Does the Implementation of Clinical Pathways Affect Hierarchical Structures Within a Surgical Department? A Qualitative Study

In order to achieve optimal outcomes for patients undergoing surgery, it needs to be ensured that the right task is carried out by the right person at the right time. As a tool to address this challenge, clinical pathways (CPs) have gained popularity. The nature of a CP as a multidisciplinary, standardized, evidence-based instrument seems to considerably conflict with what is commonly referred to as “surgical hierarchy.” Historically grown, the concept of “one leader” deciding mostly independently about the treatment of “his” (or her) patients, often based rather on “eminence” than “evidence,” and using “subordinates” to carry out his/her decisions, has strongly influenced the way surgeons work.¹ Certain “rites” have been established within surgical departments to foster and maintain this hierarchy.² This phenomenon is at least partially owed to the nature of the subject. In surgery, the impact of the single physician performing the operation has a much more direct influence on patients' outcome than in non-surgical disciplines.³ This might also be the reason why the interaction between surgeons and patients has traditionally been of a hierarchical nature with a rather limited degree of patient participation and shared-decision making.^4–7 Although modulated by peculiarities of the geographical and cultural setting, the described concept of hierarchy seems to be present universally, albeit to a variable degree, in all surgical environments.

Numerous studies have assessed the effects of CP implementation on quality of care. In surgery, it has been shown that the implementation of a CP is associated with improvements in process and outcome quality, measured, among other indicators, by morbidity, mortality, cost, and patient satisfaction.^8–14 Studies have also explored determinants of successful CP implementation, and what effects CPs have on processes and management structures within institutions. Although many reports were based on theoretical frameworks and individual perceptions,^15–19 fewer studies have collected evidence using a structured quantitative or qualitative approach.^20–23 They identified a series of factors including multidisciplinarity, early and continuous feedback of outcomes, and the flattening of hierarchical structures, which leads to a strengthening of the confidence of “junior” health professionals. However, there is a complete lack of data on what effects CP implementation actually has on hierarchical structures in a surgical setting.

Materials and Methods

Results

Eight staff members were asked to be interviewed and consented. After these interviews, the analysts conducted an interim analysis and felt that saturation had been reached. The details of the single interviewees regarding formal position within the department and tasks within the CP project are presented in Table 1.

Table 1  CP project collaborators with their formal position within the department and their project task²⁰

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Findings from interviews are illustrated using verbatim translated quotations and grouped according to themes. Demographic information is omitted from quotations to ensure confidentiality. The designation assigned to each respondent (A to F) does not correspond to the position of respondents in Table 1.

Discussion

The present study used qualitative methods to explore how the implementation of perioperative CPs influences surgical hierarchy, i.e., the mode of interaction among staff and between staff and patients. Although the concept of surgical hierarchy has been the subject of research in many settings,^1,2,29,30 to our knowledge this study is the first to specifically evaluate if CP implementation influences surgical hierarchy.

Our study has some methodological limitations. It was based on a small sample from a single institution. This represents a constraint according to traditional views of generalizability. Importantly though, while statistical generalizability is a key quality criterion in quantitative research, its adoption as a methodological quality indicator is less established in qualitative research.³¹ This is because qualitative approaches seek to explore the full range of potential views on a topic of interest in depth and aim to enable researchers to evaluate the potential transferability of findings to populations or settings of interest. Given the heterogeneity in care patterns and professional cultures across countries and health care systems, the generalizability of our findings to other settings might yet be limited. The strength of our study is that, compared to previous studies on CP implementation, which did not use a comprehensive approach but rather reflected subjective views of project leaders, and which did not specifically explore issues related to surgical hierarchy,^{15,17–19,32–37} it relied on semistructured interviews with multidisciplinary staff members at all seniority levels. The use of an external interviewer without a clinical background in surgery and of external analysts minimized bias.

The interviews yielded a number of intriguing findings. First, and probably most important, it was widely acknowledged that the implementation of a CP into clinical routine has the potential to change traditional surgical hierarchy structures. In particular, the top-down order chain, i.e., that diagnostic and therapeutic measures are only carried out after a senior staff member ordered them or at least approved of them,^30,38–40 is interrupted. This leads to a feeling of increased autonomy and competency in individual staff, particularly so at junior levels. This feeling was enhanced by the fact that the CP project was initiated and carried out by representatives of lower hierarchy levels in a horizontal manner. This poses an enormous contrast to the way projects have traditionally been conducted in many surgical departments, i.e., the initiation by the head and the execution of specific tasks by subordinates.^38,41 This particular approach, given it leads to more perceived homogeneity within project teams, has been identified as additional success factor for quality improvement projects.^20,42 This is underlined by the initial reluctance towards the CP project expressed by nurses, who despite efforts to involve them felt excluded in the early phase.²⁰ To achieve homogeneity within the project team and to give all disciplines a genuine sense of inclusion, participation should therefore be one of the early aims during such projects.³⁷

Importantly, it cannot be fully excluded that some staff members still perceived the project to be of a somewhat top-down nature. Although the head of department did not initiate or carry out the CP project himself, the mere fact that he granted permission for the project to be carried out in the department might have created a notion of traditional hierarchy. However, the head of department displayed his initial skepticism towards CPs rather overtly, so that most staff members probably felt that the project was implemented in a more horizontal than vertical manner.

Several interviewees were convinced that a certain degree of hierarchy is indispensable for successful CP implementation. They refer to personal control on wards in an indirect (recording CP deviations) and direct (asking staff to adhere to CPs) manner. Interestingly, the project leaders had no intention to establish a control system. Recording of CP deviations took place exclusively for research purposes,^{11–14,24,25} and was never meant to be a means of controlling staff. Direct control and requests of CP adherence were not made by the project leaders unless patients under their immediate treatment were affected.²⁰ This shows that the project initiated a change resulting in the development of an informal hierarchical structure not created by defined positions in the traditional hierarchy roster of the department. Evidence from previous studies suggests that “champions,” i.e., visible proponents of CP usage, could be important for implementation.^17,18,43,44 These reflect mostly personal experiences and therefore it must remain the subject of future investigations if a certain degree of hierarchy and control is truly indispensable for the success of complex clinical projects like CP implementation.

From several comments, it became clear that CPs change clinical decision-making away from the traditional “eminence base” towards an “evidence base.”^1,45–47 In other words, decisions on patient management are taken in a consensus based on scientific evidence and not according to the individual judgement of senior staff.^27,28 Obviously, this holds true only if CPs are, like in our case, indeed evidence-based. This should be a prerequisite for good CPs, but is unfortunately not always ensured.⁴⁸ As described already, this shift away from “eminence-based medicine” granted a sense of increased autonomy and empowerment especially to junior staff.

The last element to be explored was the hierarchical relationship between caregivers and patients. In the “traditional” surgical culture, it is often perceived that patient participation and knowledge concerning specific treatments is limited.^4–7 Probably this is not true per se but rather it depends on attitudes and behaviors of single surgeons. Participants in our study perceived CPs as a good means to make treatment decisions more transparent to patients. There is only limited data if this holds true from patients' point of view, but anecdotal evidence suggests that this is the case, especially if a redesigned “patient pathway” is given to the patient as reference.^49,50 Such a document did not exist for our patients, so it remains speculative if they indeed gained a sense of increased participation and transparency. Some respondents expressed concerns that CPs lead to less individualization of treatment, which would imply less participation and less adaptation of the treatment to the single patient's needs. However, there is no evidence supporting the view that patients perceive pathways as too rigid a framework with negative effects on attention paid by staff.

Our findings have implications for future research. Studies should assess structural and organizational changes brought along by CP implementation using both quantitative and qualitative methods. They should extend to other perioperative disciplines and other health systems, as these all have their peculiarities. A very interesting topic in the context of CP implementation is the perceived change towards a more evidence-based medicine. Future studies should try to objectify this perception.

This qualitative study identified effects of the implementation of CPs on various dimensions of hierarchy in the surgical setting. Most importantly, CP implementation leads to a feeling of increased autonomy and competency in junior staff and induces a change from “eminence-based” to “evidence-based” practice. Moreover, CPs are perceived to increase transparency of treatment to patients. The knowledge about these induced changes plays an important role for planning and carrying out CP projects. The obtained views may pertain primarily to the given CP project and generalizability to other settings might be limited. We therefore encourage conducting more studies exploring the effects of CPs on hierarchy in surgery.