Can quantification of congestive heart failure care convince medical doctors to use a care pathway? A process analysis

Introduction

The Dutch national health-care policy has two seemingly opposite objectives: firstly care has to be cost-effective and secondly the quality of care has to improve. ^1–3 Concurrently the demand for health care is increasing. The following question is the crux of the current dilemma health care is facing: is it possible for a hospital to meet the increasing demand of cost-effective care and simultaneously improve the quality of care? Several studies have reported that care pathways may provide the key solution by providing systematic care according to international guidelines by decreasing the length of in-hospital stay and the readmission rate. ^4–11

To improve the quality of care for congestive heart failure (CHF), the Haga Hospital Heart Centre in The Hague decided to develop a care pathway aiming to improve patient care outcomes. The Haga Hospital has a catchment area of one million people; of this population 5000 will be admitted to the heart centre with cardiac illnesses, 10% of whom will be diagnosed with CHF. The quality of care here is expressed in the registration of delivered care in medical and nursing records according to international guidelines, the duration of in hospital stay and the re-admission rate. According to a literature review from Cabana et al., ⁵ 15 of 76 sources indicated a lack of agreement by the medical doctors (MDs) as a root cause for malfunctioning care pathways. Evans-Lacko et al. ¹¹ state that the successful implementation of care pathways, to a large extent, depends on the involvement and investment of clinical service providers. Based on the literature and our own experience with a failed implementation of the first version of the CHF care pathway, we decided on a strategy to secure the participation of the MDs in the design process of the care pathway. To convince the MDs that their participation is needed in the design process we wanted them to have insight into the necessity and urgency to implement a care pathway. Hence this survey.

In current literature and practice, MDs are likely to call care pathways ‘cookbook medicine’ ^5,11–15 and are unsupportive in implementing care pathways. In order to gain support for the change and participation in the change process, the MDs have to be persuaded that care pathways are the desired intervention to achieve cost-effective, accessible and qualitative CHF care. This survey was the first to gain the support of the MDs, by the quantification of the CHF care results.

Methods

A theoretical approach to quantifying CHF care outcomes can help to provide insight into the care delivered. This survey evaluated the variation in current care processes in comparison with the international guidelines. These outcomes might convince the MDs of the urgency to implement the CHF care pathway. ^5,16

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Figure 1

Sample selection 1

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Figure 2

Sample selection 2

Results

This research produced the invaluable insight of the MDs into the results and registration of the medical care of CHF patients. The current registered medical care was compared with the international guidelines and the points for improvement were determined. In this manner, insight into the quality of medical record filing made the MDs aware of their own accountability. These insights created a sense that changes to the care process for CHF were urgently needed and transparent to all of the MDs, which resulted in the participation of two MDs in the care pathway design group; the care pathway is supported by the whole MD group.

Discussion

In spite of the method outlined above illustrating a well-designed survey according to a solid data collection protocol, some limitations were experienced. Firstly, while conducting the survey the data requested were organized on a ward level; however, this is impossible with the current registration system. The supplied data were organized on an individual level. The designed solution for this limitation is to only select patients with a cardiologist as both admitting and discharging specialist. Secondly, the researchers had insufficient knowledge of the hospital registration system. A substantial part of the data turned out to be contaminated. For a vast number of patients, the CHF diagnosis was not the primary reason for admission. As a consequence of this finding, a last selection in the population based on the primary diagnosis was made. The initial population of 504 patients was reduced to a population of 362 patients with CHF as the primary diagnosis and both admitted to and discharged from the hospital by a cardiologist in 2008. A sample of 137 patients was drawn from this population (Figure 2). Finally, the current hospital mortality registration system was found to be incomplete. When a patient died while not admitted, the hospital had to depend on the patients’ family to inform the hospital registry; however, this did not always happen.

Given these limitations, the quality of the research results may be incomplete or invalid, but the process of research is valid and the MDs did gain insight into the medical care process of CHF care and did commit themselves to the desired changes in the process by participating in a care pathway team.

Conclusions

Implementing change is a complex process; however, with the support of the MDs in the change process the first hurdle is crossed. As a result of this support the second version of our care pathway was implemented in July 2011. This provides supporting evidence that change needs a broad supporting network and the MDs are essential supporters to implement change in the care process. The method to gaining support as described in this research can be used to gain support in similar situations. However, we do agree with Vleugels that the researcher should stay alert in their specific situation. ²⁴

Lessons learned

The two most important lessons learned by this project are firstly not to start a project without a thorough and quantified evaluation of the current situation. With the pressure on public health care in the Netherlands, both the MDs and the managers need a quantification of the current situation to initiate and support a change in the current work processes. Secondly, the implementation of a care pathway will greatly benefit from the support of all the stakeholders. This support is of key importance to reach the desired change.

DECLARATIONS

Conflicts of interest: N/A.

Funding: N/A.

Ethical approval: The Medical Ethical Committee (METC) of the South West Netherlands agreed with the research on 12 November 2009. No special approval was required. METC-code: 09-140.

Guarantor: TCM Heemskerk.

Contributorship: LJ Förster initiated the research by expressing the desire to improve and quantify the care of chronic heart failure on a nursing ward. All authors were involved in the design of the care pathway. TCM Heemskerk and M Hugo researched the literature and conceived the study. AJ te Hoonte and MJW Götte were also involved in the design of the data collection protocol. TCM Heemskerk wrote the first draft of the manuscript. All authors reviewed and edited the manuscript and approved the final version of the manuscript.