The patient journey, how important is it?


17th Sep 2012

For much of my career in public healthcare I have heard the mantra that “the patient should be at the centre of our work”. This desire for a patient-centric approach to everything we do makes complete sense. As healthcare professionals, or allied healthcare professionals, all of us should have three key goals:

1) to improve healthcare outcomes;
2) to improve the patient’s journey through the healthcare system; and
3) to enable, support, and engage in continuous improvement in healthcare to further enable the above.

It is not relevent whether you are a doc, nurse, administrator, manager, ambo, cleaner, accountant, planner, chief exec, cook, pharmacist, or surgeon. If you work in the public healthcare system, your success should be tied to how closeley you are able to align to these goals.

I have been criticised in the past for this statement, from accountants who feel that their key focus is “managing money” to public health officials who have lost sight of why public health is important. I reject the criticism, it is this simple folks, three objectives, in the order shown. Everything else that we do in a large public healthcare system, if we are doing the right thing, including providing IT support, and managing our resources wisely, should support these three objectives.

So why is it that so few of the professionals we encounter in our day to day work in healthcare seem unable to clearly make a connection between the patient experience of the healthcare system and their own behavior?

Examples abound, from the patient who visited one of the UK’s largest hospitals to have three vertebrae fused and was made to stand and wait, in pain, for around an hour while a bed was made for her; to the inpatients who, daily, have multiple blood samples taken because no one checked the computer system to see if they had already been tested; to the folk who contract hospital acquired infections or suffer as a result of lack-of or the wrong-kind-of care in our healthsystems.

So why is it so hard to get this right? Why is it so hard for healthcare staff who work with patients to put themselves in the patient’s shoes and work out how the experience could be improved?

I worked with a colleague once who felt strongly that everyone who worked in a hospital should experience a patient journey through that facility, the wait in the emergency department, investigations in laboratories and x-ray, the transfer to an inpatient ward, the operating theatre, recovery, discharge, the journey home and the followup care. But this is of course impractical and, as with any complex system every journey is different and each patient has their own needs and special concerns.

As I have travelled and visited many facilities around the world I think I have seen some of the best examples of care in terms of improving the patient journey. I will try to highlight some examples.

  • At one University of Pittsburgh Medical Centre (UPMC) hospital they have, outside the operating theatres, live television displays in the waiting room showing for relatives and friends of patients, the status of their loved-one’s procedure – pre-operative preparation, in theatre, in recovery, and so on. of course information is anonymised but the recipients receive a small card showing the patient number that they need to interpret the screens.
  • At the Freeman Hospital in Newcastle Upon Tyne in the UK nurses record their activity when they give medicines to patients. The event is timestamped and compliance with medication regimes can be monitored and tracked.
  • Patients in Wellington New Zealand can, via the internet, book their own appointment with a private doctor after reviewing the slots available in the doctor’s schedule themselves.
  • In the outpatients department at Surrey Memorial Hospital, near Vancouver in Canada, patients can self-register for their outpatient appointments. Updating incorrect information and noting their arrival. This helps to ensure more accurate information and shorter queues.
  • In Taranki Base Hospital in New Zealand, medicines are dispensed to nurses from a ward-based machine as and when they are needed by the patient. The medicine requested is checked against the patient’s medical record every time to minimise the chances of the wrong medicine going to the wrong patient.
  • In at least one dental surgery in Doha, Qatar, the dentists chairs have built in massagers to relax patients should they wish to use them, and televisions in the ceiling. Porcelain crowns and inserts can be manufactured, on-site, while you wait. Meaning only one local anaesthetic for a procedure and no return visit is necessary.
  • In Western Australia, waiting times in emergency departments are publicly available, on the Internet and updated in real-time for all public hospitals

Many of these things are becoming increasingly common and, indeed, might be considered “no brainers” when it comes to planning a patient-centered service. I am still bemused though at some of the following practices that still occur so regularly:

  • Patients left in fouled beds overnight because carers either don’t know or don’t care that the bed needs changing. No electronic monitoring of the situation.
  • Slips, trip and falls being a major cause of injury and even mortality in hospitals because frail patients left their beds without this being detected.
  • Paper medical records being used in healthcare facilities (with all the attendant issues associated with security, lost and missing files, lack of legibility and difficulty of access)
  • Duplicated patient information across departments and facilities within a single health care system resulting in files in one place not containing information from another, disjointed patient journeys and gerneral confusion.
  • Patients in hospitals pressing nurse-call buzzers for hours to try to get attention because response to the buzzers is neither monitored or managed
  • Lack of simple facilities such as television and wireless Internet in patient waiting rooms
  • Patients are discharged from hospital into the care of a hospice or other community care facility where information regarding their hospital and past medical history is not available to support their care. Hospice records are not available to the hospital in the event of a return visit.
  • Abnormal high incidence of elderly patients suffering kidney failure as a result of dehydration after orthopaedic surgery due to lack of proper post-operative care

I could go on but it is not valuable to labour the point.

While researching this blog entry I was not surprised to find many reports on the patient journey and its value in improving health care.  Perhaps typical of these reports is that of Sue Baron BSc., RN, from June 2009 Evaluating the patient journey approach to ensure health care is centred on patients in which she identifies the following recommendations that could have broader implications for practice as examples produced during the project:

  • Improved information systems are needed between primary and acute care to reduce the risk of patients falling through the net, for example in GP referrals, patient discharge and outpatient follow-up;
  • NHS uniforms should be standardised to enable everyone to readily identify staff;
  • A centralised patient record should be introduced – one place for interprofessional documentation to reduce risks to patients from misinformation or lack of information. This would also reduce duplication and time wasted searching for information;
  • NHS management should have a higher profile through talking to staff and patients – for example with ‘walkabouts’;
  • Greater recognition should be given to the value of the patient’s voice.

I could feel my blood pressure rise as I read this, it all so obvious, all so much “more of the same”. The solutions seem so easy and yet, at the same time are so often NOT put into practice.

Perhaps what is needed is reasearch into why, when we know the answers, our healthcare systems are unable to  effectively respond and, in doing so, to meet our needs.

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