Setting
Serving a diverse population of 1.2 million residents with over 45,000 employees and physicians, the SHA is responsible for delivery of the majority of publicly funded health services throughout the province of Saskatchewan (22). The SHA was launched in December 2017 through the amalgamation of 12 former health regions. The Clinical Excellence portfolio of the SHA is responsible for the development, implementation, and evaluation of new clinical pathways that guide clinical care for targeted conditions (23). The SHA currently has clinical pathways for Acute Stroke, Bariatric Surgery, Chronic Pain, Fertility Care, Hip and Knee Replacement Surgery, Lower Extremity Wounds, Multiple Sclerosis, Pelvic Floor, Prostate Cancer, and Spine (23). Additionally, there are pathways for Diabetes, Chronic Obstructive Pulmonary Disease (COPD), and Long COVID that are in development (Table 1). These pathways have been or are being developed by multidisciplinary stakeholder teams consisting of operational leaders, clinical experts, and patient and family partners (PFPs) (23).
Table 1
List of Clinical Pathways in Saskatchewan
Name
|
Development Date
|
Developed by SHA (including former health regions) or MoH*
|
Status
|
Bariatric Surgery
|
2009
|
MoH
|
Fully Developed But Implemented in One Local Setting**
|
Hip and Knee Replacement Surgery
|
2009
|
MoH
|
Fully Developed and Implemented Provincially**
|
Spine
|
2010
|
MoH
|
Fully Developed and Implemented Provincially
|
Pelvic Floor Care
|
2012
|
MoH
|
Fully Developed and Implemented Provincially
|
Prostate Cancer
|
2012
|
MoH
|
Fully Developed and Implemented Provincially
|
Fertility Care
|
2015
|
MoH
|
Fully Developed and Implemented Provincially
|
Lower Extremity Wounds
|
2016
|
MoH
|
Fully Developed and Implemented Provincially
|
Acute Stroke
|
2017
|
MoH
|
Fully Developed and Implemented Provincially
|
Multiple Sclerosis
|
2019
|
MoH
|
Fully Developed and Implemented Provincially
|
Chronic Pain
|
2022
|
SHA
|
Fully Developed but Implemented in One Local Setting
|
Chronic Obstructive Pulmonary Disease (COPD)
|
TBD***
|
SHA
|
Under Development**
|
Diabetes
|
TBD
|
SHA
|
Under Development
|
Long COVID
|
TBD
|
SHA
|
Under Development
|
* SHA, Saskatchewan Health Authority; MoH, Saskatchewan Ministry of Health
** Fully Developed and Implemented Provincially indicates the pathway is no longer in the development phase and has been implemented across Saskatchewan. The pathway is monitored and modified as new evidence and best practice emerge; Fully Developed but Implemented in One Local Setting indicates that the pathway is no longer in the development phase but has not been implemented across Saskatchewan; Under Development indicates the pathway is in the development phase and has not been implemented.
*** TBD, To Be Determined
|
In 2021, nine pathways developed by the Saskatchewan Ministry of Health (MoH) were transitioned to the SHA, for a total of 13 pathways that fall within SHA accountability (Table 1). At a provincial level, this accountability includes the responsibility of supporting development and implementation, maturing of clinical pathways, and progress reporting to the MoH. As the former MoH pathways were developed without a standardized approach, they varied in their design and scale (provincial versus local settings). Gaps were recognized in that no processes, tools, or methods existed to validate the maturity of each pathway, to compare the pathways to one another, and to provide progress reporting to the MoH. The SHA CPCT planned to develop a maturity evaluation matrix to bridge these gaps by providing a tool that could measure levels of maturity via design, awareness, usage, metrics inclusion, owner engagement and participation, and provincial replicability of the clinical pathways.
Developing the maturity matrix
A search of published English language literature in MEDLINE via Pubmed, CINAHL, Cochrane Library, and Google Scholar for maturity evaluation matrices or models for clinical pathways resulted in identification of only one relevant publication (13). The maturity matrix published by Schriek et al. (13) contained five enablers and 19 weighted sub-enablers with four trajectory definitions (low, moderate, high, and top) for each sub-enabler. The matrix was initially examined and evaluated by the SHA CPCT to determine its compatibility within the specific context of Saskatchewan. Our CPCT included members with various backgrounds (medicine, quality improvement, implementation science, learning health systems, research, and psychology) as well as a pathway development team leader. The assessment of Schriek et al.’s matrix revealed the need to modify it based on the current knowledge in the fields of quality improvement, implementation science, and evaluation.
Using an iterative consensus-based process, email invitations (one initial and one reminder email two weeks later) were sent to SHA and MoH stakeholders with differing levels of experience in clinical pathway development and implementation as well as PFPs. Both emails were sent from the Director of Clinical Excellence in July 2022 with an attached copy of the draft maturity matrix (Fig. 1). We used purposeful and snowball sampling methods to identify the stakeholders from SHA and MoH. They came from diverse disciplines within the SHA, including nursing, executive directors, managers, clinical department heads, physicians, administrators, and a pathway developer from the MoH. Knowledge of pathway development among stakeholders ranged from those that had been involved with development and utilization of pathways to those that had moderate to no exposure in this area. To identify the PFPs, we asked the SHA or MoH stakeholders to recommend PFPs who they had previously worked with as well as contacted the SHA’s Patient and Client Experience (PCE) department (24, 25). All PFPs were registered with the SHA’s PCE department and were compensated as per the organization’s PFP policy (26). Knowledge of pathway development among the PFPs ranged from involvement with pathway development and related concepts to no previous exposure in this area.
The stakeholders and PFPs were asked to review the draft maturity matrix, determine which enablers and sub-enablers of the matrix should be kept and weighted more importantly on a 10-point Likert scale, choose which sub-enablers to be removed, and complete a REDCap (Research Electronic Database Capture) questionnaire (Supplementary File 1) (27, 28). Sub-enablers with a mean of 7 to 10 were considered important for inclusion.
After receiving the feedback, all potential participants were invited to attend virtual follow-up meetings in September 2022 via Webex platform (29). Participation was voluntary and no identifiable information was collected during the virtual meetings (Fig. 1).
During the sessions with the SHA and MoH stakeholders, questions were posed to participants about the inclusion of categories integral to pathway development, including pathway ownership (i.e., owner identity), patient involvement (e.g., ongoing stakeholder engagement), provincial integration (e.g., network of pathways) and replication (e.g., capacity monitoring). Content and face validity related to the relevance, appropriateness, and utility of the tool were explored and verified through discussions regarding the purpose of the tool and potential end users.
The session with PFPs had a series of seven questions seeking patients’ perspectives (five general questions and two questions related to the importance of sub-enablers) (Table 2). The questions were designed in consultation with the SHA’s PCE department and based on the SHA’s “Setting the stage for successful meetings with patient family partners (PFPs)” guidelines (internal document). Highlights of the guidelines include building in sharing time (ice breakers, stories), avoiding medical jargon or acronyms, and listening to PFPs stories, even if they are about care that did not go well. We started with open ended questions about PFPs’ experience in pathways or Saskatchewan’s health system and asked questions related to what is important to them in their care (i.e., pathway outcomes). To ensure the use of plain language and avoid using jargon, the CPCT conducted a readability analysis on the matrix. Results indicated that the matrix was at the university graduate level on the Flesch Readability Scale. Given this, the CPCT decided to focus on overarching concepts instead of one by one sub-enabler review. This was done to promote PFP’s engagement in an open and inviting discussion.
Table 2
List of Questions Asked During a Session with Patient and Family Partners
Type of Question
|
Question
|
General
|
Have you ever heard of the term “Clinical Pathways” or been involved in Clinical Pathway work?
|
General
|
From a patient perspective, what are the most important outcomes (measures, metrics) of the pathways? What outcomes would indicate successful pathways?
|
General
|
From a patient perspective, what are some indicators of a ‘good’ pathway? What are the things that make you confident you are receiving appropriate care? (appropriate could mean streamlined or seamless, clear communication, patients’ preferences considered in treatment, shared decision making, patients’ concerns addressed)
|
General
|
Are there any barriers that you have experienced when engaging in Clinical Pathway development or SHA activities? Any facilitators?
|
General
|
What are some challenges you have noticed in the healthcare system? (So that we can factor these into pathways).
|
Sub-enabler related
|
When looking at the list of enablers and sub-enablers, are there any that seem most important? Or, are there any that don’t seem important at all?
|
Sub-enabler related
|
Stakeholder engagement, owner identity, and metrics. For these three sub-enablers we would ask for more feedback. What are your thoughts on this? What would success in these areas look like?
|
Notes were taken during the meetings and summarized to participants who then provided additional feedback or context and validated the summary.
Applying the maturity matrix
We chose the Chronic Pain Pathway (CPP) because it was a newly developed pathway that had not been put into practice across the province. Using the Webex platform, the CPCT and the CPP development team leader met virtually from June to September 2022 (first round) and used the draft matrix to evaluate the CPP. The draft matrix contained 19 sub-enablers, each with four trajectories (low, moderate, high, and top). The purpose of the first round evaluation was to focus on the utility, clarity, and applicability of the draft matrix’s various components and scoring definitions (Fig. 1). From February to March 2023 (second round), the CPCT asked the pathway leader for her input on the elements of the revised maturity matrix, which contained 20 sub-enablers with three trajectories (low, moderate, and high). For this round of evaluation, we wanted to know if the terminology was relevant and if the matrix could be effectively used to rate the development of the pathway.