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

Abstract

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.

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

“…The project task principally cannot be solved in a satisfactory manner if all quality measurements, available resources and available time slots are fixed and do not leave room for any flexibility, slack and room for negotiation [32,33]. This challenge is exacerbated in situations characterized by extended complexity and shortage of available time limiting the ability to arrive at a complete overview of the chosen interventions and outcome [25,34]. This is presumably why ICPs primarily entered health care in sheltered elective pathways suited to deliver a predefined quality and volume with a fixed time frame and resource base [18,35].…”

“…Quality of outcome can hardly be negotiated, but certain standard pathway processes should allow some room for improvisation to adapt to restricted flexibility of time and resources. This will open up for identifying the optimal way to implement CPPs under variable conditions [15,25] and provide knowledge on the type of and variation in complexity and uncertainty and thus open for identifying the corresponding management strategies. CPPs are interpreted as a measure to reduce complexity and unpredictability and thus make rational planning achievable [36] while others claim that these pathways have to adapt to the complexity and fluidity of the context in which they are deployed [7,37].…”

“…The problem-solving webs is close to its pure form in the pathway coordinator office at the two community hospitals. The employees in these units have their major legitimacy and work related to connecting information and demanded resources to patient and to the physicians present at any time in the CPPs [25]. Handling variation in predictability combined with complexity challenge the ability practicing preplanned processes [32] and require management characterized by brokering [50] related to information and access to resources and to building communication channels suitable for this performance.…”

“…Accordingly, the literature has debated the general usefulness of ICP as a tool to optimize care in more complex and/or less predictable patient pathways. Thus, one takeaway is that ICP is not a measure fit for achieving industrialized standardization when the conditions for such standardization are not present [25].…”

“…However, in several hospitals in Norway, elements of CPPs were already present and had been put into practice. The national CPP documents gave room for customization [25]. What we will study is not primarily the intention of the CPPs as phrased in national documents, but real-life CPPs in hospitals in the context of cancer diagnosis, treatment, organizational structures and governance systems.…”