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Barriers and facilitators to implementation of the Liverpool Care Pathway in the Netherlands: a qualitative study Natasja Raijmakers,1,2 Anneke Dekkers,3 Cilia Galesloot,3 Lia van Zuylen,2 Agnes van der Heide1
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Department of Public Health, Erasmus MC, Rotterdam, The Netherlands 2 Department of Medical Oncology, Erasmus MC, Rotterdam, The Netherlands 3 Palliative Care, Comprehensive Cancer Centre, The Netherlands Correspondence to Dr Natasja J H Raijmakers, Department of Public Health, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands; [email protected] Received 23 March 2014 Revised 24 July 2014 Accepted 24 August 2014
To cite: Raijmakers N, Dekkers A, Galesloot C, et al. BMJ Supportive & Palliative Care Published Online First: [ please include Day Month Year] doi:10.1136/bmjspcare2014-000684
ABSTRACT Objectives The Liverpool Care Pathway (LCP) is a quality instrument for the dying patient. This study evaluates barriers and facilitators to its implementation in the Netherlands from the perspective of key stakeholders, to inform future implementation processes. Methods An interview study was conducted among 28 stakeholders involved in implementation of the LCP in the Netherlands, followed by a consecutive focus group with 8 interviewees to discuss and validate the findings of the interview study. Interviews were conducted by telephone and the notes taken during the interviews and focus group were transcribed into non-verbatim transcripts. Data collected during the interviews and focus group were evaluated using thematic analysis. Results According to the stakeholders, a context analysis prior to implementation was useful to find the appropriate orientation to adequately motivate healthcare professionals as well as management. The main contributing factors were the quality of the LCP (including its evidence-based character and completeness), and that it fitted the needs of healthcare professionals. During the implementation phase, a multidisciplinary project team, competent support and continuous monitoring were identified as important facilitators. Furthermore, for successful implementation, a facilitator working in liaison with others was helpful. To guarantee sustainability of the use of the LCP, it was important to disentangle tasks from the project leader and formally integrate these into the quality systems of the organisation. Conclusions The Dutch experience with largescale implementation of the LCP has identified important barriers and facilitators to the implementation of a quality instrument within palliative care. To successfully implement such a
promising instrument, liaison with others is important. The sense of being part of a process of improvement is valuable, while consolidation of this idea contributes to successful implementation.
INTRODUCTION The Liverpool Care Pathway (LCP) for the dying patient is a quality instrument that aims to support the care of patients in the final days or hours of life1; it was developed in the 1990s in the UK by the Royal Liverpool University Hospital and the Marie Curie Hospice, Liverpool. The aim of the LCP is to transfer the gold standard of care for the dying, as provided in UK hospices, to other care settings.2 The LCP is a care pathway covering palliative care options for patients in the final days of life and helps physicians and nurses to provide highquality end-of-life care. However, in 2013, the LCP received adverse criticism in the British media; this led to an independent panel to review the use and experiences of the LCP in England.3 This panel (chaired by baroness Neuberger) demonstrated that when the LCP is operated by well-trained, well-resourced and sensitive clinical teams, it works well. However, British physicians and nurses poorly understand its guidance for care of the dying, leading to poor care; the panel also emphasised the need for training and continuous professional development of healthcare professionals involved in care for dying patients. Furthermore, the panel recommended that the LCP should be phased out3; this was immediately accepted by the UK government.4
Raijmakers N, et al. BMJ Supportive & Palliative Care 2014;0:1–7. doi:10.1136/bmjspcare-2014-000684
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Research In 2001, the LCP was introduced in the Netherlands. First, it was translated into Dutch by the Erasmus Medical Centre Rotterdam, using the EORTC guidance. Second, a pre–post study was performed to evaluate the effect of the LCP on quality of care in hospitals, nursing homes and in home care; this latter landmark study demonstrated the positive impact of the use of the LCP, with a decrease in symptom burden for patients in the last days of life, a decrease of the grief burden for relatives and improvement of the documentation of care.5–7 International research on the LCP has mainly focused on staff experiences and showed that healthcare professionals indeed perceive the LCP to have positive impact on patients and relatives; i.e. staff members thought that the LCP improved the delivery of care to dying patients and also improved levels of staff confidence.8–15 After the promising results of the Dutch pre–post study, the Comprehensive Cancer Centre the Netherlands (the CCCN) decided to support implementation of the LCP in Dutch hospitals, hospices, nursing homes and home care settings as one of its priority activities. The CCCN is a knowledge and quality institute for healthcare professionals in oncology and palliative care that aims to optimise cancer care and palliative care by developing guidelines, ensuring quality of care, facilitating collaboration and by stimulating expertise.16 Implementation of the LCP was rolled out via 66 regional palliative care networks. A palliative care network is a collaborative of healthcare organisations in a geographical area. It is characterised by intensive collaboration and synchronisation of all care providers of palliative care in that area, supported by a network coordinator. The network coordinators support regional collaboration and synchronisation of the supply and demand of palliative care and also promote initiatives to improve the quality of palliative care.17 The activities of the CCCN and the regional palliative care networks with respect to implementation of the LCP included proclaiming and promoting the LCP, offering a 2-day training for project leaders from healthcare organisations that planned to implement the LCP and providing support to project leaders through a helpdesk for questions on the implementation process. Currently, the Dutch version of the LCP (in Dutch: Zorgpad Stervensfase) is used in over 100 healthcare organisations in the Netherlands.18 Implementation research is important to bridge the gap between research and practice,19 and to maximise the likelihood of successful long-term adoption of quality instruments in clinical practice.20 Numerous theories and models have been developed to understand barriers and facilitators to implementation processes in healthcare.21–23 However, implementation research within palliative and end-of-life care is not widespread. The process of implementation of the LCP in different care settings gives the unique 2
opportunity to fill this gap in research. Therefore, the main aim of this study was to identify crucial barriers and facilitators to successful implementation of a quality improvement instrument for palliative care, such as the LCP, in different healthcare settings. METHODS Design and population
This qualitative study included interviews and a focus group among key stakeholders who were involved in implementation of the LCP in the Netherlands. Implementation of the LCP in the Netherlands aims at making its use standard practice for care of the dying in the organisations concerned. Key stakeholders were CCCN consultants, palliative care network coordinators and project leaders of organisations that implemented the LCP. The CCCN is divided into eight regions; we interviewed the CCCN consultant involved in the training and dissemination of the LCP in each of these regions. Subsequently, we randomly selected one palliative care network from each CCCN region and interviewed the related network coordinator. Finally, the interviewed CCCN consultants were asked to identify 3–5 organisations that have successfully implemented the LCP, including a hospital, a hospice, a home care setting and a nursing home. Identification of a successful implementation trajectory depended on the assessment of the CCCN consultants. In total, 25 organisations were mentioned by the CCCN consultants: from these, a purposeful sample of 10 organisations was selected to guarantee maximum variation of settings and geographical regions. Thus, we interviewed project leaders from three hospitals, four hospices or palliative care units within nursing homes and three home care organisations. After the interviews, all interviewees were invited to participate in the focus group. Interviews
The semistructured topic list used for the interviews addressed the key stakeholders’ experiences with the implementation process of the LCP and their perceptions of barriers and facilitators (box 1). The list of topics was developed by the research team, based on the implementation model developed by Grol et al.22 All interviews were conducted by telephone and the notes taken during the interview were subsequently transcribed (by NR) into non-verbatim transcripts. Focus group
The focus group was informed by the findings of the interviews and was led by an experienced moderator (AvdH). Based on the interviews, all identified barriers and facilitators were listed and were sent to the participants prior to the focus group. Additionally, this list was printed on a large sheet of paper and the participants were asked to assess and rank these factors prior
Raijmakers N, et al. BMJ Supportive & Palliative Care 2014;0:1–7. doi:10.1136/bmjspcare-2014-000684
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Research Box 1 Topic list used for interviews with the project leaders of successful implementation trajectories Implementation trajectory 1. How did your organisation learn about the Dutch Liverpool Care Pathway (LCP)? 2. Why did your organisation decide to implement this instrument? 3. What was the composition of the project team? 4. How did you try to create commitment to the Dutch LCP? 5. What do you think about the documents and materials used for the Dutch LCP? 6. Did you perform a baseline measurement before implementation? If yes, how? What was the impact of the baseline measurement? 7. How did you provide education on the use of the Dutch LCP for the healthcare professionals within your organisation? 8. How did you support and stimulate the use of the Dutch LCP during the implementation phase? 9. Have you performed an interim evaluation of the use of the Dutch LCP? If yes, how? What was the impact of the interim evaluation? 10. Have you provided feedback on the results of the evaluation? If yes, how? 11. What is the current status of the use of the Dutch LCP in your organisation? (number, satisfaction… protocol, quality indicator, education, etc.) 12. What future developments of the Dutch LCP do you foresee within your organisation? Barriers and facilitators to implementation of the Dutch LCP 13. How have you experienced your role as project leader? 14. What was the contribution of the network coordinator to the implementation trajectory? 15. Have you received any support from the Comprehensive Cancer Centre the Netherlands (CCCN)? If yes, how? How did you experience this support? Success implementation trajectory 16. Do you consider the implementation of the Dutch LCP in your organisation a success? If yes, why? 17. What factors have contributed to this success? (facilitators) 18. What barriers did you encounter during this implementation trajectory? How have you solved these issues? General remarks 19. What have you learned from the implementation of the Dutch LCP in your organisation? 20. What would you do differently next time? 21. What is the most important advice you would give to others who would like to implement the Dutch LCP in their organisation?
to the group discussion to validate the findings as well as to prepare for the group discussion. Two assistant moderators (AD and NR) were present to take notes. Participants verbally consented to the discussion being audio-taped. Afterwards, a summary report was sent to all participants of the focus group. Participants were invited to provide their comments on the summary report, which acted as a means of respondent validation. Analyses
All interviews were independently read by two researchers (AD and NR). Barriers and facilitators to the implementation process were initially thematically coded by one researcher (AD), which was subsequently checked by the interviewer (NR) for accuracy. The list of identified barriers and facilitators was discussed with other members of the research team (AvdH and CG). The focus group was used to check the findings of the interviews and to complete the list. Ethical considerations
In the Netherlands, the Medical Research Involving Human Subjects Act (also known by its Dutch abbreviation: WMO) does not apply to this particular study. Therefore, no formal approval was required of the local Medical Ethical Committee. To ensure confidentiality, all data were collected anonymously and the researchers (except the interviewer NR) had no knowledge of personal data. RESULTS A total of 28 interviews were held: 8 with consultants of the CCCN, 8 with coordinators of palliative care networks and 12 with project leaders of 10 successful implementation projects. The 12 project leaders included 8 nurses, 2 physicians and 2 team managers. Subsequently, one focus group was held with 8 participants. Figure 1 presents an overview of the main barriers and facilitators. General facilitators of successful implementation
All respondents mentioned characteristics of the instrument itself as general facilitators. These included: the evidence-based character of the LCP, that it fitted the needs of healthcare professionals, and that it was conceived as a complete product that encompasses training, education materials and support. Respondents also identified process-related facilitators of successful implementation: these included having sufficient time and resources and implementing the LCP in liaison with others. The importance of connections and/or relationships at the regional and national level was often emphasised. The respondents also mentioned that firm and clear decision-making by managers regarding the implementation of the LCP was an important factor, as well as their commitment to support it. Furthermore,
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Research
Figure 1
Overview of key facilitators and barriers of implementation of a quality instrument within palliative care.
almost all respondents felt that it was crucial for implementation to install a multidisciplinary project team (with sufficient power and influence) and to have a competent project leader. Enthusiasm, persuasion and perseverance were among the identified essential characteristics of the project leader and project group. Facilitators per implementation phase
The participants of the focus group emphasised that the different phases of implementation involved specific factors to enhance the chance of success. The interviewees suggested that before the actual implementation, in the so-called orientation phase, a context analysis, i.e. an analysis of the environment in which the LCP is going to be implemented, had facilitated the implementation phase. Such a context 4
analysis had provided insight into the questions: “Is this the right instrument for our organisation? Is it the right timing for our organization? What aspects of palliative care are open to improvement?”. The CCCN consultants mentioned that context analysis was often used as a go/no-go sign that sometimes resulted in postponing the implementation of the LCP. Another facilitator was extensive communication with caregivers and the management: i.e. to inform them about the implementation plan and provide them with evidence of its positive impact. It was important to have everybody on board, at all levels of the organisation. All project leaders of the participating departments have received the LCP training of the CCCN. Following this training, the context analysis provided many insights and made clear which aspects of care
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Research were open to improvement. (Project coordinator in a large hospital)
During the implementation process, extensive and competent support (both on the content and process level), on-the-job training and continuous attention for and reflection on the results of the implementation were mentioned as important facilitators. The project leader gave on-the–job coaching to nurses and functioned as a helpdesk for all questions about the use of the LCP in practice. (Project leader in a hospice)
Respondents also mentioned several facilitators essential for the sustainability of the use of the instrument. Important factors were: explicit closure of the pilot phase, unravelling the tasks of the project leader and the project team, formally integrating the responsibilities into the protocols and incorporating the LCP in the introduction programme for new employees. It is important to fully integrate the LCP into daily practice. Nowadays, we have LCP training for new employees, the LCP is part of the quality management, it’s been included in manuals and we have people in place who can answer questions about the LCP. They work organisation wide, which supports the sustainability of the use of the LCP. (Project leader in a nursing home)
Continuous monitoring and feedback of the results of implementation to relevant healthcare professionals and managers was also perceived as an important facilitator of continual use of the LCP, including feedback on its use and effects in annual reports. Potential barriers
Several potential barriers to implementation of the LCP were mentioned, including the presence of other priorities in the organisation, a project team with insufficient authority and sphere of influence, and too few deaths to develop sufficient experience and expertise. A project team that consisted only of healthcare professionals without a member of the management was not able to further disseminate the LCP into their organisation and ensure its continual use. After the pilot period, the use of the LCP often decreased. Also, practical issues, including the administrative burden of using the instrument and lack of integration with electronic patient files, were mentioned as factors that potentially hamper successful implementation. Respondents also mentioned fragmentation of care practices as an important barrier to implementation of a multidisciplinary quality instrument such as the LCP: this seemed to apply particularly to the home care setting. DISCUSSION This study aimed to identify important barriers and facilitators to implementation of a quality instrument,
such as the Dutch LCP, within healthcare organisations providing palliative care. The data show that important facilitators include the quality of the instrument itself (which is preferably evidence-based), installation of a multidisciplinary project team with sufficient influence, full commitment of management and implementation of the instrument in liaison with others. The sense of being part of a larger improvement process is valuable; consolidation of this idea contributes to successful implementation. Practical issues, such as lack of time and fragmented organisation of care, were identified as barriers to successful implementation. The interview data indicated that implementing the LCP in liaison with others was crucial, as was the commitment of management and a multidisciplinary project team. Moreover, the stakeholders emphasised the importance of connections and relationships at the institutional, regional and national level. Similar findings were found in a pilot for implementing the LCP programme within the inpatient hospice setting in Italy. This Italian pilot showed that implementation processes to improve the provision of palliative care can be supported by local, regional and national meetings and networks, and by external support from trained palliative care professionals.24 Moreover, Grol and Grimshaw25 suggested that comprehensive approaches at different levels (healthcare professionals, team, institution and wider environment) are required to achieve sustainable improvements in healthcare practices; this underpins the importance of working in close liaison with others. Our findings from the focus group suggest that it is relevant to distinguish different phases in the implementation process; this has been emphasised before by others.22 Our study indicates that proper identification of the needs of an organisation based on a context analysis facilitates the implementation process and provides a sufficient support base. This is in line with Watson et al,26 who stated that some organisations may not be ready or able to implement quality instruments to improve end-of-life care: this could be due to a lack of knowledge in this area, difficulties with identifying patients with a life-limiting prognosis and/or a lack of confidence among caregivers to engage in difficult end-of-life discussions. In the Netherlands, large-scale implementation of the Dutch LCP has been perceived as a valuable first step. This has led to the nomination of the Dutch LCP as a ‘best practice’ in the National Framework for the Improvement of Palliative Care.27 However, the care pathway for dying patients is not a solution or a goal in itself; it can merely guide healthcare professionals in their wider efforts to provide high-quality end-of-life care. Our findings indicate that the LCP should also include education and monitoring (completeness of instrument), which is in line with the conclusions of the review of Neuberger.3 The implementation guide of the LCP, which is used in the UK, also emphasised
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Research this point. This implementation guide also advises training, continuous development of competencies regarding end-of-life care and the establishment of an education programme.28 The importance of these steps has previously been demonstrated.29 A practical implication of these findings is that the LCP should not be used as a check box, but as a tool to support and guide healthcare professionals involved in care for the dying. The users of the instrument should understand the rationale and ideas underpinning the LCP, to be able to reflect on their acts.
conception and design of this study, were involved in interpretation of the data and preparation of the manuscript, by drafting or revising the manuscript.
Study limitations
REFERENCES
First, this study concerns Dutch experiences, our results may not be applicable to other countries where healthcare and palliative care may be organised and structured differently. It is also likely that our findings do not apply to countries that prefer a national top-down approach, such as in New Zealand, where a centralised LCP office supports implementation of the LCP on a national level; this national LCP office has proven to be of crucial importance to key stakeholders in New Zealand.30 The study has some other limitations. For example, a relatively low number of stakeholders participated in the focus group, which limits the ‘richness’ of the group discussion. However, 28 stakeholders with a variety of backgrounds participated in the interview study. Furthermore, our purposive sampling of 10 organisations that successfully implemented the LCP implies that we gained only limited insight into the barriers to implementation. Moreover, no specific definition of ‘successful implementation’ was used, i.e. the assessment of success depended on the opinion of the CCCN consultant. However, the CCCN consultants had supported multiple implementation trajectories of the LCP and could therefore be considered capable of distinguishing between successful and less successful trajectories.
1 Ellershaw J, Ward C. Care of the dying patient: the last hours or days of life. BMJ 2003;326:30–4. 2 Ellershaw J, Wilkinson S. Care for the dying: a pathway to excellence. 2nd edn. Oxford: University Press, 2011. 3 Neuberger J. More care, less pathway. A review of the Liverpool Care Pathway. 2013 July, 2013. 4 Hawkes N. Liverpool care pathway is scrapped after review finds it was not well used. BMJ 2013;347:4568. 5 Veerbeek L, van Zuylen L, Swart SJ, et al. The effect of the Liverpool Care Pathway for the dying: a multi-centre study. Palliat Med 2008;22:145–51. 6 Veerbeek L, van der Heide A, de Vogel-Voogt E, et al. Using the LCP: bereaved relatives’ assessments of communication and bereavement. Am J Hosp Palliat Care 2008;25:207–14. 7 van der Heide A, Veerbeek L, Swart S, et al. End-of-life decision making for cancer patients in different clinical settings and the impact of the LCP. J Pain Symptom Manage 2010;39:33–43. 8 Jack BA, Gambles M, Murphy D, et al. Nurses’ perceptions of the Liverpool Care Pathway for the dying patient in the acute hospital setting. Int J Palliat Nurs 2003;9:375–81. 9 Clark JB, Sheward K, Marshall B, et al. Staff perceptions of end-of-life care following implementation of the Liverpool care pathway for the dying patient in the acute care setting: a New Zealand perspective. J Palliat Med 2012;15:468–73. 10 Clark J, Marshall B, Sheward K, et al. Staff perceptions of the impact of the Liverpool Care Pathway in aged residential care in New Zealand. Int J Palliat Nurs 2012;18:171–8. 11 O’Hara T. Nurses’ views on using the Liverpool care pathway in an acute hospital setting. Int J Palliat Nurs 2011;17:239–44. 12 Di Leo S, Beccaro M, Finelli S, et al. Expectations about and impact of the Liverpool Care Pathway for the dying patient in an Italian hospital. Palliat Med 2011;25:293–303. 13 Walker R, Read S. The Liverpool Care Pathway in intensive care: an exploratory study of doctor and nurse perceptions. Int J Palliat Nurs 2010;16:267–73. 14 Gambles M, Stirzaker S, Jack BA, et al. The Liverpool Care Pathway in hospices: an exploratory study of doctor and nurse perceptions. Int J Palliat Nurs 2006;12:414–21. 15 Marshall B, Clark J, Sheward K, et al. Staff perceptions of end-of-life care in aged residential care: a New Zealand perspective. J Palliat Med 2011;14:688–95. 16 Integraal Kankercentrum Nederland (IKNL) The Comprehensive Cancer Center the Netherlands. [cited 2014 July, 14th] http://www.iknl.nl. 17 Network Palliative Care the Netherlands 2013. [cited 2014 July, 14th] http://www.netwerkpalliatievezorg.nl/ 18 Dekker AGWM, Raijmakers NJH. Zorgpad Stervensfase, verspreiding van een goed voorbeeld: hoe doe je dat? [The
CONCLUSION The Dutch experience with implementing the LCP on a large scale, as described here, demonstrates which factors are crucially important in achieving the envisaged quality improvement. Important facilitators for successful implementation of a quality instrument such as the LCP are the quality and completeness of the instrument itself, the installation of a multidisciplinary project team, and implementation in liaison with important parties within the organisation, as well at the regional and national level. Finally, the drive of healthcare professionals to improve care of the dying is an essential factor for successful implementation. Acknowledgements The authors thank those involved in implementation of the Liverpool Care Pathway in the Netherlands, who made a valuable contribution to this study. Contributors NR and AvdH were involved in the acquisition of data and analysed the data. All authors have contributed to
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Funding This work was supported by a grant from the Netherlands Organisation for Health Research and Development (ZonMw). The sponsors approved the study design, but were not involved in the collection, analysis and interpretation of data. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed.
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Ducth LCP, how to implement a good example?]. Rotterdam: The Comprehensive Cancer Center, the Netherlands, 2012. Kutner JS. A significant milestone for palliative care: imperative for dissemination and implementation research. J Palliat Med 2011;14:1194–5. Demiris G, Parker Oliver D, Capurro D, et al. Implementation science: implications for intervention research in hospice and palliative care. Gerontologist 2014;54:163–71. Grol R, Wensing M. What drives change? Barriers to and incentives for achieving evidence-based practice. Med J Aust 2004;180:S57–60. Grol R, Wensing M, Hulscher M, et al. Theories on implementation of change in healthcare. In: Grol R, Wensing M, Eccles M, eds. Improving patient care: the implementation of change in clinical practice. Edinburgh: Elsevier, 2005. May CR, Mair F, Finch T, et al. Development of a theory of implementation and integration: Normalization Process Theory. Implement Sci 2009;4:1–9. Di Leo S, Bono L, Romoli V, et al. Implementation of the Liverpool Care Pathway (LCP) for the dying patient in the inpatient hospice setting: development and preliminary assessment of the Italian LCP Program. Am J Hosp Palliat Care 2014;31:61–8.
25 Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet 2003;362:1225–30. 26 Watson J, Hockley J, Dewar B. Barriers to implementing an integrated care pathway for the last days of life in nursing homes. Int J Palliat Nurs 2006;12:234–40. 27 ZonMw Verbeterprogramma Palliatieve Zorg [Improvement Framework Palliative Care] The Hague, the Netherlands 2013 [cited 2013 14 February]. http://www.zonmw.nl/programma -palliatieve-zorg/algemeen 28 Institute TMCPC. Liverpool Care Pahtway for the Dying Patient (LCP) Liverpool2013 [cited 2013 14 February]. http:// www.liv.ac.uk/mcpcil/liverpool-care-pathway/implementationlcp/ 29 Finucane AM, Stevenson B, Moyes R, et al. Improving end-of-life care in nursing homes: Implementation and evaluation of an intervention to sustain quality of care. Palliat Med 2013;27:772–8. 30 Mackenzie T, Innes J, Boyd M, et al. Evaluating the role and value of a national office to coordinate Liverpool Care Pathway implementation in New Zealand. Int J Evid Based Healthc 2011;9:252–60.
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Barriers and facilitators to implementation of the Liverpool Care Pathway in the Netherlands: a qualitative study Natasja Raijmakers, Anneke Dekkers, Cilia Galesloot, Lia van Zuylen and Agnes van der Heide BMJ Support Palliat Care published online September 8, 2014
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Research
Barriers and facilitators to implementation of the Liverpool Care Pathway in the Netherlands: a qualitative study Natasja Raijmakers,1,2 Anneke Dekkers,3 Cilia Galesloot,3 Lia van Zuylen,2 Agnes van der Heide1
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Department of Public Health, Erasmus MC, Rotterdam, The Netherlands 2 Department of Medical Oncology, Erasmus MC, Rotterdam, The Netherlands 3 Palliative Care, Comprehensive Cancer Centre, The Netherlands Correspondence to Dr Natasja J H Raijmakers, Department of Public Health, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands; [email protected] Received 23 March 2014 Revised 24 July 2014 Accepted 24 August 2014
To cite: Raijmakers N, Dekkers A, Galesloot C, et al. BMJ Supportive & Palliative Care Published Online First: [ please include Day Month Year] doi:10.1136/bmjspcare2014-000684
ABSTRACT Objectives The Liverpool Care Pathway (LCP) is a quality instrument for the dying patient. This study evaluates barriers and facilitators to its implementation in the Netherlands from the perspective of key stakeholders, to inform future implementation processes. Methods An interview study was conducted among 28 stakeholders involved in implementation of the LCP in the Netherlands, followed by a consecutive focus group with 8 interviewees to discuss and validate the findings of the interview study. Interviews were conducted by telephone and the notes taken during the interviews and focus group were transcribed into non-verbatim transcripts. Data collected during the interviews and focus group were evaluated using thematic analysis. Results According to the stakeholders, a context analysis prior to implementation was useful to find the appropriate orientation to adequately motivate healthcare professionals as well as management. The main contributing factors were the quality of the LCP (including its evidence-based character and completeness), and that it fitted the needs of healthcare professionals. During the implementation phase, a multidisciplinary project team, competent support and continuous monitoring were identified as important facilitators. Furthermore, for successful implementation, a facilitator working in liaison with others was helpful. To guarantee sustainability of the use of the LCP, it was important to disentangle tasks from the project leader and formally integrate these into the quality systems of the organisation. Conclusions The Dutch experience with largescale implementation of the LCP has identified important barriers and facilitators to the implementation of a quality instrument within palliative care. To successfully implement such a
promising instrument, liaison with others is important. The sense of being part of a process of improvement is valuable, while consolidation of this idea contributes to successful implementation.
INTRODUCTION The Liverpool Care Pathway (LCP) for the dying patient is a quality instrument that aims to support the care of patients in the final days or hours of life1; it was developed in the 1990s in the UK by the Royal Liverpool University Hospital and the Marie Curie Hospice, Liverpool. The aim of the LCP is to transfer the gold standard of care for the dying, as provided in UK hospices, to other care settings.2 The LCP is a care pathway covering palliative care options for patients in the final days of life and helps physicians and nurses to provide highquality end-of-life care. However, in 2013, the LCP received adverse criticism in the British media; this led to an independent panel to review the use and experiences of the LCP in England.3 This panel (chaired by baroness Neuberger) demonstrated that when the LCP is operated by well-trained, well-resourced and sensitive clinical teams, it works well. However, British physicians and nurses poorly understand its guidance for care of the dying, leading to poor care; the panel also emphasised the need for training and continuous professional development of healthcare professionals involved in care for dying patients. Furthermore, the panel recommended that the LCP should be phased out3; this was immediately accepted by the UK government.4
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Research In 2001, the LCP was introduced in the Netherlands. First, it was translated into Dutch by the Erasmus Medical Centre Rotterdam, using the EORTC guidance. Second, a pre–post study was performed to evaluate the effect of the LCP on quality of care in hospitals, nursing homes and in home care; this latter landmark study demonstrated the positive impact of the use of the LCP, with a decrease in symptom burden for patients in the last days of life, a decrease of the grief burden for relatives and improvement of the documentation of care.5–7 International research on the LCP has mainly focused on staff experiences and showed that healthcare professionals indeed perceive the LCP to have positive impact on patients and relatives; i.e. staff members thought that the LCP improved the delivery of care to dying patients and also improved levels of staff confidence.8–15 After the promising results of the Dutch pre–post study, the Comprehensive Cancer Centre the Netherlands (the CCCN) decided to support implementation of the LCP in Dutch hospitals, hospices, nursing homes and home care settings as one of its priority activities. The CCCN is a knowledge and quality institute for healthcare professionals in oncology and palliative care that aims to optimise cancer care and palliative care by developing guidelines, ensuring quality of care, facilitating collaboration and by stimulating expertise.16 Implementation of the LCP was rolled out via 66 regional palliative care networks. A palliative care network is a collaborative of healthcare organisations in a geographical area. It is characterised by intensive collaboration and synchronisation of all care providers of palliative care in that area, supported by a network coordinator. The network coordinators support regional collaboration and synchronisation of the supply and demand of palliative care and also promote initiatives to improve the quality of palliative care.17 The activities of the CCCN and the regional palliative care networks with respect to implementation of the LCP included proclaiming and promoting the LCP, offering a 2-day training for project leaders from healthcare organisations that planned to implement the LCP and providing support to project leaders through a helpdesk for questions on the implementation process. Currently, the Dutch version of the LCP (in Dutch: Zorgpad Stervensfase) is used in over 100 healthcare organisations in the Netherlands.18 Implementation research is important to bridge the gap between research and practice,19 and to maximise the likelihood of successful long-term adoption of quality instruments in clinical practice.20 Numerous theories and models have been developed to understand barriers and facilitators to implementation processes in healthcare.21–23 However, implementation research within palliative and end-of-life care is not widespread. The process of implementation of the LCP in different care settings gives the unique 2
opportunity to fill this gap in research. Therefore, the main aim of this study was to identify crucial barriers and facilitators to successful implementation of a quality improvement instrument for palliative care, such as the LCP, in different healthcare settings. METHODS Design and population
This qualitative study included interviews and a focus group among key stakeholders who were involved in implementation of the LCP in the Netherlands. Implementation of the LCP in the Netherlands aims at making its use standard practice for care of the dying in the organisations concerned. Key stakeholders were CCCN consultants, palliative care network coordinators and project leaders of organisations that implemented the LCP. The CCCN is divided into eight regions; we interviewed the CCCN consultant involved in the training and dissemination of the LCP in each of these regions. Subsequently, we randomly selected one palliative care network from each CCCN region and interviewed the related network coordinator. Finally, the interviewed CCCN consultants were asked to identify 3–5 organisations that have successfully implemented the LCP, including a hospital, a hospice, a home care setting and a nursing home. Identification of a successful implementation trajectory depended on the assessment of the CCCN consultants. In total, 25 organisations were mentioned by the CCCN consultants: from these, a purposeful sample of 10 organisations was selected to guarantee maximum variation of settings and geographical regions. Thus, we interviewed project leaders from three hospitals, four hospices or palliative care units within nursing homes and three home care organisations. After the interviews, all interviewees were invited to participate in the focus group. Interviews
The semistructured topic list used for the interviews addressed the key stakeholders’ experiences with the implementation process of the LCP and their perceptions of barriers and facilitators (box 1). The list of topics was developed by the research team, based on the implementation model developed by Grol et al.22 All interviews were conducted by telephone and the notes taken during the interview were subsequently transcribed (by NR) into non-verbatim transcripts. Focus group
The focus group was informed by the findings of the interviews and was led by an experienced moderator (AvdH). Based on the interviews, all identified barriers and facilitators were listed and were sent to the participants prior to the focus group. Additionally, this list was printed on a large sheet of paper and the participants were asked to assess and rank these factors prior
Raijmakers N, et al. BMJ Supportive & Palliative Care 2014;0:1–7. doi:10.1136/bmjspcare-2014-000684
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Research Box 1 Topic list used for interviews with the project leaders of successful implementation trajectories Implementation trajectory 1. How did your organisation learn about the Dutch Liverpool Care Pathway (LCP)? 2. Why did your organisation decide to implement this instrument? 3. What was the composition of the project team? 4. How did you try to create commitment to the Dutch LCP? 5. What do you think about the documents and materials used for the Dutch LCP? 6. Did you perform a baseline measurement before implementation? If yes, how? What was the impact of the baseline measurement? 7. How did you provide education on the use of the Dutch LCP for the healthcare professionals within your organisation? 8. How did you support and stimulate the use of the Dutch LCP during the implementation phase? 9. Have you performed an interim evaluation of the use of the Dutch LCP? If yes, how? What was the impact of the interim evaluation? 10. Have you provided feedback on the results of the evaluation? If yes, how? 11. What is the current status of the use of the Dutch LCP in your organisation? (number, satisfaction… protocol, quality indicator, education, etc.) 12. What future developments of the Dutch LCP do you foresee within your organisation? Barriers and facilitators to implementation of the Dutch LCP 13. How have you experienced your role as project leader? 14. What was the contribution of the network coordinator to the implementation trajectory? 15. Have you received any support from the Comprehensive Cancer Centre the Netherlands (CCCN)? If yes, how? How did you experience this support? Success implementation trajectory 16. Do you consider the implementation of the Dutch LCP in your organisation a success? If yes, why? 17. What factors have contributed to this success? (facilitators) 18. What barriers did you encounter during this implementation trajectory? How have you solved these issues? General remarks 19. What have you learned from the implementation of the Dutch LCP in your organisation? 20. What would you do differently next time? 21. What is the most important advice you would give to others who would like to implement the Dutch LCP in their organisation?
to the group discussion to validate the findings as well as to prepare for the group discussion. Two assistant moderators (AD and NR) were present to take notes. Participants verbally consented to the discussion being audio-taped. Afterwards, a summary report was sent to all participants of the focus group. Participants were invited to provide their comments on the summary report, which acted as a means of respondent validation. Analyses
All interviews were independently read by two researchers (AD and NR). Barriers and facilitators to the implementation process were initially thematically coded by one researcher (AD), which was subsequently checked by the interviewer (NR) for accuracy. The list of identified barriers and facilitators was discussed with other members of the research team (AvdH and CG). The focus group was used to check the findings of the interviews and to complete the list. Ethical considerations
In the Netherlands, the Medical Research Involving Human Subjects Act (also known by its Dutch abbreviation: WMO) does not apply to this particular study. Therefore, no formal approval was required of the local Medical Ethical Committee. To ensure confidentiality, all data were collected anonymously and the researchers (except the interviewer NR) had no knowledge of personal data. RESULTS A total of 28 interviews were held: 8 with consultants of the CCCN, 8 with coordinators of palliative care networks and 12 with project leaders of 10 successful implementation projects. The 12 project leaders included 8 nurses, 2 physicians and 2 team managers. Subsequently, one focus group was held with 8 participants. Figure 1 presents an overview of the main barriers and facilitators. General facilitators of successful implementation
All respondents mentioned characteristics of the instrument itself as general facilitators. These included: the evidence-based character of the LCP, that it fitted the needs of healthcare professionals, and that it was conceived as a complete product that encompasses training, education materials and support. Respondents also identified process-related facilitators of successful implementation: these included having sufficient time and resources and implementing the LCP in liaison with others. The importance of connections and/or relationships at the regional and national level was often emphasised. The respondents also mentioned that firm and clear decision-making by managers regarding the implementation of the LCP was an important factor, as well as their commitment to support it. Furthermore,
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Research
Figure 1
Overview of key facilitators and barriers of implementation of a quality instrument within palliative care.
almost all respondents felt that it was crucial for implementation to install a multidisciplinary project team (with sufficient power and influence) and to have a competent project leader. Enthusiasm, persuasion and perseverance were among the identified essential characteristics of the project leader and project group. Facilitators per implementation phase
The participants of the focus group emphasised that the different phases of implementation involved specific factors to enhance the chance of success. The interviewees suggested that before the actual implementation, in the so-called orientation phase, a context analysis, i.e. an analysis of the environment in which the LCP is going to be implemented, had facilitated the implementation phase. Such a context 4
analysis had provided insight into the questions: “Is this the right instrument for our organisation? Is it the right timing for our organization? What aspects of palliative care are open to improvement?”. The CCCN consultants mentioned that context analysis was often used as a go/no-go sign that sometimes resulted in postponing the implementation of the LCP. Another facilitator was extensive communication with caregivers and the management: i.e. to inform them about the implementation plan and provide them with evidence of its positive impact. It was important to have everybody on board, at all levels of the organisation. All project leaders of the participating departments have received the LCP training of the CCCN. Following this training, the context analysis provided many insights and made clear which aspects of care
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Research were open to improvement. (Project coordinator in a large hospital)
During the implementation process, extensive and competent support (both on the content and process level), on-the-job training and continuous attention for and reflection on the results of the implementation were mentioned as important facilitators. The project leader gave on-the–job coaching to nurses and functioned as a helpdesk for all questions about the use of the LCP in practice. (Project leader in a hospice)
Respondents also mentioned several facilitators essential for the sustainability of the use of the instrument. Important factors were: explicit closure of the pilot phase, unravelling the tasks of the project leader and the project team, formally integrating the responsibilities into the protocols and incorporating the LCP in the introduction programme for new employees. It is important to fully integrate the LCP into daily practice. Nowadays, we have LCP training for new employees, the LCP is part of the quality management, it’s been included in manuals and we have people in place who can answer questions about the LCP. They work organisation wide, which supports the sustainability of the use of the LCP. (Project leader in a nursing home)
Continuous monitoring and feedback of the results of implementation to relevant healthcare professionals and managers was also perceived as an important facilitator of continual use of the LCP, including feedback on its use and effects in annual reports. Potential barriers
Several potential barriers to implementation of the LCP were mentioned, including the presence of other priorities in the organisation, a project team with insufficient authority and sphere of influence, and too few deaths to develop sufficient experience and expertise. A project team that consisted only of healthcare professionals without a member of the management was not able to further disseminate the LCP into their organisation and ensure its continual use. After the pilot period, the use of the LCP often decreased. Also, practical issues, including the administrative burden of using the instrument and lack of integration with electronic patient files, were mentioned as factors that potentially hamper successful implementation. Respondents also mentioned fragmentation of care practices as an important barrier to implementation of a multidisciplinary quality instrument such as the LCP: this seemed to apply particularly to the home care setting. DISCUSSION This study aimed to identify important barriers and facilitators to implementation of a quality instrument,
such as the Dutch LCP, within healthcare organisations providing palliative care. The data show that important facilitators include the quality of the instrument itself (which is preferably evidence-based), installation of a multidisciplinary project team with sufficient influence, full commitment of management and implementation of the instrument in liaison with others. The sense of being part of a larger improvement process is valuable; consolidation of this idea contributes to successful implementation. Practical issues, such as lack of time and fragmented organisation of care, were identified as barriers to successful implementation. The interview data indicated that implementing the LCP in liaison with others was crucial, as was the commitment of management and a multidisciplinary project team. Moreover, the stakeholders emphasised the importance of connections and relationships at the institutional, regional and national level. Similar findings were found in a pilot for implementing the LCP programme within the inpatient hospice setting in Italy. This Italian pilot showed that implementation processes to improve the provision of palliative care can be supported by local, regional and national meetings and networks, and by external support from trained palliative care professionals.24 Moreover, Grol and Grimshaw25 suggested that comprehensive approaches at different levels (healthcare professionals, team, institution and wider environment) are required to achieve sustainable improvements in healthcare practices; this underpins the importance of working in close liaison with others. Our findings from the focus group suggest that it is relevant to distinguish different phases in the implementation process; this has been emphasised before by others.22 Our study indicates that proper identification of the needs of an organisation based on a context analysis facilitates the implementation process and provides a sufficient support base. This is in line with Watson et al,26 who stated that some organisations may not be ready or able to implement quality instruments to improve end-of-life care: this could be due to a lack of knowledge in this area, difficulties with identifying patients with a life-limiting prognosis and/or a lack of confidence among caregivers to engage in difficult end-of-life discussions. In the Netherlands, large-scale implementation of the Dutch LCP has been perceived as a valuable first step. This has led to the nomination of the Dutch LCP as a ‘best practice’ in the National Framework for the Improvement of Palliative Care.27 However, the care pathway for dying patients is not a solution or a goal in itself; it can merely guide healthcare professionals in their wider efforts to provide high-quality end-of-life care. Our findings indicate that the LCP should also include education and monitoring (completeness of instrument), which is in line with the conclusions of the review of Neuberger.3 The implementation guide of the LCP, which is used in the UK, also emphasised
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Research this point. This implementation guide also advises training, continuous development of competencies regarding end-of-life care and the establishment of an education programme.28 The importance of these steps has previously been demonstrated.29 A practical implication of these findings is that the LCP should not be used as a check box, but as a tool to support and guide healthcare professionals involved in care for the dying. The users of the instrument should understand the rationale and ideas underpinning the LCP, to be able to reflect on their acts.
conception and design of this study, were involved in interpretation of the data and preparation of the manuscript, by drafting or revising the manuscript.
Study limitations
REFERENCES
First, this study concerns Dutch experiences, our results may not be applicable to other countries where healthcare and palliative care may be organised and structured differently. It is also likely that our findings do not apply to countries that prefer a national top-down approach, such as in New Zealand, where a centralised LCP office supports implementation of the LCP on a national level; this national LCP office has proven to be of crucial importance to key stakeholders in New Zealand.30 The study has some other limitations. For example, a relatively low number of stakeholders participated in the focus group, which limits the ‘richness’ of the group discussion. However, 28 stakeholders with a variety of backgrounds participated in the interview study. Furthermore, our purposive sampling of 10 organisations that successfully implemented the LCP implies that we gained only limited insight into the barriers to implementation. Moreover, no specific definition of ‘successful implementation’ was used, i.e. the assessment of success depended on the opinion of the CCCN consultant. However, the CCCN consultants had supported multiple implementation trajectories of the LCP and could therefore be considered capable of distinguishing between successful and less successful trajectories.
1 Ellershaw J, Ward C. Care of the dying patient: the last hours or days of life. BMJ 2003;326:30–4. 2 Ellershaw J, Wilkinson S. Care for the dying: a pathway to excellence. 2nd edn. Oxford: University Press, 2011. 3 Neuberger J. More care, less pathway. A review of the Liverpool Care Pathway. 2013 July, 2013. 4 Hawkes N. Liverpool care pathway is scrapped after review finds it was not well used. BMJ 2013;347:4568. 5 Veerbeek L, van Zuylen L, Swart SJ, et al. The effect of the Liverpool Care Pathway for the dying: a multi-centre study. Palliat Med 2008;22:145–51. 6 Veerbeek L, van der Heide A, de Vogel-Voogt E, et al. Using the LCP: bereaved relatives’ assessments of communication and bereavement. Am J Hosp Palliat Care 2008;25:207–14. 7 van der Heide A, Veerbeek L, Swart S, et al. End-of-life decision making for cancer patients in different clinical settings and the impact of the LCP. J Pain Symptom Manage 2010;39:33–43. 8 Jack BA, Gambles M, Murphy D, et al. Nurses’ perceptions of the Liverpool Care Pathway for the dying patient in the acute hospital setting. Int J Palliat Nurs 2003;9:375–81. 9 Clark JB, Sheward K, Marshall B, et al. Staff perceptions of end-of-life care following implementation of the Liverpool care pathway for the dying patient in the acute care setting: a New Zealand perspective. J Palliat Med 2012;15:468–73. 10 Clark J, Marshall B, Sheward K, et al. Staff perceptions of the impact of the Liverpool Care Pathway in aged residential care in New Zealand. Int J Palliat Nurs 2012;18:171–8. 11 O’Hara T. Nurses’ views on using the Liverpool care pathway in an acute hospital setting. Int J Palliat Nurs 2011;17:239–44. 12 Di Leo S, Beccaro M, Finelli S, et al. Expectations about and impact of the Liverpool Care Pathway for the dying patient in an Italian hospital. Palliat Med 2011;25:293–303. 13 Walker R, Read S. The Liverpool Care Pathway in intensive care: an exploratory study of doctor and nurse perceptions. Int J Palliat Nurs 2010;16:267–73. 14 Gambles M, Stirzaker S, Jack BA, et al. The Liverpool Care Pathway in hospices: an exploratory study of doctor and nurse perceptions. Int J Palliat Nurs 2006;12:414–21. 15 Marshall B, Clark J, Sheward K, et al. Staff perceptions of end-of-life care in aged residential care: a New Zealand perspective. J Palliat Med 2011;14:688–95. 16 Integraal Kankercentrum Nederland (IKNL) The Comprehensive Cancer Center the Netherlands. [cited 2014 July, 14th] http://www.iknl.nl. 17 Network Palliative Care the Netherlands 2013. [cited 2014 July, 14th] http://www.netwerkpalliatievezorg.nl/ 18 Dekker AGWM, Raijmakers NJH. Zorgpad Stervensfase, verspreiding van een goed voorbeeld: hoe doe je dat? [The
CONCLUSION The Dutch experience with implementing the LCP on a large scale, as described here, demonstrates which factors are crucially important in achieving the envisaged quality improvement. Important facilitators for successful implementation of a quality instrument such as the LCP are the quality and completeness of the instrument itself, the installation of a multidisciplinary project team, and implementation in liaison with important parties within the organisation, as well at the regional and national level. Finally, the drive of healthcare professionals to improve care of the dying is an essential factor for successful implementation. Acknowledgements The authors thank those involved in implementation of the Liverpool Care Pathway in the Netherlands, who made a valuable contribution to this study. Contributors NR and AvdH were involved in the acquisition of data and analysed the data. All authors have contributed to
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Funding This work was supported by a grant from the Netherlands Organisation for Health Research and Development (ZonMw). The sponsors approved the study design, but were not involved in the collection, analysis and interpretation of data. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed.
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25 Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet 2003;362:1225–30. 26 Watson J, Hockley J, Dewar B. Barriers to implementing an integrated care pathway for the last days of life in nursing homes. Int J Palliat Nurs 2006;12:234–40. 27 ZonMw Verbeterprogramma Palliatieve Zorg [Improvement Framework Palliative Care] The Hague, the Netherlands 2013 [cited 2013 14 February]. http://www.zonmw.nl/programma -palliatieve-zorg/algemeen 28 Institute TMCPC. Liverpool Care Pahtway for the Dying Patient (LCP) Liverpool2013 [cited 2013 14 February]. http:// www.liv.ac.uk/mcpcil/liverpool-care-pathway/implementationlcp/ 29 Finucane AM, Stevenson B, Moyes R, et al. Improving end-of-life care in nursing homes: Implementation and evaluation of an intervention to sustain quality of care. Palliat Med 2013;27:772–8. 30 Mackenzie T, Innes J, Boyd M, et al. Evaluating the role and value of a national office to coordinate Liverpool Care Pathway implementation in New Zealand. Int J Evid Based Healthc 2011;9:252–60.
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Barriers and facilitators to implementation of the Liverpool Care Pathway in the Netherlands: a qualitative study Natasja Raijmakers, Anneke Dekkers, Cilia Galesloot, Lia van Zuylen and Agnes van der Heide BMJ Support Palliat Care published online September 8, 2014
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References
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