Identification of core components and implementation strategies for a Conservative Kidney Management Pathway across a complex, multisector healthcare system in Canada using World Cafés and the Theoretical Domains Framework.

OBJECTIVE: Develop a Conservative Kidney Management (CKM) Pathway for patients unlikely to benefit from dialysis. We sought to determine (1) core components of care and (2) implementation strategies across a multisector healthcare system. DESIGN: We used the Knowledge to Action Cycle and the Theoretical Domains Framework to identify barriers and facilitators to CKM. Activities included a current state assessment, World Cafés, interviews, focus groups and readiness for change assessments. SETTING: A provincial initiative in Alberta, Canada. PARTICIPANTS: 282 participants were purposively selected to reflect those involved in the care of patients receiving CKM. This included policy-makers, multidisciplinary healthcare professionals, patients and their family. MAIN OUTCOME MEASURES: Theoretical domains linked to pathway content and implementation strategies. RESULTS: Environmental context and resources, social/professional role and identity, knowledge and social influences were the most influential behaviour change domains identified. The most effective strategies for facilitating behaviour change were identified to be education, training, environmental restructuring and modelling. Core components of care were determined to be guidelines for treating symptoms and disease complications consistent with the philosophy of CKM, timely communication of the choice for CKM, coordination with community services, crisis planning, advance care planning and tools to enhance patients' capacity for self-management and shared decision-making. This resulted in development of Alberta's CKM Pathway, an interactive, digital, decision-support tool consisting of: (1) a patient decision aid; (2) a patient/family portal; and (3) a healthcare professional portal, where all resources can be freely accessed. CONCLUSIONS: The pathway was codesigned by patients and healthcare professionals and involves tailor-made combinations of tools to address unique patient needs and system-community circumstances. Most of the strategies are adaptable to local context and are likely translatable to the implementation of sustainable CKM in other national and international jurisdictions.

Improving the quality of care for older adults using evidence-informed clinical care pathways.

BACKGROUND: There has been an intensified focus on quality initiatives within health care. Clinical Networks have been established in Alberta as a structure to improve care within and across settings. One method used by Clinical Networks to improve care is clinical care pathways. The objective of this study was to evaluate an evidence-informed hip fracture acute care pathway before broad implementation. METHODS: The pathway was developed by a provincial Clinical Network and implemented at four of 14 hospitals across the province. Within four months of implementing the pathway, experienced interviewers conducted focus groups with end-users at the four sites. Domains of inquiry focused on indentifying barriers and facilitators to use of the pathway. RESULTS: Fifteen physicians and 29 other health-care providers participated in eight focus groups. Common themes identified around the pathway order sets included issues with format, workflow and workload, and dissemination. The patient/family educational materials were deemed to be beneficial. Health-care provider education required better support. Overall the pathway was seen to be comprehensive. However, communication about the pathway could have been improved. CONCLUSIONS: This care model is novel in that it combines the concepts of clinical networks, care pathways, and knowledge translation in an effort to provide high-quality, evidence-informed care in a standardized equitable manner across a diverse geographic area.