Policies Make Coherent Care Pathways a Personal Responsibility for Clinicians: A Discourse Analysis of Policy Documents about Coordinators in Hospitals

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Abstract
In response to increase of patients with complex conditions, policies prescribe measures for improving continuity of care. This study investigates policies introducing coordinator roles in Norwegian hospitals that have proven challenging to implement. This qualitative study of policy documents employed a discourse analysis inspired by Carol Bacchi's 'What's the problem represented to be?'. We analysed six legal documents (2011-2016) and selected parts of four whitepapers presenting the statutory patient care coordinator and contact physician roles in hospitals. The 'problem' represented in the policies is lack of coherent pathways and lack of stable responsible professionals. Extended personal responsibility for clinical personnel as coordinators is the prescribed solution. Their duties are described in terms of ideals for coherent pathways across conditions and contexts. System measures to support and orchestrate the individual patient's pathway (e.g. resources, infrastructure) are scarcely addressed. We suggest that the policies' construction of the 'problem' as a responsibility issue, result in that neither diversity of patients' coordination needs, nor heterogeneity of hospital contexts regarding necessary system support for coordinators, is set on the agenda. Adoption of rhetoric from diagnosis-specific standardized pathways obscures unique challenges in creating coherent pathways for patients with complex needs.

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