title: Patient assessment within the context of healthcare delivery packages: A comparative analysis.
abstract: BACKGROUND
  Due to an increased focus on productivity and cost-effectiveness, many countries across the world have implemented a variety of tools for standardizing diagnostics and treatment. In Denmark, healthcare delivery packages are increasingly used for assessment of patients. A package is a tool for creating coordination, continuity and efficient pathways; each step is pre-booked, and the package has a well-defined content within a predefined category of diseases. The aim of this study was to investigate how assessment processes took place within the context of healthcare delivery packages.
  
  
  METHODS
  The study used a constructivist Grounded Theory approach. Ethnographic fieldwork was carried out in three specialized units: a mental health unit and two multiple sclerosis clinics in Southern Denmark, which all used assessment packages. Several types of data were sampled through theoretical sampling. Participant observation was conducted for a total of 126h. Formal and informal interviews were conducted with 12 healthcare professionals and 13 patients. Furthermore, audio recordings were made of 9 final consultations between physicians and patients; 193min of recorded consultations all in all. Lastly, the medical records of 13 patients and written information about packages were collected. The comparative, abductive analysis focused on the process of assessment and the work made by all the actors involved. In this paper, we emphasized the work of healthcare professionals.
  
  
  RESULTS
  We constructed five interrelated categories: 1. "Standardized assessing", 2. "Flexibility", which has two sub-categories, 2.1. "Diagnostic options" and 2.2. "Time and organization", and, finally, 3. "Resisting the frames". The process of assessment required all participants to perform the predefined work in the specified way at the specified time. Multidisciplinary teamwork was essential for the success of the process. The local organization of the packages influenced the assessment process, most notably the pre-defined scope of relevant diseases targeted by the package. The inflexible frames of the assessment package could cause resistance among clinicians. Moreover, expert knowledge was an important factor for the efficiency of the process. Some types of organizational work processes resulted in many patients being assessed, but without being diagnosed with at package-relevant disease.
  
  
  CONCLUSIONS
  Limiting the grounds for using specialist knowledge in structured health care delivery may affect specialists' sense of professional autonomy and can result in professionals employing strategies to resist the frames of the packages. Finally, when organizing healthcare delivery packages, it seems important to consider how to make the optimal use of specialist knowledge.
authors: Research Unit of Mental Health, Odense, Institute of Regional Health Services, SDU & Neurological Research Unit, Sønderborg, Denmark. Electronic address: cbrossen@health.sdu.dk.
authors: Camilla Blach
authors: CB
authors: Rossen
authors: User Involvement, Institute of Public Health, University of Southern Denmark, J.B. Winsløws Vej 9B, 5000 Odense C, Denmark. Electronic address: nbuus@health.sdu.dk.
authors: Niels
authors: N
authors: Buus
authors: Institute of Regional Health Research, University of Southern Denmark & MS Clinic of Southern Jutland, Department of Neurology, Sønderborg Hospital, Denmark. Electronic address: egon.stenager@rsyd.dk.
authors: Egon
authors: E
authors: Stenager
authors: Research Unit of Mental Health, Odense, Denmark & Institute of Regional Health Research, University of Southern Denmark & Psychiatric Research Unit, Aabenraa, Denmark. Electronic address: elsebeth.stenager@rsyd.dk.
authors: Elsebeth
authors: E
authors: Stenager
mesh_terms: D003695:Delivery of Health Care / Q000379:methods*; D003718:Denmark; D006331:Heart Diseases / Q000628:therapy; D009103:Multiple Sclerosis; D009369:Neoplasms / Q000628:therapy; D009730:Nursing Assessment
keywords: Assessment packages; Care pathways; Coordinated care; Denmark; Grounded Theory; Healthcare delivery; Multiple sclerosis; Professional autonomy; Psychiatry; Reference standards