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Résumé :
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"Teams matter in healthcare. In an increasingly complex, knowledge-intensive medical environment, effective interprofessional teamwork is an essential component for the delivery of high-quality patient care. Furthermore, the World Health Organization (WHO) World Alliance for Patient Safety points out that improving communication and coordination has to be priority number one for patient safety research and practice in developed countries. Nonetheless high-level evidence is lacking, one intervention that can promote teamwork in healthcare is mentioned to be the implementation of care pathways. The primary objective of this dissertation was therefore to evaluate the impact of care pathways on interprofessional teamwork in an acute hospital setting. A secondary objective is to build up knowledge on the active components of care pathways and on the conditions under which they can be most effective through evaluation of the implementation processes. The study consists of four phases.In a first phase, we identified team indicators that can be used to measure interprofessional teamwork in care processes. Based on a literature search a list of 44 team indicators was developed. Afterwards an international expert panel was set, and the Delphi consensus method was used to support the process of effective decision making in selecting team indicators. For this process a purposively selected group of experts in teamwork consisting of both scientific researchers and hospital managers was chosen. Thirty-six experts from 13 countries participated. A final list of 19 indicators was generated: 5 on team context/structure, 8 on team process, and 6 on team outcomes.Secondly, a systematic review was performed to study the impact of existing care pathways on interprofessional teamwork. We included 26 studies in this review. In total, we identified 20 team indicators that were used to study the relationship between CPs and teamwork. We found that CPs positively affected 17 of 20 indicators. However, the level of evidence found was rather low. Thirdly, A post-test-only cluster randomized controlled trial was performed in Belgian acute hospitals. Teams caring for patients hospitalized with a proximal femur fracture and patients hospitalized with an exacerbation of chronic obstructive pulmonary disease were randomized into intervention and control groups. The intervention groups implemented a CP. The control group provided usual care. A set of team input, process, and output indicators was used as effect measures. To analyze results, we performed multilevel statistical analysis. Thirty teams and a total of 581 individual team members participated. The intervention teams scored significantly better on conflict management (ß=0.30 (0.11), 95% CI 0.08 to 0.53); team climate for innovation (ß=0.29 (0.10), 95% CI 0.09 to 0.49); and level of organized care (ß=5.56 (2.05), 95% CI 1.35 to 9.76). They also showed lower risk of burnout as they scored significantly lower on emotional exhaustion (ß= -0.57 (0.21), 95% CI -1.00 to-0.14) and higher on level of competence (ß=0.39, 95% CI 0.15 to 0.64). No significant effect was found on relational coordination.Fourthly, semi-structured, one-to-one interviews were performed after CP implementation with a purposive sample of key representatives of the 17 teams that were randomized in the intervention group. The Normalization Process Model (NPM) was used as theoretical framework to guide the inductive thematic analysis. Emerging themes were mapped onto the four NPM constructs. In total, we identified 21 elements that influenced the workability of CPs, and 23 elements that influenced their level of integration. The interviews also suggested that most teams were able to adopt the complex intervention and will be able to integrate the CP into daily practice. We conclude that CPs are an effective intervention for improving interprofessional teamwork and conflict management, increasing the organizational level of care processes, and decreasing risk of burnout for healthcare teams caring for COPD exacerbation and PFF patients in an acute hospital setting. Through this, they can tackle several barriers against interprofessional teamwork that are present in healthcare organizations, and create required essential job resources that can buffer the impact of the increasing job demands within today’s healthcare environment. CPs can therefore be used to build high-performance teams that can be supported and guided in actively improving the quality and safety of care processes."
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