Impact of care pathway implementation on interprofessional teamwork: An international cluster randomized controlled trial

ABSTRACT

This study evaluates whether the implementation of an in-hospital care pathway (CP) improves interprofessional teamwork across countries and tests whether improved communications (“relational coordination”) is the mechanism of action. A hospital-based cluster randomized controlled trial in Ireland, Belgium, Italy, and Portugal was performed. Fifty-six interprofessional teams caring for patients admitted with an exacerbation of chronic obstructive pulmonary disease or for patients with a proximal femur fracture were included and randomly assigned to an intervention group (31 teams and 567 team members), where a CP was implemented, and a control group (25 teams and 417 team members) representing usual care. Multilevel regression and mediation analysis were applied. First, although no significant effect was found on our primary outcome relational coordination, our CP significantly improved several team inputs, team processes (team climate for innovation) and team output (the level of organized care, level of competence) indicators. Second, our team process indicator of team climate for innovation partially mediated the association between CP implementation and team output indicator of better level of organized care. In conclusion, a CP sets in motion various mechanisms that improve some but not all aspects of interprofessional teamwork. Relational coordination does not appear to be the mechanism by which team outputs are enhanced.

KEYWORDS:

• Quality of care
• teamwork
• randomized trial
• interprofessional care

Acknowledgments

We thank all professionals in the participating hospital wards who were involved in the development and implementation of the CP and who were involved in the data collection.

Declaration of Interest

The authors declare no other conflicts of interest with respect to the authorship and/or publication of this article.

Additional information

Funding

European Pathway Association (E-P-A) obtained an unrestricted education grant from Pfizer SA. We also acknowledge the support of the Clinical Research Fund of University Hospitals Leuven, Belgium. The funders had no role in the design, data collection, analysis, interpretation of data, writing of the manuscript or decision to submit the manuscript for publication. The autonomy of E-P-A and all involved academic institutions with regard to scientific independence and intellectual property on the methodology was guaranteed.

Notes on contributors

Deborah Seys

Deborah Seys is postdoctoral reseracher at Leuven Institute for Healthcare Policy and data analysist at Flemish Institute for Quality of Care. She holds a PhD in biomedical sciences, a MSc inHealthcare Management.

Svin Deneckere

Svin Deneckere is doctor in biomedical sciences and director of the Flemish Institute for Quality of Care. He teaches 'Models for Care Organisations' at the Master in Healthcare Management and Policy at University of Leuven

Cathy Lodewijckx

Cathy Lodewijckx gained her bachelor degree in nursing in 1997, and obtainded her master’s degree in nursing science in 2004. In the same year she incorporated a mandate as clinical nurse specialist in COPD. In 2008 she started a research fellowship at Leuven institute for healthcare policy. She conducted a PhD Study on the impact of care pathways for COPD exacerbation from 2008 to 2012. This study was integrated into the European Quality of Care Pathways (EQCP) study. In 2018 she started working as ahead urse of a cancer day hospital center.

Luk Bruyneel

Luk Bruyneel is a post-doctoral researcher at the Leuven Institute for Healthcare Policy at KU Leuven, Belgium. After receiving a Master’s degree in Nursing (2008), he joined the Registered Nurse Forecasting (RN4CAST) consortium, evidencing the association between nursing delivery systems and patient mortality and patient experiences with care. Luk is passionate about all aspects of hospital care that affect the delivery of safe patient care and improve patient experiences. His interest in knowledge gaps that result from methodological and statistical challenges resulted in additional Master’s degrees in Economic Policy (2013) and Statistics (2015), and a PhD in Biomedical Sciences (2015). For his PhD (2015) he was awarded the Karolinska Medical Management Center/EHMA research award for the best contribution associated with a doctoral thesis in the field of health. He has (co-)authored highly-cited research published in The Lancet, The BMJ, BMJ Quality and Safety, Medical Care, and several other health care sciences journals.

Walter Sermeus

Walter Sermeus is professor of healthcare management, Leuven Institute for Healthcare Policy, University of Leuven KU Leuven, Belgium. He holds a PhD in Public Health, a MSc in Biostatistics, a MScin Healthcare Management and a BA in Nursing. He is Program Director of the Master in Health Care Policy & Management and Head of KU Leuven WHO Collaboration Centre on Human Resources in Health Research & Policy. He is Senior Fellow to the Center for Health Outcomes and Policy Research at the University of Pennsylvania School, USA, Fellow of the European Academy of Nursing Science, Fellow of the American Academy of Nursing, Fellow of the Belgian Royal Academy of Medicine, Fellow of the Royal Society of Medicine, UK and the European coordinator of the EU RN4CAST-network, Nurse Forecasting in Europe.

Paulo Boto

Paulo Boto is assistant Professor in the Department of Health Policy and Management of the Portuguese National School of Public Health. He holds a PhD in Health Policy and Management from the Johns Hopkins School of Public Health, a post-graduation in Hospital Administration from the Portuguese National School of Public Health, a MSc in Health Services Management from the London School of Hygiene & Tropical Medicine and a medicaldegree from the Medical School of the Universidade de Lisboa.

Massimiliano Panella

Prof. Massimiliano Panella, MD, PhD, Associate Professor in Public Health, University of Eastern Piedmont “Amedeo Avogadro”, Faculty of Medicine, Department of Translational Medicine (2000-today). President of the European Pathway Association (E-P-A).

Kris Vanhaecht

Kris Vanhaecht is associate professor at Leuven University Belgium and holds the research chair in Quality of Care and Patient Safety. As secretary general of the European Pathway Association he is the principal investigator in several international research projects on the organization of care processes.