Unveiling the Steps of Cancer Patient Pathways: On managing coordination in complex health care processes

Abstract

Developments in cancer care are characterized by functional and organizational fragmentation resulting in complex structures and processes that still are closely interdependent. We rely on demanding processes of coordination to connect the mutually dependent steps - interacting in time, in space, and across organizational borders between linked specialists and entities and between several organizational levels - involving politics, administration, professionals, and patients. The main objective of this thesis is to expand our understanding of this coordination by answering the questions: How can we explain the coordination of politics and of practice related to cancer pathways?

The project consisted of two qualitative comparative case studies. One study includes the national decision and implementation processes of a similar reform in three Scandinavian countries investigating into coordination processes aiming to integrate policy goals with actual professional and administrative behavior. Another study explore the coordinating mechanism in the actual practicing of cancer patient pathways by studying this in three diagnoses and four hospitals. The analysis build on knowledge, concepts and models from the disciplines of sociology, political science and health care research.

The thesis concludes that coordination in this kind of complex implementation process and complex organizational context depends on managing the alignment of the legitimate institutional logics present – the medical logic, the economic-administrative logic and the patient related logic. This has an impact on managing the structuring organizational contexts of the pathways through different rules of conduct (direct control, negotiation, consensus processes, and consultation). When the processes of coordination in these cases seem to work, they are characterized by a certain mixture and iterative interaction between standardization and improvisation. This should be performed based on the recognition of that one size does not fit all—whether it is patients, diagnoses, pathways, hospitals, or health care systems.