Research Article |
The effectiveness of quality improvement tools: joint working in integrated community teams
1 University of Edinburgh, Division of Community Health Sciences/General Practice, Edinburgh, UK, 2 RMIT University, Department of Psychology and Disability, Melbourne, Bundoora, Australia
Objective. To explore the effectiveness of integrated care pathways in facilitating integration in community-based teams.
Design. Case comparison of models of integrated care pathways in two different settings: community mental health teams in one Scottish region and care of the elderly rapid response teams in three Scottish regions. In both settings, an integrated care pathway was used as a tool for integration, but in different ways. Comparison is made by first identifying key factors structuring team-work in both settings, then analysing how the constellation of these factors results in different dynamics of team-work in each setting. The pathway tool used in each setting is then outlined and an analysis presented of how the tool interacts with the organizational dynamics in and around the teams to produce observed outcomes in each setting.
Results. In both settings impact of tool was shaped by the same organizational dynamics which produced the nature of team-work. In neither setting was the tool optimally effective in improving integration. In community mental health teams a prescriptive, management-driven integrated care pathway was introduced. This presumed a degree of task sharing in teams which was absent. It was resisted by the teams. In rapid response teams a flexible, team-driven pathway tool was being introduced to help teams conceptualize and communicate about the service. This approach fitted with autonomy and task sharing in rapid response teams and uptake was good. However, management did not engage.
Conclusion. The effectiveness of the tool in both settings requires attention to organizational context.
Keywords: case studies, elder care, evaluation, health care quality improvement, integrated care pathways, mental health, quality improvement implementation
Address reprint requests to Guro Huby, Community Health Sciences, GP Section, University of Edinburgh, 20, West Richmond Street, Edinburgh, EH8 9DX. E-mail: guro.huby{at}ed.ac.uk
Accepted for publication October 7, 2004.
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Introduction |
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Integration: definitions and issues
Integration is a key agenda of ‘quality improvement’ [1] in the British National Health Service (NHS) and involves collaboration between members of different organizations or professions to deliver a service centred on service users’ needs rather than organizational imperatives. ‘Horizontal’ integration of services across similar organizational levels needs to be underpinned by ‘vertical’ integration of different levels of these organizations: strategic, managerial, and operational [2]. However, decision-making operates according to different principles at different organizational levels, and linking between them is problematic [3].
At strategic levels in Scotland, UK, new legislation has enabled health and social work to fuse finance and management arrangements [4]. At the operational level, integration is driven for example by the formation of multi-disciplinary teams or networks with varying relationships to ‘parent’ organizations and professions. Different histories produce different conditions for integration in individual localities [2].
Integrated care pathways as a tool of integration
‘Quality improvement tools’ are introduced to facilitate redesign in health services [5,6]. Integrated care pathways explicitly seek to improve integration at operational level and are the topic for this paper. Integrated care pathways first emerged in the USA in the late 1980s as a way of monitoring the cost and quality of multi-professional patient treatments [7]. A national survey showed that in 1998 approximately 250 UK NHS organizations were either developing or using pathways in the UK [8]. Pathways are used for a number of purposes [9]. They can be used as a clinical management tool or a tool for clinical audit [10]. They have a managerial function in shaping multi-disciplinary documentation, communication and care planning [11], and systematic data collection and assessment of standards [12].
The principles of integrated care pathways are simple. Once the pathway and its desired outcomes have been established, the elements of care within it are mapped out and the input of each profession in each element defined to agree outcomes within specific time periods. A pathway can be an end-point of service redesign and a blueprint for practice, or it can be used flexibly as a tool to conceptualize, evaluate, and improve a complex care process. In practice, both functions can be present.
The effectiveness of ‘quality improvement tools’, including integrated care pathways, is uncertain [13,14]. The link between complex interventions and their effect is difficult to establish and evaluations are few [15]. What evidence there is indicates that quality interventions have variable effects, which are dependent on methods of and context for, implementation [16]. While ‘quality improvement tools’ can facilitate organizational change, they are clearly no magic formula.
Integrated care pathways resemble maps, in that they are not objective mirrors of the terrain they purport to describe [17]. They are necessarily simplifications. It is possible to draw a map or a model in different ways, each of which emphasizes different aspects of the terrain and reflects the perspectives of particular readers. The choice and adaptation of models of integration therefore have to be carefully attuned to the particular circumstances in the setting concerned, to achieve a relationship between ‘terrain’ and ‘map’, which can guide appropriate action.
The aim of this paper is to compare the impact of an integrated care pathway on integration in two different settings. In both settings, an integrated care pathway was used, but in different ways. The ways in which these approaches interacted with their specific contexts is compared, and in conclusion, some implications for the use of ‘quality improvement tools’ to facilitate integration are outlined.
Design: comparative case studies
A case comparison has been carried out of the development, use, and impact of different models of integrated care pathways in two settings. The settings are (i) community-based health and social care teams for people with chronic mental health problems (community mental health teams) in one Scottish region, and (ii) community-based health and social care teams for older people (rapid response teams) in three Scottish regions. This work was conducted as part of a national Scottish R&D initiative [18]. Researchers worked collaboratively with practitioners to assist with evaluation and development of integrated services [19] and had a different relationship to the implementation of the Integrated Care Pathway in the two settings (see Table 1).
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Methods |
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Data were collected about each case on an ongoing basis, through notes from meetings and interviews with teams and their various stakeholders. Accounts of team dynamics around Integrated Care Pathway implementation were built up in the two settings. An in-depth understanding was attempted through rigorous description and analysis [15].
Analysis
Analysis focused on two outcomes, namely the effect of the Integrated Care Pathway on collaboration within teams and on the relationships between teams and managers. Initial analysis identified key features impacting on integration in each setting, namely (i) team history, (ii) nature of work, (iii) team members’ relationships to ‘parent’ organizations, and (iv) management arrangements. Further analysis proceeded according to the constant comparative method [20] and the principles of case study analysis [21], involving comparison of the different constellations of these key features in the two settings. The analysis aimed to describe the impact of the Integrated Care Pathway as a logical outcome of ways in which the intervention interacted with the organizational dynamics in each setting.
We first present an account of the community mental health teams, followed by an account of the rapid response teams. Summaries of the team features and the impact of the integrated care pathway in each setting are provided in Table 2.
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Case 1. Implementation of an integrated care pathway in community mental health teams |
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Context
Team history.
At an operational level, community-based mental health services in the UK are generally organized as community mental health teams, which comprise both health and social care professionals [22,23]. The five adult community mental health teams taking part in this project were formed over time from a programme which relocated mental health provision from one acute hospital to a system of care dispersed throughout the region. Informal arrangements of co-operation were formalized between 1999 and 2002, with the formation of the community mental health teams. Team members thus maintained their relationship to their ‘parent organizations’ while developing new interdisciplinary work practices within teams over a long time period.
Nature of work.
Managing chronic and severe mental health problems in the community is an ongoing commitment. Work is unfocused and potentially without limits as people’s mental states fluctuate for reasons outside care workers’ control. According to team interview data, one way to avoid ‘getting swamped’ by the work is to maintain role boundaries.
Relationships to ‘parent organization’.
Social workers are paid and managed by the mainstream Department of Social Work. They also have mainstream duties outside the teams, which may take substantial amounts of time away from team-work. In interviews, team members described how other professionals are reluctant to take on social work roles, because they cannot rely on social workers being able to return the favour. This is another reason why maintaining professional boundaries in teams is considered important.
Management arrangements.
Day-to-day operational management of teams is conducted by a team leader from either health or social work. The team leader allocates tasks and ensures that work is carried out, a task made difficult by the emphasis on role boundaries between team members. Team leaders are thus caught between the imperatives of task sharing, to ensure the smooth running of the service on the one hand, and the realities of team-work on the other. Team members are to a large extent exempt from responsibility to reconcile this tension.
The interaction of these factors results in importance being attached to maintenance of role boundaries, which creates a barrier to collaboration in the form of task sharing [24].
The Integrated Care Pathway in this setting
A management-driven integrated care pathway for use in these teams has been under development since 2000. The aims are to strengthen multi-disciplinary collaboration within the teams and to facilitate audit and continuous improvement. The pathway has considerable potential, because it sets up a region-wide system of care for people with severe and enduring mental illness. It also brings together the paperwork and systems used by social work and health.
The care pathway is laid down in standard paperwork which structures data collection around required practice at key points, such as assessment of risk, allocation of ‘key workers’ responsible for co-ordinating a patient’s care, arrangements of care packages, and client review. It requires the documentation of ‘variance’ from required practice and thus means that multi-disciplinary practice be made explicit. It involves extra paperwork, improved information technology (IT) equipment and investment in time for teams to learn how to use it. At the time of this project, health service middle management from outside the teams was attempting to implement the integrated care pathway and the research team was evaluating the implementation.
Outcomes
Impact on teams.
Interviews suggest that team members were clear about the potential benefits of the Integrated Care Pathway for both team members and service users but were reluctant to implement it. They quoted several reasons. One had to do with lack of ownership of the new systems put in place. In spite of considerable efforts by the Integrated Care Pathway Working Group to involve the teams in drawing up the paperwork and procedures, teams claimed not to have understood the full implications of the forms and processes they helped to develop. Added workload and lack of administrative and IT support to implement and maintain the new procedures was another important reason. Teams also expressed weariness of change and the expectation that, as so many other interventions, this one would pass without ramifications for daily practice. Social workers were unhappy that the pathway failed to accommodate key social work perspectives. Another issue was that key functions upon which the integrated care pathway rests, such as task sharing around the formalities of arranging care, are not easily accommodated within the teams [24].
Impact on management.
Team leaders were most resistant to the integrated care pathway on the grounds of lack of resources within teams to carry out the extra administrative work. For them, implementation of the pathway exacerbates the tensions they face in making a team insistent on role boundaries accommodate extra tasks. The implementation thus lacked clear leadership from within teams which could respond to the directions coming from middle management.
New members of staff coming into the teams are beginning to use the pathway. As a result of the evaluation, teams have been given autonomy in the implementation process. The implementation is proceeding, but issues still remain in bringing the reality of team-work closer to the ideal of the pathway.
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Case 2. A flexible pathway in rapid response care of the elderly teams |
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Context
Team history.
Rapid response teams have emerged during the last 2 years, as a requirement of the Joint Future policies [4]. They aim to provide rapid response to older people’s care needs at home and so reduce the pressure on acute hospital services. Teams have been set up ‘from scratch’, and new relationships and ways of working have been established within a short time scale.
These teams are being developed in different ways in different areas. However, they have certain features in common of which team autonomy and task sharing within teams are natural consequences.
Nature of work.
As a team, staff from different professions within health and social work can work together to meet patients’ needs more quickly than the procedures of mainstream health and social work organizations allow. Referrals between team members are acted on within very short time scales, and most teams have instant access to home care and aid appliances—often stumbling blocks to timely organization of care at home.
Sharing responsibility is made easier than in community mental health teams because tasks are time limited and focused. Teams stay involved for a specified period, after which the service user is discharged into mainstream care. Although rapid response staff provide emotional support to their clients, work tasks, for example, installing daily living appliances, are tangible compared to mental health work.
Relationship to ‘parent’ organizations.
Team members are seconded from their ‘parent’ organization. New staff, often committed to the idea of team-work, have been recruited to new posts. In interviews, team members described how joining a team means to a certain extent breaking loose from a well-defined place in an established system and joining a team at the margins of mainstream organizations. The longer people stay in the teams, the more uncertain their positions in mainstream services become. The permanent posts of the staff seconded on to the team will be replaced after a while, and team members become deskilled in terms of mainstream posts. This makes for a cleaner ‘break’ with mainstream-work practices than is the case for community mental health teams.
The uncertainty of funding is often discussed. Funding often consists of dedicated and short-term monies released on a yearly basis. If policy regarding the best way to tackle pressure on acute services changes, the funding might dry up and the teams be disbanded. In all areas there is a history of this happening to similar services.
Management arrangements.
These are a recurring theme in interviews and conversations with team members and managers. Many teams are managed by representatives from both health and social work, which lack the overall integration to provide clear management structure to the teams. Moreover, management resource for the service has often not been allowed for and long-term development tasks beyond details of budgeting, sick leave, and holiday arrangements are not easily accommodated. Added complexities stem from the number of different stakeholders within each organization, reflecting the multi-professional nature of the teams. Thus, in addition to everyday operational management, team members need supervision from their own professional line managers.
These arrangements result in a curious mix of over-management by a range of stakeholders, on the one hand, and under-management, in terms of lack of clear decision-making, on the other. In response, teams have learned to find their own solutions to problems.
The marginal and uncertain position of the teams, together with the lack of direction from management, create the necessity and the conditions for team members to become reliant on each other. Co-location and daily communication also mean that team members learn about each others’ skills and responsibilities, and they share tasks.
Practice within teams is thus integrated, although the structures around them are not. Indeed, it is perhaps due to their lack of integration into the wider structures that integration within teams is successful. This holds generally true for teams in all three areas involved in the study, although the dynamics of team integration and their relationships to wider structures differ.
The Integrated Care Pathway in this setting
Particularly in view of the insecurity regarding funding, there was a strong commitment in teams to use evaluation to make visible what they see as a valuable service. The researchers therefore used the Integrated Care Pathway concept to develop a programme of evaluation by teams. The principles of this approach are the same as for the Integrated Care Patway in community mental health teams, but it is not prescriptive. Through joint workshops and training initiated by the researchers the individual teams were helped to first define the outcomes to which they are working and then draw up the Pathway or care process they operate to reach these outcomes. Barriers within the Pathway which prevent outcomes were then identified by the teams. The researchers provided training in evaluation tools (routine database, combined with qualitative audit tools [25]) to identify issues and their solutions.
The integrated care pathway was used as a tool to structure thinking about the service in order to facilitate service development through improved communication and collaboration between the teams and their management.
Outcomes
Impact on teams.
The use of the Integrated Care Pathway to support an evaluation has been taken up with enthusiasm. Teams spend time and effort considering the Pathway, learning new evaluation techniques, redesigning their routine database, and analysing data. Reports about service activity have improved in all teams. Evaluation tools are used to change practice and to problem-solve.
Impact on management.
Management has, however, been slow to use the evaluation as a resource for service development. Although individual managers are, on the whole, helpful and supportive of the evaluation work, the focus of the intervention gets lost in the many agendas that operational and middle managers have to address. Through a concerted effort by researchers and teams to involve managers, this is slowly changing but remains an issue. This may undermine sustainability of the evaluation because lack of management support may affect the teams’ motivation.
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Discussion: comparison between cases |
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TopIntroductionMethodsCase 1. Implementation of...Case 2. A flexible...Discussion: comparison between...References |
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The majority of evaluations of integrated care pathways have focused on the impact on uptake of audit, length of hospital stay and patient satisfaction [26]. This paper concerns the effects of an integrated care pathway on relationships within multi-disciplinary teams. Few studies explore this and those that do show inconsistent results [27,28]. The present study goes some way to explaining this inconsistency. The ‘terrain’ of multi-disciplinary work can vary enormously between settings, and one integrated care pathway model does not fit all. Each setting requires a tailor-made ‘map’ of integration that guides action through the particular complexities at hand.
The different ‘terrains’ of team integration have been described here as products of the history of the service, nature of work, relationship to mainstream organizations, and management arrangements. The combination of these factors led to a low degree of flexible working among different professionals in community mental health teams and a high level in rapid response teams.
A different integrated care pathway model has been introduced in each setting to facilitate integration: a prescriptive and management-driven model in the community mental health teams; and a flexible team-driven model in the rapid response teams. Both models have had success in changing practice. However, in neither setting has the model so far been optimally successful as a ‘quality improvement tool’ because it has failed to engage all key stakeholders. In community mental health teams the teams failed to engage, while in rapid response teams management does not.
This systematic case comparison suggests how the models have interacted with the organizational dynamics around the teams to produce these outcomes. This learning is transferable to other settings. The key to sustained success of the Integrated Care Pathway approach may lie in the relationships between teams and the organizations between and within which they nest, that is, between the networks in and around teams on the one hand, and the hierarchies from which these networks originate on the other [29]. The role of middle management seems to be a key one. The relationships between networks and hierarchies are mediated by middle management in both cases, and this affects the impact of the tool. For community mental health teams, management (and the integrated care pathway) was too structured, whereas for rapid response teams, management (and the integrated care pathway) is not structured enough.
A quality improvement tool can facilitate organizational development around integrated teams. However, its effectiveness depends on continuous monitoring of the tool’s impact and evaluation-informed management [30] of the process whereby the tool engages or excludes key partners at different levels of the organizations.
Markus Themessl Huber (University of Dundee) and Gill Hubbard (University of Glasgow) gave general help and support, as did Sally Wyke, Helena Chesser, and everybody at the Scottish School of Primary Care offices. Teams and their managers supported the projects in the midst of many other demands and made this work an extremely enjoyable experience. The editor and two anonymous reviewers helped us to improve an earlier version of the paper. This work was funded collectively by Scottish Primary Care Trusts through the SSPC. Sharon Edmunds, Rosemary Porteous (Edinburgh University), and Lian McDade (University of Stirling) contributed to this particular project. Thanks to you all!
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