Care pathways and organizational systems: the basis for a successful connection

During the last 10 years in Europe, the rationale for the use of care pathways has progressively shifted from their use as an individual patient care management tool to a clinical governance methodology, to the point that today pathways are expected to raise the overall quality of the care process, and provide evidence of high-quality care for the whole organization. Why has this happened? Why is the relationship between pathways and organizational systems so strongly entwined? In our opinion the powerful link between care pathways and organizational systems has been created by the uniqueness of this complex intervention, as pathways work on different levels and in many different ways. First, care pathways are a flexible methodology and therefore it is possible to implement them in every health-care environment, ranging from hospitals to primary care. They are focused on improving the overall spectrum of clinical practice in a measurable way (with process and outcome indicators). As a consequence, pathways are effective in improving clinical outcomes (from disease identification to cure), as well as organization-related and patient-related outcomes (efficient and effective care). Second, pathways are also comprehensive, so that embedded within a care pathway are tools that can be used for analysis (such as process analysis and expected outcomes). Pathways support clinical and organizational decision-making methodologies (such as evidence-based medicine and lean management) and this is crucial when implementing a systemic approach to the process of care. Care pathways are a ‘democratic’ methodology: their development is based on multidisciplinary team work and local agreement and their success is based on effective implementation of networks of activities of different professionals, even including staff and people who are not directly linked to the direct process of care. Moreover, the use of pathways focuses the system of care centrally on the patient. As part of the development of pathways that place the patient at the centre, it is necessary to clearly identify all the relevant expected patient-related outcomes. This approach enhances the empowerment of the patients and helps the pathway team to identify the best outcomes. Pathway development enables the breaking down of potential barriers to the integration of care between professionals and organizations. Pathways can furthermore be a building block to the enhancement of accountability in health-care organizations, a central element of an effective system of clinical governance. It is also important to recognize that care pathways are intrinsically a systemic methodology. Pathways need to reflect the patients’ journey into the health-care system, taking account of the disease-subsystem and of the caresubsystem that occur independently of the wide ranging nature of the pathways. In fact, care pathways are developed taking into account the ‘natural trajectory’ of diseases. This is crucial to elicit the critical nodes or gaps of care that may need to be revised. Pathways need to define the overall process of care and its input–output chain structure, identifying every step of care, including intermediate and final outcomes and related performances along the overall process of care. Such a systemic approach is more in line with the complexity of ‘real’ health care and reduces the risk of focusing only on some elements of care that can reduce the impact on the overall organizational system. Finally, care pathways have proved to be effective as a learning tool both at professional (individual) and organizational (team) level. This is probably due again to a developing system of care pathways that are based on several shared steps that provide an ideal opportunity for people involved to receive and to share a clinically based education. This working together offers a real opportunity for benchmarking different clinical and organizational processes, which can be withinand cross-organization. Care pathways are necessary tools to generate efficiency, achieving the best clinical and care outcomes utilizing appropriate resources. Pathways enable the re-design of services, monitoring critically the activities of every component or professional within the process of care, enabling concrete evidencebased decision-making to promote a real learning organization. Care pathways can enable health-care managers to measure the governance of health-care processes and support good practice within organizations. If pathways are viewed as management tools to provide evidence of service improvement, this may explain why some organizations have significantly few pathways or in some situations where there is superficial use of this methodology. To this purpose we suggest reading carefully the commentary by John Ovretveit regarding the paper ‘Is there a future for care pathways? Five pieces of the puzzle’. In this excellent commentary, Ovretveit concludes that pathways are one of the practically effective ways to bring the independent parts (of the system of care) into interaction to produce better outcomes, and reduce waste and the risks from under-coordination. We think that Ovretveit, together with Don Goldmann’s ‘Five puzzle pieces, ten cautionary notes’ published in the previous issue of this journal, add important elements to the discussion about the potential of pathways to benefit patients and health-care organizations. The European Pathway Association (EPA) will take these suggestions into account while developing international research projects on pathways. In this issue the history, project management and overall approach of the European Quality of Care Pathway study will be presented. This international research study under the supervision of the EPA is being performed in Belgium, Italy, Ireland and Portugal.