E-P-A 7 phase approach for care pathways

Transcription

1 E-P-A 7 phase approach for care pathways Kris Vanhaecht #$ Ruben van Zelm # * # European Pathway Association $ Center for Health Services & Nursing Research Catholic University Leuven, Belgium *Q-Consult, Arnhem, the Netherlands

2 Definition of care pathway A care pathway is a complex intervention for the mutual decision making and organization of care processes for a well-defined group of patients during a welldefined period. Defining characteristics of care pathways include: (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 the 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. The aim of a care pathway is to enhance the quality of care across the continuum by improving risk-adjusted patient outcomes, promoting patient safety, increasing patient satisfaction, and optimizing the use of resources. Vanhaecht, De Witte, Sermeus, 2007 E-P-A, 2008 European Pathway Pathway Association, Association, Panella & Vanhaecht, IJCP, 2010 Vanhaecht et al, BMC,

3 This means not easy Care pathways are A complex intervention! They are health service interventions that are not acting as single drugs or surgical procedures but have many potential active ingredients. A complex intervention combines different components into a whole that is more than the sum of its parts. Campbell, BMJ 2000, Oakley, BMJ 2006, Campbell, BMJ 2007 Development and implementation are equally important as the pathway document! European Pathway Association,

4 Pathways as continuous quality improvement Deming & Juran: Every improvement is done project by project and step by step Phase 7: Continuous Follow-up Phase 6: Evaluation of pathway Phase 5: Implementation of pathway Phase 4: Development of pathway Phase 3: Diagnose the problem ( as-is ) Phase 2: Project Management Phase 1: Screening if pathway is appropriate tool for that problem Source: Vanhaecht, K, Van Gerven, E, Deneckere, S., Lodewijckx, C., Panella, M., Vleugels, A., Sermeus, W. (2011) The 7 phases plan to develop, European implement, Pathway evaluate Association, and 2013 continuously follow up a care pathway. 4 Belgian Dutch Clinical Pathway Network, Leuven. Belgian Journal of Medicine

5 7 phases approach is - NO standing order - BUT a pathway for an advisor who is supporting a team in their pathway project What about informing the team about the approach? (yes but not too much ) European Pathway Association, 2013

6 7 Phases Model: Phase 1: Screening Phase start: Question for care pathway or care process redesign is posed by someone. Goal: What is the question? Is care pathways an answer? What about ownership? Defining goals Tools & Techniques: Interviews talks Who asked the question? What kind of team have you got (innovative, willing to change, )? Do we have available data on the actual organization of care? Evaluation: Do you think CP can be successful? Will a project be launched? Is the team cooperative? Is the management interested? Who is engaged to collaborate? What is the level of quality of the care process? European Pathway Association,

7 Phase 1: Screening Methods: Find out how the actual care process is organized (as is situation) Already AVAILABLE info Results on 5 domains of Care Pathway Compass (Vanhaecht & Sermeus, 2003) Clinical: safety, outcome, knowledge, from indicator projects / benchmarking / Service: patient satisfaction, complaint letters, Team: CPSET, team measures, relational coordination, Process: volume of patients, number of X-rays, door to needle times, Financial: cost, length of stay, Gathering new info Quickscan CPSET Brainstorm (ex. metaplan method) & 3 blackboard method (Goals Key elements - Questions) Data from databases (easy accessible) Info on organization structure & context (ward, role of supporting departments, operating theatre, ) TIMING: a maximum of 2-3 weeks only available info can be used European Pathway Association, 2013

8 Phase 1: Screening European Pathway Association, 2013

9 7 Phases model: Phase 2: Projectmanagement Phase start: CP project will be started, decission has been made. Goal: Decission on patient group and time-frame Project team Task devision within project team Tools & Techniques Multidisciplinary meetings Core project team vs working group Information to team European Pathway Association,

10 7 Phases model: Phase 2: Project management Tools & Techniques: Information: Information session to core project team Information session to whole multidisciplinary team Projectmanagement Role and tasks chairman vs pathway facilitator Project charter / contracting Gantt Chart for project planning (time-task matrix) Deal about meeting reports / meeting planner / Evaluation: We know the population and time frame. All involved personnel is aware of project and possible role All members of core project team know their role & tasks Project is planned European Pathway Association,

11 Relation CPSET & Outcomes Outcome positief Not aware of High performance Aware of High performance ZPZET laag ZPZET hoog Aware of Low performance Not aware of Low performance Outcome negatief Vanhaecht, De Witte, Sermeus, CZV-K.U.Leuven, 2007 European Pathway Association, 2013

12 7 Phases model: Phase 3: Diagnose & objectivation Phase start: When patient group is known, team is prepared and project is prepared. Goals: Make diagnosis and make objective data available on the actual organization of the care process, from 4 different angles: OWN ORGANISATION & TEAM PATIENTS & FAMILY EVIDENCE & LEGAL EXTERNAL PARTNERS Tools & techniques: Different quality analysis tools used Evaluation: Do we have objective data on the organization of the care process from the 4 different angles? European Pathway Association,

13 7 Phases model: Phase 3: Diagnose & objectivation Goals: CPSET/ 3 blackboard/compass/ Evid. Based Key interventions. Bottlenecks: Patient record analysis/flowchart/ prospective measurements/ Resources: do we have the necessary resources available to obtain goals? OWN ORGANISATION & TEAM Expectations: own patients / patient associations Evaluation: interviews / walkthrough / focusgroup / questions to family PATIENTS & FAMILY EVIDENCE & LEGAL EXTERNAL PARTNERS Guidelines: Evidence based key interventions: M.O.M. Indicators: AHRQ / Medal.org Legal: Governement websites European Pathway Association, 2013 Expectations: GP associations / home care nurses / nursing homes / / other hospitals Evaluation: interviews / walkthrough / focusgroep / surveys / 13

14 7 Phases model: Phase 3: Diagnose & objectivation PITFALL IN PHASE 3 We always overestimate what we can do in short term but we always underestimate what we can do in long term Bill Gates European Pathway Association,

15 Phase start: Necessary data are available on actual organization of the care process Goals: Development of the pathway based on Predetermined goals Data from phase 3 Available resources Practical constraints (record, ICT, ) Tools & techniques: Redefine patient group and time frame (based on phase 3 outcomes) Key interventions on timeline (process flow) Lay-out care pathway document Patient version of the pathway 7 Phases model: Phase 4: Development Final version approved by core project team, working group and discussed with involved departments / management / audit cell / European Pathway Association,

16 Evaluation: 7 Phases model: Phase 4: Development Basic requirements for document Multidisciplinary Defined patient group Time task with start & end point Key interventions are visual Intermediate & final outcomes included Reporting system included for indicators Approval from necessary commissions Attention for communication with patients & family Patient version Relation with external partners (transfer criteria) European Pathway Association,

17 7 Phases model: Phase 5: Implementation Phase start: Pathway is developed and team is ready to use it Goals: All involved team members know the content, the change, their role and tasks, the reporting system, the communication, Test phase of the pathway Test phase evaluation Implementation of (revised) pathway for daily use Tools & Techniques: Implementation plan Information session Test phase (10 patients or 3 weeks) Multidisciplinary discussion on test of pathway Revision if necessary Evaluation: Path is discussed and tested Path is implemented in daily care European Pathway Association,

18 7 Phases model: Phase 5: Implementation Pick the low hanging fruit or wait for a full redesign? Both! European Pathway Association,

19 7 Phases model: Phase 6: Evaluation Phase start: Pathway is in use and will be evaluated for first time. Goals: Evaluation of usability Evaluation of effect Tools & Techniques: Same techniques as in phase 3 Variance analysis / compliance Evaluation: Objective evaluation performed OWN ORGANISATION & TEAM EVIDENCE & LEGAL Difference between diagnosis (phase 3) and actual organization is transparent and tested PATIENTS & FAMILY EXTERNAL PARTNERS European Pathway Association,

20 7 Phases model: Phase 7: Continuous follow-up Phase start: Pathway is in use, was evaluated and will be used for the daily organization of the care process. Goals: Keeping pathways alive Continuous use Continuous follow-up To close the project setup Tools & Techniques: Follow up is task of specific person (Q-manager, head nurse, facilitator, ) Every 6 months meeting with core team on content of pathways At least once a year objective evaluation of organization (with measures) Possible continuous follow-up with exit poll to follow up key interventions Evaluation: Someone is responsible for organization of follow up Has there been a meeting in the past 6 months to discuss content? Has there been a meeting in the past 12 months to discuss outcomes / measures? Do we have an idea on the compliance to the pathway? European Pathway Association,

21 Pathways as continuous quality improvement Deming & Juran: Every improvement is done project by project and step by step Phase 7: Continuous Follow-up Phase 6: Evaluation of pathway Phase 5: Implementation of pathway Phase 4: Development of pathway Phase 3: Diagnose the problem ( as-is ) Phase 2: Project Management Phase 1: Screening if pathway is appropriate tool for that problem Source: Vanhaecht, K, Van Gerven, E, Deneckere, S., Lodewijckx, C., Panella, M., Vleugels, A., Sermeus, W. (2010) The 7 phases plan to develop, European implement, Pathway evaluate Association, and 2013 continuously follow up a care pathway. 21 Belgian Dutch Clinical Pathway Network, Leuven. Submitted for publication

22 In conclusion Pathways are flexible BUT Pathway methodology = systematic approach European Pathway Association,

23 In conclusion Step by step approach is necessary You should define the approach based on your culture strategy goals resources Development of the pathway is very important & pathway document has to standardize the change Top-down commitment of the management needed Ownership of clinicians (including physicians) Continuous Follow-up European Pathway Association,

24 The run for Quality European Pathway Association,