Quality indicators for ambulatory colectomy: literature search and expert consensus.

BACKGROUND: Care for patients undergoing elective colectomy has become increasingly standardized using Enhanced Recovery Programs (ERP). ERP, encorporating minimally invasive surgery (MIS), decreased postoperative morbidity and length of stay (LOS). However, disruptive changes are needed to safely introduce colectomy in an ambulatory or same-day discharge (SDD) setting. Few research groups showed the feasibility of ambulatory colectomy. So far, no minimum standards for the quality of care of this procedure have been defined. This study aims to identify quality indicators (QIs) that assess the quality of care for ambulatory colectomy. METHODS: A literature search was performed to identify recommendations for ambulatory colectomy. Based on that search, a set of QIs was identified and categorized into seven domains: preparation of the patient (pre-admission), anesthesia, surgery, in-hospital monitoring, home monitoring, feasibility, and clinical outcomes. This list was presented to a panel of international experts (surgeons and anesthesiologists) in a 1 round Delphi to assess the relevance of the proposed indicators. RESULTS: Based on the literature search (2010-2021), 3841 results were screened on title and abstract for relevant information. Nine papers were withheld to identify the first set of QIs (n = 155). After excluding duplicates and outdated QIs, this longlist was narrowed down to 88 indicators. Afterward, consensus was reached in a 1 round Delphi on a final list of 32 QIs, aiming to be a comprehensive set to evaluate the quality of ambulatory colectomy care. CONCLUSION: We propose a list of 32 QI to guide and evaluate the implementation of ambulatory colectomy.

The determinants of expert opinion in the development of care pathways: insights from an exploratory cluster analysis.

BACKGROUND: We performed a secondary exploratory cluster analysis on the data collected from the validation phase of the study leading to the development of the model care pathway (CP) for Myasthenia Gravis (MG), in which a panel of 85 international experts were asked some characteristics about themselves and their opinion about the model CP. Our aim was to identify which characteristics of the experts play a role in the genesis of their opinion. METHODS: We extracted the questions probing an opinion and those describing a characteristic of the expert from the original questionnaire. We performed a multiple correspondence analysis (MCA) and a subsequent hierarchical clustering on principal component (HCPC) on the opinion variables, integrating the characteristic variables as supplementary (predicted). RESULTS: After reducing the dimensionality of the questionnaire to three dimensions we noticed that the not-appropriateness judgement of the clinical activities may overlap with the completeness one. From the HCPC it seems that the working setting of the expert may play a crucial role in determining the opinion about the setting of the sub-processes of MG: shifting from a cluster where the experts do not work in sub-specialist settings to one where the experts are working in them, the opinion changes accordingly from a mono-disciplinary setting to a multi-disciplinary one. Another interesting result is that the experience in neuromuscular diseases (NMD) measured in years and the expert typology (whether general neurologist or NMD expert) seem not to contribute significantly to the opinions. CONCLUSIONS: These findings might indicate a poor ability of the expert to discriminate what is not appropriate from what is not complete. Also, the opinion of the expert might be influenced by the working setting, but not by the experience in NMD (as measured in years).

Variation in stroke care at the hospital level: A cross-sectional multicenter study.

Introduction: Stroke is one of the leading causes of mortality and disability. Improving patient outcomes can be achieved by improving stroke care and adherence to guidelines. Since wide variation in adherence rates for stroke guidelines still exists, we aimed to describe and compare stroke care variability within Belgian hospitals. Materials and methods: An observational, multicenter study was performed in 29 Belgian hospitals. We retrospectively collected patient characteristics, quality indicators, and time metrics from the last 30 consecutive patients per hospital, diagnosed with ischemic stroke in 2019 with structured questionnaires. Mean adherence ratios (%) ± SD (minimum - maximum) were calculated. Results: We analyzed 870 patient records from 29 hospitals. Results showed large inter- and intrahospitals variations in adherence for various indicators. Almost all the patients received brain imaging (99.7%) followed by admission at a stroke unit in 82.9% of patients. Of patients not receiving thrombolysis, 92.5% of patients were started on antithrombotic drugs. Indicators with moderate median adherence but large interhospital variability were glycemia monitoring [82.3 ± 16.7% (26.7-100.0%)], performing clinical neurological examination and documentation of stroke severity [63.1 ± 36.8% (0-100%)], and screening for activities of daily living [51.1 ± 40.3% (0.0-100.0%)]. Other indicators lacked adequate adherence: swallowing function screening [37.0 ± 30.4% (0.0-93.3%)], depression screening [20.2 ± 35.8% (0.0-100%)], and timely body temperature measurement [15.1 ± 17.0% (0.0-60%)]. Conclusion: We identified high adherence to guidelines for some indicators, but lower rates with large interhospital variability for other recommendations also based on robust evidence. Improvement strategies should be implemented to improve the latter.

A Breakthrough Improvement Collaborative Significantly Reduces Hospital Stay After Elective Colectomy for Cancer Across a Healthcare System.

OBJECTIVE: This multicenter study aimed to assess (1) the effect of an improvement collaborative on enhanced recovery after surgery (ERAS) protocol adherence after elective colectomy and (2) the association between adherence and patient outcomes. BACKGROUND: ERAS pathways provide a framework to standardize care processes and improve postoperative outcomes in patients after colon surgery. Despite growing evidence of its effectiveness, adherence to these guidelines remains a challenge. METHODS: This prospective, multicenter collaborative was initiated throughout 11 hospitals in Flanders, Belgium. A structured audit tool was used to study patient outcomes and adherence to 12 ERAS components, defined by the collaborative. Three retrospective audits (based on patient record analysis) were conducted in 2017, 2019, and 2021, respectively. RESULTS: Overall, 740 patients were included (45.4% female; mean±SD age, 71±12 years). The overall adherence increased from 42.8% in 2017 to 58.4% in 2019 and 69.2% in 2021. Compared with low adherence, length of stay was increasingly reduced by 1.3 days for medium [95% confidence interval (95% CI): -2.5; 0.0], 3.6 days for high (95% CI: -4.9; -2.2), and up to 4.4 days for very high adherence (95% CI: -6.1; -2.7). Corresponding odds ratios for postoperative complications were 0.62 (95% CI: 0.33; 1.17), 0.19 (95% CI: 0.09; 0.43), and 0.14 (95% CI: 0.05; 0.39), respectively. No increase in 30-day readmissions was observed. CONCLUSIONS: A peer-constructed improvement collaborative effectively increases adherence to an ERAS protocol in individual hospitals. Across time, length of stay and postoperative complications decreased significantly, and a dose-response relationship was observed.

Quality indicators in the treatment of geriatric hip fractures: literature review and expert consensus.

PURPOSE: Even though hip fracture care pathways have evolved, mortality rates have not improved during the last 20 years. This finding together with the increased frailty of hip fracture patients turned hip fractures into a major public health concern. The corresponding development of an indicator labyrinth for hip fractures and the ongoing practice variance in Europe call for a list of benchmarking indicators that allow for quality improvement initiatives for the rapid recovery of fragile hip fractures (RR-FHF). The purpose of this study was to identify quality indicators that assess the quality of in-hospital care for rapid recovery of fragile hip fracture (RR-FHF). METHODS: A literature search and guideline selection was conducted to identify recommendations for RR-FHF. Recommendations were categorized as potential structure, process, and outcome QIs and subdivided in-hospital care treatment topics. A list of structure and process recommendations that belongs to care treatment topics relevant for RR-FHF was used to facilitate extraction of recommendations during a 2-day consensus meeting with experts (n = 15) in hip fracture care across Europe. Participants were instructed to select 5 key recommendations relevant for RR-FHF for each part of the in-hospital care pathway: pre-, intra-, and postoperative care. RESULTS: In total, 37 potential QIs for RR-FHF were selected based on a methodology using the combination of high levels of evidence and expert opinion. The set consists of 14 process, 13 structure, and 10 outcome indicators that cover the whole perioperative process of fragile hip fracture care. CONCLUSION: We suggest the QIs for RR-FHF to be practice tested and adapted to allow for intra-hospital longitudinal follow-up of the quality of care and for inter-hospital and cross-country benchmarking and quality improvement initiatives.

Overview on the target population and methods used in care pathway projects: A narrative review.

BACKGROUND: There is evidence that the efficiency and effectiveness of care processes can be improved in all countries. Care pathways (CPs) are proposed as a method to improve the quality of care by reducing variation. During the last decades, CPs have been intensively used in practice. The objective of this study is to examine the study designs for investigating CPs, for which pathologies CPs are used and what the reported indicators to measure the impact of CPs are. METHODS: A narrative review of the literature published from 2015 to 2019 was performed. RESULTS: We identified 286 studies, of which 207 evaluated the impact of CPs, 33 were review articles, 29 studies described the development of a CP, 12 were study protocols and 5 opinion papers. The most frequently reported study design for studying the impact of a CP is pre-posttest (n = 82), followed by cross-sectional studies (n = 50). Oncology, cardiovascular disease and abdominal surgery are the domains with the highest numbers of studies evaluating the impact of CPs. Financial (n = 86), process (n = 76) and clinical indicators (n = 74) are the most frequently reported indicators while service (n = 12) and team indicators (n = 6) are less reported. CONCLUSIONS: Based on the relative low number of identified studies compared with the number of CP projects in organisations, we conclude that the CP knowledge is not only found in the literature. We, therefore, argue that (inter)national scientific societies should not only focus on searching and spreading evidence on the content of care but also enhance their knowledge sharing initiatives on the organisation of care processes.

Peer support by interprofessional health care providers in aftermath of patient safety incidents: A cross-sectional study.

AIM: To investigate the health care professionals' preferences pertaining to support in the aftermath of patient safety incidents and potential variation thereof depending on the degree of harm. BACKGROUND: Peer support systems are available to support health care professionals in the aftermath of patient safety incidents. It is unclear which type of support is best offered by whom. METHODS: A cross-sectional study in 32 Dutch hospitals. RESULTS: In total, 2,362 nurses and 1,404 doctors indicated they were involved in patient safety incidents at any time during their career (86%). Less than 10% of health care providers had spoken with professional support, and less than 20% admitted a need to do so. They used different support. A higher degree of harm related to higher odds of desiring support. Respondents mainly wanted to understand what happened and how it can be prevented. CONCLUSION: The desired support of health care professionals in the aftermath of patient safety incidents depends on the level of harm. IMPLICATION FOR NURSING MANAGEMENT: Health care professionals seem to mostly rely on persons they are close with, and they mainly desire information related to the aftermath of patient safety incidents. This should be taken into account when support programmes are set up.

A 15-Year Follow-up Retrospective Study on 959 Spine Surgeries: What Can We Learn From Real-world Data?

STUDY DESIGN: This was a retrospective study. OBJECTIVE: The aim of this study was to investigate the patient flow and need for additional surgery after first-time lower back surgery. Next, we analyzed the patients who developed chronic low back pain (LBP) and were treated with spinal cord stimulation. SUMMARY OF BACKGROUND DATA: LBP has a lifetime prevalence of 84% and imposes a high economic burden. Treatment is focused on preventing chronic pain. Research has shown the efficacy of treatment options. However, less is known about who benefits the most from which therapy and when they should be positioned in the treatment algorithm. METHODS: In this retrospective study, data of all patients who underwent first-time surgery from 2000 to 2004 were included. After 10-15 years, patients were contacted about their quality of life (QoL) (EuroQoL-5 Dimension) and life and heath perception (EuroQoL Visual Analogue Scale). RESULTS: In all, 959 patients underwent surgery at the lower back area. Follow-up time ranged from 13 to 17 years; 225 patients (23.5%) underwent a second surgery. In total, 20 patients (2.1%) developed chronic neuropathic back pain and received spinal cord stimulation therapy. Ten years postsurgery, 438 (45.7%) patients completed the QoL and LBP questionnaires. The health-related QoL and health situation were significantly lower in patients with multiple surgeries ( P <0.001). CONCLUSIONS: The study results indicate that large data sets, with multiple outcome measurements and long-term follow-up are necessary to improve our knowledge and to optimize the therapeutic pathway. In that way, we might learn how to select a patient for the right treatment or treatments at the right moment and shorten the circulation in our health care system.

International comparative study of low back pain care pathways and analysis of key interventions.

PURPOSE: Low back pain (LBP) is a major public health problem worldwide. Significant practice variation exists despite guidelines, including strong interventionist focus by some practitioners. Translation of guidelines into pathways as integrated treatment plans is a next step to improve implementation. The goal of the present study was to analyze international examples of LBP pathways in order to identify key interventions as building elements for care pathway for LBP and radicular pain. METHODS: International examples of LBP pathways were searched in literature and grey literature. Authors of pathways were invited to fill a questionnaire and to participate in an in-depth telephone interview. Pathways were quantitatively and qualitatively analyzed, to enable the identification of key interventions to serve as pathway building elements. RESULTS: Eleven international LBP care pathways were identified. Regional pathways were strongly organized and included significant training efforts for primary care providers and an intermediate level of caregivers in between general practitioners and hospital specialists. Hospital pathways had a focus on multidisciplinary collaboration and stepwise approach trajectories. Key elements common to all pathways included the consecutive screening for red flags, radicular pain and psychosocial risk factors, the emphasis on patient empowerment and self-management, the development of evidence-based consultable protocols, the focus on a multidisciplinary work mode and the monitoring of patient-reported outcome measures. CONCLUSION: Essential building elements for the construction of LBP care pathways were identified from a transversal analysis of key interventions in a study of 11 international examples of LBP pathways.

Qualitative Evaluation of the Implementation of a Care Pathway for Colorectal Cancer Surgery.

Colorectal cancer care can be standardized by using enhanced recovery protocols. However, adherence to these protocols varies. Using Medical Research Council (MRC) guidance on process evaluations, we examined the experience of health care professionals in the implementation of a care pathway for colorectal surgery, by describing the intervention, context, implementation, mechanisms, and outcomes. Based on data from semi-structured interviews, we divided respondents into two groups: those who perceived positive outcomes of the implementation and those who perceived no effect. Respondents who perceived positive outcomes reported clinical leadership, use of feedback, positive effects of standardization, and teamwork as factors contributing to positive perceived outcomes. Respondents who perceived no effect reported a lack of organizational support, as well as challenging collaboration and standardization as mechanisms potentially explaining the poorer perception of outcomes. Multiple implementation activities were used, focusing on competence, behavior, or workplace. Our findings suggest that feedback is an important implementation activity.

Mangomoments - preconditions and impact on patients and families, healthcare professionals and organisations: a multi-method study in Flemish hospitals.

OBJECTIVE: Understanding how small unexpected acts or gestures by healthcare professionals, known as Mangomoments, are translated into practice, what their preconditions are and what their impact is on patients and families, healthcare professionals and organisations. DESIGN: A multi-method design was used based on four phases: (1) A (media)campaign to collect Mangomoment stories (n=1045), of which 94% (n=983) were defined as Mangomoments; (2) Semi-structured interviews (n=120); (3) Focus group interviews (n=3); and (4) A consensus meeting. SETTING: Respondents from a hospital and primary care setting. PARTICIPANTS: Patients, family, healthcare professionals, managers, researchers and a policymaker participated. RESULTS: Mangomoments are mainly classified in the dimensions 'Respect for values, preferences and needs' and 'Emotional support'. Differences in importance of the dimensions were found between healthcare professionals, oncological patients and family and non-oncological patients and family. The results of the interviews, focus groups and consensus meeting were visualised by the Mangomoment model. It identifies several preconditions on the level of patients, healthcare professionals and leadership. For each of these preconditions a catalyst was identified to increase the prevalence of Mangomoments. In general, Mangomoments improved the patient and family experience and facilitated adherence to therapy and led to a positive perception on the healing process. Positive effects for professionals include personal accomplishment and anti-burnout, joy in work and a positive team atmosphere. This led to positive resonance by a relationship of trust between the patient and the healthcare professionals, feelings of tolerance during negative experiences and open communication and a safe climate. Overall, patients and healthcare workers concluded that Mangomoments led to loyalty to the healthcare organisation. CONCLUSION: Mangomoments do not only have a positive impact on patient and family but also on the healthcare professional. Leadership should shape several preconditions and catalysts which can lead to positive resonance and loyalty of patients and professionals.

Effects of implementing a care pathway for colorectal cancer surgery in ten European hospitals: an international multicenter pre-post-test study.

Adherence to evidence-based recommendations is variable and generally low. This is also followed in colorectal surgery, despite the availability of the ERAS® protocol. The aim of the study was to evaluate the effect of implementing a care pathway for perioperative care in colorectal cancer surgery on outcomes and protocol adherence. So, we performed an international pre-test-post-test multicenter study, performed in ten hospitals in four European countries. The measures used included length of stay, morbidity and mortality, and documentation and adherence on intervention and patient level. Unadjusted pre-test-post-test differences were analyzed following an analysis adjusted for patient-mix variables. Importance-performance analysis was used to map the relationship between importance and performance of individual interventions. In total, 381 patients were included. Length of stay decreased from 12.6 to 10.7 days (p = 0.0230). Time to normal diet and walking also decreased significantly. Protocol adherence improved from 56 to 62% (p < 0.00001). Adherence to individual interventions remained highly variable. Importance-performance analysis showed 30 interventions were scored as important, of which 19 had an adherence < 70%, showing priorities for improvement. Across hospitals, change in protocol adherence ranged from a 13% decrease to a 22% increase. Implementing a care pathway for colorectal cancer surgery reduced length of stay, time to normal diet and walking. Documentation and protocol adherence improved after implementing the care pathway. However, not in all participating hospitals protocol adherence improved. Only in 25% of patients, protocol adherence of ≥ 70% was achieved, suggesting a large group is at risk for underuse. Importance-performance analysis showed which interventions are important, but have low adherence, prioritizing improvement efforts.

The pivotal role for the multidisciplinary approach at all phases and at all levels in the national pathway for the management of low back pain and radicular pain in Belgium.

INTRODUCTION: High level evidence on management of spinal disorders is scarce, which results in guidelines being of limited practical use for practitioners. Care pathways are complex interventions intended for the mutual decision making of organization of care processes for a well-defined group of patients. The goal of this project was to design a pathway for the management of low back pain and radicular pain for national implementation in Belgium. EVIDENCE ACQUISITION: An international and Belgian study on characteristics of low back pain care pathways was performed along with a literature study and focus group interrogation. Based on essential building elements identified and a consensus approach among all relevant stakeholders in primary, hospital and reintegration care, a national pathway was constructed. The process was endorsed by the Belgian Health Care Knowledge Center, Belgian National Institute of Health and Disability Insurance and the Spine Society of Belgium. EVIDENCE SYNTHESIS: Eleven international pathways were identified, varying in implementation width from hospital-based to region/province-based. Seven Belgian pathway initiatives were detected. Notwithstanding differences, consistent building elements were identified. Three groups of caregivers, divided in primary care, hospital care and reintegration and including all relevant medical/paramedical disciplines, worked on integrating the essential building elements into a single concrete patient pathway of direct use to any caregiver and patient and based on a consensus model including reference to the 2017 Belgian adaptation of the 2016 NICE guidelines. The resulting pathways on management of low back pain and radicular pain underpin the importance of multidisciplinary teamwork. CONCLUSIONS: Essential building elements were identified from literature and established pathways and were successfully integrated in a Belgian national low back pain and radicular pain pathway using an integrative consensus approach. The pathways are consultable at www.lowbackpain.kce.be.

Prolonged mental health sequelae among doctors and nurses involved in patient safety incidents with formal complaints and lawsuits.

We evaluated the presence of prolonged mental health sequelae in the aftermath of a patient safety incident and the impact of a formal complaint or lawsuit on these mental health sequelae in 19 hospitals and 2635 nurses and doctors. Of 2635 respondents, 983 (37.3%) reported a complaint and 190 (7.2%) reported a lawsuit. In both doctors and nurses prolonged mental health sequelae reflecting a stressor-related disorder were highly prevalent, each well over 20% overall. They were consistently more prevalent in case of a formal complaint or lawsuit. Lawsuits showed 2-, 3- and 4-fold increases in prevalence of mental health sequelae.

Duration of second victim symptoms in the aftermath of a patient safety incident and association with the level of patient harm: a cross-sectional study in the Netherlands.

OBJECTIVES: To describe healthcare providers' symptoms evoked by patient safety incidents (PSIs), the duration of these symptoms and the association with the degree of patient harm caused by the incident. DESIGN: Cross-sectional survey. SETTING: 32 Dutch hospitals that participate in the 'Peer Support Collaborative'. PARTICIPANTS: 4369 healthcare providers (1619 doctors and 2750 nurses) involved in a PSI at any time during their career. INTERVENTIONS: All doctors and nurses working in direct patient care in the 32 participating hospitals were invited via email to participate in an online survey. PRIMARY AND SECONDARY OUTCOME MEASURES: Prevalence of symptoms, symptom duration and its relationship with the degree of patient harm. RESULTS: In total 4369 respondents were involved in a PSI and completely filled in the questionnaire. Of these, 462 reported having been involved in a PSI with permanent harm or death during the last 6 months. This had a personal, professional impact as well as impact on effective teamwork requirements. The impact of a PSI increased when the degree of patient harm was more severe. The most common symptom was hypervigilance (53.0%). The three most common symptoms related to teamwork were having doubts about knowledge and skill (27.0%), feeling unable to provide quality care (15.6%) and feeling uncomfortable within the team (15.5%). PSI with permanent harm or death was related to eightfold higher likelihood of provider-related symptoms lasting for more than 1 month and ninefold lasting longer than 6 months compared with symptoms reported when the PSI caused no harm. CONCLUSION: The impact of PSI remains an underestimated problem. The higher the degree of harm, the longer the symptoms last. Future studies should evaluate how these data can be integrated in evidence-based support systems.

Protocol for process evaluation of evidence-based care pathways: the case of colorectal cancer surgery.

BACKGROUND AND AIM: Care pathways are complex interventions, consisting of multiple 'active ingredients', to structure care processes around patient needs. Numerous studies have reported improved outcomes after implementation of care pathways. The structure-process-outcome framework and the context-mechanism-outcome framework both suggest that outcomes can only be achieved through a certain process within a context or structure. To understand how and why care pathways are effective, understanding of both this process and context is necessary. The aim of this article is to propose a study protocol to evaluate the implementation process of evidence-based care pathways, including the influence of the context. This protocol is explained by applying it to the implementation of a colorectal cancer surgery pathway in an international setting. METHODS: The Medical Research Council (MRC) guidance on process evaluations for complex interventions is used as the basis for the protocol. The key components of process evaluation are intervention, context, implementation, mechanisms of impact and outcomes. In process evaluations, these components are studied using quantitative and qualitative methods. Among them are patient record analysis, questionnaires, on-site visits and interviews. DISCUSSION: To guide our methodological choices, the MRC guidance for process evaluations of complex interventions, and published protocols for process evaluations of complex interventions were used. Our protocol is now tailored for the process evaluation of evidence-based care pathways and provides researchers and clinicians methods and tools, as well as a worked example, that can be used to study the process of care pathway implementation. As a result, healthcare professionals will be informed on context factors and implementation processes that can facilitate the implementation of care pathways, improving quality and effectiveness of care processes.

Patient experiences with care across various types of mental health care: Questionnaire development, measurement invariance, and patients' reports.

To describe the development, validation, and findings of a patient experience questionnaire across 7 types of residential and ambulatory mental health care services. Thirty-five items were hypothesized to cover information, participation, therapeutic relationship, personalized care, organization and collaboration, safety, patient rights, outcomes of care, and discharge preparation and after-care. Also included were 2 overall rating items (scoring and recommending the organization). This Dutch questionnaire was applied in 79 organizations in Belgium (N patients = 5,168). Exploratory structural equation modelling was conducted on a random split-half sample to examine dimensionality. Confirmatory factor analysis and multiple group confirmatory factor analyses were conducted on the holdout sample to confirm dimensionality and assess measurement invariance across type of service and patient characteristics. Multilevel logistic regression models linking subscale top box scores to overall rating items were used to assess criterion validity. The hypothesized dimensionality was partly confirmed, and configural and scalar invariance were demonstrated across types of organizations and patient characteristics. Subscale scores were significantly associated with overall ratings. Process evaluation showed that participating organizations strongly support continued use of this questionnaire. This validated patient experience questionnaire supports comparison across organizations from different types of services to improve the quality of mental health care.

Development of a model care pathway for adults undergoing colorectal cancer surgery: Evidence-based key interventions and indicators.

RATIONALE, AIMS, AND OBJECTIVES: During the last decades, perioperative care for patients with colorectal cancer has shifted towards more standardized care, so-called "enhanced recovery after surgery." Those programs aim to optimize interventions in perioperative care to decrease the rate of postoperative complications, improve patients' recovery, and shorten hospital stay. The purpose of this literature review is to identify, summarize, and operationalize the clinical content of both key interventions and clinical indicators to develop an evidence-based model pathway for surgical patients with colorectal cancer. METHODS: A systematic search in 3 databases was conducted to identify key interventions (KIs) and indicators to measure the effect of implementation of care pathways. The KIs from the enhanced recovery after surgery protocol were listed and used as framework to identify and match KIs used in the included studies. The Clinical Pathway Compass was used to categorize the indicators. RESULTS: Fifteen studies were included. The number of KI used in the study protocols ranged from 9 to 20. In total, 33 KIs were identified. Little information was available concerning the implementation of and compliance to the protocol. Length of stay and complication rate are the most common used indicators (used in 15/15 and 14/15 of the studies), followed by 21 other measures. All but one of the included studies reported a reduction in length of stay. CONCLUSION: There is a considerable variation in both number of KIs and indicators as well as operationalization of key interventions, for surgical patients with colorectal cancer documented in literature. Therefore, we summarized the input from different studies and developed an evidence-based model pathway, which can serve as a basis for a local/regional care pathway team to build their own pathway.

Key interventions and quality indicators for quality improvement of STEMI care: a RAND Delphi survey.

OBJECTIVE: Identification, selection and validation of key interventions and quality indicators for improvement of in hospital quality of care for ST-elevated myocardial infarction (STEMI) patients. METHODS AND RESULTS: A structured literature review was followed by a RAND Delphi Survey. A purposively selected multidisciplinary expert panel of cardiologists, nurse managers and quality managers selected and validated key interventions and quality indicators prior for quality improvement for STEMI. First, 34 experts (76% response rate) individually assessed the appropriateness of items to quality improvement on a nine point Likert scale. Twenty-seven key interventions, 16 quality indicators at patient level and 27 quality indicators at STEMI care programme level were selected. Eighteen additional items were suggested. Experts received personal feedback, benchmarking their score with group results (response rate, mean, median and content validity index). Consequently, 32 experts (71% response rate) openly discussed items with an item-content validity index above 75%. By consensus, the expert panel validated a final set of 25 key interventions, 13 quality indicators at patient level and 20 quality indicators at care programme level prior for improvement of in hospital care for STEMI. CONCLUSIONS: A structured literature review and multidisciplinary expertise was combined to validate a set of key interventions and quality indicators prior for improvement of care for STEMI. The results allow researchers and hospital staff to evaluate and support quality improvement interventions in a large cohort within the context of a health care system.