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Using Realistic Evaluation to identify factors affecting the successful implementation and sustainability of the Liverpool Care Pathway for the dying patient.

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Presentation on theme: "Using Realistic Evaluation to identify factors affecting the successful implementation and sustainability of the Liverpool Care Pathway for the dying patient."— Presentation transcript:

1 Using Realistic Evaluation to identify factors affecting the successful implementation and sustainability of the Liverpool Care Pathway for the dying patient – preliminary findings Supervisors: Dr. Peter O’Halloran, Prof. Sam Porter & Dr. Michael Donnelly Tracey McConnell BSc (Hons) Funded by Centre for Health Improvement

2 Overview of Presentation Liverpool Care Pathway Research objectives Methodology Data collection and analysis Preliminary findings

3 Palliative Care Approximately 56 million people die each year Approximately 15, 000 people die in Northern Ireland each year Projections for 2017: approximately 310,000 people will be 65 years and over Increasing prevalence of chronic conditions mean demand for palliative and end of life care services likely to increase

4 Limitations and Problems Gold standard of care – Hospice Hospital – least preferred (Agar et al, 2008) Paradox: this is the place where most people die (DH, 2008; Gomes and Higginson, 2008; Cohen et al., 2008) Difficult challenges

5 Hospice model of care Relief from pain and other stressful symptoms Affirmation of life and dying viewed as normal process Integrates psychological and spiritual aspects Supports family/carers cope during illness and bereavement

6 Hospital model of cure Diagnosing dying Communicating about end of life Withdrawing unnecessary treatment Medical failure Emphasis on cure Suffer physical, psychological and social symptoms Inappropriate use of life-sustaining interventions Costly to health service, patients and families

7 Liverpool Care Pathway Key sections - Initial assessment - Ongoing assessment - Care after death Aim -to improve care of the dying in the last hours/days of life Key domains of care - Physical - Psychological - Social - spiritual

8 LCP - UK - Europe - International Northern Ireland Wales Scotland Netherlands Sweden Switzerland Republic of Ireland Germany Italy Slovenia Spain New Zealand Australia China India Japan

9 Issues - rationale National Care of the Dying Audit – Hospitals (NCDAH) (2009) England: overall high standard of patient care Shortcomings: failure to inform relatives about pathway (28%) or that relative was entering dying phase (24%); and spiritual/religious needs assessed in only 30% of patients NCDAH (2009) N.I. Similar pattern Only 20% entered on pathway

10 Key Challenge: Understanding Success and Failure Mostly descriptive (Mirando et al, 2005; Veerbeek et al, 2008; Van der Heide et al, 2010) Systematic review – Integrated care pathways (Allen et al, 2009) Past experimentalist approach – focus on outcome Context viewed as confounding factor No explanation of how or why

11 Research Objectives What are the underlying mechanisms influencing the implementation of the Liverpool Care Pathway (LCP)? What are the key enabling/disabling characteristics of the context for implementation of the LCP? How do the mechanisms of implementation and the characteristics of the context combine to support or hinder the implementation of the LCP and achievement of the desired outcomes?

12 Methodology – Introduction to Realistic Evaluation Pawson and Tilley (1997) ‘What works for whom in what circumstances? Realist signature – ‘What works for whom in what circumstances ….. and why?’

13 Context-Mechanism-Outcome Configurations Realist terminology Context = values, needs Mechanism = reasoning Outcome = outcome patterns

14 Starting Point If → then propositions If the right processes operate in the right conditions then the programme will be successful Evaluation then tests these programme theories.

15 Theoretical Model Greenhalgh et al (2004) The innovation The outer/inner context Adopters Communication and influence Implementation and sustainability Complementary

16 Study design Organisational Case Study Cancer and Specialist Services and Acute Services Two wards

17 Realistic Evaluation Process Stage one: Context-mechanism-outcome theory formulation Realist review Semi-structured interviews Audit data Mapping of all data on to Greenhalgh et al’s (2004) model

18 Interviewees Stage 2 Data Collection Type of InterviewAnonymous code FacilitatorF1 Palliative Care ConsultantsP3 and P4 Senior Medical StaffSMS1, SMS2, SMS3 and SMS4

19 Stage 3 Data analysis Interviews Coded Audit data - outcomes CMO configurations

20 Recruitment Identification of potential participants How approached Steps taken to facilitate recruitment process

21 Cancer and Specialist Services Ward 1 and Ward 2 Type of IntervieweeAnonymous Code Ward SisterW1, W2 Staff NurseSN3, SN1 Senior DoctorSD1 (covered both wards) Junior DoctorJD2 (covered both wards) Service ManagerS1 (covered both wards)

22 Acute Services Ward 1 Type of IntervieweeAnonymous Code Service ManagerS2 (covered both case study sites) Deputy Associate Director of Nursing M1 (covered both case study sites) Ward SisterW3, W4 Staff NurseSN4, SN2 Junior DoctorJD1(covered both case study sites)

23 Interviewees involved in the wider context Type of IntervieweeAnonymous Code FacilitatorsF1; F2; F3 Palliative Care ConsultantsP3; P4; P5 Policy MakersP1; P2

24 Audit Data Results – Organisational Case Study Number and proportion of wards using LCP – 36% (33/91) Evidence it is sustained – no continuing LCP education, training or audit Proportion of deaths where LCP been used – 18%

25 Findings from Stage 1 Data collection and analysis – C – M – O Configurations ContextMechanismOutcome Enabling Full-time facilitator at implementation stage Support staff through practice change and facilitate vital processes such as education along with audit and feedback Increase confidence and reduce anxiety in staff to provide end of life care DisablingLack of funding/adequate staffing levels No one to support the pathway Sustainability less successful

26 CMO 2 ContextMechanismOutcome Enabling Visible benefits of change Winning hearts and minds Buy-in at organisational and individual practitioner level DisablingCulture of curePerception of death as a failure Resistance to the pathway

27 CMO 3 ContextMechanismOutcome Enabling Mandatory training for all staff All staff attend training so know what the pathway is and how to use it Patients eligible for the pathway started on it DisablingLack of knowledge what the pathway is and how to use it Medical staff will not initiate pathway because they do not see the need for it and are apprehensive about diagnosing dying Not all patients eligible for the pathway started on it.

28 CMO 4 ContextMechanismOutcome EnablingTop management support and ownership of LCP Motivates allocation of resources for continuing education programme and establishment of the LCP within the governance/management agenda Successful implementation and sustainability of the LCP

29 CMO 5 ContextMechanismOutcome Enabling Whole systems approach Involvement of all staff at Policy, organisational and individual practitioner levels Adoption of the pathway by ALL staff DisablingNo champion from within medical profession Some medical staff did not see value of pathway for improving practice Resistance to pathway by some medical staff

30 What works, for whom in what circumstances … and why? What Works?For whom?In what Circumstances? Why? The Innovation Key attributes as perceived by intended users: a) Relative advantage (is the innovation seen as effective?) Yes: - Nursing Staff and Junior Doctors No: - Some Senior Medical Staff Saw pathway as effective for guiding care at the end of life (tension for change) Did not see the pathway as having any advantage over the care already provided (no tension for change)

31 Research Outcomes Organisational case study explaining: Success of implementation and sustainability CMO configurations What works, for whom, how, and in what circumstances Middle-range theory Presented for use by those involved in implementation

32 References Allen, D., Gillen, E. & Rixson, L. 2009, "Systematic review of the effectiveness of integrated care pathways: what works, for whom, in which circumstances?", International Journal of Evidence Based Healthcare, vol. 7, pp Cohen, J., Bilsen, J., Addington-Hall, J., Lofmark, R., Miccinesi, G., Kaasa, S., Onwuteaka-Philipsen, B. & Deliens, L. 2008, "Population-based study of dying in hospital in six European countries", Palliative medicine, vol. 22, no. 6, pp DoH. 2008, End of Life Care Strategy – Promoting High Quality Care for all Adults at the End of Life. Department of Health, London Available at: Gomes, B. & Higginson, I.J. 2008, "Where people die ( ): past trends, future projections and implications for care", Palliative Medicine, vol. 22, pp Greenhalgh, T., Robert, G., Bate, P., Kyriakidou, O., Macfarlane, F., Peacock, R. 2004, How to Spread Good Ideas. A systematic review of the literature on diffusion, dissemination and sustainability of innovations in health service delivery and organization, Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R&D (NCCSDO), Available at: Mirando, S., Davies, P.D. & Lipp, A. 2005, "Introducing an integrated care pathway for the last days of life", Palliative medicine, vol. 19, pp Pawson, R. and Tilley, N. (1997) Realistic Evaluation Sage Van der Heide, A., Veerbeek, L., Swart, S., Van der Rijt, C., Van der Maas, P. J. & and Van Zuylan, L. 2010, "End-of-Life Decision Making for Cancer Patients in Different Clinical Settings and the Impact of the LCP", Journal of Pain & Symptom Management, vol. 39, no. 1, pp Vanhaecht, K., De Witte, K. & Sermeus, W. 2007, The impact of clinical pathways on the organisation of care processes., Katholieke Universiteit Leuven. Veerbeek, L., van Zuylen, L., Swart, S.J., van der Maas, P.J., de Vogel-Voogt, E., van der Rijt, C.C. & van der Heide, A. 2008, "The effect of the Liverpool Care Pathway for the dying: a multi-centre study.", Palliative medicine, vol. 22, no. 2, pp

33 Thank you

34 ‘How people die remains in the memory of those who live on’ Dame Cicely Saunders Founder of the Modern Hospice Movement


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