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Background Care pathways (CPs) offer a proven method of systematically improving patient care. CPs are particularly helpful in complex clinical conditions where variation in care is a problem such as patients undergoing major head and neck resection with free flap reconstruction. Although CPs have been used to manage this patient group, most CPs are implemented as part of relatively short-term quality improvement projects. This paper outlines a detailed methodology for designing and delivering a quality management program sustained for 9 years. Methods We describe a change management approach informed by Kotter’s “8 Step Process” that provided a useful framework to guide program development and implementation. We then provide a detailed, step by step description of how such a program can be implemented as well as a detailed summary of time and costs for design, implementation and sustainability phases. An approach to design and delivery of a measurement, audit and feedback system is also provided. Results We present a summary of resources needed to design and implement a head and neck surgery quality management program. The primary result of this study is a design for a sustainable quality management program that can be used to guide and improve care for patients undergoing major head and neck resection with free flap reconstruction. Conclusions A change management approach to design and delivery of a head and neck quality management program is practical and feasible.

Background Care pathways (CPs) are helpful in reducing unwanted variation in clinical care. Most studies of CPs show they improve clinical outcomes but there is little known about the long-term impact of CPs as part of a sustained quality management program. Head and neck (HN) surgery with free flap reconstruction is complex, time-consuming and expensive. Complications are common and therefore CPs applied to this patient population are the focus of this paper. In this paper we report outcomes from a 9 year experience designing and using CPs in the management of patients undergoing major head and neck resection with free flap reconstruction. Methods The Calgary quality management program and CP design is described the accompanying article. Data from CP managed patients undergoing major HN surgery were prospectively collected and compared to a baseline cohort of patients managed with standard care. Data were retrospectively analyzed and intergroup comparisons were made. Results Mobilization, decannulation time and hospital length of stay were significantly improved in pathway-managed patients (p = 0.001). Trend analysis showed sustained improvement in key performance indicators including complications. Return to the OR, primarily to assess a compromised flap, is increasing. Conclusions Care pathways when deployed as part of an ongoing quality management program are associated with improved clinical outcomes in this complex group of patients.

Stray cats trapped in various areas of Basseterre, the capital of St Kitts in the West Indies, were tested for infection with feline immunodeficiency virus (FIV) and feline leukemia virus (FeLV) using commercial kits. Of 99 (51 male and 48 female) cats trapped in 2006/7, 15% (12 males and three females) were positive for FIV while none were positive for FeLV. Of 72 (41 males and 31 females) cats trapped in 2009, 14% (nine males and one female) were positive for FIV while none were positive for FeLV. Polymerase chain reaction analysis revealed DNA of Bartonella species in whole blood collected from 60/95 (63%) cats trapped in 2006/7. Sequencing of the 16S–23S rRNA gene intergenic transcribed spacer (ITS) region of a convenience sample of nine amplicons and the 11 isolates made from 43 blood samples which were cultured using Bartonella alpha Proteobacteria (BAPGM) enrichment medium revealed B henselae (14) and B clarridgeiae (six).