The analysis resulted in seven themes, some focusing on the benefits of implementing CPP, some describing facilitators in the implementation process, and others identifying challenges in working with CPPs (Figure 1). Below, each theme is described and illustrated by quotations from different interviews. As all interviews were conducted in Swedish, direct translations of the quotes were not possible. Quotes are altered to better enhance the respondent’s formulation, without compromising their meaning.
Increased focus on patients
Participants expressed that, before the CPPs, there was a tendency to regard patients as anonymous samples. Now, there was a far greater focus on patients’ perspectives and experiences of care.
“You devote more time to thinking about each individual patient. It’s so easy to become anonymous in a laboratory. You only see anonymous samples and not the patient behind them. The patient’s needs, and the complexity of cancer care are raised far more now. You work a little extra and prioritize patients because you see them as people and not as anonymous samples.” (pathology)
Many described this increased focus on the patient as a long-awaited development in cancer care.
“It has finally been understood that waiting is torment for patients. A difference compared to before is that now, every patient in a CPP is asked: ‘how did you experience your treatment?’ That’s something that hasn’t been emphasized much earlier, but now it’s very much in focus.” (radiology)
Moreover, several participants felt that the increased patient focus also had led to a deeper understanding of how the various parts of the care chain were connected and how responsibility for the patients was shared among colleagues in different units. Participants noted how they themselves, as well as colleagues in other units, had become more process-oriented since they started working with CPPs. There was an increased motivation to speed up investigations to reduce long waiting times for patients.
“Now, the focus is on how you can make investigations faster. If a referral is labelled CPPs, you understand the need to handle it faster. In that way, it has an effect.” (endoscopy)
Many participants reported that the CPPs contributed to a greater consensus on how the work within cancer care should be carried out, even among the competing private businesses.
“Obviously, as private X-ray departments, many of us are competitors, but we have opened up to a common vision of what to do and how to do it, which we did not have before.” (radiology)
It was also emphasized how multidisciplinary conferences, which have become a more integral part of cancer care since the introduction of the CPPs, enabled closer collaboration among different caregivers in the care chain.
“We work in a fairly integrated way with the units through multidisciplinary decision-making conferences, and as we are also sub-specialized, we have good contact with our referrals.” (pathology)
Some participants described that they had collaboration with other external units already in place before the CPPs, which they believed constituted a good foundation for the implementation of CPPs.
Existing well-functioning processes
Many of the participants expressed that they were familiar with working in controlled processes with high demand for quick investigations before implementation of CPPs. They stated that their work structures already functioned well, which facilitated the implementation of CPPs.
“We have a well-established routine for where and when the referral examination should take place, how it should be done and who should do what. It’s generally a good structure and raises very few questions. We work according to templates, and therefore, we can follow these CPPs very well. That’s our strength.” (endoscopy)
Some participants from endoscopy stated that there was a noticeable difference when CPPs were implemented compared to their previous way of working, because the CPPs provided them with more structure.
Other participants expressed that nothing had changed since the implementation of CPPs, except that the name used for different things in the work process, i.e. time-slots, was new, but they actually did the same work as before.
“For those of us who worked in a similar way before CPPs were implemented, there was no major change. We just took the slots we already had, labelled them CPPs and went on with our usual routine.” (radiology)
Many described that CPP coordinators, in particular, and other supportive functions, such as external developers, added during implementation were perceived as fundamental toe advancing the work with CPPs. They were described as invaluable to get the CPP in place.
“These coordinators have an important function. They make the system work more smoothly so that we are able to fix this [the CPPs], as it is a little unpredictable which patient will have cancer and not. It’s a really good function to have.” (endoscopy)
One of the participants described how using an external developer resulted in a more effective CPP implementation process.
“One of our chief physicians hired a strategic business developer who did not have any healthcare experience but was really talented when it came to developing effective processes. She standardized the way of working so that everybody in the unit started working in the same way.” (radiology)
Lack of resources
In all units, lack of staff and equipment were mentioned as hindrances when working with the CPPs, and these deficits were perceived as stressful and made the work with the CPPs more difficult. At an early stage in the implementation, the investigatory units communicated that it would be impossible to achieve the goal of the CPPs without the necessary resources. However, many felt that this feedback was not considered by those responsible for management of the CCPs.
“There was already some frustration when the CPPs were introduced. In the initial phase of the CPP [implementation], it was already claimed from our side that this isn’t something we can achieve with existing resources, it is a dream scenario that requires the provision of resources to be in place.” (radiology)
Furthermore, there was a shortage of several crucial occupational categories, including nurses, doctors and biomedical analysts. The staff shortage became particularly problematic during holidays and absence due to sickness. There was also a lack of clinical supervisors for the junior medical doctors. Not receiving the time needed for supervision made it difficult for new doctors to build on their expertise and handle more advanced patient cases.
“There is a shortage of radiologists. It’s a problem that takes time to fix, and now we have had to hire more doctors, which in itself is positive. At the same time, they must also have supervision and there is a shortage of supervisors.” (radiology)
Moreover, the lack of equipment hampered work with the CPPs. Pathologists highlighted the wish that digital diagnostics would soon be implemented at all pathology units in Sweden. This would make it possible to use competence from the few existing pathologists in the CPPs, and they believed that this could lead to shorter lead times and a more equal quality of care across the whole country. However, the introduction of digital pathology seemed to progress slowly in several units.
“Every analysis needs one or more people, and each analysis costs and takes time. There is a new machine model that can gather all these analyses and leave a response, which can help us save personnel, time and costs.” (pathology)
Meeting the growing need to achieve the requirement for shorter lead-times was sometimes described as frustrating by the participants. Lead-times were difficult to maintain due to lack of resources, holidays and that preparations sometimes needed to be complemented by additional analyses and second opinions from colleagues. For instance, in most cases, endoscopic examinations required preparation for patients that went beyond the established ten calendar days.
“This time requirement, that it should be done within ten calendar days, it’s not even ten working days, that’s an extremely tough criterion if one takes into account how we usually examine referrals.” (endoscopy)
There was a concern about whether the CPPs’ strict time requirements were always medically justified, especially in terms of slow-growing tumours. Several participants were critical of the idea that faster investigations yielded better results and argued that useful answers could, in fact, justify longer waiting times. Speeding up investigations that were not medically urgent was difficult to justify, given the widespread staff and resource shortages.
“As an experienced pathologist, I know that a disease has its natural course, that is, if you get a response a few weeks later it has no effect on the cancer. I prefer to give an accurate answer that ‘yes that was microscopic colitis.’ Then you get the right treatment, you come to the right doctor, you know what to do. If you do a good quality job, it ultimately benefits the patient and that must take time.” (pathology)
Finally, participants addressed the difficulties that emerged when CPP referrals were mislabelled or incomplete, mainly from primary care but also from other healthcare providers. For example, patients without malignancy were sometimes labelled CPPs, while patients with malignancy were not, leading to the risk that cancer may not be detected in time. The problem also caused an unnecessary influx of patients, so that those with malignancy had to wait longer for investigation. Therefore, the participants argued that they could not assume that only the marked referrals should be dealt with promptly and they felt the need to be observant.
“We still think there is a certain gap, or maybe we have interpreted the message differently. How do you label these samples that come primarily from primary care and what is it that you label and how do you keep the CPP separate from acute marking?” (pathology)
Another common error was that referrals lacked relevant information and contact details were missing. Consequently, questions arose, and it was difficult for the investigatory units to contact patients.
“Something that’s often missing when we receive the referrals and you have to handle them within five days is contact information for the patient and their telephone number. That should be a mandatory field in a CPP referral, because otherwise it can take a long time to get hold of the patient. It may take several days just to book them for an appointment. We don’t have many extra times that we can set aside. We are often fully booked so it becomes a problem.” (radiology)