, phase 1, etc.). This time frame is usually known before the start of the group meeting based on benchmarking data or clinical guidelines;
Later one the right board (GOAL-board) is filled up. The two kinds of objectives are described as objectively as possible. Goals on which there is disagreement or ambiguity are listed on the left board (Bottlenecks – Question Marks). In order to let this run smoothly, participants are asked in advance to reflect on these goals and possible bottlenecks (it is therefore important to define the time frame in advance);
Now the middle board is filled in. This board is only now completed because: ‘You first have to identify your goals and then, plan the activities to achieve those goals!’. The tasks are classified (medication, consultations, etc., see Figure 1). The key interventions per task and per time unit/phase are noted down. This way the first version of the care pathway is drawn. It is advisory to firstly define the medical key interventions (defined by the medical doctors present), afterwards other professionals can complete this list. The interventions or outcomes that need to be followed up, or on which there is disagreement (does this need to be done or does this happen at present at this time unit?), are added to the left board (Bottlenecks – Question Marks). Matters on which there are different opinions or questions are not discussed in detail during this meeting. The 3-blackboard method is only used to get a general overview. In a later stage of the project, everything will be discussed in detail and will be objectified;
This way the left board is automatically filled in. At the end of the exercise the left board is run through and if necessary completed with other bottlenecks or ambiguities.
The 3-blackboard method
During this meeting, the project manager has to facilitate the group-consensus process. This means that he/she needs to make sure that the three boards are filled up. There should be few or no clinical discussions. The goal is to get an overview of the targets, the key interventions (without details) and the possible bottlenecks and ambiguities.
What happens after the 3-blackboard meeting?
On the basis of the 3-blackboard method, the Diagnosis-phase of the seven-phase model plan can be carried out. 18 The three boards will be objectified. For this purpose different methods can be used, such as case studies, prospective analysis, patient surveys, document analysis, process mapping, etc., as described above. In addition, norm data will be searched in the literature and the key interventions can be founded with evidence.
After the diagnostic stage 18 we need to know: (1) if the targets (right board) are achievable and how far away from those targets we are; (2) if the key interventions in the time matrix (middle board) can be carried out in the postulated time frame; and (3) if the bottlenecks/question marks really are bottlenecks/question marks (left board).
Conclusion
The 3-blackboard method is a practice-based exercise to: (1) define pathway components based on expert opinion; (2) evaluate the current organization of the care process and define bottlenecks in a fast and efficient way; and (3) set-up clear patient and team goals at the level of the care process as well as at the level of the project. This exercise is a formal, standardized method to develop consensus between a group of experts. The project team is very closely involved with this method and provides the content of the three blackboards. The process manager will need to have the necessary skills to guide this group process. He/she will also need to ensure that as few solutions as possible are discussed during this meeting. The goal of this method is not to solve these bottlenecks at this moment but to get an overview of what can be carried out in a more structured and goal-oriented way in the Diagnosis-phase. Through the use of this method, a first version of the care pathway can be built up based on group consensus and potential bottlenecks concerning the organization of the care process can be identified.
DECLARATIONS
Footnotes
Acknowledgements
The authors acknowledge the management and pathway facilitators of the members of the Belgian Dutch Clinical Pathway Network (