Effective Interventions Unit
Integrated Care Pathways
Guide 3: Implementing Integrated Care Pathways
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WHAT IS THE PURPOSE OF THIS GUIDE?
This is the third in a series of guides on developing and implementing Integrated Care Pathways (ICPs). This guide provides practical advice on how to maximise the impact of the ICP prior to implementation.
Harry was introduced in Integrated Care for Drug Users: Principles and Practice (2002) to illustrate how the design and delivery of integrated drug services might affect the individual.
Harry's keyworker has been taking part in a multi-agency group that has been developing an ICP for use in their area. They are now ready to put their ICP in to practice. This guide sets out a number of issues which they might consider before implementing the new pathway.
WHO SHOULD READ IT?
Anyone involved in commissioning, planning, developing, delivering and evaluating services for drug users.
READY TO GO?
Having spent spent much time and effort on developing an ICP, your multi-disciplinary team will be keen to get it into operation and start to see the benefits. However, your pathway will have a much greater impact if time is spent now ensuring that those people who will use it in their day-to-day work understand the benefits and do not see it as, for example, extra paperwork. There are a number of factors which will improve the chances of a successful implementation and these are set out below.
DEVELOPING AN IMPLEMENTATION STRATEGY
Your strategy should not be overly complicated. It should identify the key stages of implementation and identify the key actions. The strategy can offer a checklist of tasks that are shared out among the implementation group.
Your strategy should include:
Training & Support
It is vital that those people who will soon be asked to work in a different way because of the introduction of the pathway are supportive. Many good pathways flounder because the concerns of staff have not been heard and their questions not addressed. The pathway may require staff to work with some agencies or services for the first time. It is important to the implementation to invest time in discussing and understanding the issues around professional regulation and accountability and exploring areas of commonality as well as unique roles.
This question will always be around even if it is not said out loud, so it is important to tackle it. Different things motivate people and the benefits that are most obvious to you may not strike a chord with others. You should build in time in your implementation strategy to explore fully the potential benefits of the ICP with the people who will be asked to work within it and the service users who will experience it. Remember, you may be looking for some of these people to be 'champions for change' for the ICP.
One of the biggest selling points will be that the ICP has been designed by a multi agency group to produce a better outcome for people who will receive care through the pathway. After all, this will have been the initial reason for developing the pathway in the first place. It will be useful to re-state the difference between the current system and the ICP approach to the provision of services.
All staff who will be using the pathway will require information about the 'whys and hows'. All relevant stakeholders should have access to awareness sessions. These sessions should cover the principles of the pathway; the practicalities of how to work within it and how to make the most of it.
However, it is often difficult to get everyone together at the same time to provide a formal awareness session. You might consider:
copying your materials or presentations onto handouts to put in people's pigeonholes or resource library
putting it onto a webpage or PowerPoint file and e-mailing it to all concerned or
writing it onto a CD to make it accessible and consistent, if applicable.
During the development of your ICP you will have had contact with a number of different people. It is important at this point to consider whether you have spoken to everyone that you need to and that you are confident that you have listened to their input and acted accordingly. You should also ensure that everyone has the most up-to-date information, including the final copy of the ICP, the start date and the contact details of the ICP co-ordinator. If there is any doubt you should send everyone a final copy.
Consider whether it is worth adding a communication strategy to the ICP documentation that details who can be contacted, how, and in what circumstances. The result should be the development of robust partnership arrangements among all stakeholders which sets out the actions required and the steps required to achieve them.
You will be keen to introduce the new ICP at the earliest opportunity. However it is often useful to do a quick 'horizon scanning' to make sure that the launch does not clash with events or circumstances, locally or nationally, which might adversely affect it. This could include peak holiday seasons, changes of key personnel or the introduction of other 'new working systems'.
It is worth getting a number of key dates decided and put in the diary now. These would include start dates, review dates and a number of in-service training dates. The evaluation process nearly always takes longer than people allow for so make sure that your timescales can accommodate a degree of flexibility.
Already there will have been a considerable amount of resource invested in the development of your ICP. The number of hours spent to date by all involved including travelling time, meetings, administrative time, pathway design and development and training will amount to a considerable investment.
The transition between the old working system and the new ICP based process will need to be well supported. It may be necessary to resource a short period of 'double system running' so that staff have time to deal with new systems of documentation and new procedures without detracting from their direct client contact time.
The amount of extra resource required will depend on a number of factors:
the size of the project. Is it a service-wide pathway involving high numbers of staff or a small local initiative?
the number of staff involved
the extent of change from current system
the length of time required for double running
the level of confidence and motivation of staff at the outset
Staff may suggest that the ICP documentation takes longer to complete than the existing system of documentation and this may well be accurate. Middleton & Roberts suggest that new documentation is likely to take more time to complete for one of two reasons, neither of which is likely to continue in the long term. 1
Any new system requires familiarisation time. The act of having to turn pages over to find where to document a particular piece of information rather than simply writing it down on the next piece of blank paper will be more time consuming until staff are able to turn to the required place automatically.
ICPs may actually require some staff to write more than they did before, particularly in situations where previous documentation was not well completed and where routine notes about clients' progress were not kept to an adequate standard.
Improving the administrative burden on clinical and social care staff is a welcome bi-product of a well-structured ICP. For example, Cavanagh et al introduced a care pathway in their area of work where staff reported that the previous documentation system had been onerous, time-consuming and duplicative. 2
In the evaluation of their ICP they found that staff reported spending less time on paperwork and having more structured communication channels.
TIPS FOR IMPROVING DOCUMENTATION
ICPs documentation is concerned with anticipating the 'routine' of record keeping and pre-printing it, thus allowing the practitioner to follow or not follow what was anticipated (see Variance Tracking, forthcoming Guide 4). Pre-printing cuts down on the amount of 'narrative' note writing required.
Try to stick to a standard format including:
Care plan and management notes
Variations from the expected pathway
Consider colour coding different parts of the document for easy navigation
Keep it short and concise
Be clear who produces and disseminates documentation
There is always going to be a tension between consistency and flexibility, whether to keep things exactly the same across different sites or departments, or to allow a degree of local decision-making and ownership in order to help 'bed it in'. The bottom line is that the pathway must do what it is designed to do. As long as the agreed performance indicators and objectives are met, local procedures that reflect the local system of care should be considered.
TRAINING & SUPPORT
There is a continuing role for the ICP development group to address the need for ongoing training. The need for training occurs when:
new staff coming into the area need orientation to the ICP
new evidence becomes available prompting a review of the ICP
the review and analysis of the ICP suggests that changes should be made
the ICP has to incorporate information from evaluation of compliance and acceptance by clients and staff
The 'support' role will probably be a mix of policing and hand-holding. The facilitator/co-ordinator will need to ensure that the ICP is being adhered to and implemented effectively and be able to provide guidance and practical assistance in areas where things are not going so well. This person will be required to provide a clear project/visionary lead and will need to be empowered and supported to do so by all partner agencies. This will be a crucial role in defining the success or failure of your pathway so make sure that you get the right person with the right competencies for the job!
Now that you have completed your checklist you are ready to implement your ICP. It would be helpful if you let the EIU know how you get on with this process to ensure practice development and continuous improvement.
The next ICP Guide (No.4) will explore the Analysis and Review of Integrated Care Pathways. Later guides will apply these processes to developing outline ICPs for specific situations including:
Integrated Care Pathways Users Scotland
National Electronic Library for Health
Health Service Utilization and Research Commission
The National Pathways Association
Thanks to the ICP Development Group and others for contributing to this guide.