Are project presentations important?

In the previous issues of this journal, we have discussed the need for knowledge sharing and research on pathways as complex interventions. Other papers have also recently been discussing that if we want to use pathways as one of the tools to change the future of health care, the need for continuous learning and understanding of how, when and where pathways were developed, is crucial to understand the effect on the main outcome. The organization of care processes has been receiving increasing attention from clinicians and managers and many care processes are undergoing change; but although every improvement involves change, not all changes are improvements. To know that change is producing improvement, we need information about what is happening. Different authors have discussed the direct relationship between interventions or organizational changes and outcomes. Based on Donabedians’ paradigm of Structure–Process–Outcome, the Realistic Evaluation Configuration contends that causal outcomes follow from mechanisms acting in a context (Context þ Mechanism 1⁄4 Outcome [CMO]). The Realistic Evaluation approach offers researchers the opportunity to look at evaluation from a realistic perspective, one in which action is not happening in a laboratory environment. The questions posed are ‘What works, for whom, in what circumstances?’ instead of ‘Does this work?’ or ‘What works?’. The basic CMO concern is still, of course, the outcome. However, the explanation first focuses on the mechanism (e.g. the program that was introduced, known as the process in Donabedians’ paradigm) and second focuses on the context (e.g. the characteristics of the organization where the programme was introduced, known as the structure in Donabedians’ paradigm). The Realistic Evaluation Configuration has previously been used in a wide range of health-care projects. The care process organization triangle is a conceptual framework to better understand how pathways work, and was developed based on different models of care organization (see Figure 1). The care process organization triangle suggests that if we want to understand how pathways work, we need to understand the structure (defined by other authors as the context, the system, the design, the company and the firm) and the process (defined by other authors as the mechanism, the interventions, the professional development, the frontline employee and the delivery of care) in order to understand the effect on the outcome (defined by other authors as the results, the patient, the customer and the client). In evaluating pathways, we need to make sure we fully understand the type of information we are searching for. When we want to understand what is happening in our own organization with regards to the care process, and what the impact is of our care pathway in our care organization, the aim is a formative evaluation. When we are searching for the proof that pathways work, the aim is a summative evaluation. For summative evaluation, the Medical Research Council advises to use cluster randomized controlled trials (cRCTs), because pathways are complex interventions. cRCTs ask a lot from resources, and are not easy to design, organize, plan and carry out, and therefore it is not possible to use this research design in every setting and in every circumstance. Also, meta-analyses of individual pathway projects, with weaker study designs, that are not disease-specific or without knowledge about the context of the organization or the content of the complex intervention, are difficult to understand and will not help the pathway community to provide all the answers. Information on the context of the organization (the structure in Figure 1) and the complex intervention (the process in Figure 1) is crucial if we want to understand why and when pathways work. This is the reason why the International Journal of Care Pathways will be happy to accept project presentations for review. This was recently discussed during the International Care Pathway Conference in London on 24 June 2010, where Professor Davina Allan of Cardiff School of Nursing and Midwifery Studies asked for more attention to be paid to the possible gap in pathway publications and internal reports, if they do not include information on the organization, the team and the context. ‘Project presentations’ were already included as one of the publication types when the International Journal of Care Pathways was launched. The content of the project presentation was recently revised based on discussions within the European Pathway Association, the International Care Pathways Conference held in London in 2010 and international collaboration involving preparation of papers with Professor John Ovretveit, Sweden; Professor Don Goldman, USA; Professor Martin Elliot, UK; Professor John Ellershaw, UK; and Professor Walter Sermeus, Belgium (see Box 1).