Achieving Organizational Culture Change in Your Practice to Support an Effective Pathways Program

Gordon Kuntz is a health care consultant and strategic advisor with over 30 years’ experience in a multitude of health care settings, working with payers and providers, and in technology and strategy. He began his involvement with oncology care pathways in 2004 as a consultant with US Oncology as they were deploying Level 1 pathways. He subsequently led payer strategy with ION Solutions, a division of AmerisourceBergen, where he gained familiarity with many other pathways vendors, especially in the context of the oncology medical home model. As senior director of strategy for Via Oncology, he deepened his knowledge of the pathway development process, physician adoption, and how both impact cancer center strategies. Mr Kuntz now provides support in strategy and product design as well as assistance in navigating the cancer care ecosystem to established and emerging companies.

Over the last 5 years, many oncology practices have adopted clinical pathways, often with mixed results.¹ The same product may be implemented in different practices and see much lower adoption and utilization rates, or low adherence to the recommended treatments. For instance, through my experiences, I have even heard of clinicians using pathways to record the on-pathways recommendation, then ordering what they believe to be the “right” treatment despite it not being the recommended standard of care, so as not to incur the “off-pathway” mark on their record.

Effectively implementing a pathways program can be more challenging than one might initially believe. If a practice goes into the project simply thinking it is an IT implementation, they will be disappointed. Implementing a pathways system and making it an effective part of the practice’s daily efforts for success are two very different approaches. Although the pathways implementation has numerous technical components, the clinical and operational components are among the most important.

There are often several simultaneous goals for a practice in deploying a pathways system. This may often include a single, pressing reason—for example, that a payer program requires the use of pathways. However, concurrent with that imperative is the realization that there are several strategies that pathways can support. As described in a recent article in this series, these may include marketing, standardization of care among a network of remote sites, or readiness for advanced payment programs.² 

The central foundation necessary to accomplish any and all of these various goals through pathways is the culture change that must occur within the practice among the physicians and staff. In order to encourage the correct shift in organizational culture, practices should demonstrate their full commitment to the ideologies underlying clinical pathways across the organization focusing on several key areas of pathway implementation that will be expanded upon below.

Culture Change 

“An organization’s culture comprises an interlocking set of goals, roles, processes, values, communications practices, attitudes and assumptions.”³ Many of the roles, attitudes, and assumptions in cancer centers are built on the primacy of independent physician decision-making and actions. Similarly, I have heard from many colleagues that their cancer center only treats the sickest patients and that there is some sort of “secret sauce” in how they provide care. This creates a shared belief within the cancer center that it is somehow “special,” that is, they are only successful through extreme measures of independent brilliance and effort—not from a predictable set of processes and models of care. 

The success of a pathways program, however, relies on the willingness of oncologists and the broader staff to accept that pathway recommendations are valid and meaningful for about 80% of patients. Without this belief, the notion that one could create a repeatable process for delivering the most appropriate treatment for a specific disease presentation seems unimaginable.

Creating this shift in the organization’s culture requires a myriad of tools and approaches that require high levels of organizational leadership and commitment, and an understanding of the reach and impact of pathways implementation.

Pathways impact many departments in the organization, not just the oncologists seeing patients. For example, pathway recommendations can help optimize inventory management for costly drugs, which may in turn impact the finance department and the group purchasing organization programs in which the practice is involved. The clinical trials team will be required to manage the placement of clinical trials on pathways but may also be able to use the data collected along the pathway to identify areas where additional trials should be considered. The pharmacy department, often responsible with IT for managing orders within the electronic medical record (EMR) and order entry system, will need to manage the library of orders more closely and ensure its ongoing alignment with pathways recommendations. Finally, nursing and advance practice providers may be impacted due to changes in workflow, and on and on. 

A practice’s organizational culture must evolve and mature to affect a true culture change among physicians and staff so that each team and process noted above are working in harmony toward the same goal. The attitude toward the new initiative is as important as all of the operational changes taking place for pathways implementation. In many cancer centers, prior to the introduction of pathways and the clear establishment of a limited standard of care, oncologists were allowed to select and order the therapies they felt were best. While it is likely that most oncologists chose among therapies that were included in broad guidelines, there may have been significant variance and use of “favorites” in the ordering system. Effectively using pathways means accepting that strong evidence dictates that there is a “best way” to treat a specific disease presentation and trusting that pathways can provide that recommendation about 80% of the time. 

The culture shift required for the organization is profound and often overlooked. While doctors absolutely retain their independence of professional judgement and can order off-pathway treatments as appropriate, they must trust that the pathway recommendation should be the first option considered and that any off-pathways choice should be justified from patient-specific considerations. Difficult as it is, clinicians also need to accept the inherent monitoring that comes along with use of a pathways tool. The challenge is that, without being able to track pathway compliance—both the use of the pathway tool and the on-pathway compliance rate—cancer centers cannot demonstrate quality and will not achieve the goals of implementing the pathways in the first place.

This tension between using the pathways software—including the tracking and standardization that comes with it—and achieving the larger goals of the organization is what drives the need for culture change in deploying pathways. However, administrators should recognize that gaining support and participation from clinicians early and throughout the process of selecting and deploying pathways will help ensure that their needs are met. 

Because of the complexity of the culture change needed in deploying a pathways program, there are a number of critical success factors for cancer centers to consider.

Determining Key Objectives

Prior to selecting a pathways system, cancer centers are well served by understanding the specific strategies they hope to support with pathways. How a practice decides to deploy pathways can impact their ability to reach certain strategic goals. If a practice decides to document their own pathways, they may find that the results do not carry the same weight with payers as a nationally-recognized pathway would. Similarly, using flowcharts or written guides of pathways can be helpful in achieving standardized care but do not allow for easy data collection.

Knowing the goals to be achieved also allows the cancer center to feel comfortable applying appropriate resources and enforcement to the pathway’s deployment. For example, if one strategic goal of the practice is to demonstrate use of a common standard of care across all physicians in all sites, it would be best to set the expectation from the outset that the pathways tool will be used for all patients without exception, even if it is just to indicate that a patient is a consult-only or is a nonmalignant hematology patient. If the utilization is hit or miss, it is hard to represent that there is one standard of care.

For a cancer center, clearly articulating the objectives it is pursuing and how pathways are an essential element of achieving those objectives creates trust and understanding with clinicians, which provides a strong imperative for clinicians to use the pathways tool in support of the organization’s goals. 

Institutional Commitment and Leadership Support

Commitment to effectively deploying pathways at the most senior levels is critical for the success of the program. If clinical leadership does not reinforce, through words and actions, that pathways are important, their staff will see that and will be less likely to use the pathways tool.

Commitment in this context means not just sending an email announcing the project; it means following up with staff according to a regular, frequent communication plan. It means providing sufficient resources to the project and to the individual clinicians to allow them time to use the pathways as expected.

Governance

One of the key ways that the organization can show its commitment to the pathways initiative is by establishing clear administrative and clinical governance. An involved steering committee and executive administrative and clinical sponsors help to communicate the importance of the initiative. 

The governance structure needs to link senior leadership with staff clinicians and support staff. There should be clear accountability at each level for communicating, monitoring, and supporting staff as they begin to use the pathways. The governance should continue following the go-live to allow for ongoing monitoring of pathways use and helping those who may not be meeting organizational standards regarding its use.

I have been involved with a couple pathways implementations that had very different timelines and outcomes. The two cancer centers were of about the same size and complexity, but one progressed very slowly while the other was accomplished in record time. In particular, there were comparable volumes of clinical trials to be added to the pathway tool. In the case where the entire deployment went smoothly, the clinical trials coordinator divided up the work and worked diligently to get it done; in the other, the work seemed insurmountable to the staff and was delayed over and over again. That cancer center ultimately went live without clinical trials in the pathways software.

There may have been mitigating factors and competing priorities, of course, that inhibited the work at the center with the slower implementation, however, a large part of the issue seemed to be the pervasive attitude among staff that delays and avoidance on this project were acceptable. The opinion and attitude that the staff have about pathways is largely a function of leadership and communication. Cooperation is more likely to follow if the strategic connection is made, the importance of pathways to the organization is communicated clearly, and resource are made available. 

Project Timing

As the cancer center finalizes its approach to pathways and selects a vendor partner, it is important to understand other major initiatives in the organization, whether operational or technical. If the practice is undergoing a major workflow analysis or EMR upgrade, these will need to be factored into the project plan.

The issue is not only one of competing resource priorities but may also have to do with organizational readiness. For example, it may not make sense to integrate with an existing EMR if a project is underway to bring in a new package. 

The trade-off is, of course, that a cancer center cannot get the benefits of the pathways without using the pathways tool. It would be useful to conduct a cost/benefit analysis that considers the opportunity cost of waiting (eg, missing out on the benefits of pathways) compared to the cost of additional integration work or short-term manual work-arounds. 

Planning and Project Management

This may be obvious, but the more time spent planning for the implementation and preparing for the project, the more smoothly it is likely to go. The person responsible for managing the project is a critical resource that needs to be brought into the process as early as is practical. There are a number of moving parts to consider during a pathway implementation, including technical implementation, security, interfaces and integration work, order alignment and reconciliation, clinical trials preparation, training, go-live support, etc.

The project manager selected for the project should have strong organizational relationships and know the operations, workflow, support departments, and technical issues that will present themselves. Having the right relationships will facilitate the necessary coordination. The project manager should have experience with technical and operational projects and should be well versed in change management techniques. It is also critical that they have experience building consensus among clinicians in various roles, especially physicians. While the cancer center’s leadership is ultimately responsible for forming the culture that encourages use of the pathways, the project manager will be initially responsible for ensuring that clinicians are trained and ready on the live date.

Pathways vendors generally provide project management and implementation support, and they generally provide a roadmap for the implementation, but their involvement is meant to supplement client project management roles. There are activities that the cancer center itself must be responsible for and take ownership of in conjunction with the vendor. In my experience, the most successful implementations have been driven by strong project managers with a strong charter from the organization.

The project charter ensures that the scope of the project is clear, and that everyone involved understands the priority. It should link to the governance plan, ensuring that appropriate administrative and clinical leadership understand their roles and accountability. By creating a set of common goals and objectives, the charter helps ensure alignment among all of those involved in the pathways deployment project.

Sufficient Time and Resources

One of the key complaints clinicians have about pathways use (and technology in general) is that each system, each keystroke, takes up more time in their day. If pathways is truly a core technology that underlies the organization’s strategies, the organization should be willing to allocate sufficient time for its use.

Similarly, alignment and standardization of data assets and processes are time-consuming yet critical implementation activities. Client clinical trials coordinators will need to identify active trials and should ensure that there is a consistent and easily understood naming convention prior to placing them at the appropriate recommendation points on the pathways. They will also be called on to maintain/update them within the pathways on an on-going basis. 

Also, pathways deployment will be most effective if the orders available to oncologists are cleaned up and duplicates removed prior to implementation. Many practices have multiple names for the same chemotherapy orders and order sets. Deciding on a naming convention and eliminating duplicates will make the standardization around pathways much easier. This is a big undertaking depending on how actively the available orders in the EMR and computerized physician order entry have been monitored and maintained in the past. 

Neither of these are trivial activities and will need to be factored into the project planning with appropriate resources and timelines.

Clinician Engagement

Clinician engagement may well be the single most important factor in the success of a pathway deployment. And while it is dependent on many of the factors already discussed, it is itself a major undertaking. Having strategic support for pathways and senior level commitment, good project management, and the rest are necessary conditions but still require a concerted effort to engage clinicians and keep them engaged.

Absent pathways, treatment choices may be made for a variety of reasons including oncologist experience and comfort with certain treatments, GPO contracts, or local P&T committee preferences. Without pathways, these decisions fundamentally rest with each individual oncologist and do not require alignment with their colleagues, so practices often see significant variation in treatment selection pre-pathways.

Moving to a single standard of care across the organization requires a change in clinician mindset, specifically that pathways represent the best treatment option for patients about 80% of the time. For certain common disease presentations, the standard of care is well known, and oncologists are likely to choose the optimal treatment even without pathways to prompt them to do so. It is those cancers that are less common, or where treatments are rapidly evolving, where greater variation exists.

We will explore clinician engagement in a future article in this series but suffice to it to say that engaging clinicians is essential to the success of pathways and in helping support the organization’s strategic goals and requires a concerted effort to be effective. In fact, involving clinicians from the beginning of the evaluation process will be beneficial. By enlisting their help in determining the best approach (eg, building vs buying pathways) and the most appropriate vendor, clinicians will feel greater ownership over the process and its outcome.

A Note to Practices Who Already Have Pathways and Final Thoughts

Many practices reading this have already implemented pathways and may be thinking that they wished that they had known this earlier. While these are critical factors to consider, ideally in advance, there is always an opportunity to recover from a problematic implementation. 

If you have already deployed your pathways program but did not initially pay sufficient attention to these factors, your experience may show lower utilization rates and on-pathway performance than you had expected. Although it is hard to retrospectively include some of the items referenced above, you may benefit by at least increasing your focus on improving clinician engagement. Future articles in this series will provide more specifics in this area, but concentrating on identifying, articulating, and reinforcing the importance of pathways in achieving your organization’s strategies to your clinicians is a great place to start. 

Involve clinical and administrative leadership in establishing clear expectations about pathways usage, and communicate—frequently, clearly, and unambiguously—what those expectations are. Although it is more challenging to create a culture that values pathway usage after the fact, it is possible. However, it requires a true demonstration of the organization’s commitment to and belief in the benefits of pathways. 

References

1. Daly B, Zon RT, Page RD, et al. Oncology clinical pathways: charting the landscape of pathway providers. J Oncol Pract. 2018;14(3):e194-e200. doi:10.1200/JOP.17.00033 

2. Kuntz G. First things first: deciding why your practice is implementing pathways.
J Clin Pathways. 2019;5(2):35-37. doi:10.25270/jcp.2019.03.00064

3. Denning S. How do you change an organizational culture? Forbes. July 23, 2011. https://www.forbes.com/sites/stevedenning/2011/07/23/how-do-you-change-an-organizational-culture/#3265e6739dc5. Accessed May 1, 2019.