Implementering av pakkeforløp for kreft: Nasjonal plan for implementering av pakkeforløp for kreft 2014-2015

Objectives

Norway’s cancer pathway programme supports the national cancer strategy ambition to become a leading country for high-quality cancer care. It seeks to establish standardised, evidence-based and professionally normative pathways that improve quality, continuity and coordination, reduce unnecessary waiting and enable rapid diagnosis and treatment without medically unjustified delay.[1][2]The pathways are intended to cover the patient journey from referral to specialist services, diagnostic assessment, treatment, follow-up and monitoring, while supporting patient information and participation in care decisions.[2][3]

• Implement 29 national cancer pathways and associated diagnostic guides for general practitioners, developed by 21 working groups and informed by the Danish pathway model.[1][2]
• Introduce the first pathways for colorectal, breast, prostate and lung cancer on 1 January 2015, then introduce the remaining pathways and guides during 2015.[4][5][6]
• Apply differentiated recommended times for each cancer type and organise care to avoid clinically unjustified waiting, improve investigation times and strengthen continuity.[2][7]
• Embed pathway and diagnostic-guide use in everyday practice among regional health authorities, health trusts, hospital managers, health professionals, general practitioners and relevant municipal health and care personnel.[8][9]
• Strengthen multidisciplinary assessment, ensuring access to the required expertise for cancer-treatment decisions and using videoconferencing or referral where expertise is unavailable locally.[10]
• Address diagnostic and treatment bottlenecks, including constraints in radiology, pathology, endoscopy, surgery, intensive care and specialist availability, while improving capacity use across hospitals and regions.[11][12]
• Further develop national cancer action programmes to promote good and equitable treatment, appropriate allocation of tasks and more targeted resource use, including recommendations on imaging, general-practitioner roles, follow-up and responsibilities between primary and hospital care.[13][12]
• Maintain national standards through annual review of cancer action programmes and alignment of diagnosis-specific pathway updates with relevant action-programme revisions.[14]

Implementation

Implementation is coordinated nationally by the Norwegian Directorate of Health and delivered progressively through the four regional health authorities, health trusts, hospitals, general practitioners, municipal services and relevant private providers.[2][15][16]The Directorate of Health is responsible for national measures, whereas regional health authorities and health trusts are responsible for regional and local implementation, capacity, organisational arrangements and operational delivery.[2][17]Implementation relies on leadership, clear responsibilities, pathway coordination, multidisciplinary working, communication, training, coding and continuous use of monitoring information for improvement.[11][9]

• Govern implementation through a national implementation group comprising the Directorate of Health, four regional health authorities and the Norwegian Medical Association, including general-practice representation; use regional representatives as links to regional leadership.[17][9][18]
• Prepare regional implementation plans and encourage health-trust plans that define pathway responsibilities, contact persons, coordinator roles, cross-specialty arrangements, reserved appointment capacity, monitoring and responsibility for analysis.[19][20]
• Establish pathway-coordinator teams in hospitals that investigate or treat cancer, with authority to arrange examinations and appointments across departments, support patient flow and provide a clear daytime contact point for patients, relatives and referrers.[21][22]The national planning estimate is approximately 100 coordinators, or two per 100,000 inhabitants, with regional assessment of local staffing needs.[21]
• Appoint a pathway-responsible doctor for each cancer pathway in each hospital and convene regular meetings with relevant departmental leaders, including pathology and radiology, to resolve organisational issues and review monitoring data.[7]
• Secure sufficient diagnostic and treatment capacity, assess whether local services can meet recommended pathway times, and respond to bottlenecks through task sharing, revised working arrangements, equipment renewal, redistribution of functions and improved use of existing capacity.[15][10][12]
• Use private providers where agreed pathway specifications are maintained, and strengthen communication, shared examination protocols and multidisciplinary collaboration between public hospitals and private specialists to reduce duplication and delay.[16]
• Engage general practitioners and municipal personnel through a general-practitioner reference and advisory group, digital access to pathways and guides, direct distribution of diagnostic guides, regional information meetings, professional conferences and communication through relevant professional and patient organisations.[18][23]
• Provide digital publication of pathways, diagnostic guides and local coordinator contacts through Directorate, regional and hospital websites, supported by national communication and media planning.[5][13][23]
• Implement multidisciplinary team arrangements with defined membership, meeting frequency, preparation, decision records and follow-through, supported where relevant by common protocols, telepathology and teleradiology.[20][10]
• Register five pathway milestones: referral received, first specialist-service attendance, biopsy, clinical decision and treatment start.[24]Require monthly reporting of pathway codes to the Norwegian Patient Registry, including from participating private providers, and publish monitoring information through the Directorate of Health and Helsenorge websites.[24][25][14]
• Train coding personnel, establish local coding procedures and quality control, use available patient-administration-system functions and coding guides, and feed registry data back to health trusts for quality improvement.[24][26][25]
• Review and update pathways through professional update groups with representation from all four regional health authorities, including a dedicated update group for pathways concerning metastases of unknown primary origin and diagnosis.[14]

Monitoring & Evaluation

Cancer care pathway monitoring combines mandatory coding of defined patient-pathway milestones with registry reporting, public publication and use of results for management and quality improvement. The framework assigns implementation, coding and follow-up responsibilities to the Norwegian Directorate of Health, regional health authorities, health trusts, hospitals and participating private providers.[6][24][25]

• Monitor pathway performance against calendar-day targets at five points: pathway start or referral receipt, first specialist assessment, biopsy, clinical decision and treatment start.[24]
• Register pathway codes alongside routine patient and treatment information, using existing Patient Administrative System and DIPS functions because major system changes can take one to two years.[24]
• Require monthly submission of pathway-code data to the Norwegian Patient Registry from participating providers, including private providers, as a condition of participation in the pathways.[24]
• Adapt data extracts and Norwegian Patient Registry messaging for reporting, and extend registration capability to private hospitals and contracted specialists using an estimated 10 to 15 different systems.[26]
• Test technical solutions in at least one health trust using each supplier, including St Olavs Hospital and Sykehuset Vestfold, before national implementation of the first four pathways on 1 January 2015.[26]
• Train coding personnel, require health trusts to identify responsible coders, establish fixed registration routines and apply quality control to pathway coding.[20][6][22][25]
• Assign each health trust responsibility for determining who registers pathway codes and for documenting coding procedures, while pathway coordinators have a specific role in ensuring that coding is completed accurately.[6][22]
• Use registry data to provide feedback to health trusts, although the format and content of feedback were still to be clarified.[25]
• Update Norwegian Patient Registry data daily for DIPS customers from 1 April 2015; updates for Patient Administrative System users and potentially other systems may take longer.[25]
• Publish monitoring information and quality indicators through the Norwegian Directorate of Health website and Helsenorge, including distribution through an application programming interface to other services.[5][25][14]
• Use monitoring results systematically in health-trust improvement work and in meetings between pathway-responsible doctors and departmental leaders, particularly to identify bottlenecks and review pathway organisation.[8][7]
• Require regional and local implementation plans to explain how monitoring will support learning and quality improvement, including who is responsible for analysis.[20]
• Maintain and update pathways through annual review of national cancer action programmes, update groups involving all four regional health authorities, and notification of required pathway changes by professional communities and other stakeholders.[14]
• Support implementation oversight through a national implementation group, led and organised by the Norwegian Directorate of Health, involving regional health authorities and general-practice representatives.[15][17][9]
• Maintain accountability through active management follow-up of implementation plans, reporting lines and objectives at all levels rather than leaving delivery solely to local department managers.[6]
• Draw on Danish experience in which mandatory registration of defined measurement points was introduced from late 2012 after earlier regional reporting generated poor-quality data; quarterly published results were discussed by a task force, and regions reported improvement measures to the Danish Health Authority.[11]

The material identifies pathway-time measurement, coding, reporting, publication, feedback, quality control and management responsibility, but does not provide a complete numerical indicator set, target values for individual cancer pathways, a standard evaluation design, formal sanctions or comprehensive reporting schedules beyond monthly registry reporting and the stated daily-update plan.[6][24][25]

Costing & Financing

No Norwegian monetary budget, cost estimate, financing model, funding allocation, funding gap or economic assumption is specified for cancer pathway implementation, monitoring or related information activities.[15][27][28][24]

• Assess the economic and administrative consequences of introducing cancer care pathways.[5]
• Secure diagnostic and treatment capacity, pathway-coordinator functions, organisational arrangements and management structures as resource-related prerequisites for implementation.[15][6]
• Allocate resources for a regional implementation project leader where a regional project structure is used, without stating an amount or funding source.[7]
• Plan approximately 100 pathway coordinators nationally, equivalent to two per 100,000 inhabitants, while allowing regional health authorities to assess local staffing needs.[21]
• Address capacity pressures through equipment renewal, task sharing, revised working arrangements, local agreements for key staff, redistribution of functions and improved use of existing capacity.[12]
• Consider use of private providers for parts of pathways, subject to agreements that preserve pathway requirements and coordination with public hospitals.[16]
• Provide Danish regions with additional resources through the national budget and internal regional prioritisation, although no amounts or detailed costed plan are given.[29]
• Allocate Danish implementation resources to equipment and premises, followed by personnel, while evaluation findings emphasised willingness to provide necessary resources.[11][30]
• Offer planned one-day information meetings or courses for general practitioners without a course fee, with no further financing details supplied.[23]

Resource requirements are therefore described principally as staffing, capacity, equipment, technical-system adaptation and organisational needs rather than as a costed financing plan.[30][21][12][26]