Barriers and facilitators for the implementation of Integrated Care Pathways ICPs: a systemic perspective

Abstract

Introduction: Integrated Care Pathways are a proven effective intervention to improve care coordination and quality of care, however their implementation presents important challenges and barriers at the clinical, meso and macro level. The literature identifies actions and elements to be considered that contribute to their effective implementation. However, their implementation is context-dependent, needing a systemic perspective to understand the barriers and elements that can facilitate its deployment in the Spanish National Health System. Theory: We understand ICPs as a pact between professionals and organizations from different healthcare areas that operate in the same territory and serve the same population affected by a specific health problem/s, to apply the criteria of good practice, optimize care circuits and plan responses to foreseeable scenarios. A qualitative research session was conducted with a multidisciplinary group of key opinion leaders 19, including clinicians, healthcare managers and policy makers from 9 different Spanish regions. Design thinking methodology was used to identify and agree upon key barriers and enablers for the implementation of ICPs from a macro, meso and micro perspective. The session was underpinned, by the knowledge gathered through systematic review and lessons learned from a best practice of ICPs implementation in Spain. Results: Structured list of key barriers and enablers at macro, meso and micro level for an effective implementation of ICPs. The identified barriers were: lack of systemic and integrative vision; clinical and social complexity of the patient, rigidity and work in silos, non-integrated information systems; individualist professional culture, absence of transformational leadership, patient not located in the center, and lack of training. Enablers were also identified. Discussions: As the literature highlights, successful ICP implementation requires a deep understanding of the local contexts and alignment between bottom-up initiatives and top-down support Conclusions: There are several issues preventing a larger deployment of ICPs in Spain: at macro level there is a general lack of strategic vision towards integrated care from a systems perspective, especially from a multisector approach. At meso level, the historical fragmentation of organizations poses a strong challenge towards care coordination. At the micro level a lack of clinical leadership and buy-in hinders the needed multidisciplinary and collaborative work. Strategic alignment, better information systems, improving data collection, continuous monitoring and evaluation, feedback looping to professionals, incentives and training healthcare professionals in communication and team-work skills were identified as facilitators. Lessons: Although coming from different regions and professional backgrounds, all participants have experienced similar problems with the implementation of ICPs. ICPs implementation go beyond the development of a booklet with a set of guidelines, they imply local agreements, cultural change and doing things differently. They need a strong sustained buy-in from every level, a leading core team, sufficient resources, and a continuous support to manage cultural change and adaptation to local context. Limitations: This research has been focused on a particular health system. Conclusions should be generalized with caution. Suggestions: Further research is needed to demonstrate if the conclusions of this study are applicable to other settings, particularly in non NHS-like systems.