Sandra Bryan, CNS; Shirley Holmes, CNS
Breast care nurses
The health service is currently undergoing another period of intense change. Nowhere is this more apparent than in the delivery of cancer care. The Government has set out targets and aspirations in The NHS Plan (DoH, 2000a) and The Cancer Plan (DoH, 2000b) The aim of these targets can be simply summarised: to promote increasingly efficient and patient-centred care. This means making sure patients get the treatment they need, how and when they need it. This may need to be accomplished without any significant increase in staffing or funding, which means that efficiency must increase.
The Salisbury breast care service pathway is as an example of how a care pathway can be used to achieve these aims. The lessons learned and tools developed can also be adapted to improve care delivery for patients with different types of cancer and other serious conditions.
The Salisbury care pathway
In Salisbury we have been interested in care pathways since 1996 and set up a project to promote further development in the area. The trust was then asked by the South West Region to develop a breast-care pathway, which led to our unit being awarded Beacon Status in 1998. The unit was one of the original eight Cancer Beacons and one of two dealing with breast cancer. Beacons were recognised as centres of good practice and have been encouraged to utilize a variety of strategies to disseminate their ideas to other centres. From 1999 onwards we have been involved in phase one of the National Cancer Collaborative. This project has been developing practical ways of changing services to improve the experience and outcomes of care for people with cancer (Kerr, 2002). The project uses Predict Do Study (PDSA) cycles to refine the components of the care pathway and improve care. It is unique in trying to change the process of cancer care delivery in the UK.
Integrated care pathways
An integrated care pathway is a map of the process involved in managing a common clinical condition or situation. It should detail what to do, when to do it, by whom the action should be undertaken and where the task should be performed. It should also challenge the effectiveness of the conventional scheme of care and thereby improve the quality of the care given (Wigfield, 1996).
To form a care pathway the first step is to identify the members of the multidisciplinary team that are to be involved (Kitchiner, 1996) (Figure 1). This includes all the providers of care, nurses, medical and allied staff involved in the treatment of a particular patient group. It is often a surprise to discover how many different individuals are involved in the treatment of a particular patient group. If professionals do not work in a co-ordinated way, it is likely that the results of treatment will be variable. It is also important to remember that patients and their carers are part of the team and efforts need to be made to incorporate them into it.
Once the team has been identified, its members need to discuss the existing patient journey and map it out (Wigfield, 1996). The process needs to be followed through from GP referral, clinic attendance, in-patient treatment, discharge from hospital and then aftercare. Storyboards may help to visualise this journey. The range of delays at all stages of the pathway should be recorded to identify areas where change would have the most effect. Patients’ views on when they feel least supported and informed and most vulnerable should be used to support these interventions. We initially used and continue to use input from individual patients’ comments, gathered from talking to patient support groups and via community health council reports.
In a complicated disease process it may be most efficient to divide the team into appropriate sub-groups in order to seek solutions for the parts of the pathway that fall within each individual’s area of expertise (Johnson, 2000). It is important that the whole team meet up regularly to discuss the progress made within each sub-group, to identify common areas of need and to provide support and feedback. Discussion should take place in an atmosphere that allows all members of the team to contribute fully.
Once all groups have completed their individual work, the patient journey can then be modified to produce an ‘ideal’. The performance of the pathway should be continuously monitored by a pathway co-ordinator (Riches, 1994). If variances occur, adjustments in the pathway will need to be made (Ibarra, 1996). In a motivated team new ideas on how to approach a particular part of the journey arise and by interacting with other teams new concepts may also be introduced. The pathway should allow for these to be tested using the PDSA approach outlined above and, if it is found to be beneficial, it should be incorporated.
Finally, once the pathway has been developed it should be documented. This piece of documentation should include the standards of good current practice and be designed to allow regular analysis of variances from the pathway. The documentation should form a single record for use by the whole team and each item of data should ideally be gathered and recorded only once (Lowe, 1998). As an example, in our pathway the page for the first post-operative day has a section in green which is filled in by medical staff. The area below is completed by ward and breast care nurses.
Areas of care that can be improved
The benefits of forming an integrated care pathway extend far beyond the production of a good pathway document. The discussions that take place during the development of the pathway also encourage closer team working. Those involved may not previously have fully appreciated how their role fits into the whole scheme. This can lead them to undervalue their contribution or that of others. Because patients are involved in the development of the pathway they are able to specify what information they would like to be given at the various stages of the process. If patients are active participants in their treatment they feel more empowered. This leads to better satisfaction with treatment (Coulter, 1999) and possibly improved outcomes (Street, 1995).
The pathway document should facilitate the analysis of variance and clinical audit (Ibarra, 1996). Analysis of variance automatically monitors deviations from the pathway standards, since the pathway predicts the standard journey (Riches, 1994). These variances may be system derived, for example, when a member of the hospital team has failed to complete a task, or community derived, for example, a lack of social services delaying discharge, and can be addressed by the team. If some part of the process commonly does not go to plan then obviously either the standard or the pathway need modification. As the pathway evolves and is modified, fewer system- and community-derived anomalies should be detected. There will, however, continue to be the occasional patient variance due to unexpected complications. The results of initial variance analysis and the general monitoring of the pathway allow the components of clinical governance to be performed in a seamless fashion (Kitchiner, 1996). These components include audit, risk management, staff education and development and clinical information.
The pathway should incorporate the standards of care in an easily accessible form. If delays in any part of the pathway or any outcome measure fall below these standards it becomes apparent and remedial action can be taken. The major components of risk are variable patient experience and poor record keeping. Both of these are minimised with the use of a pathway (Kitchiner, 1996).
Staff education and development is commonly improved by using a pathway (Royal College or Nursing, 2002). A function of the pathway’s developmental process is to identify which member of staff can most appropriately perform a particular task. It may be, for example, that a role traditionally performed by medical staff is in fact more suited to the sensitivities and training of nursing staff. We now have nursing rather than medical staff performing follow-up of patients with breast cancer and assessing women with a family history of breast cancer. In this case, occupational standards may need to be acquired and a strategy for their acquisition formed and implemented.
We have found that both the trust and senior professionals are responsive to a well-argued case for this type of change. We have also found that an undesirable side-effect of specialisation in the team can be deskilling in core areas. For example, a role previously performed by junior medical staff or ward nurses may be reallocated to a specialist nurse. An induction programme to take new staff through the entire pathway to ensure a clear understanding of the process can address this situation. If at any stage the pathway is altered significantly an update for all staff may be needed.
The patients’ experience is central to the changes in care proposed by the Government (DoH, 2000) and to the function of the pathway. Feedback from patient groups can lead to further improvements in the service, for example with refinements to patient-held records (McQueen, 1997).
Improvements in the way clinical information is documented are long overdue. The integrated care pathway documentation should be of use to all members of the multidisciplinary team and is designed to reduce the number of times any piece of information is gathered and recorded, while ensuring that the record is comprehensive and triggers the appropriate interventions and assessments (Wigfield, 1996). We have found the use of clinical headings helpful in achieving this goal and expect that this will be a major aid in a move towards the use of electronic patient records (NHS Communication Authority, 2000).
Opponents to the use of care pathways may argue that they do not have time to stand back from clinical work to generate a pathway. However, if a pathway has been well-constructed, everyone in the team should feel that his or her job is made simpler and more satisfying. Each individual will be performing the role for which they are most suited and therefore able to perform it efficiently, resulting in less duplication of tasks.
If still unconvinced about starting a pathway from scratch, the Cancer Services Collaborative has produced a set of solutions for common problem areas such as referral, the diagnostic clinic and follow-up, that can be used as a guide to help you produce your own pathway. It may also be useful to visit other units to see how their pathways works. You can contact the Beacon team at www.nhs.uk/beacons and the collaborative on www.nhs.uk/npat.
Others can be put off because they feel that pathways act as strait-jackets that do not allow for any movement outside of its confines. It should be remembered that pathways only act as a guide for the management of ‘most’ patients and their experiences. As a pathway matures a greater percentage of patients will in fact experience the ‘ideal’ way, however variances should be expected and the team is responsible for treating these patients as individuals.
- The second article, appearing in the November issue, will describe the care pathway in detail and explore how the role of nurses has been extended within the department to the benefit of both patients and staff.
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