Care pathways and operations management in the organisation of ophthalmic care

Rationale Care Pathways (CP) and Lean Management (LM) are two approaches for streamlining care processes that have their roots in industry. CP derived from the critical path method. The European Pathway Association defines a CP as a ‘complex intervention for the mutual decision-making and organisation of care for a well-defined group of patients during a well-defined period of time’. LM is an operations management strategy that was originally developed in Japan by the Toyota Motor Corporation in the 1940’s. To reduce costs and lead times, Toyota focused on eliminating waste that prevented the value-added flow of products through a series of operations. CP and LM concepts might be complementary in organising care. CP defines key elements of care and coordinates team roles. LM encloses techniques to optimise resource scheduling of activities in the CP. Effects of applying a CP together with LM have not been reported yet. It would be of interest to investigate how CP and LM intervene in the organisation of care and how these two concepts relate to each other. Objective and research questionsThe aim of this study is to investigate the impact of care pathways and lean management on the organisation of ophthalmic care. Three research questions were formulated:1. What is the relationship between care pathways and lean management?2. What are effects of applying care pathways and lean management on adherence, patient outcomes and efficiency?3. What are experiences of care teams with applying care pathways and lean management? Study settingThe study was conducted in the Rotterdam Eye Hospital (REH), located in Rotterdam, the Netherlands. Study design and patient groupsThis research consists of a systematic literature review, two controlled-before after studies, i.e., the strabismus and cataract study, and a mixed methods study, i.e., the team study. The intervention is applying a care pathway with lean management techniques to the organisation of ophthalmic care, further referred to as ‘lean care pathway’ (LCP). Based upon the findings of the literature, we defined the lean care pathway intervention as ‘a multidisciplinary process improvement approach to streamline the care process, based upon evidence-based guidelines, and the supporting business processes for a well-defined group of patients during a well-defined period of time’.The LCP was developed and implemented according toa protocol that followed the structure of the Seven Phases Model© of the Belgium-Dutch Care Pathways Network. The researcher fulfilled the role of pathway facilitator. Systematic literature reviewTo acquire knowledge on the content of CP and LM concepts, a systematic review of the literature related to applying CP or LM to hospital care was carried out. Articles were identified through electronic databases Medline, Embase and Business Source Premier limited from January 2007 to May 2010. After categorising the content of the papers, we included 28 CP studies and 20 LM studies. We scored the objectives and outcome measures reported in each CP and LM study and categorised these in the five domains of the Leuven Clinical Pathway Compass: ‘process’, ‘clinical’, ‘service’, ‘financial’ and ‘team’. We used a service operations management framework to classify and reflect on the impact of CP and LM on the organisation of care. The framework aligned the service concept and service delivery system with the objectives and target patient groups. Strabismus study The strabismus study investigated effects of implementing an LCP for strabismus surgery on adherence, patient outcomes and efficiency. The LCP was developed between January and October 2007 and implemented in November 2007. Objective was decreasing waiting time for surgery, while maintaining a high quality of care. A service concept was defined and four interventions were implemented, i.e., 1) takt times to synchronise resources in the LCP; 2) pull planning to integrally schedule all activities in the LCP; 3) one-stop preoperative visit; and 4) checklists for patient education.To analyse effects on procedural adherence and efficiency outcomes, we selected all 522 patients that underwent strabismus surgery between 1 January and 30 September 2007 in the pretest group and all 460 patients that underwent strabismus surgery between 1 January and 30 September 2008 in the posttest group. To analyse effects on clinical adherence and patient outcomes, we included a random pretest sample of 125 patients and a random posttest sample of 126 patients. All 251 patients filled in a Consumer Quality Index (CQI) questionnaire three months after surgery to measure their experiences with the quality of care. The pretest control group enclosed all 664 patients with retinal detachment that underwent acute vitreoretinal surgery between 1 January and 30 September 2007. The posttest control group enclosed all 510 patients with retinal detachment that underwent acute vitreoretinal surgery between 1 January and 30 September 2008. All patients in the control group received the same care. Cataract studyThe cataract study investigated effects of implementing an LCP for cataract surgery on adherence, patient outcomes and efficiency. The LCP was developed between February and December 2008 and implemented in January 2009. Objectives were to narrowthe gap between realised and expected performance and to increase value for patients in terms of fewer hospital visits and better experiences with the quality of care. A service concept was defined and four interventions were implemented, i.e., 1) a new admission form to eliminate all duplicated and ambiguous information; 2) a cataract care centre to group activities on one location; 3) surgery under topical anaesthesia to reduce costs; and 4) tailored patient brochures.We included a random pretest sample of 181 patients that underwent first-eye cataract surgery between 1 March and 30 June 2007 and a random posttest sample of 181 patients that underwent first-eye cataract surgery between 1 March and 30 June 2009. All 362 patients filled in a Consumer Quality Index (CQI) questionnaire two months after surgery to measure their experiences with the quality of care.The pretest control group enclosed all 283 patients with retinal detachment that underwent acute vitreoretinal surgery between 1 March and 30 June 2007. The posttest control group enclosed all 268 patients with retinal detachment that underwent acute vitreoretinal surgery between 1 March and 30 June 2009. All patients in the control group received the same care. Team studyThe quantitative part of the team study consisted of annual measurements of the Care Process Self Evaluation Tool (CPSET) and the Workforce Development (WD) Survey to investigate the team’s experiences with the organisation of care and the impact of the LCP on team engagement respectively. For the CPSET, we selected random samples from the strabismus team and the cataract team. In 2007, 28 strabismus team members and 22 cataract team members filled-in the CPSET; in 2008, 26 and 20 members respectively; and in 2009, 27 and 28 members respectively. For the WD Survey, we selected random samples from the business units that were involved in the implementation of an LCP, i.e., three clinical divisions, the ward and operating theatre, and the back office. In 2007, 68 team members filled-in a WD Survey; in 2008, 46 members; and in 2009, 66 members. In the qualitative part of the study, in 2009, an independent researcher conducted semi-structured interviews to explore the experiences of 14 members of the strabismus and/or cataract care team with implementing an LCP. Convenience sampling was used to select interviewees. Main outcome measuresIn the strabismus, cataract and team study main outcome measures were also defined in the five domains of the Leuven Clinical Pathway Compass, i.e., in the process domain clinical and procedural adherence (data source: hospital database and patient record analysis); in the clinical domain clinical outcome measures (data source: patient record analysis) and patient-reported outcome measures (data source: CQI questionnaire); in the service domain patient experiences with the quality of care (data source: CQI questionnaire); in the financial domain lead times, number of hospital visits, direct costs andgaps between realised and expected performance (data source: hospital database); and in the team domain the team’s experiences with the organisation of care (data source: CPSET), team engagement (data source: WD Survey), team functioning (data source: interviews) and the team’s experiences with implementing an LCP (data source: interviews). Results Relationship between care pathways and lean managementCP was frequently applied to improve appropriateness and timeliness of executing key elements of care, based upon evidence-based guidelines, and LM to improve efficiency and throughput times. In contrast with LM, CP regularly monitored if the clinical quality of care was maintained. Most CP and LM concepts standardised the sequence and timing of process steps, specified the roles of the care team and were implemented by a multidisciplinary team. Initiators of care pathways usually had a clinical background and initiators of lean management more often had a managerial background. Both CP and LM concepts seldom applied techniques to improve resource scheduling, tracing performance, team functioning or patient involvement. LM studies primarily applied easy-to-copy techniques, such as value stream mapping and 5-Why root cause analysis. The literature review shows that CP and LM concepts can be used complementary to each other in organising the care process and the supporting business processes. Effects of care pathways and lean management on adherence, patient outcomes and efficiencyThe LCP for strabismus surgery significantly improved adherence and efficiency outcomes, while patient outcomes remained at the same level. Waiting time for surgery decreased with 38%. Patients reported good experiences with the quality of care.The LCP for cataract surgery also significantly improved adherence and efficiency outcomes, while patient outcomes remained stable. Mainly the increased use of co-managed care (i.e., first-day telephone review by a nurse and final review by an optometrist) in combination with a decreased frequency of ophthalmic screening appointments increased clinical productivity with 18%. Patients in the LCP graded the overall care delivered by the hospital and by the nurse significantly higher and reported significantly more often that they received postoperative instructions. The care team’s experiences with care pathways and lean management Having an LCP implemented significantly improved the care professionals’ perception of the overall organisation of care. Team members perceived that implementing an LCP increased the patient focus of the organisation and their chances to develop and grow as a team. The team’s experiences were influenced by experienced benefits, the impact on work and by participating in the implementation process of the LCP. The organisation structure and mutual interdependency between team members determined to what extent the pathway team evolved into a more structural multidisciplinary team. Discussion and conclusionThis study shows that applying a CP with LM techniques in the organisation of two surgical ophthalmic procedures significantly increased efficiency outcomes while maintaining a high quality of care. Improved performance in the process domain was associated with a more cost-effective use of resources in the pathway. In this study, letting the multidisciplinary team conduct a current state analysis and construct a service concept was an important facilitator to change. The current state analysis revealed hidden assumptions and process knowledge gaps. Defining the CP explicated the service concept that was present in the minds of the care professionals. This service concept stated all conditions on which the care process could be designed and created confidence that the clinical quality was guaranteed. Barriers to change arose as soon as the intervention affected the care professional’s activities. When pathway teams aim to eliminate or reallocate clinical activities, they should be able to quantitatively motivate their reasons. Spending enough time on identifying the root causes that prevented implementing the new pathway design enabled the pathway teams to overcome most problems. This study shows that CP and LM are used as projects. To facilitate follow-up and innovation, a structure with communication lines, integrated task forces and a performance system should be implemented as part of the project. Framing the CP and LM concepts in a service operations management context facilitated analysis and comparison of the CP and LM concepts and provided insight on the interventions’ impact on the hospital service delivery system. We recommend that reporting complex interventions such as applying CP and LM concepts should be done in a more structured and standardised style. The service operations management checklist developed in this study can be used for such purposes.