Social scientific insights into a complex intervention: the case of care pathways

1. Social scientific insights into a complex intervention: the case of care pathways Davina Allen

2. Care Pathway Research Programme • The impact of ‘care pathway technologies’ on service integration in stroke care (systematic review) • The effectiveness of integrated care pathways: what works, for whom and in what circumstances? (systematic review) • A mini ethnography of the pathway community • Empirical research on the social organisation of pathway development

3. Care pathways as understood by the pathways community Care pathways understood through the lens of social science What am I going to be talking about?

4. Multidisciplinary care management tools Workflow systems and record of care Variance analysis Example of new mode of governance Introduced into healthcare in the US in 1980s to increase efficiency and reduce LOS Growing international community of pathway enthusiasts using pathways to address wide ranging healthcare agenda What are care pathways?

5. Care Pathway Community • Users • Senior clinicians • Service managers • Methodologists • Clinical academics • Pathway facilitators

6. Development and Implementation Apocryphal tales Training for pathway development Pathway development guides Models of pathway development 30 steps methodology 4-meetings model Care pathways – R&D priority 1

7. Diversity Local, regional, national and global Abstraction versus specificity Audiences Differences in pathway development, implementation and use European Pathway Association definition Pathway assessment tool (ICPAT)(Whittle et al) Care pathways – R&D priority 2

8. Limited evidence of pathway effectiveness so... what gives pathways their appeal? Looking at pathways through the lens of social science

9. Uses and benefits of pathways Pathways ensure a good standard of documentation meeting legal requirements and requirements of professional colleges. They reflect patient need and support a patient centred environment. They are a methodology through which to demonstrate evidence based medicine. They can be used to monitor goals and benchmark, promote multidisciplinary working, clarify roles, improve communication, empower staff, support variance analysis, and manage risk and clinical governance and to support world class commissioning agenda [Speaker 2008 Pathway Conference]

10. Uses and benefits of pathways • Frontline service delivery • Goal setting & care planning • Monitoring, review, evaluation of services and outcomes • Demonstrating evidence of consistent best practice delivered at the frontline • Managing variation in practice (including understanding, reducing choice) • Cross-boundary communications • Risk management & reduction • Clinical Audit, Surveys, Interviews • Clinical effectiveness (R&D) • Patient/ service-user /public engagement involvement empowerment (including knowledge and expectations) • Staff skill mix (staff disciplines & grades) • Accountability • Continuing professional education, training & development • Streamlining & addressing of duplication, blockages, delays, whinges and grumbles, aspirations, service shortfalls/gaps, service/resource re-design. • Capacity resource management • Cost/waste/value cost benefit, activity-based costing • Central and local targets, monitoring, reporting (i.e. Waiting lists, length of stay, trolley times, access etc)

11. A common purpose…. Deep down we all have a commitment to high quality health care. We want to see patients have timely provision of care, also want to see consistency of care and we want to look at the evidence to find out the right course of treatment. This leads to effective health care and that’s important in the modern NHS and we can’t ignore costs….There are tensions between targets, effective healthcare delivery and costs. […] I put it to you that a good pathway will do both’ ((nods of approval around the room)). [Speaker - Regional Workshop] The foremost challenge facing healthcare professionals, managers and administrators in the UK today is trying to make the best use of limited resources, whilst providing high quality, timely, evidence-based best practice. [Flyer advertising Venture and Formic Software]

12. Pathways aim to have: “the right person, in the right place, doing the right thing, at the right time, with the right outcome and all with attention to the patient experience”. A single solution…..

13. Pathway methodology = boundary concept Boundary concepts are loosely defined concepts which, precisely because of their vagueness, are adaptable to local sites and may facilitate communication and cooperation A ‘trading zone’ enables members of distinct professional groups to work together and to develop areas of efficient collaboration without obliging them to give up the advantages of their respective group identities [Lowy 1992]

14. Pathways = boundary objects A boundary object is an object that inhabits several social worlds and which fulfils a role in structuring interactions between individuals (Star 1989). As multidisciplinary technologies designed to link clinical and management interests, care pathways are complex ensembles requiring the negotiation and reconciliation of different interests and forms of action (Dodier 1998).

15. The Social Organisation of Care Pathway Development

16. Ethnographic Data Audio-recordings of meetings Interviews with stakeholders (development team, pathway users) Documentary analysis (emails, iterations of the tool, minutes)

17. Studies of Technology-in-Practice • Prescription – behaviour imposed by tool onto human actors • Tools do not slip into a pre-existing space in a workplace, getting a tool to work involves negotiation with all relevant ‘actors’ • Tool construction is always a political process and involves ad hoc compromises. • Mundane technologies have a generative power • Generative power arises from the inter-relations between the tool and its use in practice • ANT – associations between human and non-human ‘actors’ • Delegation – action delegated to the tool

18. The Patient Safety Care Pathway A Case Study

19. The Patient Safety Care Pathway Writing Group Reference Group • Nurse Consultant • Clinical Nurse Leader • Occupational Therapist • Service Manager • Service User • Ward Manager/Proxy • Junior Doctor • ICP facilitator • Consultant psychiatrists • Ward staff

20. Data Analysis • Chronological reading of data • Description of evolution of pathway • Identification of critical decision points • Exploration of agenda in play and their negotiation

21. Purpose of the Pathway “To improve the processes through which patients deemed to be at risk are managed”

22. Aim 1: Record-keeping Peter: [W]e were criticised because of these major incidents that we’ve had within the service over the last few years […] that it was never clear from the records when observations were put on or taken off and it was never a clear record of this occurring or any discussion about it […] In the cases that were identified and scrutinised […] they found it very difficult to find out where the risk changed and what was done.

23. [W]e […] use our least qualified nursing staff to do the most highly specialised task of looking after patients at risk of harming themselves or others […]. ‘Without taking risks people cannot learn how to utilise strategies that help them manage risk it is therefore important to integrate risk taking into the risk management and personal safety plans of inpatients’ [Discussion Document] Aim 2: Re-formulate the work

24. At the moment, levels of care have been more about well what are nurses or nursing assistants doing and how far away they are from someone. They don’t say much about the therapeutic engagement [..] basically we gonna be looking at enhanced sort of interventions Aim 3: Service standards

25. Aims of the Patient Safety Pathway • Improve systems of record keeping • Reformulate the work • Agree organisational standards • Account for practice for a medical legal audience • Agent of professionally-driven practice change • Represent practice for a service user audience

26. Aim 2: prompt staff to work more therapeutically Nigel: Give things sort of headings to guide people and also gives sort of prompt, it comes back to that prompt about in the last 24 hours has a person had an opportunity to meet with their the lead nurse. Reconciling multiple agenda: quality, safety, accountability

27. Aim 1: improve systems of record keeping Peter: Previously there would be a separate recording form for each of the observations but now [...] we’re gonna do it all on one form. [...] So previously the observation form would say ‘close obs’ on the top and if that’s discontinued it would then say ‘intermittent x15minutes.’ Whereas this one is a general observation recording form. Maurice: I’ve been thinking as well there could be an information handover error, if you look at the form ‘cause there’s three on it you might be doing close [observations] and it was actually 15 [minutely]. Reconciling multiple agenda: quality, safety, accountability

28. Coordinating and Accounting Nigel: On one level it’s about not making, making sure that [observations are] not seen as anything more special than the others, the evidence base is […] that these other elements [therapeutic interventions] […] can be more important than observations in themselves in managing the risk [...] [But] you can imagine someone ticking the wrong box here, they go to another form and someone carries it over and you’ve lost it then.

29. Had originally intended that the document be used with service users, but these components removed from the main pathway. “Service User: Are patients supposed to see all this lot? [the components of the pathway] Nigel: No Service User: That’s ok then ‘cause it’s starting to be a bit ((pulls face)) it is though isn’t it?” Reconciling multiple agenda: users and providers

30. Summary Pathway development brings into sharp relief many of the tensions they are designed to resolve Pathways include messiness designed to erase Care pathways are more complex than leaders in the field have acknowledged When a single representation is used as the basis for visualising activity to quite different ends, this always introduces a problem from one perspective or another.

31. Pathway methodology = boundary concept Artefact = boundary object Focusing on pathway development as a management challenge ignores the intellectual challenges of pathway development Standardisation of pathway design will make it more difficult to design bespoke tools in response to local organisational issues Lose trading zone in which stakeholders can come together Care Pathway R&D agenda – reframing the issues

32. Identify kinds of intervention which emerge from pathway development processes Identification of pathway’s active ingredients and their inter-relations Two levels of complexity – intervention and context What combination of active ingredients are required for which purposes… Social science sheds new light on issues involved and provides a vocabulary through which they can be articulated ........and rethinking the solutions..

33. Laura Rixson and Elizabeth Gillen – Research Assistants to the Project Trust staff who allowed us to peer over their shoulders and gave time to participate in the study Acknowledgements

34. Publications Allen, D. (2009) From boundary concept to boundary object: the practice and politics of care pathway development, Social Science and Medicine (available on line) Allen, D. Gillen, E. and Rixson, L. (2009) A systematic review of the effectiveness of integrated care pathways: What works for whom, in what circumstances? International Journal of Evidence Based Health Care 7, 61-74. Allen, D. and Rixson, L. (2008) How has the impact of 'care pathway technologies' on service integration in stroke care been measured and what is the strength of evidence to support their effectiveness in this respect? International Journal of Evidence-based Healthcare 6, (1) 78-110.