For the third year running, throughout the Care Pathways 2008 conference organized by Healthcare Events, posters were displayed, and poster presenters were available to talk about their displays and answer questions. This formed a valuable and interesting part of the annual conference, giving ample opportunity for sharing and dissemination of best practice and ideas. Eight posters that were displayed are reproduced below along with summary reviews covering the projects’ main aims and objectives, methods, results and conclusions.

This paper describes the rationale and methodology for three exercises used to critically appraise the quality of the two main tools supporting implementation of the care pathway continuous improvement methodology. The Venture care pathway journey quality scorecard and the Venture care pathway paper-document quality scorecard builds a greater understanding of the value provided by different components of content and layout. In addition, the Venture paper care pathway document template provides a basic design guide for teams, based on 20 years of experience in developing, implementing and evaluating care pathway documents.

As clearly demonstrated in Dr Smith’s Letter to the Editor published in this issue of Journal of Integrated Care Pathways, just having a care pathway in existence, however well-designed, is not enough to ensure improved care to the patient. Over the past 20 years, I have seen innumerable examples of care pathways that appear well-designed from the perspectives of both content and layout, having little effect either way on the care delivered. On the other hand, I have also seen as many care pathways that by anyone’s standards appear poor, but that have been embraced by the local team and that have had a significant, measurable effect on the quality and efficiency of processes and the outcomes of care. This poses the question ‘does a care pathway have any real impact on improving care, and if so, what determines its effectiveness?’ Part of the answer lies in common sense. The most perfectly designed care pathway, if little understood and poorly used, can hardly be expected to make any difference to anything. On the other hand, a care pathway thoughtfully designed with the involvement of those whowill use it, that seeks to ease, coordinate and streamline the provision of the best possible care, and that provides relevant, regular and well-targeted feedback to inform and interest those same people, has far more chance of having an impact on process and outcomes. I have recently been contacted by a Publishing Director who is interested in the better understanding of what is ‘good practice’ when it comes to reviewing pathways. To date, a surprisingly little amount of effort or research has gone into this area. Some examples of pathway audit tools that consider issues such as the content and layout of care pathway tools and the mechanisms of organizing care include: the Clinical Path Assessment developed in the late-1990s by the Centre for Case Management (USA); the ‘badge of quality’; an integrated care pathways appraisal tool developed in 2002 by De Luc et al.; the Integrated Care Pathway Appraisal Tool (ICPAT) developed in 1999 by Wittle et al.; with the support of the Partnership for Developing Quality, West Midlands Regional Levy Board; the ICP Key Elements Checklist developed in 2004 by Croucher as part of a Masters thesis; and the Care Process Self Evaluation Tool (CPSET) developed between 2004 and 2007 by Vanhaecht as part of a thesis to obtain the degree of Doctor in Social Health Sciences. Venture Training & Consulting has developed and used two Care Pathway Quality Scorecards as an exercise over the past 10 years to help teams to ‘know a good care pathway when they see one’ and to decide what they want out of the care pathway that they plan to develop locally. However, none of these tools fully address the relationship between key characteristics of the care pathway and successful implementation. It is certainly possible to teach and to recognize quality content and good design of a care pathway. This supports a growing view that nationally developed and accredited, high-level care pathway maps/ algorithms and supporting care pathway documents, decision scorecards, guides, etc., that can be adapted and built upon for local use, are a valuable starting point. These high-level care pathways are in the most part uncontentious and can provide local teams with the information and confidence that they are implementing the nationally agreed key elements of evidence-based best practice. Guidelines, protocols and initiatives such as the UK Standards for Better Health and Care Bundles can be incorporated to inform evidence-based best practice. Variation can Jenny Gray MCSP SRP Grad Dip Phys, Managing Director, Venture Training & Consulting, Manor Farm Barns, Selsey Road, Donnington, Chichester, West Sussex PO20 7PL, UK.

Travelling around the country observing the approaches of different organizations and listening to people talk about their experiences of implementing change initiatives, one message becomes clear. Making the strategy a reality is a great challenge, one that is seldom perceived by the majority to have been achieved. Even in cases that boast impressive initial achievements, further down the line there is rarely evidence that the services continue to improve, and that the early motivation and drive for improvements have been sustained. Changes both in frontline staffing, management and leadership, as well as the unsettling pressures of organizational mergers and other cultural changes are often cited as reasons for this failure to sustain results. So what can we do in the future to embed the changes into everyday practice and behaviour and to prevent the fast start that fizzles?

A new era of health care characterized by the demand for systematic, demonstrable efficiency and effectiveness requires a fresh approach on how we manage our services. Our methodologies need to support the practical implementation of Lean Operations, seeking to scrutinize and minimize waste, at the same time motivating, driving and implementing tangible and measurable improvements in activities, outcomes and performance. We must turn our organizations' strategies into reality at the frontline, gaining buy-in to the new way of thinking, and adoption of the new ways of working. And we must prove our success by measuring the impact of change. The Venture Care Pathway Service Improvement Methodology, with a proven track record of success over the past 17 years, meets these new challenges using the continuous improvements care pathway approach. This paper seeks to provide a brief outline of some of the key activities involved in implementing this model successfully. The software applications used in this paper to illustrate the practical implementation of the model include Nimbus Pathway (Nimbus Partners' controlES, a process and performance management application), 1 Formic Pathway (Formic's Fusion, intelligent document recognition software for the capture of data and the transfer of data to systems) and Microsoft

Throughout the Integrated Care Pathways 2007 conference, organized by Healthcare Events, posters were displayed, and poster presenters were available to talk about their displays and answer questions. This formed a valuable and interesting part of the annual conference, giving ample opportunity for the sharing and dissemination of best practice and ideas. The previous issue of the Journal of Integrated Care Pathways featured 13 of the posters and the remaining three are reproduced below along with summary reviews covering the project’s main aims and objectives, methods, results and conclusions.

In supporting teams across the UK to develop care pathways, I have discovered that the promise of transparency and the opportunity for consistently measuring success strikes fear into the hearts of many. Frank discussions reveal that there is uncertainty about who will gain from transparency and how. What will professionals who have historically held the balance of power by keeping what they do shrouded in mystery, gain from sharing this information? What shifts and changes to services will managers and commissioners make based on their interpretation of this information? How will politicians, so skilled in manipulating information, use this new source of knowledge and insight? Knowing more or different things about the care of patients has always been a fundamental part of the games played by each party; how would these games change if everyone had all the information? If we honestly want a patient-centred health service, based on evidence, with services fit for purpose and equality of access, then why would we be afraid of transparency? A knowledge management framework based on transparency of the patient-centred end-to-end process of care (the business of health care) provides:

Everyone seems to be 'doing' service re-design and focusing on service improvement initiatives. In the UK, the Government's commitment to reduce the National Health Service (NHS) waiting list time to 18 weeks has been a powerful driver for adopting the Lean Operations approach that has been gaining popularity across the globe for some time now. This editorial explores the various popular theories and approaches to service improvement and efficiency, and seeks to understand the contribution that each could make in the field of health and social care.

What do service users, patients and carers think about the risks and experience of receiving health care in the UK National Health Service (NHS) today? Most people perceive that health care is a risky business. A UK National Audit Office report entitled A Sqfer Place for Patients: Learning to Improve Patient Safet/ noted that one in 10 patients experience some sort of safety incident when they go into hospital. The number of staff and patients seeking redress through litigation when things go wrong is on the increase. Not surprisingly, much of the UK Department of Health (DOH) guidance is focused on service re-design and service improvement. We know that simply working harder and more diligently will not improve safety and that the responsibility for safety cannot be delegated. Safety requires a culture shift, dedicated leadership and a change in behaviour. The same goes for service improvement in general. We will need to take a considered look at our organizations' systems, structures and functions, and at our people's activities, actions and behaviours. To change our behaviour, if we wish to avoid causing undue stress, we must want to change it, and to want to, we must understand why we need to behave differently.

People who have heart attacks come in all shapes, sizes and personality types. So it makes sense that they will want to exercise personal choice about how and where they receive rehabilitation and follow-up support. Some will feel more secure in a hospital-based patient group, while others would prefer the privacy and convenience of their own homes.

Time and time again local evaluations seek to explore why compliance with recording in 'care pathway (CP) documents' is an ongoing problem and why staff are still recording elsewhere in the notes; teams debate the legalities of record keeping and argue hotly about how much detail should be included in a CP document, and there is real, ongoing confusion about the 'CP variance tracking record'. Countless reviews of the literature seek to evaluate the efficacy and effectiveness of CPs, and yet, as was highlighted in the last issue of the Journal, like is not being compared with like. Documents labelled 'care pathways' vary in style from process maps and decision trees with their characteristic boxes and lines, and checklists that follow guidelines and protocols, to comprehensive structured documentation aimed at capturing the information related to all activities, detail and outcomes, including the comparison between planned and actual. Despite their name, which is misleading and somewhat unhelpful, CPs are not restricted to describing 'care'; nor are they used exclusively in health care or indeed for patients/service users. CPs are used for describing any process, which could include staff or resource pathways. Nowadays they are being given other names such as 'service pathways' or 'pathways' to reflect their wider use across health and social care. So what is the 'genuine care pathway'? Is it one thing? Perhaps one way forward would be to question what outcome is desired locally and then to work backwards to establish the most appropriate style and format for the CP, i.e. to decide what we want out of

Critical path and process-mapping methodology was used in industry, particularly in the field of engineering from as early as the 1950s. In the 1980s, clinicians in the USA began to develop the pathway tool within managed care; they were re-defining the delivery of care and attempting to identify measurable outcomes. They were focusing on the patient rather than the system, but needed to demonstrate efficient processes in order to fulfill the requirements of the insurance industry. In the early 1990s the National Health Service (NHS) in the UK funded a patient-focused initiative to support organizational change. This resulted in the investigation and development of concepts such as pathways. In 1990, a team from the UK visited the USA to investigate the use of these pathways, or ‘Anticipated Recovery Pathways’ as they were then called. As a result of this visit, 12 pilot sites for pathways were set up in Northwest London in 1991–92. The West Midlands Pathway Development work also got underway. By 1994, the Anticipated Recovery Pathway had evolved into the Integrated Care Pathway (ICP) in the UK. ICPs were clinician led and driven, and had patients and locally agreed, best practice at their heart. In response to demand for a coordinated UK ICP users group, the National Pathways User Group (later re-named the National Pathways Association [NPA]) was set up in 1994. A popular and well-supported group, it finally folded in 2002, a casualty of the time required by volunteers to lead the group and administer its running. In 2002, at about the same time that the NPA folded, the National Electronic Library for Health (NeLH) Pathways Database was launched to enable the free sharing of ICPs and ICP projects across the UK. Since 1991, ICPs have been developed and implemented across all health care settings in the UK (acute, community, primary, mental health, private, independent, NHS). ICPs are now used all around the world including Africa, Australia, Belgium, Canada, Denmark, Germany, Hong Kong, Italy, the Netherlands, New Zealand, the UK, and the USA. However, the UK has formalized the systematic development, implementation and use of care pathways by embedding them in national policy, identifying them as the vehicle for implementation, demonstration/monitoring and evaluation of all health and social care policies, strategies, initiatives and agendas at the frontline.

When I started thinking about the issue of adoption in relation to care pathways, I quickly realized that care pathways are somewhat unique. They themselves are a vehicle for the implementation and adoption of initiatives at the frontline, but there is also the question of adoption and uptake of care pathways as an initiative in their own right. This editorial therefore explores the subject of adoption in relation to getting results, followed by how care pathways contribute to the adoption of initiatives and lastly how the adoption of care pathways themselves might be addressed.

Heralded as one of the world's most ambitious IT projects ever undertaken in the public services, England's National Programme for IT (NPflT) has pathways and Integrated Care Pathways (ICPs) at its heart. With the programme now entering its imple­ mentation phase, it would be a good time for those within the ICP community of practice who have not yet got involved, to do so. This issue of the [ournal oj Integrated Care Pathways covers the full circle of electronic ICP (eICP) devel­ opment and delivery: considering the patient expe­ rience; exploring the evidence; electronic authoring of pathways and ICPs; ICP data capture from paper; implementation of the UK NPflT and NHS care record service solution over the next 10 years and beyond.