Implementing cancer patient pathways in Scandinavia how structuring might affect the acceptance of a politically imposed reform.

Through political decisions all three Scandinavian countries implemented national reforms in cancer care introducing cancer patient pathways. Though resistance from the professional community is common to top-down initiatives, we recognized positive receptions of this reform in all three countries and professionals immediately contributed in implementing the core measures. The implementation of a similar reform in three countries with a similar health care system created a unique opportunity to look for shared characteristics. Combining analytical framework of institutional theory and research on policy implementation, we identified common patterns of structuring of the initial implementation: The hierarchical processes were combined with supplementary structures located both within and outside the formal management hierarchy. Some had a permanent character while others were more project-like or even resembled social movements. These hybrid structures made it possible for actors from high up in the hierarchy to communicate directly to actors at the operational hospital level. Across the cases, we also identified structural components acting together with the traditional command-control; negotiation, consensus and counseling. However, variations in the presence of these did not seem to have significant impact on processes causing decisions and acceptance. These variations may, however, influence the long-term practice and outcome of cancer-care pathway-reform. Knowledge from our study should be considered when orchestrating future health care reforms and especially top-down politically initiated reforms.

Mind the Differences: How Diagnoses and Hospital Characteristics Influence Coordination in Cancer Patient Pathways.

Integrated care pathway (ICP) is a prevailing concept in health care management including cancer care. Though substantial research has been conducted on ICPs knowledge is still deficient explaining how characteristics of diagnose, applied procedures, patient group and organizational context influence specific practicing of ICPs. We studied how coordination takes place in three cancer pathways in four Norwegian hospitals. We identified how core contextual variables of cancer pathways affect complexity and predictability of the performance of each pathway. Thus, we also point at differences in core preconditions for accomplishing coordination of the cancer pathways. In addition, the findings show that three different types of coordination dynamics are present in all three pathways to a divergent degree: programmed chains, consultative hubs and problem-solving webs. Pathway coordination also depends on hierarchical interaction. Lack of corresponding roles in the medical-professional and the administrative-institutional logics presents a challenge for coordination, both within and between hospitals. We recommend that further improvement of specific ICPs by paying attention to what should be standardized and what should be kept flexible, aligning semi-formal and formal structures to pathway processes and identify the professional cancer related background and management style required by the key-roles in pathway management.

Exploring the triggering process of a cancer care reform in three Scandinavian countries.

Cancer incidence is increasing, and cancer is a leading cause of death in the Scandinavian countries, and at the same time more efficient but very expensive new treatment options are available. Based on the increasing demand, high expectations and limited resources, crises in public legitimacy of cancer care evolved in the three Scandinavian countries. Similar cancer care reforms were introduced in the period 2007-2015 to address the crisis. In this article we explore processes triggering these reforms in countries with similar and well-developed health care systems. The common objective was the need to reduce time from referral to start treatment, and the tool introduced to accomplish this was integrated care pathways for cancer diagnosis, that is Cancer Patient Pathways. This study investigates the process by drawing on interviews with key actors and public documents. We identified three main logics in play; the economic-administrative, the medical and the patient-related logic and explored how institutional entrepreneurs skillfully aligned these logics. The article contributes by describing the triggering processes on politically initiated similar reforms in the three countries studied and also contributes to a better understanding on the orchestrating of politically initiated health care reforms with the intention to change medical practice in hospitals.

Practicing Integrated Care Pathways in Norwegian Hospitals: Coordination through Industrialized Standardization, Value Chains, and Quality Management or an Organizational Equivalent to Improvised Jazz Standards.

The goal of coordinating pathways for cancer patients through their diagnostic and treatment journey is often approached by borrowing strategies from traditional industries, including standardization, process redesign, and variation reduction. However, the usefulness of these strategies is sometimes limited in the face of the complexity and uncertainty that characterize these processes over time and the situation at both patient and institutional levels. We found this to be the case when we did an in-depth qualitative study of coordination processes in patient pathways for three diagnoses in four Norwegian hospitals. What allows these hospitals to accomplish coordination is supplementing standardization with improvisation. This improvisation is embedded in four types of emerging semi-formal structures: collegial communities, networks, boundary spanners, and physical proximity. The hierarchical higher administrative levels appear to have a limited ability to manage and support coordination of these emerging structures when needed. We claim that this can be explained by viewing line management as representative of an economic-administrative institutional logic while these emerging structures represent a medical-professional logic that privileges proximity to the variation and complexity in the situations. The challenge is then to find a way for emergent and formal structures to coexist.