QWhat competencies are needed by operational

Review

.................................................................................................................................

competencies are needed by operational Q What managers in managing care pathways? Jeannette Verkerk-Geelhoed*† and Ruben van Zelm‡§ *Quality and Care Development, Groene Hart Ziekenhuis, Gouda, The Netherlands; †Member, Executive Board of Dutch Department Clinical Pathways Network; ‡Q-Consult, Arnhem, The Netherlands; §Secretary of the European Pathway Association

Summary Within the Belgian –Dutch Clinical Pathway Network, there is a need for research concerning the management of care pathways in care processes. The purpose of this research is to develop a list of required competencies for operational managers regarding the process management of care pathways by means of a literature review. A search in Pubmed/Medline, Embase and Cinahl was carried out between 2001 and 2006. Twenty-three articles were found and 10 of them were included. The study describes experiences of professionals, in relation to tasks and skills. These descriptions are compared and connected to the competencies according to the Schouten & Nelissen Competence Model. The results are combined in order to create competencies for the operational manager to manage care pathways. These factors can be influenced by managers if they have the appropriate competencies.

Introduction

(2)

.............................................................. (3) Within the Dutch and international health care there is a need to organize the care in an efficient and effective way based on the latest medical and nursing evidence.1 This can be achieved by developing, implementing and evaluating care pathways. In the USA, the introduction of care pathways started in 1985, and in the UK it started at the beginning of the 1990s.1 The way care pathways are developed differs between the two countries. In the USA, the cost-effectiveness and efficiency is emphasized. In the UK, the importance of quality is emphasized, and this is specified in detailed paper files.2,3 In Belgium, the Belgian–Dutch Clinical Pathways Network (CPN) was initiated at the end of the 1990s. Within this network, over 100 hospitals and other health-care organizations (e.g. rehabilitation clinics) have been developing care pathways.4 The CPN mainly follows the USA school, which emphasizes the process of the care pathway. The organization and the clinical expertise are brought together, aiming to organize optimal care in an optimal way.2,3 The definition used within the CPN is: a care pathway is a complex intervention for the mutual decision-making and organization of care processes for a well-defined group of patients during a well-defined period. Defining characteristics of care pathways include: (1)

An explicit statement of the goals and key elements of care based on evidence, best practice and patients’ expectations and their characteristics;

Accepted 9 February 2010 Correspondence: Jeannette Verkerk-Geelhoed, Groene Hart Ziekenhuis, PO Box 1098, 2800 BB Gouda, The Netherlands (Email: [email protected])

International Journal of Care Pathways 2010; 14: 15– 22

(4) (5)

The facilitation of communication among team members and with patients and families; The coordination of the care process by coordinating the roles and sequencing the activities of the multidisciplinary care team, patients and their relatives; The documentation, monitoring and evaluation of variances and outcomes; and The identification of the appropriate resources.

The aim of a care pathway is to enhance the quality of care across the continuum by improving risk-adjusted patient outcomes, promoting patient safety, increasing patient satisfaction and optimizing the use of resources.5 Care pathways are developed in and between the different disciplines and wards, with the patient at the centre. The care pathway focuses on standardizing the care through a description of what care will be delivered, by whom and at what time.6,7 In hospitals, nurses usually fulfil the role of coordinating patient care. As a result of the use of care pathways, nurses can perform this role more easily, for standard procedures about the care for a particular patient group have been laid down.6 Hospitals usually start with the development and implementation of a small number of care pathways. The CPN has conducted a survey of the number of care pathways that have been developed among its members.8 This survey shows that many hospitals have developed only a few care pathways, and that the development of more care pathways has stagnated. The CPN wants to do research into the management of care pathways as a part of all care processes in the hospital. The research question will be focused on this subject. DOI: 10.1258/jicp.2010.010007

J Verkerk-Geelhoed and R van Zelm Competencies needed by operational managers in managing care pathways

Definition of the used concepts

(1)

At the time of the literature review, most Dutch hospitals were organized in a functional or divisional structure: strategic management at the top and operational units at the bottom, which are divided in separate divisions. The strategic management of a hospital consists of the managing directors, the Board of Directors and they represent the hospital and formulate the policy. The middle management is responsible for the broad outlines of the hospital’s policy by drawing up, implementing and monitoring the annual plan. The tactical manager runs a division. Most hospitals are divided into a number of divisions (e.g. surgical, internal medicine, medical imaging), depending on the kind of care or service delivered. The operational manager runs an operational unit (e.g. nursing ward, A&E department, radiology) and is accountable to the middle manager of the division his or her ward/unit is located in. In this structure, negotiating with an operational manager from another division often causes difficulties, because the other operational manager is responsible to a different middle manager and is therefore less bound by agreements made outside his or her division.8,9 Competencies can be defined in different ways. For operational managers it is important to develop competencies within their work. The researchers have performed a search on the Internet for existing competence models. Three criteria were used to select a model as follows:

(2)

..............................................................

(3)

The model has to be a general, broad model and not specifically designed for distinct functions or industries; The competencies in the model must have a clear title and description; The model is used in Dutch health care.

Besides these criteria the competence model has to be easily accessible. The Schouten & Nelissen Competence Model (SNCM) has been chosen for this research because it complies to all the criteria.10 The SNCM aims to determine and develop competencies, and supports health-care institutions in implementing competence management. The model is divided into three basic dimensions and three derived dimensions as described in Figure 1.10 Van Dongen10 uses the following definition of competencies: ‘Competencies are specific characteristics that are expressed in successful behaviour and are described in behavioural terms.’ Competencies can consist of a combination of knowledge, skills, attitudes, convictions, qualities and intelligence.

Research question and purpose

.............................................................. It is assumed that the implementation of some care pathways within a hospital setting can be realized without changing the hospital organization. However, the development

Figure 1 Schouten & Nelissen Competence Model (SNCM)

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International Journal of Care Pathways Volume 14 Number 1

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of more care pathways does call for an adaptation of the hospital organization.8 The care pathways and the auxiliary disciplines (like operating room, radiology) cannot be adequately geared to one another. There is not enough literature yet to support this. The question presents itself of how the operational managers can be stimulated to produce figures that measure the results of care pathways in a way that enables them to manage the processes that affect the results. To be able to manage the processes the operational managers need to have the right competencies. In this literature review the research question is formulated proceeding from this problem. Which competencies of operational managers regarding the process management of care pathways have been described in the literature? Subquestion: Which knowledge, skills and attitude are necessary for describing these competencies? The purpose of this exploratory research is to develop a list of required competencies for operational managers regarding the process management of care pathways by means of a literature review. This list can be developed further in supplemental research by prioritizing these competencies through tests.

Research strategy

We used Grounded Theory to answer the research question. We chose this method because there is little known about competencies for operational managers relating to care pathways. We used only open coding to map the descriptions of the competencies to the literature.11 All articles were reviewed and relevant content relating to skills, attitude and knowledge was retrieved and put in an Excelw database. The next step was to map these transcripts to the descriptions of the competencies (see Table 1). This procedure was checked by the second author.

Results

.............................................................. In the articles found, the development of care pathways has been examined,12 – 14 as well as descriptions of leadership and the management of organizations.12,13,15 – 18 Behavioural characteristics have been found in these articles. These behavioural characteristics have been related to the competencies needed by operational managers to manage care pathways. The competencies of the SNCM have been used as a framework to describe the behavioural characteristics.19 In Table 2 the behavioural aspects have been related to the competencies.

.............................................................. MeSH searching was conducted with the assistance of an experienced clinical librarian, using the following terms: ‘critical pathways’, ‘clinical pathway’, ‘leadership’, ‘competenc ’, ‘communication’, ‘professional competence’ and ‘standards’ (see Appendix A for the full search strategy). Within the MeSH term ‘organization and administration’ several subheadings were used. The following terms were used as free text: ‘care path ’, ‘care map’, ‘fast track’, ‘manager?’, ‘management role/process’ and ‘managing’. These terms were used to search in Medline. In Pubmed, Embase and Cinahl the following terms were used to search for relevant literature: ‘critical pathways’, ‘competence’, ‘operational management’, ‘leader ’, ‘communication’ and ‘education’. The subject headings were sometimes used in combination depending on the number of results found. References in the included articles were also checked. We looked for English, Dutch and German articles published between 2001 (the year care pathways were introduced in Dutch health care) and 2006. This research strategy resulted in 114 articles. The inclusion criteria were development or evaluation of care pathways and management descriptions. Twenty-three articles were selected on the basis of their title. Based on the abstract 10 articles were selected to use in this literature review. The exclusion criteria were the absence of an abstract and the absence of description(s) of management aspects (see Appendix B for the flowchart of the literature selection). All articles used were available in full-text. International Journal of Care Pathways Volume 14 Number 1

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Behavioural characteristics The manager needs to understand what processes affect the results of the care pathway, like not having available the results of tests in time, physiotherapist not working in weekends, flexibility in the planning and availability of hospital beds. The manager can monitor and check on this process through variance coding.12,20 The knowledge of procedures is important to make the care pathway work well. The aim of the care pathway has to be clear to everyone; unambiguous use of language among the health professionals is essential.12 Knowledge is needed about precluding double filing, good accessibility to the care pathway and making the care pathway standard for every patient in the category, emphasizing the possible modification of the care pathway for individual patients.21 Training of professionals, project team members12 and students22 in working with care pathways is of major importance. Continuing this training after the implementation of care pathways is a part of this project. The organization of the training requires that the manager should have knowledge on how to implement changes.22 The manager should be able to support the health professional in using the guidelines or care pathways. Reinforcement of the organization’s goals and philosophy, the connection with a role model and influencing changes can affect the acceptation of guidelines in a positive way.16 Strategic goals can be integrated in everyday practice.13 This means that the manager needs to have knowledge about different implementation strategies.

17

J Verkerk-Geelhoed and R van Zelm Competencies needed by operational managers in managing care pathways Table 1 Competencies from the SNCM with their description of content Competency (number of times mapped) Coaching (5) Innovation/focus on renewal (5) Vision (4) Tact/sensitive behaviour (4) People-oriented leadership (3) Progress control (3) Task-focused leadership (3) Verbal skills (3) Stress management (3) Problem analysis (3) Planning and organizing (3) Tactical behaviour/adaptability (2) Decisiveness (2) Negotiating skills (2) Goal orientation/result orientation (2) Customer focus (2) Conversational skills (2) External orientation (2) Initiative (2) Conflict management (2) Listening (2) Authority (2) Cooperation (1) Assertiveness (1) Risk-taking (1) Interactive learning ability (1) Flexibility/adaptability (1) Perseverance/persistence (1) Judgement (1) Presentation (1) Creativity/ingenuity (1)

Description Encouraging people to achieve their personal goals by developing knowledge, competencies and talents. With an exploring and interested attitude, focusing on possibilities for future innovation of strategy, products, services and markets. Developing and propagating an inspiring picture for the future of the organization, department, products or services, while taking a step back from the daily routine. Responding to people’s thoughts, feelings, viewpoints and situation in a way that prevents or dispels unnecessary irritations. Directing and coaching employees in an inspiring way. Adjusting your management style and method to the individuals in question. Encouraging cooperation. Anticipating and guarding the progress of agreements and plans. Managing and directing employees in a result- and goal-oriented way. Formulating goals for the department and duties, dividing tasks, give instructions, making agreements, controlling the process and correcting. Being able to clarify ideas, opinions, viewpoints and decisions to others in a comprehensible message tailored to the receiver. Keeping up effective performance under pressure caused by time, multiple or difficult tasks, social pressure, setbacks or crises. Getting a clear picture of a problem by searching for and examining important data, and identifying connections between these. Determining goals and priorities effectively, specifying time, actions, resources and people required, and organizing efficiently in order to meet these goals. Changing your behavioural style, tactic, strategy if problems or opportunities arise in order to achieve a set goal; the ability to improvize and adapt. Daring to make decisions or take action, even if you do not have complete sight of the possible consequences of each alternative, or if there are strongly conflicting interests. Achieving optimal results in conversations with conflicting interests, both in terms of content and preservation of the relationship. Staying focused on achieving a goal, despite problems, drawbacks, resistance or distractions. Giving high priority to customer satisfaction and the provision of service and support and acting accordingly. For internal customer orientation: replace customers by colleagues, also in the indicative behaviours. Structuring, partaking and intervening in conversations so that the desired results are achieved in an effective way. Demonstrating awareness of organizational, economical, social, or political developments or other relevant external factors. Spotting problems or hurdles and solving them as quickly as possible. Being alert to opportunities, new situations or problems and take action at an early stage. Tactful treatment and solution of conflicts of interest which have great sensitivity. Showing an interest in, and ability for, picking up important information from conversations. Having a natural influence on people and being accepted as an authority. Contributing to a collective result by optimizing the balance between one’s own qualities and interests and those of the group/other parties. Standing up for one’s own opinion, needs or interests in a tactful, non-offensive way. Having the confidence to take (calculated) risks in order to achieve a particular long-term identifiable benefit. Being able to learn from interaction, cooperation and communication with others and to transfer quickly the learning points into more effective interpersonal behaviour. Being able to adapt easily to changing ways of working, working times, tasks, responsibilities, policies and other people’s behaviour. Being able to engage oneself with a particular task intensively for a longer period of time. Persisting with a plan until the desired goal is met. Weighing up data and procedures on the basis of relevant criteria to form well-founded judgements. Conveying one’s vision, ideas or opinion, in a comprehensible, clear and, if necessary, fascinating or captivating way. Coming up with original solutions for job-related problems. Using imagination to invent new ways of working.

SNCM, Schouten & Nelissen Competence Model

Two authors describe a different possibility: to appoint a coordinator to stimulate and supervise the development of the care pathways. This coordinator has a central place in the hospital organization and coordinates the continuation and revision of the care pathways. This coordinator also plays a role in coordinating adequate variance coding and measurements, which will provide extra time for the manager.14,22 Changes can be organized in the form of experiments. Knowledge of change management is needed to perform these. Improvements of working processes can be initiated through observation of the working processes.17 Nurses need support from their managers to develop and make use of evidence-based practice in care pathways.16,20

18

Communication and consultation with the various disciplines and departments of the hospital is important for this.16,22 Supporting the development of clinical leaders has an encouraging effect.16 The culture within the multidisciplinary teams plays a role in the development of care pathways. It is necessary to assess the facilities and barriers related to culture that may cause procedural problems. The use of previous positive experiences is important to reduce barriers and procedural problems.21 Resistance from various groups of professionals often arises when changes are implemented, especially in the case of great complexity and group diversity. This is a challenge the manager should face.12 The International Journal of Care Pathways Volume 14 Number 1

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J Verkerk-Geelhoed and R van Zelm Competencies needed by operational managers in managing care pathways Table 2 Behavioural characteristics related to competencies of SNCM Author Atwal and Caldwell (2002)

Bragato and Jacobs12

Spear17

Spear17 Spear

17

Pace et al. 21


Gifford et al. 16 Mellor et al.

22

Mellor et al. 22 Gifford et al. (2006)16

Hahn et al. 13 Jackson et al. 14 Mellor et al. 22 Atwal and Caldwell20 Gifford et al. 16 Mellor et al. 22 21

20

Text in article

SNCM competency

It is significant that there were many organizational causes of discharge delays, such as waiting for test results and X-rays, and no therapists available at weekends. Organizations are not flexible enough and factors such as time and shortage of emergency hospital beds have a direct impact on the discharge process. Knowledge of planning patient flow influences the workability of the care pathway (emergency versus elective). Members of the project team train the professionals in using the CP. Providing the right timing. Monitoring and controlling the process by variance coding. Proposed changes should always be structured as experiments. Understand the problem and its solution. Staff members and managers should experiment as much as possible (often, simple and incremental). Know the working processes, focus on one or two issues ( productivity and safety) in order to improve. There is no substitute for direct and precise observation; this provides the opportunity to improve the working processes. Excluding duplicate documentation; improving training and communication; making the CP more accessible and automatic for every patient; and reinforcement of modification of the CP for individual patients. Training was initiated to the steering group and professionals. Appoint a key person to overcome the resistance. Make the goals of the CP explicit, if possible three goals. Provide a common language between professionals. Facilitating the clinical leaders to use guidelines.

Tactical behaviour/adaptability, decisiveness and negotiating skills

Through liaison with medical team consultants and the training centre, there was a possibility to train new doctors during the introduction programme. When the foundations were laid, the nursing staff were responsible for continuing the CP training throughout the hospital. Reinforcing goals and philosophy of the organization. Influencing changes; commitment to role models and acceptation of guidelines. Ensuring training and policy; monitoring clinical results. Integrating strategic goals in daily practice. Senior manager supports junior manager by giving high priority to the best service. Providing a coordinator on a temporary basis to develop the CP. Select the right person as fulltime staff nurse on a temporary basis. Supporting the nursing management staff and board is considered necessary when nurses want to use evidence-based practice. Offering support and communicating well. Supporting the development of clinical leaders. Supporting nurses in discussing the CP with the medical staff.

Gibbon et al. 15

Assessing the facilities and barriers related to culture, and the development of procedural problems. Using positive experiences for future projects. Handling the resistance of various groups of professionals. Complexity and low group identity require more skills of the management. Managing a lack of participation by groups of professionals. Building cohesion, shared values and a positive climate within a team.

Gibbon et al. 15

Offering leadership.

Hahn et al. 13

Monitoring client satisfaction and discussing this in team meeting, aiming at high scores. The efforts of the senior manager should be focused on excellent leaders who learn by continuously experimenting. Practice in changing is not possible, but practising the process of observing and testing is. Connecting culture and innovation by adjusting the perception.

Pace et al.


Spear

17

Pace et al. 21 Gibbon et al.

15

Gibbon et al. 15 Gifford et al. 16

Creating a climate which contributes to a sense of safety of the team members, in order to stimulate participation in decision-making. Envy can cause barriers in the interdisciplinary cooperation.

Gifford et al. 16

Creating a positive environment for best practice. Influencing organizational structures and processes. Available and visible.

Hahn et al. 13 Jackson et al. 14

Taking care of the right culture. Clear leadership is necessary to maintain the CP.

Vision and progress control

Coaching and tactical behaviour/ adaptability Vision and progress control Progress control and innovation/focus on renewal Customer focus, planning and organizing, and goal orientation

Progress control, goal orientation and people-oriented leadership Coaching, initiative, people-oriented leadership and vision Planning and organizing, conversational skills and tact/sensitive behaviour Progress control, planning and organizing, and task-focused leadership Tact/sensitive behaviour, people-oriented leadership and innovation/focus on renewal External orientation, people-oriented leadership, customer focus and vision Decisiveness, planning and organizing Judgement and progress control Coaching, creativity and innovation/focus on renewal Coaching, listening and verbal skills Assertiveness, negotiating skills and conflict management Problem analysis, stress management and perseverance Stress management, conflict management, people-oriented leadership and tact/ sensitive behaviour Problem analysis, flexibility, coaching skills and tact/sensitive behaviour Task-focused and people-oriented leadership Verbal skills, customer focus and presentation Coaching, external orientation, verbal skills and self-knowledge Interactive learning ability and tactical behaviour/adaptability Coaching, vision and innovation/focus on renewal Tact/sensitive behaviour, stress management and verbal skills Risk-taking, coaching and innovation/ focus on renewal People-oriented leadership, listening and coaching Coaching, authority and vision Task-focused leadership, initiative and authority

CP, care pathway; SNCM, Schouten & Nelissen Competence Model


2010

19


manager is expected to be able to influence the culture in a positive way through stimulating the group cohesion, shared values and a positive climate.15 Another skill that the manager should demonstrate is being able to lead the multidisciplinary team. Monitoring and discussing the results is an essential part of this, aiming to gain better results.13,15 Managerial skills also involve the skill to choose opinion leaders and encourage them to try new things. This should be done within the company’s agreed structure.17 The culture contributes to the perception of the innovation, and will have a positive effect if it corresponds to the characteristics of the care pathway. The manager can influence the culture by expressing the right attitude.13,21 The climate can contribute to a sense of safety of the team, which will encourage their participation in decision-making. Envy between the different disciplines can cause barriers in the interdisciplinary cooperation. The manager should be able to handle and solve this.15 Retaining the care pathways calls for strong leadership.14 A positive climate stimulates the development of best practice. Organizational structures and processes need to be influenced in order to reach that goal.16 Therefore, the manager needs to be visible and available to the health professionals. A coaching role of managers is more stimulating to self-managing teams than when managers themselves solve the problems.17

Relation between the behavioural characteristics and competencies Table 2 shows the behavioural characteristics of management of care processes, as distilled from the literature. These behavioural characteristics are mapped on the competencies of the SNCM.19 The relevant text from the articles is related to the description of the competencies as listed in the SNCM. The first table contains the title and description of the competencies, as mentioned in the SNCM. Only the competencies for which behavioural characteristics were found in the literature are shown in Table 1. The frequency is based on the number of times the mapped behavioural characteristic (Table 2) is used in the literature.

Discussion

.............................................................. This exploratory study aimed at developing a list of competencies for operational managers in relation to managing care pathways. The research question focused on the competencies of the direct manager in regard to the process management in care pathways. Before we present our conclusion, we want to address a number of (methodological) issues: the search strategy and the type of articles used, the method of retrieving the competencies from the articles and the term ‘manager’.

20

The search strategy used in this study is limited to published articles. Hence this possibly biased the results of the search strategy. The articles were of different methodology. Three research articles were found in the descriptive category,13,17,20 one of which is a case study,12 and two of which are qualitative research studies.16,21 Furthermore, two quantitative studies were found, which have a quasi-experimental design,15,18 and a cohort study based on file analysis.14 The research studies describe experiences of professionals, in relation to tasks and skills of the manager. No randomized trials were found, but given the research question, this was expected. The articles describe the results of different questions in the form of tasks, skills and behaviour of managers within the nursing hierarchy of the hospital, management possibilities, and positive and negative experiences of professional teams. Up to now, few research studies focused on leadership and multidisciplinary collaboration have been conducted.15,16 Spear17 states that the manager has to know what is going on in the ward and how to make improvements in order to coach the employees. This research study, however, was performed outside the health-care setting, and can therefore only be applied to the health care with the necessary adjustments. This article has been included because it will add a different viewpoint. The article written by Gifford et al. 15 focuses on the development of guidelines and the support given from outside the hospital. This gives a clear picture of the necessary strategies and major managerial competencies of managers. The article describes a qualitative research study based on the ‘grounded theory’ and produced a core category with a clear description of leadership. This article is useful as an important part of care pathways is the use of guidelines. We think that we used a valid search strategy, and that we identified the existing literature. However, the date limit of 2001 is arbitrary. Older publications are not included. We think that this is acceptable, because the use of care pathways is a relative new development. The search terms ‘education’ was added because education is always an important part in implementing care pathways. The search term ‘communication’ was added because this is important in the development of care pathways to gain commitment and consensus between the professionals. A great variety of behavioural characteristics is described in the articles. These characteristics are mapped to competencies from the SNCM by comparing the descriptions of the competencies to the behavioural characteristics.19 Although we used elements of Grounded Theory as methodology, the process with two reviewers is still subjective. A follow-up research study should verify the described competencies and examine which are the most important. In the literature, found in this research, the term ‘manager’ refers to the middle manager, the operational manager, the nursing executive or the board. In this review, these differences are taken into account. Besides this, the coordinator is described separately in taking responsibility for certain tasks in developing care pathways.12 – 14,22 International Journal of Care Pathways Volume 14 Number 1

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Conclusion

.............................................................. This research study has focused on finding the competencies needed by the operational managers in developing care pathways. Despite the relatively low methodological quality of the studies, and the fact that they were mainly forming opinions, a conclusion can be drawn from this literature study. All but two16,17 research studies focused mainly on the development and evaluation of care pathways. Other research studies show that a good development and implementation of care pathways promote the extent to which professionals use the care pathway, the way in which they work with it,12,14,21 and the way the outcomes are monitored.18,20 Monitoring the results is a way to achieve and maintain the goals of the care pathway.23 The literature contained the necessary competencies for the operational manager to monitor the care pathways. The middle managers can support and coach the operational managers in order to gain the necessary competencies.16,20,22 In the research studies, the role of the coordinator of care pathways is explicitly described in the development and support of the professional teams.12,22

Recommendation

.............................................................. A new research study should explore whether the formulated competencies are equally necessary for the operational manager to enable them to monitor the care pathways. This research should focus on completing the list of competencies and prioritizing them. It might be interesting to find out what management style matches with these competencies. In a selection procedure, the candidate managers can be chosen on the basis of the formulated competencies. It is therefore necessary to draw a competency profile of the operational manager based on the competencies found in this and future studies. The tactical manager can support and coach the operational manager in developing the right competencies. The list of competencies can be used in formulating a function profile or job description, or in the yearly interviews with the operational manager.

References 1 Vanhaecht K, Bollman M, Bower K, et al. Prevelance and use of clinical pathways in 23 countries –an international survey by the European Pathway Association. J Integr Care Pathways 2006;10:28 –34 2 Zander K. Integrated care pathways: eleven international trends. J Integr Care Pathways 2002;6:101 –7 3 van Zelm R, Kolkman E, Vanhaecht K, DeBleser L, Depreitere R, Sermeus W. Handboek zorgvernieuwing. Klinische paden: optimale zorg optimaal organiseren. Houten: Bohn Stafleu Van Loghum, 2005 4 Sermeus W, Giebens Y, Vanhaecht K, De Witte K, Haspeslagh M, Vleugels A. Het Vlaams-Nederlands Netwerk Klinische Paden. Acta Hosp 2002;3:29 –39


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5 Vanhaecht K, De Witte K, Sermeus W. The Impact of Clinical Pathways on the Organisation of Care Processes. PhD dissertation. Leuven: Katholieke Universiteit Leuven, 2007, 154 pp 6 Hoekstra TS, Vanhaecht K, Sermeus W. Het klinisch pad CABG. TVZ Tijdschrift voor verpleegkundigen 2003;3:51 –5 7 Vanhaecht K, Sermeus W. Draaiboek voor de ontwikkeling, implementatie en evaluatie van een klinisch pad. 30 stappenplan van het Netwerk Klinische Paden. Acta Hosp 2002;3:12 –27 8 Deneckere S, Vanhaecht K, Sermeus W. Gebruik en organiseren van klinische paden binnen het Belgisch –Nederlands Netwerk Klinische Paden. Leuven, Belgie¨: Netwerk Klinisch Paden, Centrum voor ziekenhuis – en verplegingswetenschap, 2007 9 Mintzberg H. Organisatiestructuren. 1st edn. Amsterdam: Pearson Education, 2006 10 van Dongen T. Competentiemanagement. En dan? 2nd edn. Zaltbommel: Thema, 2007 11 Polit DE, Beck CT. Nursing Research. Principles and Methods. 7th edn. Philadelphia, PA: Lippinicot Williams & Wilkins, 2004 12 Bragato L, Jacobs K. Care Pathways: the road to better health services? J Health Organ Manage 2003;16:154 –70 13 Hahn J, Bishop G, Fennell L. Integrating service excellence in a CHF clinical pathway pilot project. J Healthc Qual 2002;24:35 –9, 44 14 Jackson D, Turner-Stokes L, Khatoon A, Stern H, Knight L, O’Connell A. Development of an integrated care pathway for the management of hemiplegic shoulder pain. Disabil Rehabil 2002;24:390 –8 15 Gibbon B, Watkins C, Barer D, et al. Can staff attitudes to team working in stroke care be improved? J Adv Nurs 2002;40:105 –11 16 Gifford WA, Davies B, Edwards N, Graham ID. Leadership strategies to influence the use of clinical practice guidelines. Nurs Res 2006;19: 72 –88 17 Spear SJ. Learning to lead at Toyota. Harv Bus Rev 2004;82:78 –86, 141 18 Schilling MK, Richter S, Jacob P, Lindemann W. Klinische Behandlungspfade. Erste Ergebnisse des systematischen IT – gestutzten Einsatzes an einer chirurgischen Universita¨tsklinik. Dtsch Med Wochenschr 2006;121:962 –7 19 van Dongen T. Competenties in Kaart. Zaltbommel: Thema, 2004 20 Atwal A, Caldwell K. Do multidisciplinary integrated care pathways improve interprofessional collaboration? Scand J Caring Sci 2002;16: 360– 7 21 Pace KB, Sakulkoo S, Hoffart N, Cobb AK. Barriers to successful implementation of a clinical pathway for CHF. J Healthc Qual 2002;24: 32 –8 22 Mellor F, Foley T, Connolly M, Mercer V, Spanswick M. Role of a clinical facilitator in introducing an integrated care pathway for the care of the dying. Int J Palliat Nurs 2004;10:497 –501 23 Van Herck P, Vanhaecht K, Sermeus W. Effects of clinical pathways: do they work? J Integr Care Pathways 2004;8:95 –105

Appendix A: Full search strategy

..............................................................

No.

Records

1 2 3 4 5 6 7

502740 4507 1233 663 699 701 488

8 9 10 11 12 13 14 15

609 295 3264921 2641 0 1184 0 83643

Request 2001 in py 20070302 in ud ‘Critical-Pathways’/all subheadings (care near3 ( path or map?)) in ti,ab (clinical near3 pathway?) in ti,ab ‘Critical-Pathways’/all subheadings in mjme ((care near3 (path or map?)) in ti) or ((clinical near3 pathway?) in ti) (fast near5 track ) in ti,ab (fast near5 track ) in ti (dutch or german or english) in la #3 or #4 or #5 or #8 ‘P voor klinische paden’ #6 or #7 or #9 ‘P voor klinische paden focus’ ORGANIZATION-AND-ADMINISTRATION in SH

(Continued )

21

J Verkerk-Geelhoed and R van Zelm Competencies needed by operational managers in managing care pathways Appendix A: (Continued) No.

Records

16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

5352 1588 322 290 766 150 1366 140 627 2776 3550 617 1675 4172 3801 23547

32 33 34 35 36 37 38 39 40 41

5592 61023 863 4129 3448 5516 4003 2118 34862 108668

42 43 44 45 46 47 48 49 50 51 52 53 54 55 56

23 16 52006 27 5900 13 6609 35483 35483 220 121 105 13 11 24190

57 58

2 27

59 60 61 62 63 64 65 66 67 68 69 70

11 10 68137 126462 168 97 95 49 48 36 12 9

22

Request ‘Professional-Competence’/all subheadings ‘Personnel-Management’/all subheadings ‘Employee-Discipline’/all subheadings ‘Employee-Incentive-Plans’/all subheadings ‘Employee-Performance-Appraisal’/all subheadings ‘Management-Quality-Circles’/all subheadings ‘Negotiating’/all subheadings ‘Personnel-Delegation’/all subheadings ‘Personnel-Loyalty’ in MIME,MJME,PT ‘Personnel-Selection’/all subheadings ‘Personnel-Staffing-and-Scheduling’/all subheadings ‘Physician-Incentive-Plans’/all subheadings ‘Staff-Development’/all subheadings ‘Workload’/all subheadings ‘Workplace’/all subheadings #16 or #17 or #18 or #19 or #20 or #21 or #22 or #23 or #24 or #25 or #26 or #27 or #28 or #29 or #30 explode ‘Practice-Management’/all subheadings explode ‘Risk-Management’/all subheadings ‘Time-Management’/all subheadings ‘Total-Quality-Management’/all subheadings explode ‘Appointments-and-Schedules’/all subheadings ‘Efficiency-Organizational’/all subheadings ‘Organizational-Culture’ in MIME,MJME,PT ‘Planning-Techniques’ in MIME,MJME,PT explode ‘Professional-Practice’/all subheadings #32 or #33 or #34 or #35 or #36 or #37 or #38 or #39 or #40 #13 and #10 and #31 #13 and #10 and #31 and #15 manage in ti #13 and #10 and #15 and #44 manager? in ti,ab #13 and #10 and #15 and #46 ‘Leadership-’ in MIME,MJME,PT explode ‘Personality’/all subheadings #48 or #49 #13 and #10 and (#31 or #41) #13 and #10 and (#31 or #41) and #15 #52 not #43 #13 and #10 and (#31 or #41) and (#50 or competenc ) #54 not #43 (leadership or (management near5 role?) or (management near5 proces ) or manager? or managing) in ti,ab #13 and #10 and ((#50 in mjme) or (competenc in ti)) #13 and #10 and (#31 or #41) and (#50 or competenc or #56) #58 not (#43 or #54) #11 and #10 and #16 explode ‘Communication’/all subheadings standards in sh #11 and #10 and #15 and #62 #11 and #10 and #15 and #62 and (#61 or #31 or #41) #11 and #10 and #15 and #62 and (#31 or #41) #13 and #10 and #15 and #62 and (#31 or #41) #43 or #47 or #58 (#13 and #10 and #15 and #62 and (#31 or #41)) not #67 #13 and #10 and #15 and #61 (#13 and #10 and #15 and #61) not (#67 or #68)

Appendix B: Flowchart of literature selection

..............................................................

The inclusion criteria were as follows:

† Development or evaluation of care pathways; † Management descriptions. The exclusion criteria were as follows:

† Absence of an abstract; † Absence of management descriptions. Process: Both authors independently assessed all 114 articles for relevance based on the title. If both decided the article was not relevant, the abstract was not retrieved. If one or both authors thought the article relevant, the abstract was retrieved. The abstracts were also reviewed by both authors independently. If both authors agreed, the article was either included or excluded. If there was no consensus, the abstract was reviewed by a third reviewer.


2010