Mind the Differences: How Diagnoses and Hospital Characteristics Influence Coordination in Cancer Patient Pathways

Integrated care pathway (ICP) is a prevailing concept in health care management including cancer care. Though substantial research has been conducted on ICPs knowledge is still deficient explaining how characteristics of diagnose, applied procedures, patient group and organizational context influence specific practicing of ICPs. We studied how coordination takes place in three cancer pathways in four Norwegian hospitals. We identified how core contextual variables of cancer pathways affect complexity and predictability of the performance of each pathway. Thus, we also point at differences in core preconditions for accomplishing coordination of the cancer pathways. In addition, the findings show that three different types of coordination dynamics are present in all three pathways to a divergent degree: programmed chains, consultative hubs and problem-solving webs. Pathway coordination also depends on hierarchical interaction. Lack of corresponding roles in the medical–professional and the administrative–institutional logics presents a challenge for coordination, both within and between hospitals. We recommend that further improvement of specific ICPs by paying attention to what should be standardized and what should be kept flexible, aligning semi-formal and formal structures to pathway processes and identify the professional cancer related background and management style required by the key-roles in pathway management.

Exploring the triggering process of a cancer care reform in three Scandinavian countries

Cancer incidence is increasing, and cancer is a leading cause of death in the Scandinavian countries, and at the same time more efficient but very expensive new treatment options are available. Based on the increasing demand, high expectations and limited resources, crises in public legitimacy of cancer care evolved in the three Scandinavian countries. Similar cancer care reforms were introduced in the period 2007-2015 to address the crisis. In this article we explore processes triggering these reforms in countries with similar and well-developed health care systems. The common objective was the need to reduce time from referral to start treatment, and the tool introduced to accomplish this was integrated care pathways for cancer diagnosis, that is Cancer Patient Pathways. This study investigates the process by drawing on interviews with key actors and public documents. We identified three main logics in play; the economic-administrative, the medical and the patient-related logic and explored how institutional entrepreneurs skillfully aligned these logics. The article contributes by describing the triggering processes on politically initiated similar reforms in the three countries studied and also contributes to a better understanding on the orchestrating of politically initiated health care reforms with the intention to change medical practice in hospitals.

Practicing Integrated Care Pathways in Norwegian Hospitals: Coordination through Industrialized Standardization, Value Chains, and Quality Management or an Organizational Equivalent to Improvised Jazz Standards

The goal of coordinating pathways for cancer patients through their diagnostic and treatment journey is often approached by borrowing strategies from traditional industries, including standardization, process redesign, and variation reduction. However, the usefulness of these strategies is sometimes limited in the face of the complexity and uncertainty that characterize these processes over time and the situation at both patient and institutional levels. We found this to be the case when we did an in-depth qualitative study of coordination processes in patient pathways for three diagnoses in four Norwegian hospitals. What allows these hospitals to accomplish coordination is supplementing standardization with improvisation. This improvisation is embedded in four types of emerging semi-formal structures: collegial communities, networks, boundary spanners, and physical proximity. The hierarchical higher administrative levels appear to have a limited ability to manage and support coordination of these emerging structures when needed. We claim that this can be explained by viewing line management as representative of an economic-administrative institutional logic while these emerging structures represent a medical-professional logic that privileges proximity to the variation and complexity in the situations. The challenge is then to find a way for emergent and formal structures to coexist.

Front-line nurses' perceptions of intra-hospital handover

AIM AND OBJECTIVE

To explore nurses' perceptions of factors that help or hinder intra-hospital handover.

BACKGROUND

Miscommunication during clinical handover is a leading cause of clinical incidents in hospitals. Intra-hospital nursing handover between the emergency department and inpatient unit is particularly complex.

DESIGN

A descriptive, qualitative study. This research adheres to the consolidated criteria for reporting qualitative research.

METHODS

Forty-nine nurses participated in group interviews, which were analysed using inductive content analysis.

RESULTS

Three categories emerged: (a) "lacking clear responsibilities for who provides handover"; (b) "strategies to ensure continuity of information"; and (c) "strained relationships during handover."

CONCLUSIONS

Intra-hospital handover requires clear processes, to promote high-quality information sharing. Ensuring these processes are broad and acceptable across units may ensure nurses' needs are met. Relational continuity between nurses is an important consideration when improving intra-hospital handover.

RELEVANCE TO CLINICAL PRACTICE

Nursing managers are optimally positioned to enhance intra-hospital handover, by liaising and enforcing standardisation of processes across units. Nurse managers could promote intra-unit activities that foster front-line nurses' communication with each other, to encourage problem-solving and partnerships.

An ecosystem perspective on care coordination: Lessons from the field

The vast majority of research and efforts towards greater care coordination have taken place at the level of single, sovereign organizations, or at the level of networks formed to address the need for cross-organizational collaboration. The recently emerging ecosystem level of analysis and intervention is still under-researched, with few if any available innovation practices that match the complexity experienced at the level of care ecosystems. Beginning with the challenge of care coordination, we discuss what care ecosystems are and how they can be defined and describe the possibilities and opportunities that come when viewing care coordination through an ecosystem lens. We underpin our plea for an ecosystem approach to health and social care coordination with seven lessons, which we draw from an extensive study of 15 care ecosystem cases from seven different countries. We end the paper with an appeal for further research in this promising field.

A theoretical framework for the social pillar of lean

Purpose

The purpose of this paper is to propose a theoretical framework for the social pillar of lean (SPL), which is a neglected topic in the lean management literature.

Design/methodology/approach

The authors first identify shortcomings in research on the SPL that are attributable to neglect of relevant perspectives in organisational research. The authors then present a theoretical case outlining the factors that should be considered in SPL research, how they relate to one another and how they should be integrated in future studies of lean change implementation.

Findings

The theoretical framework for the SPL proposes a categorisation of factors and their relationships across levels of analysis that are relevant to the SPL. The inclusion of previously neglected perspectives, such as the relational coordination theory, within this framework offers new insights and directions for research.

Practical implications

By emphasising relationships, the SPL framework sheds light on the scale and complexity of the management challenges involved in lean implementation.

Originality/value

The proposed framework promises to enhance the efficacy of lean research by focussing on factors, such as relationships, that are most relevant to lean implementation.

Advancing a Systemic Perspective on Multidisciplinary Teams: A Comparative Case Study of Work Organisation in Four Multiple Sclerosis Hospitals

Introduction:

Many care organisations claim to employ multidisciplinary teams, but the term is used to describe quite different forms of collaboration. A systemic view of the work organisation of care delivery is presented and applied in this article that allows to identify and understand often overlooked yet important differences regarding team composition, working relationships and therapeutic relationships.

Theory and Methods:

We used modern socio-technical systems theory to study care delivery for a particular patient population as a system of interrelated activities. The concept of work organisation refers to the way in which the composite task of care delivery is divided into distinct tasks and how these are grouped in either monodisciplinary or multidisciplinary organisational units. The systemic perspective was applied in a comparative case study of four Multiple Sclerosis hospitals.

Results:

Among the hospitals, one was characterised by a functional work organisation, with similar tasks grouped in monodisciplinary teams. Cross-disciplinary working and therapeutic relationships were established on an ad hoc basis. The three other hospitals adopted a more process-oriented work organisation (which groups all tasks related to a specific care process within a single, multidisciplinary team). The more process-oriented the work organisation, the more working relationships and therapeutic relationships appeared to be fixed and continuous.

Conclusion and discussion:

The systemic view adopted in this study yields a better understanding of multidisciplinary teams through the concept of work organisation. The actual composition of multidisciplinary teams, and the related working and therapeutic relationships will vary depending on the type of underlying work organisation. Further validation of this conclusion will be needed in other settings.