Health Services Research Centre
The Clinical Pathways
Collaborative
Initiative (CPC):
Evaluation Report For
The Capital and Coast
District Health Board
Greg Martin, PhD
December 2010
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Table of Contents
Abbreviations .......................................................................................................................................... 4
Executive Summary................................................................................................................................. 5
1.
Introduction .................................................................................................................................... 6
1.1.
Background ............................................................................................................................. 6
1.2.
Capital and Coast Clinical Pathways Collective Process .......................................................... 6
2.
Aims............................................................................................................................................... 10
3.
Study design and methodology .................................................................................................... 11
Participant recruitment..................................................................................................................... 11
4.
Results ........................................................................................................................................... 12
Presentation of findings .................................................................................................................... 12
CPC group meetings .......................................................................................................................... 12
Interview data ................................................................................................................................... 12
Aims of the CPC process ................................................................................................................... 13
Development of individual CPs ......................................................................................................... 15
CP implementation ........................................................................................................................... 18
Process improvement ....................................................................................................................... 19
5.
Conclusion and Recommendations............................................................................................... 24
References ............................................................................................................................................ 26
Appendix 2 ............................................................................................................................................ 29
.
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Abbreviations
A&M
Accident and medical
ACC
Accident Compensation Corporation
CCDHB
Capital and Coast District Health Board
CP
Clinical Pathway
CPC
Clinical Pathway Collaborative
EBM
Evidence based medicine
EPA
European Pathways Association
GP
General practitioner
HSRC
Health services Research Centre
PC
Primary care
PHO
Primary Health Organisation
SC
Secondary care
Acknowledgement
The author thanks the participants, who gave freely of their time to contribute to this project.
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Executive Summary
In keeping with international and national developments (e.g. The European Pathways Association,
the Canterbury Initiative) the Capital and Coast District Health Board (CCDHB) has begun a move
toward developing integrated care across Primary and Secondary care providers. The Clinical
Pathways Collaborative (CPC) was established to manage the development of Clinical Pathways to
improve communication between clinicians, smooth the patient journey between primary and
secondary care, maximise the efficient use of resources, and promote the best patient outcomes
through the implementation of best evidence-based clinical practice. The ultimate goal being to
achieve improved quality, consistent, convenient and streamlined care for patients closer to home.
For the first CPC development wave, four multidisciplinary clinical networks were brought together
to develop Clinical Pathways for the management four areas of healthcare identified : cancer,
palliative care, gastroenterology/endoscopy, and paediatric-to-adult transition. Each of these area
networks comprised a group of key stakeholders from primary, secondary and tertiary care;
including physicians, nursing staff, and healthcare managers was assembled. The development
process is intended to be clinician-led, to reflect the reality that cooperation between clinicians at
the various levels of care is critical to the success of clinical integration and CPs.
The aims of the current study were to explore the process of bringing together a multidisciplinary
clinical group from across the healthcare spectrum to develop clinical pathways for specific disease
or problem categories. It documents the barriers and facilitators to effective development of CPs
and integration across levels of healthcare, and draws on the experiences of participants to
determine how these processes could be improved.
We conducted a qualitative, process evaluation. The opinions and experiences of key stakeholders
(i.e. representatives from primary, secondary and tertiary care, health service managers) on the
clinical pathway development process were canvassed by semi-structured interview.
There was a general consensus reported by participants was that it was good to get representatives
of primary and secondary care in the same room, and talking face to face. Comments reflecting this
were made by all, including those participants most sceptical of the process, and those who judged
the current process to have been of limited success in achieving its change goals. The process is seen
to have potential to improve clinician understanding and communication, improve patient
management, and increase efficiency.
A number of less successful aspects of the current process were identified and suggestions for
improvements provided. These are documented in the report in the form of direct quotes from
those involved. Principal among the suggested improvements for future CPC projects was clearer
problem definition at the outset; there needed to be more specific aims that were to be achieved.
The topic areas to be addressed needed to be clearer and measurable. It was also suggested that
there should be greater transparency; participants should be fully informed of the goals of the
project prior to participation, including the resource constraints. Logistical and organisational
improvements (e.g. set meeting times; encouraging consistent attendance by participants) were also
suggested. It was suggested that future groups formulate the questions very early on so they have a
very clear idea of what they are trying to improve and how they are going to measure that
improvement.
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1. Introduction
1.1. Background
Integrated Care (or Clinical Integration) has become a widespread goal across health systems and
countries in response to the common challenges of the 21st century: an ageing society, long term
conditions and multiple morbidity (Chan & Webster, 2010; Bower, 2009; Ryall, 2007), and as a result
of concerns over fragmented care arising from the multiple organisations and professional groups
involved in delivering health care services. Numerous projects and a great variety of models have
been developed over recent years to overcome systemic, professional, organisational and cultural
barriers in order to smooth out patient clinical pathways and information flow and ensure equitable
provision of high quality, clinically effective services (Vanhaecht, et al., 2006; Rotter et al., 2007). Of
course this does not come without frictions, and even when integration projects have proven to be
successful, obstacles remain to be solved, such as managing the change and sustaining innovations.
1.2. Capital and Coast Clinical Pathways Collective Process
In keeping with international and national developments (eg. The European Pathways Association,
the Canterbury Initiative) at the Capital and Coast District Health Board (CCDHB), and its partner
organisations, there is an emerging move toward developing integrated care across Primary and
Secondary care providers. This is not just to look at clinical care pathways but also the priorities for
change; collaborative ways of working; value for money; health worker development; and most
importantly improved quality, consistent, convenient and streamlined care for patients closer to
home.
For CCDHB and its partners, clinical integration is:



A descriptive term for primary care physicians, specialists and hospitals working together to
care for the patient;
A clinician-led program and
A system to measurably improve patient care.
The clinical integration project at CCDHB focuses on better defining clinical pathways through
collaboration of clinicians across the healthcare spectrum. These pathways in turn aim to reduce
needless referrals and hospital visits by ensuring ready access to diagnostic and specialist support in
primary care and community settings.
The development of clinical pathways in the promotion of evidence based medicine and equity of
access to health services is now well supported in the literature (Panella et al., 2003; Rotter et al.,
2007; Gray, 2008; 2009). Clinical pathways (CPs) are multidisciplinary care plans that outline the
sequence and timing of actions that are necessary for achieving expected patient outcomes and
organisational goals regarding quality, costs, patient satisfaction, and efficiency (El Baz et al., 2007).
CPs provide specific guidelines for care that describe treatment goals and define a sequence and
timing for meeting those goals efficiently.
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According to continuous quality improvement principles, CPs stress the improvement of clinical
processes in order to improve clinical effectiveness and efficiency. Thus, CPs are clinical
management tools used by health care workers to define the best process in their organisation,
using the best procedures and timing, to treat patients with specific diagnoses or conditions
according to evidence based medicine. As a consequence, the introduction of CPs could be an
effective strategy for health care organizations to reduce or at least to control their clinical
performance variations (Panella et al., 2003).
In keeping with the policy direction of the NZ Government’s “Better, Sooner, More Convenient”
discussion paper (Ryall, 2007), CCDHB for the first wave, brought together four multidisciplinary
clinical networks (the Clinical Pathways Collaborative) to develop CPs for the management of each of
the four areas of healthcare identified : cancer, palliative care, gastroenterology/endoscopy, and
paediatric-to-adult transition.
These four initial work-stream areas were endorsed by the Primary Secondary Clinical Governance
Group; the oversight body which was established in February 2008 (with revised terms of reference
in September 2009) to oversee the development of clinical integration. The purpose of this group
was described as:
“The Primary/secondary Clinical Governance Group will ensure patient outcomes are
maximised by improving quality and reducing risk across the patient journey though
Primary/Secondary/Tertiary systems”
It was noted that the clinical Pathway collaborative would:
“feed information to this group for support, agreement to move forward, funding issues and
evaluation of change purposes”
A number of specialities expressed interest in being involved in CPC development for issues
including gastroenterology, opthamology, dermatology, heart failure, paediatric surgery, palliative
care, breast cancer diagnosis, discharge planning, neurology, general surgery, cancer (bowel and
lung pathways) and respiratory. To enable a transparent process for the identifying the four initial
CPC work-streams areas to pursue, the Primary Secondary Clinical Governance Group used a set of
evaluation criteria to identify the most appropriate candidates. These criteria included: clinical risk,
sub-optimal clinical performance, willingness to participate, funding available, limited cost
implications (if known), measureable outcomes, and fit to C&C DHB plan. As noted above the areas
identified were cancer, palliative care, gastroenterology/endoscopy, and paediatric-to-adult
transition.
For each of these area networks comprised a group of key stakeholders from primary, secondary and
tertiary care; including physicians, nursing staff, and healthcare managers was assembled. The
development process is clinician-led, to reflect the reality that cooperation between clinicians at the
various levels of care is critical to the success of clinical integration and CPs.
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The CCDHB process involves process involves:
A timed structured programme of 6 meetings over 15 weeks leading to an implementation plan for
3-4 key priorities for action (see Figure 1 for a schematic).




The first two meetings will be with clinicians from Primary and Secondary care to discuss
issues, challenges, and opportunities for improving the patient pathway for a specific area
by improved collaboration and cooperation. This will aid better understanding or roles,
respect for peers issues and develop key relationships.
Subsequent meetings with clinicians will include other stakeholders who will be involved
with the service to determine pathway details
Production of a priority list for improvements and an implementation plan to establish the
new integrated pathway
A governance structure that includes oversight by the Primary/Secondary Clinical
Governance Group, which provides a reporting line for the Clinical Pathways Collaborative
The four Clinical Pathways Collaborative projects represent an initial phase in clinical integration and
CP development at CCDHB. If this proves successful, further clinical integration and CP development
projects are likely in other areas of healthcare, e.g. respiratory, heart failure, breast cancer,
ophthalmology. A process evaluation of the initial four projects, as set out here, will provide
valuable data to inform the future development of other clinical integration and CP projects.
The CPC Initiative proposal to initiate the CPC process (dated September 2009) sets out a
governance framework, a structure for prioritising work-streams, a process to identify clinicians to
participate in the work groups, a structure and timeframe for the series of meetings themselves, and
it emphasizes the need for measurement and evaluation of outcomes to determine progress. In
addition it identifies a number of areas of risk associated with the process and some potential
mitigation of those risks.
These risk and mitigation are summarised in Table 2
Table 1
Risk
Financial risk due to:
Will need new monies
Service should move across sectors but funds
cannot follow
Contractual arrangements difficult and need
unbundling.
Lack of participation, unwillingness to
participate. Insufficient representation from
either side.
Mitigation
Expectations of new monies must not be
raised.
Information on budgets to discuss
reinvestment should be available.
Include finance/ contract personnel in
discussions as early as required.
Ensure information is shared re context;
process; outcomes and governance, along
with support from Executive level.
Arrange and provide facilities at a mutually
convenient time with refreshments and
timeframes.
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Cultural and poor inter-relationships
between professionals.
Lack of information on specific aspects of
service/pathway.
Pathway development covers sub regional
areas.
National and regional bodies developing
alternative pathways
No demonstrable or measurable
improvement in patient pathways
Lack of implementation
Obtain accreditation sign off for CME points
for Clinicians and certificates of attendance
for other Health professionals.
Follow process with timelines. Ensure all
participants have time to speak and all
opinions are respected and valued.
Provide access and availability of data and
information if requested.
Ensure participation from clinical body for all
involved areas. Provide alternative
governance from other existing forum’s for
overseeing if appropriate.
Clinical advisors maintain relationships with
national processes under development.
Strong facilitation.
Careful prioritisation to ensure linkages to
priorities and funding availability. Clear
implementation plans developed as part of
process
The extent to which these risks were apparent and/or effectively managed in the four work-streams
will be considered in relation to the interview data and the outcomes of the group processes.
The intent of this project is to provide the CCDHB with policy and clinically relevant information on
the processes involved in the development of CPs, the benefits of CPs being developed in this way,
and the challenges faced in the development phase, and to contribute to the refinement and
continuous improvement of the pathways so developed. The project also provides information
about the overall challenges faced in aiming to better integrate care across existing services and
providers.
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2. Aims
The aims of the study were to explore the process of bringing together a multidisciplinary clinical
group from across the healthcare spectrum to develop clinical pathways for specific disease or
problem categories. It documents the barriers and facilitators to effective development of CPs and
integration across levels of healthcare, and draws on the experiences of participants to determine
how these processes could be improved.
The results of the study are intended to directly aid the CCDHB in further development of additional
clinical pathways and integration projects, in addition to improving services through the coordinated
implementation of evidence based practice.
Our key research questions were:

What are the strengths and weaknesses of the governance and clinical network
arrangements being developed by CCDHB and its partner organisations, in relation to the
overall aims of improving integration of services?

What issues (barriers and facilitators) are there in relation to integrating services in the four
clinical areas where networks have so far been established? What implications do these
issues have for future integration?

What lessons can be learned from the initial CPC development streams and how can this
contribute to an improved process and implementation of future CPC efforts?
The ultimate aim of the study is to contribute to development more effective health service delivery
across and between all levels of health care for specific areas of need through examination of the
development process of clinical networks and clinical pathways. It will provide quality evidence to
decision makers and clinicians regarding the development of networks with the aim of improving
integration of services. This will explicitly aid in the translation of knowledge into “best practice” as
evidence-based clinical pathways are developed which will maximise outcomes by improving quality,
increasing efficiency, and reducing risk across the patient journey through Primary/Secondary
systems.
The contribution of the study is to support the development of efficient systems that will contribute
to improved healthcare and improve equity of access to health services through a reduction in
practice variation, and the promotion of collaborative clinical pathways.
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3. Study design and methodology
We conducted a qualitative, process evaluation. This qualitative method is appropriate for exploring
and understanding different people’s perceptions and experiences of the clinical collaborations
(Cresswell, 2009) and it involves an assessment of the processes involved in the clinical
collaborations and how well these collaborations are seen to be likely to achieve the key goals set
down for them.
The research involved two key methods – document review and key informant interviews. Key
documents examined included the terms of reference for the collaborations and minutes from the
governance groups and collaborative network meetings.
The opinions and experiences of key stakeholders (i.e. representatives from primary, secondary and
tertiary care, health service managers) on the clinical pathway development process were canvassed
by semi-structured interview (the interview schedule is attached as Appendix 1). All interviews were
recorded and transcribed for further analysis. Some quantitative data was collected in the form of
Likert scale assessment of key questions (e.g. overall satisfaction with the process, perceived
usefulness of the Care Pathway developed; extent to which the process was collaborative rather
than “top down”). Both documents and key informant interview transcripts were analysed using
thematic techniques, using the research and interview questions to guide the analysis, as well as
identifying new themes inductively from the data itself.
The research documented key activities involved with the collaborative networks, and analyse the
findings from the document analysis and interviews to identify the strengths and weaknesses, and
ways of improving, clinical network processes at CCDHB. It will also identify any key issues that arise
in relation to the aim of increasing integration of services across providers.
Participant recruitment
A list of work group participants and their contact details was provided by staff from CCDHB Planning
and Funding. Recruitment efforts were conducted in such a way as to ensure a mix of
representatives from the primary and secondary care, and senior health service managers.
Potential participants were approached, initially by email, and subsequently by telephone. Up to
four attempts were made to establish contact with each individual before they were considered
non-responders. Of the 25 potential participants contacted, four declined to be involved, one had
left the country, and five were unable to be contacted or did not respond, leaving 15 participants
who completed interviews.
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4. Results
Presentation of findings
The presentation of findings will be broadly structured as per the interview schedule. The questions
will be briefly restated and, where possible, a summary of the central theme of the responses will be
provided in addition to a selection of verbatim answers to illustrate the responses.
In some cases there is a degree of thematic unity around the responses received. In many other
cases, however, there was a broad diversity of opinion and as such responses will be reported to
reflect this diversity. In certain cases, questions were skipped due to many respondents being
unable to provide an answer; this will be noted, as appropriate.
It should be noted that the four CPC groups reported on here addressed very different CP issues and
this is reflected (and noted) among the responses. Where appropriate it will also be noted whether
the participant is a representative of primary health care (PC), secondary health care (SC) or health
management (HM).
CPC group meetings
The background document describing the CPC meeting process which was presented to the Primary
and Secondary Clinical Governance Group (September 2009; included as Appendix 2) recommended
a series of six CPC group meetings over a period of some 16 weeks. Despite an ostensibly similar
CPC development process, it was clear that the groups progressed differently. The Cancer group
met three times in total while the Palliative Care group met up to seven times (plus some additional
“offline” sub-group meetings).
The relatively low number of meetings held by the cancer group was in part due to delayed starting
and logistical issues within the hospital oncology department, rather than a lack of will.
Interview data
Prior to addressing specific questions and themes it is worth noting that a universal theme reported
by participants was that it was good to get representatives of primary and secondary care in the
same room. Comments reflecting this were made by all, including those participants most sceptical
of the process, and those who judged the current process to have been of very limited success.
“The great thing is that it does get both primary and secondary together, and talking. And I
think that’s really useful. It’s nice to see people face-to-face, actually, rather than just email
all the time. It provides a good forum...for everybody to put their ideas on the table and
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discuss them. There’s a lot from the hospital point of view that we don’t understand in
general practice....and I think that there is a lot they don’t understand” (PC)
“It was good that representatives of primary and secondary care got together in the same
room. There was no bad vibe between primary and secondary doctors”. (PC)
“meeting the GPs was good – we don’t usually get to meet them; it was good to meet a
motivated group of GPs” (SC)
“getting people together was good – to get a sense of what the issues are. It was mandated
by the CEO and Board so it had high level support” (SC)
“I think having the clinicians both primary and secondary get together in the first instance to
talk about what the issues are, what the outcomes are looking for and therefore what some
of the solutions might be is really good. Because you usually find then that they have quite a
frank, open discussion without worrying about funding and all those things that get in the
way. And then bringing in the operational management side and the funding side a bit
further into the process is good” (HM)
Aims of the CPC process
What do you understand to be the background to the CPC?
Most participants had some comment on the background of the CPC, though the understanding of
the background and aims of the group varied widely. Some expected specific issues to be addressed
while a number of others were unaware of or unclear about the group aims. Most had only a vague
or general notion of the aims of the CPC process.
“For us it was very specific, they were looking at the interrelationship between primary and
secondary care but within that, through Gastro, there were already some identified issues. So
it wasn’t a nebulous start, you had a very definite start with, what can you do about referral
numbers? Are there ways we can reduce the number of referrals?”
“I didn’t really know why we were there and who had called this together. Was it the DHB or
was the Gastroenterology clinic, or was it GPs, and what was the aims of it............I got the
feeling early on that there were people sitting around this table that don’t want to be here”
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“I understood it was to foster some understanding between primary and secondary care to
see how we could move forward, I guess, in giving patients the best treatment, but also
perhaps also taking some of the burden off secondary care....moving it a bit more into
primary care. And also i think it was an opportunity to have a bit of a discussion and perhaps
forge a few links” (PC)
“As much as possible between primary and secondary care...in agreeing on what the
evidence based pathway is and getting to a common set of principles or actions that would
occur prior to each step to actually make the continuum better for the patient but also the
most efficient use of resource.”
“...it was about facilitating interaction between primary and secondary clinicians”
“no idea....I was invited to join”
What were your expectations of the CPC?
Expectations of the process were mixed, with some scepticism but also considerable evidence of
good will.
“I don’t think I had any”
“..to me, that’s how I perceived it....looking for efficiencies. Can we achieve the same
outcomes in different ways”
“expectations were minimal due to being involved in other projects within the DHB that
become a talking shop and go nowhere....resigned to ‘here we go on anther process’. And
what is that is going to be different with this process? When we look back in two years and
see that nothing has changed. People left...senior management leave...there isn’t
funding...the politics remains the same”
“I certainly had expectations that <we> would come up with some ideas that we would be
able to implement and that it would better define what could be done in primary versus what
we’re doing currently, in secondary”
“My expectation was...I imagined there must be some issue with access to gastro stuff, or
their ability to provide a service....and we were trying to work out a way of streamlining or
improving that...but I didn’t know what the problems were, what GPs were saying to the
gastro clinics about where the shortfalls were, what gastroenterology was wanting to get
from GPs, or whether this was driven by the DHB. I suspected it was about saving money......”
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Development of individual CPs
Was the CPC process clear?
As noted above there were differing opinions on the clarity of the expected process. Was the
process clear?
“Yes”
“Not particularly, I have to say. You get on to these committees – somebody says ‘you’ll be
alright, you have some spare time, why don’t you do it’.....I’m not sure we’re always the best
representatives, if you know what I mean”
“I obviously knew it was about oncology; I was a bit hazy on everything else...it was sort of to
increase liaison between primary and secondary and see how things could be improved..”
“I don’t think the specific goals......you can talk about “we need to improve
communication”......you can say “we want to improve patient outcomes” , but what do you
want to improve by? What is the issue? It’s all very jargonised and cliché: outcomes and
measurable and so on, whatever the current words are. Is it about improving cure rates, is it
about patients being happier, is it the community being happier about what is going on.
What is it that you want to improve. And some things might not need to improve; I certainly
got the feeling in the Cancer one that a lot of things are working”.
What were the good and less good things about the CP development process?
Good things:
As noted above, the most commonly cited “good thing” about the CPC development process was
getting people in to the same room to allow a face to face dialogue, exploration of the issues, and an
understanding of each other’s perspective. This was by far the most commonly cited “good thing”
about the process.
“Getting to meet some of the Gastroenterolgists face to face - that was good”
“...we had the clinicians from the DHB and then we had primary care and they all came in
willing with a positive attitude that we can achieve something. So yeah that was good….
There seemed to be administrative support of what’s happening and that doesn’t often
happen in the DHB and that’s how a lot of things fall over, they say let’s do this, then you
turn up and you realise that you’ve got to do everything. Yeah so they seemed to have the
time and funding to do it.”
“Fostering any sort of closer relationship is positive”
“There was an underlying ethos of trying to do the best for the patient..”
15
Looking to see how you can do something better is always a good thing..”
“The potential to streamline referrals.....I would like to see some clear guidelines around
referral for gastroscopy.....we don’t want to make inappropriate referrals but it helps if we
are given guidelines as to what is an appropriate referral”
Less good things
A common theme of the “less good “aspect revolved around the difficultly of having the same
people attend consistently. This led to the revisiting of issues covered in previous meeting and the
need to spend time getting people up to date.
“The group...there was a core who might be present at most meetings.....but....a fairly
essential person was only present at one....people were present for some meeting but not for
others.....I think that was a real failing, it was difficult to get these busy people, as a group,
together at one time”
“To be truly effective you needed the same people to be present so you weren’t reinventing
the wheel – going over old ground...relitigating what had been discussed at previous
meetings”
“The only thing that did vaguely irk me...was that...the meeting nights were changed.....so
that wasn’t very well organised....expectations...you should have some sort of document that
about what the expectations are: how many meetings you are going to go to, what days
they are, what times they are, and stick to that..”
“I think it could have been organised slightly better.....and it would have been nice to have a
final meeting...it just sort of finished...I didn’t feel it was completed”
“we couldn’t get the same group of people together consistently.....so I thought that did
undermine the veracity of it”
“Just the stickability of the clinicians was poor, myself included. I tried…Also I think just the
size of the task. It sounds very simple, do this but actually to do it properly it is actually quite
an involved task. Having to turn a juggernaut around or develop new systems or having
people work a different way… it’s huge. Maybe bite size pieces would have been better.”
“One criticism I would have, or one short fall, is how are we going to measure whether we’ve
done anything? Good, bad and different.”
“We didn't pick narrow enough areas we could deliver on”.
“I got the impression that a lot of this was about improving the cancer patient ‘journey’.
Making it better for the patients. But what do the patients want? Nobody ever asks the
patients. It‘s all very well to say make it better but why not ask the patients?’
“It felt ad hoc”
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<In relation to an earlier report on the Primary/Secondary interface> “In the report he wrote
about 3 years ago were the things that we were talking about in this session........it was like
no-one had read it, or picked up the ball and run with it, or taken any notice of it. It was
extraordinary. So I thought to myself... if someone had taken the time to follow through with
the recommendations, we may not have needed to meet”
Was the CP developed based on evidence and local consensus?
There was broad agreement that discussions were based on evidence and broad consensus, even
when this did not translate into new CPC protocols. For most groups there was no successful
completion and documentation of a CP protocol .
A successful example was the FODMAP diet advice and training that emerged from the
Gastroenerology group, along with guidelines on CT Colonoscopy which are being developed and will
be distributed to GPs.
“A new diet, the FODMAP diet, was discussed and an education session was conducted for
GPs”
“The FODMAP diet was based on the evidence that in diagnosed patients with irritable
bowel syndrome forty percent would improve so we used that as basis for our
recommendation okay if the GP is confident about diagnosis of irritable bowel syndrome
immediately start the diet and see what happens and see if that has an effect on our referral
process and see if it has an effect on patient management for GP perspective. The CTC is
based on best practice”.
Other groups were less successful in developing CPs, although after-hours medication availability
was successfully addressed in the Palliative Care group.
Was the process collegial or imposed top-down? (Were all voices listened to?)
“I think it was sort of collegial.....the discussions around the table were collegial...we (GPs)
certainly respect the knowledge of our specialist colleagues.....I think it comes back to this
business of why we were there and did people want to be there...”
“The tone of the meetings was very collegial...it was refreshing..”
“Yes, all voices were listened to”
How effective was the workgroup facilitation?
Some groups found the facilitation to be excellent where others were less satisfied. This seemed to
differ across groups, with the members having differing opinions.
“From the meetings I attended I thought it was very good, ongoing follow up, emailing
updates and new information… that was what I was alluding to before that it seemed to
17
have the right back up which was a bit of a surprise… We might be talking about something
and say look is there an article that can help us out here, is there some data that we need
and that would be circulated in the group.”
“I think it was poorly facilitated”
“The facilitation was irritating.... drove it in a preconceived direction...and in the wrong
direction”
“The facilitator was excellent. Her style of engaging with people and her ability to bring
people together who may not have known each other very well, particularly primary and
secondary medical clinician”
“..the woman who facilitated it; she had a really difficult job and she actually did quite well.
She was good at trying to sum up what had been done, and sending out the mails....keeping
people in the loop, trying to keep the meetings on track, identifying the areas we thought
we’d look at and trying to get some outcomes in those areas...... but it was all a bit ‘waffly”’
really, I mean, the whole thing was a bit ‘waffly”
Is the CP documentation clear? Do you have a written CP protocol? How could it be improved?
No written CP protocols were available at the time of interview.
What monitoring and evaluation of variances from the pathway is included in the CP?
(e.g. timeframes, availability of appropriate medications)??
Who is responsible for variance analysis/detection and response?
No variance analysis was built in to the pathways as they were at an early stage of development, and
do not necessarily lend themselves to that model
CP implementation
The initial design of the evaluation included consideration of the issues surrounding the
implementation of the CP projects developed in the earlier phase, to see what could be learned
for future implementation processes.
At the time of evaluation, however, no CPC had begun implementation, although the
Gastroentetrology group was in the process beginning to do so with the FODMAP diet and the
CT Colonoscopy guideline.
Other CPCs were either still in development or were on hold following staff changes.
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Process improvement
What should future CPC development projects do differently?
Participants had a broad range of suggestion for how to improve the CPC process; these focussed on
clarity of purpose, definition of aims and goals, and choosing appropriate specific, measurable and
achievable goals.
Many of the participants recommended that the people involved in the development of CPC projects
have a much clearer idea of the content of the discussions before the first meeting:
“Before it started I’d like to know, first, whose idea it was, what the perceived problem was,
and what the aims of the group were. So, in this case it might have been useful to know, for
example, that P&F had called for this group, maybe that it was thought that there were too
many inappropriate referrals, or maybe they thought that the waiting times were too long,
or maybe they were wanting to save money and we were potentials for savings...and how is
this going to impact on general practice and how is this going to impact on the
gastroenterology clinic.” (PC)
“I think that people...before they came to the meeting should actually have garnered some
ideas or identified areas that could be improved on so we came to the meeting having
already identified a number of areas, and we thought that those identified would probably
be similar to what our colleagues identified – so that we could use our time more
efficiently”.....(SC)
“Maybe formulate the questions very early on so you have a very clear idea of what you are
trying to improve and how you are going to measure that improvement.” (SC)
“Before it started... I would have liked to have got something in writing to look at before it
started.” (PC)
“Having background material to read prior to meetings would be god...to feel prepared.”
(PC)
“I think it might have been better if, as GPs going in to it, we had more of a feel of what our
colleagues wanted....I talked a little bit to my peer review group but that was really after the
process had started. If we are representing general practice it would have been be nice to
have some more generalised views. So I suppose I felt a bit under-prepared.” (PC)
As documented above many participants commented on the need to have stable groups and regular
participation.
19
The first meeting was highlighted as being of particular importance by some of the interviewees as a
time to define the scope and direction and provide a framework upon which other meetings are
based:
“At the start there should be a sort of definitional exercise; maybe, from a general practice
point of view, what are your issues?.... from a gastroenterology point of view what are your
issues?... from a Planning and Funding point of view, what are your issues? Then everyone
has put it out there and weca look at how we can go about solving some of these.” (PC)
“The first meeting and the last meeting is really important. At the first meeting you have to
set the agenda, say why you are there and what everybody’s expectation are....” (PC)
“First meeting should give a framework for the rest of the meetings and formulate some
ideas that you can then add on in the next meetings...” (PC)
“The initial findings of areas of interest should be identified by clinicians....otherwise be up
front and say the purpose of the meeting is to save us money, which was never said as being
involved. It was not set up as a goal....if it is not transparent what the process is then we
can’t really engage”
A related issue that emerged very strongly was the requirement to have clear and appropriate goals
set out about what is being attempted to be achieved. This is where the participants showed the
clearest unity in their opinions.
“Clinical pathway means something different to me...I didn’t really feel that the patients
pathways was clarified...what do you do here and what do you do there...how can we speed
up the process. It was a lot more of a morass, it went around and around” (SC)
“They needed to have much more specific goals that they wanted to achieve...they need to
know what they are evaluating. You have to be measure it.” (PC)
“There need to be clear parameters about the what it is the needs to be sorted. Is it a clinical
question that needs to be answered; or is it a process that you want to change, alter or
improve; or is it just a discussion to get an opinion.” (PC)
“You need to be a lot more specific about the questions being asked of the people in the
group.” (PC)
“Clear objectives” (PC)
They need to have much more specific goals that they wanted to achieve...they need to know
what they are evaluating. You have to be measure it (PC)
“I think it would be easier if there was one clear problem to be addressed” (PC)
“Membership correct to begin with and they need to be clear on the parameters – everyone
needs to understand the parameters. What's the resources available?”
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“Better pick on what topics … we're going to develop them (CPs) for.” (HM)
“What we've actually picked for CPC were areas – we should have done that instead of
dumping it to the group because what we had when we dumped it to the group was just too
many personal interests on that – it needed to be pushed above that”. (HM)
This the implications for future CPC project related to this issue is perhaps best described by this
participant:
“I think in the future, from my perspective, it would be really good ... get together a group,
maybe manager and clinicians and people who are interested and say" 'what is the problem
here? and which part of this process to we want to put through a CPC process? and what
outcome are we looking to achieve, really?" ... If we know and truly understand what the
problem is then there might be 6 or 7 pieces of work are needed to find a solution to that
problem, and maybe you can't do all 6 of them or maybe there are 2 or maybe there is just
one there that might help solve all the other problems or issues - or in fact maybe the
problem definition is too broad anyway, and maybe there is a very specific component of
that greater problem definition that we want to put through that process to get to an
outcome....We need to define the problems much better.
Other comment s also relate to this issue:
“Membership correct to begin with and they need to be clear on the parameters – everyone
needs to understand the parameters. What's the resources available?”
“Set up evaluation before and after – really clear. What's the point of doing something if you
don't know if it worked?”
“I don't believe the pediatric → adult is really a CPC – can't do an algorithm”.
“We went for quite a consensus way of what we're going to do a CPC on – I would have
picked a much narrower range of things... I'd be picking a disease and condition and how
you'd manage that. But then I have a 2 fold bias – I run a hospital, and that's what I saw as
worked before coming here”.
The need for general transparency of the agenda, particularly as this related to resourcing was
mentioned by a number of participants. This may have been relieved if clearer description of the
overall process (as outlined in the Primary secondary Clinical Governance Group documents) had
been provided.
“The initial findings of areas of interest should be identified by clinicians....otherwise be up
front and say the purpose of the meeting is to save us money, which was never said as being
involved. It was not set up as a goal....if it is not transparent what the process is then we
can’t really engage” (SC)
“The process needs to be made more transparent...with the cards on the table” (SC)
21
“The reality is that you need to know what the financial constraints are......I’m a pragmatist”
(PC)
“If it is a budget, then you need to know, where is the most money being spent, where within
the budget are you able to chop. The financial agenda should be clear; I think we are all
aware that there isn’t a bottomless pit of money.” (PC)
“If me to tell you about how to cut the budget, say so; don’t tell me it’s about
communication or patient satisfaction.” (PC)
“I’d be more inclined if it wasn’t coming from planning and funding; so it wasn’t something
that was “lets save money”, if there was an obvious problem that clinicians had identified
and they were wanting help from GPs to come to a solution; then i think they would have
been more interested in finding outcomes.” (PC)
“Probably in the future we would really benefit from describing, in a big picture way, what it
is we're trying to do and that's all about linking all of this to a strategy of sorts ... you present
that bigger picture in a summary to people you've been invited to come to the party and
they're much clearer about what their role is...” (HM)
“We could have provided more executive leadership..”. (HM)
General Additional Comments about Primary/Secondary Communication
There was considerable discussion from the GPs about computer systems and the possibility of them
being used to a much greater extent to improve communication and collaboration between primary
and secondary care
“one of the recommendations that should come out of our meeting is that attention should
be given to their <the hospital> IT system(s)..”
“There was a discussion about the new pathway that will happen when all the IT systems are
up and running and that there will be far more electronic communication...and you wonder,
maybe they should address that first..and then see how that could be manage. They are going
to an electronic system between GPs and the hospital and back...that will change the nature
of how we do things....”
.
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5. Conclusion and Recommendations
There was a general consensus reported by participants was that it was good to get representatives
of primary and secondary care in the same room, and talking face to face. Comments reflecting this
were made by all, including those participants most sceptical of the process, and those who judged
the current process to have been of limited success in achieving its change goals. The process is seen
to have potential to improve clinician understanding and communication, improve patient
management, and increase efficiency.
The C&CDHB CPC process, as outlined in the document submitted to the Primary Secondary Clinical
Governance group is clear and based on other national and international best practice CPC
development processes. It seems that in this initial series of CPC developments, the development
phase did not follow the specified process as closely or successfully as it might have optimally.
Valuable lessons can be learned for how the first CPC processes evolved.
The interview data reveal key themes and lessons that could be applied to future CPC developments.
The first is that in the clinical participants’ eyes, there should be a clear purpose and a well
understood rationale for being involved in the CPC process that is clearly and fully communicated to
them prior to the beginning of the process. According to some participants, they were unclear as to
the aims and goals of the CPC and it parameters. Future CPC developments should ensure that all
participants are fully informed of the rationale and aims of the process, in detail and preferably in
writing, to remove any misunderstanding of the motivations of the process. The resource
implications (i.e. financial boundaries) of the process should also be made clear to participants from
the outset. The need for transparency of process was a common theme in this project. This could be
assisted by careful choice of participants and ensuring that groups are not brought together ad hoc,
without sufficient information about what they will involve. Written invitation to participate, with
full project description, may be preferable to , for example, a brief telephone invitation.
The appropriate choice of members of a group was also discussed by some participants and
recognised as a potential risk by C&CDHB planning documents. In particular a common theme of the
“less good “aspects revealed in this project revolved around the difficultly of having the same people
attend meetings consistently. This led to the revisiting of issues covered in previous meetings and
the need to spend time getting people up to date. While this is to some extent unavoidable, future
groups should attempt to obtain a reasonable level of commitment from participants to maintain
their involvement, and set a firm timetable.
The principal lesson to emerge from this study is that future CPCs would benefit from including a
clearer, more specific problem definition; work areas that can be defined, operationalised and
measured. While there still exists considerable debate in the literature about the nature of “clinical
pathways” (Vanhaecht et al., 2006; Gray, 2009), it is clear that being able to define them at a
functional and operational level is key. The most common concerns with the C&CDHB CPC process
was the lack of clear problem definition. The notion of “improving paediatric to adult transition”, for
example, is a type of “meta goal” that can be conceived of as consisting of smaller more clearly
defined aspects which can be pursued individually. The Christchurch Initiative has produced a
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significant number of pathways for various clinical areas; it may be that the approach they have
taken – very tightly defined problems areas and responses – is the way to make incremental
progress toward the larger strategic goals of improving patient outcomes and maximising the
efficiency of resource use in both primary and secondary care.
25
References
Bower, K.A. (2009). Clinical pathways: 12 lessons learned over 25 years of experience. International
Journal of Care Pathways,13, 78–81.
Chan R,Webster J. End-of-life care pathways for improving outcomes in caring for the dying.
CochraneDatabase of Systematic Reviews 2010, Issue 1. Art. No.: CD008006. DOI:
10.1002/14651858.CD008006.pub2.
Creswell, J.W. (2009). Research design: Qualitative, quantitative, and mixed models approaches (3rd
Ed). Los Angeles: Sage.
Cropper, S., Hopper, A. & Spencer, S.A. (2002). Managed clinical networks. Archives of Disease in
Childhood, 87, 1-4.
El Baz, N., Middle, B., van Dijk, J., Oosterhorf, A., Boonstra, P. & Reijneveld, S. (2007). Are the
outcomes of clinical pathways evidence-based? A critical appraisal of clinical pathway evaluation
research. Journal of Evaluation in Clinical Practice, 13, 920–929
Feuth, S. & Claes, L. (2008). Introducing clinical pathways as a strategy for improving care. Gray, J.
(2009). The future of care pathways and their journal. Journal of Integrated Care Pathways, 12, 5660.
Gray, J. (2008). It’s not what you do, it’s the way that you do it. Journal of Integrated Care Pathways,
12, 43-44.
Gray, J. (2009). The future of care pathways and their journal. International Journal of Care
Pathways, 13, 1-6.
Panella, M. (2009). The impact of pathways: a significant decrease in mortality. International Journal
of Care Pathways, 13, 57-61.
Panella, M., Marchisio, S. & Di Stanislau, F. (2003). Reducing clinical variations with clinical pathways:
do pathways work? International Journal for Quality in Health Care,15, 509-521.
Rotter, T., Koch, R., Kugler, J., Kinsman, L., & James, E. (2007). Clinical pathways:effects on
professional practice, patient outcomes, length of stay and hospital costs. Cochrane Database of
Systematic Reviews 3, CD006632.
Ryall, T. (2007). Better, sooner, more convenient: Health discussion paper. Wellington: Office of the
Leader of the Opposition.
Vanhaecht, K., Bollmann, M., Bower, K., Gallagher, C., Gardini, A., Guezo, J., Jansen, U., Massoud, R.,
Moody, K., Sermeus, W., Van Zelm, R., Whittle, C., Yazbeck, A.M., Zander, K. & Panella M. (2006).
Prevalence and use of clinical pathways in 23 countries-an international survey by the European
Pathway Association. Journal of Integrated Care Pathways, 10, 28-34.
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Vanhaecht, K., De Witte, K. & Sermeus, W. (2007). The care process organization triangle: a
framework to better understand how clinical pathways work. Journal of Integrated Care Pathways,
11, 54-61.
Verkerk-Geelhoed, J. & Van Zelm, R. (2010). What competencies are needed by operational
managers in managing care pathways? International Journal of Care Pathways, 14, 15-22.
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Appendix 1
WEEK
CLINICAL PATHWAY COLLABORATIVE
Step 1:
Gather information from service
providers/clinicians and identify wave 1
Use clear transparent process to identify
first wave participants
5
Step 2: Meeting 1
Primary and Secondary Care Clinicians
Presentation on background/context free to
discuss issues: challenges: concerns
7
Step 3: Meeting 2
Relevant Key Stakeholders and Clinicians
Continue discussion from above and
priority list for improvement described
9
Step 4: Meeting 3
Relevant Key Stakeholders and Clinicians
Clinicians present issues/priorities and
open discussion. Review priority list and
requirements for change
11
Step 5: Meeting 4
Relevant Key Stakeholders and Clinicians
Repeat above and discuss. Finalise
priorities list with plans to implement change
including identifying any resources required
13
Step 6: Meeting 5
Relevant Key Stakeholders and Clinicians
Finalise implementation plan with key
responsible roles agree output measures
1-3
19
Step 7: Meeting 6
ALL
Evaluate and Impact
Analyse Outcomes
Present to Primary and
Secondary Clinical
Governance Group
Present to Primary and
Secondary Clinical
Governance Group
Appendix 2
August 2010
Clinical Pathways Collaborative
Evaluation Project
Clinician/Stakeholder Interview
The following guide provides an outline of the topics that will
be covered. The questions are indicative of the subject
matter and are not verbatim descriptors of the interviewer’s
questions. Introduction
Explanations of the use of the evaluation data
Comments
Report to C&CDHB
Appreciation of contribution
Confidentiality and procedure of the interview [including
the use of audio equipment]
Confirmation of the duration of the session
Establish parameters
0.5 to 1 hour
Thank you for agreeing to be interviewed as part of the Clinical
Pathways Collaborative Evaluation. The purpose of the interview
is to examine how individual practitioners and other stakeholders
feel about the development of the CPC projects, how it is
affecting your practice, and how future CPC projects could be
improved.
CONSENT FORM

I agree to be interviewed for this research project by one or two members of the Research
Team.

I agree to the tape-recording of the interview, understanding that the tapes will be heard
only by the research team.

I understand that the discussions will be coded and identifying information will be removed.

I understand that I may withdraw information from the Project at any time.
Signed:_________________________________________
Name:__________________________________________
Date: _______________________
Please note: The Wellington Regional Ethics Committee has agreed that this research does not
require formal ethics approval. A copy of their letter is available on request.
30
1.3. 1. Participant’s role in the CPC structure and process
Which CP are you involved with?
Palliative care/Cancer/GI-endoscopy/Paedeatric to adult transition?
Your role:
Clinician? Primary/secondary? Clinical team leader?
Health manger?
Were you involved as a member of the Primary Secondary Clinical Governance Group?
How many workgroup meetings did you attend?
How useful were they?
1.4.
2. Aims of the CPC process
What do you understand to be the background to the CPC?
What were your expectations of the CPC?
1.5. 3. Development of individual CPs
How satisfied were you with the CP development process? Was the process clear?
What were the good and less good things about the CP development process?
Was the CP developed based on evidence and local consensus?
What barriers, if any, were there to the CP development process?
Was the process collegial or imposed top-down? (Were all voices listened to?)
How effective was the workgroup facilitation?
In your opinion does the CP clearly specify the desired goals and outcomes for
patients and the care activities needed to achieve these goals?
How do you feel about the recommendations?
Is the CP documentation clear? Do you have a written CP protocol? How could it be
improved?
What monitoring and evaluation of variances from the pathway is included in the CP?
(e.g. timeframes, availability of appropriate medications)??
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Who is responsible for variance analysis/detection and response?
1.6. 4.CP implementation
How are the new CP processes working?
If the CP(s) have not been implemented, why not?
What are the characteristics of the CP that have been most useful and those that have been
least useful?
What were the implications of the new CP for service delivery and for your practice?
What barriers/difficulties were there in implementing the CP?
In what way and to what extent have patient outcomes been (or will be) improved by the
CP? How would we know?
How important it is to formally evaluate the outcomes from the individual CPs.
1.7. 5. Process improvement
What should future CP development projects do differently?
How could the process of CP development have been improved?
How could the implementation of the CP been improved?
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What processes might be included to promote ongoing quality improvement?
1.8. 5. Quantitative evaluation (on a scale of 0 to 10)
How satisfied are you with the CPC development and implementation process overall?
On a scale of 0 to 10, where 0= not at all satisfied, and 10 = extremely satisfied:
How useful is the CP that has been developed?
On a scale of 0 to 10, where 0= not at all useful, and 10 = extremely useful
How successful has the CPC project been in smoothing out patient pathways and information flow
between clinicians and health services providers at all levels of the system?
On a scale of 0 to 10, where 0= not at all successful, and 10 = extremely successful
How successful has the CPC project been in improving patient experience of treatment? (or will
be if implemented)
On a scale of 0 to 10, where 0= not at all successful, and 10 = extremely successful
How successful has the CPC project been in improving patient outcomes? (or will be if implemented)
On a scale of 0 to 10, where 0= not at all successful, and 10 = extremely successful
Summary of key findings. Invitation to raise any other issues/comments
Thank and Close
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