title: The effectiveness of quality improvement tools: joint working in integrated community teams.
abstract: OBJECTIVE
  To explore the effectiveness of integrated care pathways in facilitating integration in community-based teams.
  
  
  METHODS
  Case comparison of models of integrated care pathways in two different settings: community mental health teams in one Scottish region and care of the elderly rapid response teams in three Scottish regions. In both settings, an integrated care pathway was used as a tool for integration, but in different ways. Comparison is made by first identifying key factors structuring team-work in both settings, then analysing how the constellation of these factors results in different dynamics of team-work in each setting. The pathway tool used in each setting is then outlined and an analysis presented of how the tool interacts with the organizational dynamics in and around the teams to produce observed outcomes in each setting.
  
  
  RESULTS
  In both settings impact of tool was shaped by the same organizational dynamics which produced the nature of team-work. In neither setting was the tool optimally effective in improving integration. In community mental health teams a prescriptive, management-driven integrated care pathway was introduced. This presumed a degree of task sharing in teams which was absent. It was resisted by the teams. In rapid response teams a flexible, team-driven pathway tool was being introduced to help teams conceptualize and communicate about the service. This approach fitted with autonomy and task sharing in rapid response teams and uptake was good. However, management did not engage.
  
  
  CONCLUSIONS
  The effectiveness of the tool in both settings requires attention to organizational context.
authors.affiliation: University of Edinburgh, Division of Community Health Sciences/General Practice, Edinburgh, UK. guro.huby@ed.ac.uk
authors.forename: Guro
authors.initials: G
authors.lastname: Huby
authors.forename: Gwyneth
authors.initials: G
authors.lastname: Rees
mesh_terms: D000368:Aged; D003155:Community Mental Health Centers / Q000592:standards; D019091:Critical Pathways; D019033:Delivery of Health Care, Integrated / Q000592:standards*; D006299:Health Services for the Aged / Q000592:standards; D006801:Humans; D017146:Models, Organizational; D010043:Outcome and Process Assessment, Health Care; D010348:Patient Care Team / Q000592:standards*; D011785:Quality Assurance, Health Care / Q000379:methods* / Q000458:organization & administration; D011786:Quality Control; D012111:Residence Characteristics; D012606:Scotland; D016896:Treatment Outcome