Performance-based models for health care reimbursement are designed to promote and reward an efficient allocation of resources as well as to ensure quality.1 One such model is based on adherence to predetermined clinical care pathways, which are designed to optimize care decisions in order to improve the quality of care while controlling costs. Clinical pathways are becoming more important as the standards for quality care become more stringent. Common goals of clinical pathways are to achieve quality metrics such as reducing redundant activities and reducing the total number and the length of hospital stays.2 A clinical pathway contributes towards improving quality and, as a result of better patient compliance, could promote the effective and efficient use of resources. Moreover, the need for the efficiency and effectivity that clinical pathways provide increases as hospital stays tend to get shorter, the number of patients increases due to demographic changes, and remunerations decrease. As a result of these changes, pathways are likely to become more important in the ambulatory setting.
Clinical pathways and personalized medicine
Addressing cost in clinical pathways
As the clinical pathways concept gains prominence, several concerns with their use have arisen. Many have voiced concerns about increased economic pressures in health care reducing physicians’ freedom to make care decisions autonomously.3 In the development of clinical pathways for care, medical and economic perspectives are often considered equally;1 this sometimes poses the challenge of harmonizing seeming opposite ends. Additionally, while health care provision is often based on recommended best practices and treatments outlined in clinical practice guidelines, clinical pathways go further by making recommendations of certain practices over others; this is seen as a means of synchronizing efforts to both standardize and personalize care. But standardization can pose a risk for those providing the treatment as well as to patients in cases in which pathways are applied inappropriately to individual cases that require specific considerations and treatment adaptations.4
The success of a treatment and its measurement are of great importance to all stakeholders, including health care providers, patients, patient advocates, payers, scientific societies, boards, and agencies.5 Patients are increasingly requesting to be more involved in health care decision-making processes.6 Because clinical pathways have to serve the needs and satisfy the expectations of a variety of stakeholders, the viewpoints of these stakeholders must all be considered in pathway development and implementation.7
In this context, the various functions of pathways have to be considered. These may include: (1) checklists for nursing and functional services; (2) clinical standards for diagnostic and therapeutic decision aids for medical personnel; and (3) instruments for process planning and for controlling risk, quality, and cost.8 For the patients, they represent an overview about the treatment process and can be combined with patient-reported outcomes (PRO) measurement,6,9 which are very likely to become more relevant for the evaluation of clinical pathways and their adaptation.
The contribution of clinical pathways in the hospital setting has received much attention in the last decade. Some investigations reported finding no direct relationship between clinical pathways and the quality of care or other indicators but suggested that further clarifying studies be conducted.10-13 Overall, a reduction in complications and improved documentation can be demonstrated with the use of pathways, while improvements in costs and in lengths of stay are more difficult to assess due to methodological variations in the publications reviewed, as well as other factors.14,15 Reviews of clinical pathways programs report positive outcomes for length of stay and costs16 as well as an optimization of process control.17 Analyzing the effects of care pathways on the in-hospital treatment of heart failures, Kul et al18 found hospital readmission rates and hospitalization costs to remain rather stable but observed a reduction in mortality rates and length of hospital stays. Zhao and Zang19 make similar arguments and report effects mainly for reductions in hospital-stay length and nursing cost, while other variables remained (more or less) unchanged in a comparison before and after implementing a path for uterine fibroids. The authors highlight that stability might also be equaled to constraining (negative) developments, so a no-change result can be interpreted as a positive effect.19
The effects of clinical pathways still require thorough investigation through studies evaluating economic and clinical issues as well as soft factors like satisfaction levels. Moreover, acceptance of the pathways among care providers as well as patients have to be assessed. For these studies to be done, pathways first have to be implemented in a greater number of settings so that they can be evaluated on a larger scale. However, as Jabbour et al20 noted when summarizing the current state of knowledge: “Best strategies for implementing pathways into hospital settings remain unknown.” This is a major issue, given that pathways already have been in use for a long time. There still are major obstacles to the implementation of clinical pathways in many organizations—mainly the demands on time in a context of already tight schedules, lack of resources, and limited bandwidth of medical personnel.21 The application of different models and theories for change management may serve as a useful approach to overcoming such obstacles to ensure successful implementation of clinical pathways in hospital settings.
APPLYING CHANGE MANAGEMENT CONCEPTS TO CLINICAL PATHWAYS IMPLEMENTATION
Kotter22 suggests that implementing change—in our case, a clinical pathway—within an organization requires using a second operational system that is based on a network approach while leaving the traditional operational system in place for functional processes. Being staffed with volunteers equipped with the necessary resources and highly interconnected with the traditional hierarchical structure, this supplemental structure would focus on eight “accelerators“ (Figure 1): creating a sense of urgency around a big opportunity; building and maintaining a guiding coalition; formulating a strategic vision and developing change initiatives around the opportunity; communicating the vision and the strategy in an attractive way to the organization; facilitating the realization of the vision by removing obstacles; celebrating quick wins, yet not stopping there; and institutionalizing the change culture.22
Inspiring the Need for Change
By creating a sense of urgency, the change promotors enable those who are needed to perform the change to realize its pressing necessity. To demonstrate how this might be done in health care, Campbell23 suggests showing video presentations of current internal problems and their potential lethal effect for patients, visiting Best Practice Sites, and disclosing payment sums for inefficient services or processes. Another approach can be drawn from the concept of Tipping Point Leadership, which suggests that a continuous process to overcome hurdles can bring about rapid, dramatic, and lasting change with limited resources.24 An example of such a continuous process would be to have staff members evaluate the experiences of patients going through the current system and report any required changes.24
Once the benefits of change are realized, a coalition in favor of this change that is ready to take action will evolve. Resnick25 highlighted the importance of having key leaders in this coalition, supported by the top management. She also suggests that leaders “[c]learly articulate how clinical pathways will address market or industry changes in a positive, forward-thinking way” and encourages leadership to be very explicit in laying out the route to change step-by-step.25 Kotter22 provided the following recommendations for coalitions of key leaders:
In successful transformations, the chairman or president or division general manager, plus another 5 or 15 or 50 people, come together and develop a shared commitment to excellent performance through renewal […] In the most successful cases, the coalition is always pretty powerful—in terms of titles, information and expertise, reputations and relationships.22
As Rogers26 noted, the rate of adoption of innovations is dependent on the perceived attributes of the innovation, the type of decision-taking, the communication channels, the nature of the social system, and the efforts of the change agents. A perceived advantage, low complexity, high compatibility with current processes, trialability and observability are attributes in favor of innovations like the introduction of clinical pathways.26 However, these have to be communicated using channels fitting for the target group and the message.27 It has been argued that the personal dialogue is indispensable for reflection, persuasion, solving conflicts, reaching consensus, and realignment, while mass communication can be used for widely distributing basic information.28 It should be noted that all of the positive attributes mentioned above may not be applicable to the clinical processes being implemented in accordance with the pathway. In these cases, a positive vision—for example, becoming the safest possible hospital for patients—is even more important and needs to be communicated authentically by the management.27 As Kotter put it: “Done right, with creativity, such communications can go viral, attracting employees who buy in to the ambition of the message and begin to share a commitment to it.”
Overcoming Barriers to Change
A detailed assessment of barriers to the implementation of clinical pathways specifically identified the following: lack of outcome expectancy; inertia of previous practice; lack of support for rationale behind pathway implementation; complaints that pathways are overly prescriptive; minimal buy-in due to lack of involvement at the design level; and the belief that pathways are detrimental to patient care.21 In order to make the vision of change realizable, these barriers have to be overcome and/or removed. This follows the logic of Lewin29 in his discussion of “field theory,” which is a method of analyzing and modeling causal relationships. Lewin suggested ensuring that the factors accelerating change are promoted while those that could potentially hinder it are weakened or prevented; thereby the current forces in the “field” for change are influenced in a positive way.29
Returning to Kim and Mauborgne’s discussion of Tipping Point Leadership,24 the typical barriers to change encountered are cognitive, political, motivational, or resource-related (Figure 2). Cognitive barriers should already have been dealt with by creating a sense of urgency. Political barriers in the form of opponents of the change can be countered by having a powerful guiding coalition. Motivational barriers, such as feelings of insecurity or being overwhelmed, should be reduced by communicating a step-by-step outline of how the change can be achieved. In this way, the steps for inspiring the need for change can address many potential barriers before they arise.
However, resource-related barriers still pose a potential challenge to the implementation of clinical pathways. Kim and Mauborgne suggest that managers “concentrate their resources on the places that are most in need of change and that have the biggest possible payoffs.”24 This requires a thorough analysis of the resources needed for the type of path to be implemented. Then, superfluous resources have to be identified in other areas of the organization and repurposed. Another strategy is to form strategic coalitions to exchange resources with external partners.24
Celebrating quick wins is vital to sustain employee motivation and keep the impetus for change. As a step of the change process outline is successfully reached, it should immediately be celebrated. According to Kotter,27 the best short-term wins are those that not only are visible and positive but also are clearly related to the vision. However, it is crucial to emphasize that the change has to continue until the goal has been reached and secured.27 Otherwise, the organization will fall short of reaching it.22 Moreover, not reaching the end goal can undermine future change activities by making them seem less credible, which is one more reason why a change culture is of importance.22
IMPLEMENTING CLINICAL PATHWAYS
Although implementing clinical pathways as a proactive measure is highly recommended, changes in institutions often do not occur until there are external or internal pressures. Before changing anything, it is crucial to know the treatment processes occurring within the hospital and have sufficient transparency regarding the resulting costs for medication, therapy, and personnel. This transparency should be guaranteed by the top management.30,31 The data can then be used as a starting point for implementing changes and can guide evaluation studies to demonstrate the effects of the pathways introduced.
Pathways are likely to be easier to implement by using the above approaches, and the users can be expected to be more satisfied with their design. In general, adherence to rules in organizations is associated with participation in their design.32 Choo33 and Vogel/Wilke34 suggest at least providing a presentation of the processes, interfaces, and benefits prior to the implementation of clinical pathways. For demonstrating that pathways make sense, it may help to adopt ideas of clinical pathway analysis and informatics35,36 and show the similar patterns of treatments already delivered. An interdisciplinary effort to develop such a presentation is suggested.21
Acceptance levels are reportedly low among users who are not included in the design process.37 Still, a certain degree of willingness to create standards and adhere to them is a prerequisite, just as innovation advocates who are high up in the hierarchy are necessary. Moreover, an organizational culture focused on learning is an advantage.38,39 Referring to Kotter and Schlesinger,40 Ezziane41 argued: “Stability in healthcare environments is not a goal that leaders should seek; instead, constant processes of evaluating new suggestions while making sure that high quality and safe patient care are provided should be the desired goal. “41
A system for the collaborative development, discovery, and design of clinical pathways may make this even easier to establish.42,43
Finally, given the degree of complexity of diagnoses and settings within a hospital, it might be advisable to reduce expectations regarding the array of potential positive effects clinical pathways can have and accept them as a helpful tool in different areas depending on the circumstances.18,21
As clinical pathways gain attention as tools for improving health care quality and the efficiency of resource utilization in health care settings, the application of different models and theories for change management may serve as a useful approach to successfully implementing such pathways. Applying these concepts to the implementation of clinical pathways can ensure that all stakeholders support the initiative, overcome barriers to success, and allow the benefits of pathway implementation to be sustained over time.
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