Action research as a methodology for adaptive care pathway development in a dynamic organizational context

Background: Care pathway development (CPD) is a well-known strategy in value-based quality improvement. Developing care pathways (CP) in parallel in a coordinated programme requires flexibility. In this study, CPD was based on five quality improvement principles: collaborative improvement; stepwise, goal-oriented CPD; hybrid CPD; outcome monitoring; and shared ownership. This study had two aims: (1) understand how various teams develop CPs in parallel in a dynamic organizational context and (2) explore how action research (AR) can contribute to aligning CPD with the dynamic context.

Methods: A 2-year action research guided 11 multidisciplinary teams through a CPD programme, conducted in a Dutch specialized rehabilitation hospital with 16 sites. Reflexive data were collected from journal reports(N=169), conversations with team members and senior managers (N=44), research team meetings (N=25) and programme documents (N=149). Data were analysed in four iterative phases, combining elements of process and reflexive thematic analysis. Results: This study revealed six challenges that emerged when developing multiple care pathways in parallel, each exposing assumptions embedded in the programme design that were challenged in practice and led to successive programme refinements: (1) aligning teams’ progress, learning needs, and clinical scope with the programme structure; (2) balancing innovation with manageable change; (3) the organization’s limited readiness for hybrid care; (4) problems with outcome monitoring and reliance on expert support; (5) distributed leadership and capability development; and (6) the hybrid nature of the programme, combining design elements with learning and adaptation. Action research facilitated customization, enabling teams to progress in response to the dynamic context. Conclusions: This study shows that action research can support CPD by linking change, learning and scientific knowledge generation. By embedding reflection and adaptation into the CPD programme, action research helped balance structure with flexibility, strengthened shared ownership and integrated sustainability early in the process. The findings suggest that action research offers a feasible methodology for implementing and adapting CPD methods through phased, reflective and context-sensitive learning. Thus, action research bridges the gap between CPD methods and their practical application.