Patient Journey Mapping: What it is and Why it Matters

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How can healthcare organizations make every stage of the patient journey better?

How was your last experience in a healthcare facility? Think about every step of that patient care journey - the phone calls, in person meetings, wait times, communication and all of the healthcare professional/ patient interactions. It’s a lot.

Healthcare organizations are working diligently to improve patient satisfaction and quality of care by asking, “How can we make the patient experience better?” But that’s no mean feat, trying to capture the multitude of challenges patients face when navigating a healthcare journey. That makes improving it even more difficult.

A first, fundamental step to improving patient experience is understanding what that experience looks like today. This is where patient journey mapping comes into play. You can use patient journey maps to understand the highs and lows, pain points and gaps to begin pinpointing which interventions will be most impactful. Then you can assess which changes you have the power to make.

As a result, you’ll be better able to manage your patient’s journey, improve care pathways and meet—and exceed—patient expectations, needs, and wants.

What is Patient Journey Mapping?

Patient journey mapping works to identify and understand the details of all patient touchpoints within a specific healthcare experience. It helps you visualize the process patients go through to receive care, complete a treatment plan, and/or reach a desired outcome. When done correctly, patient journey maps make it easier for you to identify pain points, discover opportunities and re-align treatment and care approaches across the entire healthcare system.

What makes up a patient’s journey?

A patient’s journey represents the entire sequence of events or touchpoints that a patient experiences within a given health system, with a specific provider, or within a specific facility. These touchpoints are either virtual or in-person. They range from the mundane to the nerve-wracking or life-changing. They comprise events from scheduling an appointment online to reviewing post-surgery instructions with a doctor.

It’s key for healthcare professionals and clinicians to recognize the patient journey extends well beyond the most obvious in-person interactions at a treatment facility. The patient journey happens before, during and after a healthcare service: pre-visit, during-visit, and post-visit. These include but are not limited to:

  • Finding the right service or practitioner
  • Scheduling an appointment
  • Submitting a list of current medications
  • Arriving at the medical facility
  • Identifying where to check-in.

These experiences can instil a sense of reassurance or unease before a patient even receives care. In essence, they set the tone and expectations for the physical visit. A frustrating or confusing experience during the pre-visit stage will impact the emotional state of the patient and family for the rest of their interactions.

During-visit

  • Checking in at the front desk
  • Waiting in the lobby to be called
  • Discussion with nurses before speaking to a doctor
  • Family waiting for updates in the lobby during a procedure
  • Care from doctor and staff.

There are an infinite number of touchpoints during the delivery of healthcare. Each one will have a different level of impact on the patient’s experience.

  • Post-care instructions at hospital
  • Hospital discharge process
  • Completing a patient feedback survey
  • Paying for the medical treatment
  • Post-surgery calls or online messages from the nurse or doctor.

The patient experience after a hospital visit plays a vital role in either reinforcing a positive experience or mitigating a negative one. Actions such as post-appointment follow-ups extend the care relationship and may help the likelihood of the patient sticking to the treatment plan

All these individual touchpoints are crucial to understand. Altogether, these positive and negative experiences — no matter how big or small — comprise the patient journey.

Who are the stakeholders?

The healthcare ecosystem is complex, involving multiple stakeholders and a wide range of internal and external factors, including:

  • People (patients, their families and caregivers, doctors, nurses, administration, parking attendants, volunteers)
  • Technology and systems (online registration, parking tickets, surgery updates, mobile app, website, social media)
  • Facilities (hospital campus navigation, parking availability, building accessibility).

Investigation of all players and systems involved is essential to seeing the multidimensional layers impacting the experience. To do this, patient journey maps should include the perspectives of patients, providers, and staff - and those perspectives must be of the same journey. Often, an interaction that occurs from one point of view will show only one reality. However, further investigation will show the many contributing factors across the care delivery process. This is only apparent by examining multiple perspectives.

Once you understand the entire journey, with pain points, you’ll be able to identify patterns across patient personas and different demographics, and any gaps within the healthcare process. You can then begin asking important questions like:

  • Which moments are most painful?
  • Why do they happen?
  • What must we change in order to improve the experience?
  • Who must we impact?
  • Which do we have the power to change?

Benefits of patient journey mapping

Patient journey mapping provides the opportunity to turn the healthcare experience from a primarily reactive experience to a proactive one. By building out care journeys for your patients, you can close any gaps in provision and establish robust preventative routines that ultimately help your patients stay healthier for as long as possible. Engaging consumers and patients based on where they are and what they want, builds trust and confidence. That retains patients in your system and encourages them to make friends and family referrals.

But how does the process work?

  • Streamline patient processes and workflows: upgrading the usability and functionality of online patient portals, websites and mobile apps can put more control in the patients’ hands, increasing patient flow and cutting operational expenses.
  • Increase staff efficiency : enhancing internal online tools and creating automation within systems can assist hospital staff in implementing protocols and schedules and help them anticipate and solve problems more easily. It can help to align the expected service delivery with the actual one.
  • Clear routes and direction across medical facilities: hospitals can be incredibly complicated to navigate - whether it’s using the right entrance, finding parking or making your way to the cafeteria for a snack. Improving signage, making visible pathways, and using landmarks to help orient users can help patients and families readily access the resources they need.
  • Improve communication between patients and providers: exchanging patient information and coordinating care can be a challenge for providers and a frustration for patients. This misalignment can be due to silos within organizations, incompatible technology systems or many other factors. Working to bridge the appropriate organizational or technological gap can help alleviate stress and anxiety.
  • Develop seamless and timely patient and family updates: waiting while a family member is in surgery or communicating with a doctor to secure care for a child is typically an extremely stressful process. Families wait anxiously for updates which can be infrequent and lacking detail. Implementing a seamless system for families to communicate directly and receive regular updates, through an app or text, can help ease these pain points.
  • Better ‘in-between visit’ care and check-ins with patients and families: communication between patients, including families and caregivers and providers can feel ‘hit or miss.’ Patients may be scrambling to answer phone calls or missing phone calls only to find themselves unable to get hold of the provider when they call back. Alternatively, providers are challenged to communicate critical information to a wide range of patients. Establishing better communication systems can improve patient engagement, build the patient’s confidence in the care they receive, and ease the care provider’s job.

In short, we’re talking happier patients who experience better communication and levels of empathy at every stage of the patient journey.

What tools and methods are used for creating a patient journey map in healthcare?

There are many ways to undertake patient journey mapping, but doing it well isn’t always as simple as it may seem. It’s not a single exercise, moving from A to B. It’s more complex, involving a series of tools.

Our team at Highland has helped a lot of our clients create their first journey map . Grab a bunch of sticky notes and pens to start your map. Our process tends to go like this:

  • Chart the course -work out what you want to achieve (your goal); determine whose journey you’re mapping, the start and end points; create the persona(s); think about what the stages of the journey may be.
  • Prepare to interview - list your potential questions being mindful that you want the interviewee to recount events rather than share opinions. Schedule interviews with a tool like Calendly. Look into other available data (such as patient feedback).
  • Interviews and coding - we interview in pairs so that one can speak whilst the other takes notes. With permission, record the interviews. Afterwards, code the responses according to thoughts, actions, experience etc. We use a simple Google Sheet to do this.
  • Building blocks - go through the interviews and notes. Start mapping. Use a specific color of sticky note for each Building Block and add points to the wall in their themes.
  • Identify opportunities - “mine” the wall for opportunities, presenting ideas to the team. Together, prioritise the top three or four to tackle.

Repeat this whole process with another persona or goal to examine.

Explore this journey mapping process in more detail

The outcome of this process should be that healthcare professionals can look after patients better. Using patient data collection to underpin your decision-making can transform your organization’s culture to one of continuous improvement. By referring constantly to patient data, you can identify the key areas to amend and improve to better the patient experience. Satisfied customers, those who’ve experienced a near seamless patient journey, will rate your facility highly and they’ll be more likely to generate new referrals.

Improve your customer experience with Highland Solutions’ help

You may know your healthcare facility like the back of your hand, but you only know it from your informed perspective. Getting a 360º view of the patient experience is the first step to improving it. A huge challenge for healthcare leaders like you is to recognize, understand and address the fact that the overall experience is created by the cumulative interactions across the various touchpoints in the healthcare journey: pre-visit, during-visit, and post-visit.

Despite years of expertise, it’s easy for healthcare providers and leaders to develop blind spots for persistent issues in the care process. Partnering with a knowledgeable research team to conduct patient journey mapping will bring expertise and a fresh perspective to your quality of care. It’s not only about uncovering in-depth insights via patient journey maps, but also translating them into actionable strategies to help you bridge any gaps between current and emerging patient needs and the present state of your healthcare organization.

Once on the right track, you’ll be enabled to manage and grow relationships at every stage of the patient journey. The more patient-centric you become, the better experience you build, reaching a higher quality of patient care, patient retention and loyalty, and improved health outcomes and overall well-being.

Get in touch to find out more about how we can help you with patient journey mapping

“Working with Highland is a really powerful experience for a company to be able to gain insights. To have real conversations with patients unlocks new pathways, ones that may be uncomfortable and uncover change, but they empower you to move forward in a way that feels really constructive.”

Chris Whitworth, Vice President, Treatment

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Your complete guide to patient journey mapping.

15 min read Healthcare organizations can increase patient retention and improve patient satisfaction with patient journey mapping. Discover how to create a patient journey map and how you can use it to improve your organization’s bottom line.

What is the patient journey?

The patient journey is the sequence of events that begins when a patient first develops a need for care. Rather than focusing on service delivery, the patient journey encompasses all touchpoints of a patient’s healthcare experience–from locating healthcare providers and scheduling appointments, to paying the bill and continuing their care after treatment.

Examining the patient journey is essential to improving the patient experience. Not all interactions a patient has with your organization are weighted the same. Gathering patient feedback and understanding perceptions all along the patient journey can help you to identify moments of truth : the touchpoints that have the biggest impact on patient loyalty.

Download eBook: The 3 steps to driving human-centered healthcare experiences

The patient journey vs. the patient experience

Unlike traditional patient experience measurement, the patient journey looks not only at service delivery but also at the steps the patient takes before and after they engage directly with your organization. It recognizes that patient interactions with a healthcare system go well beyond the walls of the medical facility itself.

What are the stages of the patient journey?

There are several stages along the patient journey. When gathering patient feedback, you should make sure to capture insights at each of these stages.

The visual stages of patient journey mapping

Stage 1: Awareness

The patient journey starts with awareness. In this stage, the patient identifies a need for care and begins searching for care providers. Examples of how patients learn about healthcare providers include online searches, review sites, marketing campaigns, networking, and community involvement.

Stage 2: Consideration

In the consideration stage, the patient weighs their options to determine if your health system can meet their needs. Factors patients consider include referrals, coverage and benefits, recommendations, access, and ratings and reviews. Often in this stage, patients interact with your website or social media pages or contact you via phone or email during this stage.

Stage 3: Access

The access stage is where the patient decides to schedule services with your healthcare organization. Direct patient engagement with your organization increases during this stage. You’ll engage with patients in a variety of ways including phone calls, the patient portal, text messages, and emails as part of the scheduling and new patient acquisition process.

Stage 4: Service delivery

The service delivery stage relates to the clinical care provided to your patients. Encompassed in this stage are the clinical visit itself, check-in and check-out, admission and discharge, and billing. Traditional patient satisfaction measurement centers around this stage of the patient journey.

Stage 5: Ongoing care

The ongoing care stage of the patient journey involves patient engagement that occurs after the interactions directly related to service delivery. In addition to wellness and care management, this stage may address social determinants of health and population health.

What is a patient journey map?

The best way to utilize the patient journey to enhance patient experiences is by journey mapping. A patient journey map is a visual tool that illustrates the relationship a patient has with a healthcare organization over time.

Patient journey mapping helps stakeholders to assess the patient experience from multiple perspectives. Journey maps provide a way to visualize the internal and external factors affecting patient flow and the different paths patients must take in order to reach their care goals.

What are the benefits of patient journey mapping?

Patient journey mapping can help you to visualize all of the steps patients take throughout the entire process of seeking, receiving, and continuing care. Creating a patient journey map is useful to identify pain points and gaps in care. Mapping the patient journey makes it easier to develop solutions that make a more seamless experience within your healthcare system.

Patient journey mapping benefits include:

  • Creating shared ownership of the patient experience
  • Refining your patient listening strategy
  • Aligning your organization with a common view of the patient experience
  • Measuring gaps between the intended experience for your patients versus the actual experience
  • Identifying and resolving common pain points for your patients

Four types of patient journey maps

When creating a patient journey map, there are four types to consider. Each type of map has an intended purpose. You might start your patient journey mapping with only one type and incorporate the others as your efforts progress.

Current state

A current state journey map tells the story of what patients do, think, and feel as they interact with your organization today. This type of patient journey map is ideally created using patient data and observational data.

The current state journey map is best for driving incremental improvements to enhance the patient experience.

Patient journey mapping flow

Future state

A future state patient journey map tells the story of what you want your patients to do, think, and feel as they interact with your organization in the future. This type of map should capture the ideal journey you’d like to see for your patients.

The future state journey map is an effective tool to drive strategy, align teams, and communicate your visions for new services, processes, and experiences.

Day in the life

A day in the life patient journey map illustrates what your patients do, think, and feel today, within a specific area of focus. Patient personas are particularly useful when creating day in the life maps; these are discussed in greater detail below.

This type of patient journey map is intended to capture what your patients experience both inside and outside of the healthcare system. Day in the life maps are valuable to address unmet needs and determine how and when you can better engage your patients.

Service blueprint

A service blueprint is a simplified diagram of a current state or future state patient journey map. In the service blueprint, you add layers to illustrate the systems of people, processes, policies, and technologies surrounding each patient touchpoint.

For current state patient journey maps, the service blueprint can help to identify root causes of pain points. For future state, the service blueprint is helpful to visualize the systems or processes that can be put in place to support the intended patient experience.

Patient journey mapping image2

How do you create a patient journey map?

Now that you know about the different types of patient journey maps and their roles in driving patient experience improvement, how do you get started on creating your own?

The most useful maps are those which can expound upon each touchpoint of the healthcare journey with operational data, such as patient demographics, as well as real patient insights and perspectives. Using a platform that can capture this data will aid significantly in your patient journey mapping process.

Patient journey mapping: getting started

Before you get started, it’s a good idea to engage individuals across all departments and include input from multiple stakeholders. Once you’re ready, follow these steps to begin creating an effective patient journey map.

Identify your target audience

What type of patient journey will you be mapping? There may be varying patient journeys within your organization; for instance, an oncology patient’s journey will look very different from that of an expectant mother. The journey of a patient with health insurance will differ from that of a patient without insurance. To map the patient journey, you’ll want to create robust patient profiles you can use to segment and track like-populations throughout the healthcare experience.

Establishing patient personas and segments

Not every patient will have the same healthcare goals. Creating patient personas based on behaviors and preferences is a good way to differentiate the needs and more clearly understand the perspectives of the unique populations you serve.

The ideal patient persona will include the following information.

  • Demographic information such as age group, gender, or location
  • Healthcare-specific goals, conditions, and treatments
  • Healthcare-specific challenges/pain points
  • Engagement patterns and expressed feedback
  • How your services fit into their life
  • Barriers to care

Specify a goal for the patient’s journey

The patient personas you create will all have unique goals within the care journey. The patient has a specific goal in mind when they initiate contact with your organization, whether it is treatment of symptoms, a diagnosis for chronic issues, or surgery.

Every interaction along the patient journey influences how successful the patient feels about achieving this goal. When mapping the patient journey, you’ll want to consider how the various touchpoints affect the patient’s ability to meet this goal.

Identify the patient’s steps to accomplish their target goal

This step is about how the patient views their care journey within your health system–not about the actual processes and systems your organization has in place. Effective patient journey mapping requires you to see how the patient navigates the journey through their point of view.

Omni-channel listening is a valuable strategy in this step of journey mapping. Listening to your patients across all the channels can provide a clearer picture of their perceptions and behaviors as they engage with your organization.

Some steps the patient takes may not even include your organization, but might still affect how they are interacting with you directly. For example, if a patient logs into their health insurance portal to check coverage for healthcare services, they are not engaging with your organization but this is still a part of their care journey that may feed into their interactions with your organization later on.

Uncover perceptions along the journey

Gather patient feedback along the touchpoints of the care journey to identify key emotional moments that may disproportionately shape attitudes. These insights shed light on what’s working and what’s not; they can also be used to highlight the moments of truth that contribute to patient loyalty.

Patient perceptions are an important piece of patient journey mapping; it will be difficult to drive action without them.

Additional tips for creating the ideal patient journey map

Patient journey mapping is a continuous process. Creating the map is the first step, but the true value is dependent upon maintaining the map as you continue to gather insights and refine processes.

This leads to the second tip: be ready to take action! You can use a patient journey map to draw conclusions about your patients’ experiences within your organization, but awareness alone will yield no benefits. The journey map is a valuable tool to be used in your wider improvement efforts.

How do you drive action using a patient journey map?

Once your patient journey mapping is complete, it’s time to put it to good use. Here are five ways patient journey maps can be used to drive action.

Identify and fix problems

The visual layout of a journey map makes it ideal to identify gaps and potential pain points in your patient journeys. This will give you a better understanding of what’s working and what’s not. It will also help you to visualize where and how improvements can be made.

Build a patient mindset

Patient journey mapping enables you to incorporate more patient-centric thinking into your processes and systems. Use your map to challenge internal ideas of what patients want or need. Invite stakeholders to navigate the touchpoints along the healthcare journey to gain perspective.

Uncover unmet patient needs

By mapping the patient journey, you can build stronger patient relationships by listening across all channels to determine where experiences are falling short or where unmet needs emerge. This enables you to look for opportunities to expand alternatives, streamline initiatives, and create new, engaging ways for your patients to share feedback.

Create strategic alignment

Utilize your patient journey map to prioritize projects or improvement efforts. It can also help you to better engage interdepartmental staff to better understand policies and work together toward patient experience goals.

Refine measurement

Patient journey mapping is a great resource to use when defining patient satisfaction metrics and identifying gaps in how you currently gather insights.

How does patient journey mapping increase your bottom line?

Patient journey mapping can increase your bottom line by laying the foundation for improved patient satisfaction and higher retention.

Organizations across all industries are looking to understand customer journeys in order to attract and retain customers by gaining deeper insights into what drives the consumer experience.

As healthcare becomes more consumer-driven, health systems must similarly map the patient journey to improve the patient experience and boost retention. The cost of patient acquisition, combined with the fact that patients are willing to shop around for the best healthcare experience, means success depends on creating the most seamless patient journey possible.

The tools for success

For the most impactful patient journey mapping experience, you’ll want the ability to link your operational and experience data to your journey map’s touchpoints. Insights about what has happened at each touchpoint, as well as why it is happening, empower you to create experiences that meet patient expectations and drive up satisfaction.

Here are some best practice considerations as you develop your patient journey mapping strategy:

  • Create a shared understanding throughout your health system of how your patients interact with your organization, and you’ll know the roles and responsibilities of your different teams
  • Design a unique patient journey based on multichannel, real-time feedback from the patient
  • Consider the frequency with which topics emerge in feedback, as well as the emotional intensity behind them to zero in on what improvements can drive the greatest impact
  • Develop empathy and collaboration between teams, working together to achieve the same outcome
  • Drive a patient-centric culture by developing a shared sense of ownership of the patient experience
  • Connect your operational patient data with your patient experience feedback in one system
  • Leverage a closed-loop feedback system that triggers actions for immediate responses to patient concerns

Qualtrics’ XM Platform™ is designed to support all of these actions throughout the journey mapping process.

The 3 steps to driving human-centered healthcare experiences

Related resources

Patient feedback 15 min read, healthcare branding 13 min read, patient journey 10 min read, patient experience 12 min read, symptoms survey 10 min read, nurse satisfaction survey 11 min read, cahps surveys 6 min read, request demo.

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Patient journey 101: Definition, benefits, and strategies

Last updated

22 August 2023

Reviewed by

Melissa Udekwu, BSN., RN., LNC

Today’s patients are highly informed and empowered. They know they have choices in their healthcare, which can put healthcare providers under a lot of pressure to provide solutions and meet their patients’ expectations.

Just like any customer, patients embark on a journey that begins before they ever contact the provider. This makes understanding the journey and where improvements can be made extremely important. Mapping the patient journey can help practitioners provide better care, retain a solid customer base, and ultimately identify ways to improve patient health.

  • What is the patient journey?

The patient journey is best described as the sequence of experiences a patient has from admission to discharge. This includes all the touchpoints between the patient and provider from beginning to end.

The patient journey continues through consultation, where they meet the potential caregiver. That portion of the journey includes interactions with a doctor and support staff, how long they wait to be seen, and the steps taken for diagnosis and treatment.

The patient’s post-care journey includes follow-ups from the healthcare provider, post-treatment care, and billing. For example, if the patient has questions about post-surgery care or how to read their invoice, how quickly their questions are answered and their problems resolved will impact their satisfaction.

Mapping the patient journey helps healthcare providers improve patient satisfaction at every step of the way. By collecting data at each stage and conducting an in-depth analysis, providers can identify patient concerns and make the necessary improvements to meet their patient satisfaction goals.

What is another name for the patient journey?

The term “patient funnel” describes the journey patients take from first learning about a healthcare provider or healthcare product to actually making an appointment or purchase. This “funnel” can be applied to any type of business, describing the stages a customer goes through to obtain a service.

  • Understanding the stages of the patient journey

Each stage of the patient journey is essential to a positive patient experience . Gathering and analyzing data can alert healthcare providers to potential issues throughout the journey.

Data collection at each of the following stages will give healthcare providers the information they need to make the necessary improvements:

1. Awareness

Awareness is where the patient journey begins. This is when they first research symptoms and identify the need to see a medical professional.

They may consider at-home remedies and get advice from friends, social media, or websites. Once they identify the need for a healthcare provider, they continue their research via review sites, advertising campaigns, and seeking referrals from friends and family.

Determining the way patients become aware they need healthcare and the sources they use for research is important. The data collected at this stage could suggest your organization has an insufficient social media presence, inadequate advertising, or a website in need of an update.

To remedy these shortcomings, you might consider adding informational blogs to your website, performing a social media analysis, or closely monitoring customer reviews.

This stage in the patient journey is where the patient schedules services with the healthcare provider.

This engagement is essential for acquiring new patients and retaining current patients. Patients will contact you in several ways to schedule an appointment or get information. Most will call on the first attempt to schedule an appointment.

This is a crucial touchpoint in the journey. A new patient may become frustrated and move on if they find it difficult to access your services or are placed on hold for a long period or transferred numerous times.

Patient engagement occurs in other ways, such as your online patient portal, text messages, and emails. Your patients may interact differently, so it’s important to gather data that represents their preferred means of communication. Work to make the improvements required to correct access issues and ensure efficient communication.

The care stage can include everything from your patient’s interaction with the front desk to how long they have to wait in the examination room to see a doctor.

Check-in, check-out, admissions, discharge, billing, and of course, the actual visit with the healthcare provider are other touchpoints in the care stage.

There are a couple of ways to gather and analyze this data. Most organizations choose to analyze it holistically, even if it’s collected separately. For example, you might gather data about the patient’s interaction with the front desk, the clinical visit, and the discharge process, but you may want to analyze the care segment as a whole.

4. Treatment

Treatment may be administered in the office. For example, a patient diagnosed with hypertension may have medication prescribed. That medication is the treatment. Gathering information at this stage is critical to see how your patient views the healthcare provider’s follow-up or responses to inquiries.

In most cases, treatment extends beyond the initial clinical visit. For example, a patient might require additional tests to get a diagnosis. Providing the next steps to a patient in a timely manner and letting them know the test results is crucial to patient satisfaction .

5. Long term

A satisfied patient results in a long-term relationship and referrals to friends and family. Most of the data collected at this stage will be positive since the patient is continuing to use your services.

Gathering data after the treatment stage allows you to expand on the qualities that keep patients returning for your services in the long term.

  • Benefits of patient journey mapping

The patient benefits from their healthcare provider understanding their journey and taking steps to improve it. Healthcare providers also reap several benefits, including the following:

1. Efficient patient care

When they understand the patient journey, healthcare providers can provide care more efficiently and spend less time and money on unnecessary, unwanted communications.

2. Proactive patient care

Proactive patient care is aimed at preventing rather than treating disease. For example, women who are over a certain age should have an annual mammogram, smokers may be tested for lung disease, and elderly women may need a bone density study. These preventative measures can help keep disease at bay, improve health outcomes, and build trust with patients.

3. Value-based patient care

Patients don’t want to feel they are being charged unfairly for their healthcare. Focusing on the individual patient promotes satisfaction and yields positive outcomes.

The Center for Medicare and Medicaid Services (CMS) has issued recent guidelines for participants that help offset the costs of high-quality care through a reward system.

4. Retention and referrals

Patients who are happy with their journey will keep returning for healthcare, and happy patients equal voluntary referrals. Many providers offer rewards to incentify referrals.

  • How to get started with patient journey mapping

Follow the steps below to start the patient journey mapping process:

Establish your patient personas

Journey mapping is a great way to identify your patient’s characteristics so that their experience can be further enhanced.

Some of the following determinations can help you pinpoint your patient’s persona and establish protocols to provide a better service:

How do your patients prefer to communicate? Are they more comfortable with phone calls, texts, or other methods?

How are most patients finding your services? Are they being referred by friends or family members, or are they seeing advertisements?

Would the patient prefer in-person communication or telecommunication?

What are the patient’s expectations of care?

This data can be complex and widespread, but it can give you the information you need to more effectively and efficiently communicate with your patients.

Understand the entire patient lifecycle

Each patient is unique. Understanding the patient lifecycle can avoid confusion and miscommunication.

To positively engage the patient, you’ll need to gather data not only about communication methods but where they are in the patient journey, their health issue, and their familiarity with the healthcare provider’s procedures and treatment options.

Understand the moments of truth

With a few exceptions, most people seek healthcare services when they are ill or have a healthcare issue. These situations can cause patients to feel stressed and anxious. It’s these moments of interaction where compassion, knowledge, and understanding can provide relief and reassurance.

When patients see their healthcare provider, they are looking for solutions to problems. It’s the provider’s opportunity to identify these moments of truth and capitalize on them.

Get the data you need

Healthcare providers can collect vast amounts of data from patients, but the data collected rarely goes far enough in analyzing and determining solutions.

Your patients have high expectations regarding personalized treatment based on data. They want personalized, easy access to medical information and records, responsive treatments and follow-up, and communication in their preferred format.

You need more than clinical data to give patients what they want. You also need personal data that sets each patient apart and ensures a tailored experience.

For example, it might be challenging for parents of small children to contact the clinic and schedule appointments at certain times of the day. As a healthcare provider, you’ll need to be aware of the best times to contact this individual and offer simple methods for scheduling appointments.

Another example is patients with physical disabilities. You can take steps to improve their access to and experience at the healthcare facility.

Encourage referrals and loyalty

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  • Published: 04 December 2019

“Patient Journeys”: improving care by patient involvement

  • Matt Bolz-Johnson 1 ,
  • Jelena Meek 2 &
  • Nicoline Hoogerbrugge 2  

European Journal of Human Genetics volume  28 ,  pages 141–143 ( 2020 ) Cite this article

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  • Cancer genetics
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“I will not be ashamed to say ‘ I don’t know’ , nor will I fail to call in my colleagues…”. For centuries this quotation from the Hippocratic oath, has been taken by medical doctors. But what if there are no other healthcare professionals to call in, and the person with the most experience of the disease is sitting right in front of you: ‘ your patient ’.

This scenario is uncomfortably common for patients living with a rare disease when seeking out health care. They are fraught by many hurdles along their health care pathway. From diagnosis to treatment and follow-up, their healthcare pathway is defined by a fog of uncertainties, lack of effective treatments and a multitude of dead-ends. This is the prevailing situation for many because for rare diseases expertise is limited and knowledge is scarce. Currently different initiatives to involve patients in developing clinical guidelines have been taken [ 1 ], however there is no common method that successfully integrates their experience and needs of living with a rare disease into development of healthcare services.

Even though listening to the expertise of a single patient is valuable and important, this will not resolve the uncertainties most rare disease patients are currently facing. To improve care for rare diseases we must draw on all the available knowledge, both from professional experts and patients, in order to improve care for every single patient in the world.

Patient experience and satisfaction have been demonstrated to be the single most important aspect in assessing the quality of healthcare [ 2 ], and has even been shown to be a predictor of survival rates [ 3 ]. Studies have evidenced that patient involvement in the design, evaluation and designation of healthcare services, improves the relevance and quality of the services, as well as improves their ability to meet patient needs [ 4 , 5 , 6 ]. Essentially, to be able to involve patients, the hurdles in communication and initial preconceptions between medical doctors and their patients need to be resolved [ 7 ].

To tackle the current hurdles in complex or rare diseases, European Reference Networks (ERN) have been implemented since March 2017. The goal of these networks is to connect experts across Europe, harnessing their collective experience and expertise, facilitating the knowledge to travel instead of the patient. ERN GENTURIS is the Network leading on genetic tumour risk syndromes (genturis), which are inherited disorders which strongly predispose to the development of tumours [ 8 ]. They share similar challenges: delay in diagnosis, lack of cancer prevention for patients and healthy relatives, and therapeutic. To overcome the hurdles every patient faces, ERN GENTURIS ( www.genturis.eu ) has developed an innovative visual approach for patient input into the Network, to share their expertise and experience: “Patient Journeys” (Fig.  1 ).

figure 1

Example of a Patient Journey: PTEN Hamartoma Tumour Syndrome (also called Cowden Syndrome), including legend page ( www.genturis.eu )

The “Patient Journey” seeks to identify the needs that are common for all ‘ genturis syndromes ’, and those that are specific to individual syndromes. To achieve this, patient representatives completed a mapping exercise of the needs of each rare inherited syndrome they represent, across the different stages of the Patient Journey. The “Patient Journey” connects professional expert guidelines—with foreseen medical interventions, screening, treatment—with patient needs –both medical and psychological. Each “Patient Journey” is divided in several stages that are considered inherent to the specific disease. Each stage in the journey is referenced under three levels: clinical presentation, challenges and needs identified by patients, and their goal to improve care. The final Patient Journey is reviewed by both patients and professional experts. By visualizing this in a comprehensive manner, patients and their caregivers are able to discuss the individual needs of the patient, while keeping in mind the expertise of both professional and patient leads. Together they seek to achieve the same goal: improving care for every patient with a genetic tumour risk syndrome.

The Patient Journeys encourage experts to look into national guidelines. In addition, they identify a great need for evidence-based European guidelines, facilitating equal care to all rare patients. ERN GENTURIS has already developed Patient Journeys for the following rare diseases ( www.genturis.eu ):

PTEN hamartoma tumour syndrome (PHTS) (Fig.  1 )

Hereditary breast and ovarian cancer (HBOC)

Lynch syndrome

Neurofibromatosis Type 1

Neurofibromatosis Type 2

Schwannomatosis

A “Patient Journey” is a personal testimony that reflects the needs of patients in two key reference documents—an accessible visual overview, supported by a detailed information matrix. The journey shows in a comprehensive way the goals that are recognized by both patients and clinical experts. Therefore, it can be used by both these parties to explain the clinical pathway: professional experts can explain to newly identified patients how the clinical pathway generally looks like, whereas their patients can identify their specific needs within these pathways. Moreover, the Patient Journeys could serve as a guide for patients who may want to write, in collaboration with local clinicians, diaries of their journeys. Subsequently, these clinical diaries can be discussed with the clinician and patient representatives. Professionals coming across medical obstacles during the patient journey can contact professional experts in the ERN GENTURIS, while patients can contact the expert patient representatives from this ERN ( www.genturis.eu ). Finally, the “Patient Journeys” will be valuable in sharing knowledge with the clinical community as a whole.

Our aim is that medical doctors confronted with rare diseases, by using Patient Journeys, can also rely on the knowledge of the much broader community of expert professionals and expert patients.

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Acknowledgements

This work is generated within the European Reference Network on Genetic Tumour Risk Syndromes – FPA No. 739547. The authors thank all ERN GENTURIS Members and patient representatives for their work on the Patient Journeys (see www.genturis.eu ).

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Bolz-Johnson, M., Meek, J. & Hoogerbrugge, N. “Patient Journeys”: improving care by patient involvement. Eur J Hum Genet 28 , 141–143 (2020). https://doi.org/10.1038/s41431-019-0555-6

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Managing Complex Patient Journeys in Healthcare

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  • Ragnhild Halvorsrud 3 ,
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Healthcare services are increasingly being digitized for greater flexibility and efficient sharing of information. There is also increased awareness among healthcare providers that they must consider their services from the perspective of the patient. To offer a coherent patient journey and efficient treatment, healthcare providers need a structured overview of their service processes and how these affect the patient journey. This chapter introduces customer journey modeling language (CJML) to support the design, management, and analysis of complex patient journeys. Through two case studies, we describe how CJML has been utilized for a shared overview of patient journeys, improvement work, internal training, and knowledge sharing. The first case study was carried out with DIPS, a supplier of eHealth systems to Norwegian hospitals. Here, CJML was used to support the documentation and rollout of a new generation of tools for surgery planning, a complex and resource-intensive process during which critical information is exchanged over time among a range of actors. The second case study was conducted at Oslo University Hospital. Cross-functional teams used CJML to document the patient journey associated with cervical cancer as the basis for improvement work. The two case studies demonstrate how CJML supports healthcare service design through a common understanding of the patient journeys among stakeholders and by visualizing the workflows and actors involved. Although several weaknesses in CJML remain to be resolved, the case studies suggest the benefit of a model-based approach in two regards: first, as an effective communication tool to unite medical, technical, and administrative expertise and second to enhance the patient focus throughout the improvement and digitization of health services.

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Halvorsrud, R., Lillegaard, A.L., Røhne, M., Jensen, A.M. (2019). Managing Complex Patient Journeys in Healthcare. In: Pfannstiel, M.A., Rasche, C. (eds) Service Design and Service Thinking in Healthcare and Hospital Management. Springer, Cham. https://doi.org/10.1007/978-3-030-00749-2_19

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Process mapping the patient journey: an introduction

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  • Peer review
  • Timothy M Trebble , consultant gastroenterologist 1 ,
  • Navjyot Hansi , CMT 2 1 ,
  • Theresa Hydes , CMT 1 1 ,
  • Melissa A Smith , specialist registrar 2 ,
  • Marc Baker , senior faculty member 3
  • 1 Department of Gastroenterology, Portsmouth Hospitals Trust, Portsmouth PO6 3LY
  • 2 Department of Gastroenterology, Guy’s and St Thomas’ NHS Foundation Trust, London
  • 3 Lean Enterprise Academy, Ross-on-Wye, Hertfordshire
  • Correspondence to: T M Trebble tim.trebble{at}porthosp.nhs.uk
  • Accepted 15 July 2010

Process mapping enables the reconfiguring of the patient journey from the patient’s perspective in order to improve quality of care and release resources. This paper provides a practical framework for using this versatile and simple technique in hospital.

Healthcare process mapping is a new and important form of clinical audit that examines how we manage the patient journey, using the patient’s perspective to identify problems and suggest improvements. 1 2 We outline the steps involved in mapping the patient’s journey, as we believe that a basic understanding of this versatile and simple technique, and when and how to use it, is valuable to clinicians who are developing clinical services.

What information does process mapping provide and what is it used for?

Process mapping allows us to “see” and understand the patient’s experience 3 by separating the management of a specific condition or treatment into a series of consecutive events or steps (activities, interventions, or staff interactions, for example). The sequence of these steps between two points (from admission to the accident and emergency department to discharge from the ward) can be viewed as a patient pathway or process of care. 4

Improving the patient pathway involves the coordination of multidisciplinary practice, aiming to maximise clinical efficacy and efficiency by eliminating ineffective and unnecessary care. 5 The data provided by process mapping can be used to redesign the patient pathway 4 6 to improve the quality or efficiency of clinical management and to alter the focus of care towards activities most valued by the patient.

Process mapping has shown clinical benefit across a variety of specialties, multidisciplinary teams, and healthcare systems. 7 8 9 The NHS Institute for Innovation and Improvement proposes a range of practical benefits using this approach (box 1). 6

Box 1 Benefits of process mapping 6

A starting point for an improvement project specific for your own place of work

Creating a culture of ownership, responsibility and accountability for your team

Illustrates a patient pathway or process, understanding it from a patient’s perspective

An aid to plan changes more effectively

Collecting ideas, often from staff who understand the system but who rarely contribute to change

An interactive event that engages staff

An end product (a process map) that is easy to understand and highly visual

Several management systems are available to support process mapping and pathway redesign. 10 11 A common technique, derived originally from the Japanese car maker Toyota, is known as lean thinking transformation. 3 12 This considers each step in a patient pathway in terms of the relative contribution towards the patient’s outcome, taken from the patient’s perspective: it improves the patient’s health, wellbeing, and experience (value adding) or it does not (non-value or “waste”) (box 2). 14 15 16

Box 2 The eight types of waste in health care 13

Defects —Drug prescription errors; incomplete surgical equipment

Overproduction —Inappropriate scheduling

Transportation —Distance between related departments

Waiting —By patients or staff

Inventory —Excess stores, that expire

Motion —Poor ergonomics

Overprocessing —A sledgehammer to crack a nut

Human potential —Not making the most of staff skills

Process mapping can be used to identify and characterise value and non-value steps in the patient pathway (also known as value stream mapping). Using lean thinking transformation to redesign the pathway aims to enhance the contribution of value steps and remove non-value steps. 17 In most processes, non-value steps account for nine times more effort than steps that add value. 18

Reviewing the patient journey is always beneficial, and therefore a process mapping exercise can be undertaken at any time. However, common indications include a need to improve patients’ satisfaction or quality or financial aspects of a particular clinical service.

How to organise a process mapping exercise

Process mapping requires a planned approach, as even apparently straightforward patient journeys can be complex, with many interdependent steps. 4 A process mapping exercise should be an enjoyable and creative experience for staff. In common with other audit techniques, it must avoid being confrontational or judgmental or used to “name, shame, and blame.” 8 19

Preparation and planning

A good first step is to form a team of four or five key staff, ideally including a member with previous experience of lean thinking transformation. The group should decide on a plan for the project and its scope; this can be visualised by using a flow diagram (fig 1 ⇓ ). Producing a rough initial draft of the patient journey can be useful for providing an overview of the exercise.

Fig 1 Steps involved in a process mapping exercise

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The medical literature or questionnaire studies of patients’ expectations and outcomes should be reviewed to identify value adding steps involved in the management of the clinical condition or intervention from the patient’s perspective. 1 3

Data collection

Data collection should include information on each step under routine clinical circumstances in the usual clinical environment. Information is needed on waiting episodes and bottlenecks (any step within the patient pathway that slows the overall rate of a patient’s progress, normally through reduced capacity or availability 20 ). Using estimates of minimum and maximum time for each step reduces the influence of day to day variations that may skew the data. Limiting the number of steps (to below 60) aids subsequent analysis.

The techniques used for data collection (table 1 ⇓ ) each have advantages and disadvantages; a combination of approaches can be applied, contributing different qualitative or quantitative information. The commonly used technique of walking the patient journey includes interviews with patients and staff and direct observation of the patient journey and clinical environment. It allows the investigator to “see” the patient journey at first hand. Involving junior (or student) doctors or nurses as interviewers may increase the openness of opinions from staff, and time needed for data collection can be reduced by allotting members of the team to investigate different stages in the patient’s journey.

 Data collection in process mapping

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Mapping the information

The process map should comprehensively represent the patient journey. It is common practice to draw the map by hand onto paper (often several metres long), either directly or on repositionable notes (fig 2 ⇓ ).

Fig 2 Section of a current state map of the endoscopy patient journey

Information relating to the steps or representing movement of information (request forms, results, etc) can be added. It is useful to obtain any missing information at this stage, either from staff within the meeting or by revisiting the clinical environment.

Analysing the data and problem solving

The map can be analysed by using a series of simple questions (box 3). The additional information can be added to the process map for visual representation. This can be helped by producing a workflow diagram—a map of the clinical environment, including information on patient, staff, and information movement (fig 3 ⇓ ). 18

Box 3 How to analyse a process map 6

How many steps are involved?

How many staff-staff interactions (handoffs)?

What is the time for each step and between each step?

What is the total time between start and finish (lead time)?

When does a patient join a queue, and is it a regular occurrence?

How many non-value steps are there?

What do patients complain about?

What are the problems for staff?

Fig 3 Workflow diagram of current state endoscopy pathway

Redesigning the patient journey

Lean thinking transformation involves redesigning the patient journey. 21 22 This will eliminate, combine and simplify non-value steps, 23 limit the impact of rate limiting steps (such as bottlenecks), and emphasise the value adding steps, making the process more patient-centred. 6 It is often useful to trial the new pathway and review its effect on patient management and satisfaction before attempting more sustained implementation.

Worked example: How to undertake a process mapping exercise

South Coast NHS Trust, a large district general hospital, plans to improve patient access to local services by offering unsedated endoscopy in two peripheral units. A consultant gastroenterologist has been asked to lead a process mapping exercise of the current patient journey to develop a fast track, high quality patient pathway.

In the absence of local data, he reviews the published literature and identifies key factors to the patient experience that include levels of discomfort during the procedure, time to discuss the findings with the endoscopist, and time spent waiting. 24 25 26 27 He recruits a team: an experienced performance manager, a sister from the endoscopy department, and two junior doctors.

The team drafts a map of the current endoscopy journey, using repositionable notes on the wall. This allows team members to identify the start (admission to the unit) and completion (discharge) points and the locations thought to be involved in the patient journey.

They decide to use a “walk the journey” format, interviewing staff in their clinical environments and allowing direct observation of the patient’s management.

The junior doctors visit the endoscopy unit over two days, building up rapport with the staff to ensure that they feel comfortable with being observed and interviewed (on a semistructured but informal basis). On each day they start at the point of admission at the reception office and follow the patient journey to completion.

They observe the process from staff and patient’s perspectives, sitting in on the booking process and the endoscopy procedure. They identify the sequence of steps and assess each for its duration (minimum and maximum times) and the factors that influence this. For some of the steps, they use a digital watch and notepad to check and record times. They also note staff-patient and staff-staff interactions and their function, and the recording and movement of relevant information.

Details for each step are entered into a simple table (table 2 ⇓ ), with relevant notes and symbols for bottlenecks and patients’ waits.

 Patient journey for non-sedated upper gastrointestinal endoscopy

When data collection is complete, the doctor organises a meeting with the team. The individual steps of the patient journey are mapped on a single long section of paper with coloured temporary markers (fig 2 ⇑ ); additional information is added in different colours. A workflow diagram is drawn to show the physical route of the patient journey (fig 3 ⇑ ).

The performance manager calculates that the total patient journey takes a minimum of 50 minutes to a maximum of 345 minutes. This variation mainly reflects waiting times before a number of bottleneck steps.

Only five steps (14 to 17 and 22, table 2 ⇑ ) are considered both to add value and needed on the day of the procedure (providing patient information and consent can be obtained before the patient attends the department). These represent from 13 to 47 minutes. At its least efficient, therefore, only 4% of the patient journey (13 of 345 minutes) is spent in activities that contribute directly towards the patient’s outcome.

The team redesigns the patient journey (fig 4 ⇓ ) to increase time spent on value adding aspects but reduce waiting times, bottlenecks, and travelling distances. For example, time for discussing the results of the procedure is increased but the location is moved from the end of the journey (a bottleneck) to shortly after the procedure in the anteroom, reducing the patient’s waiting time and staff’s travelling distances.

Fig 4 Workflow diagram of future state endoscopy pathway

Implementing changes and sustaining improvements

The endoscopy staff are consulted on the new patient pathway, which is then piloted. After successful review two months later, including a patient satisfaction questionnaire, the new patient pathway is formally adopted in the peripheral units.

Further reading

Practical applications.

NHS Institute for Innovation and Improvement ( https://www.institute.nhs.uk )—comprehensive online resource providing practical guidance on process mapping and service improvement

Lean Enterprise Academy ( http://www.leanuk.org )—independent body dedicated to lean thinking in industry and healthcare, through training and academic discussion; its publication, Making Hospitals Work 23 is a practical guide to lean transformation in the hospital environment

Manufacturing Institute ( http://www.manufacturinginstitute.co.uk )—undertakes courses on process mapping and lean thinking transformation within health care and industrial practice

Theoretical basis

Bircheno J. The new lean toolbox . 4th ed. Buckingham: PICSIE Books, 2008

Mould G, Bowers J, Ghattas M. The evolution of the pathway and its role in improving patient care. Qual Saf Health Care 2010 [online publication 29 April]

Layton A, Moss F, Morgan G. Mapping out the patient’s journey: experiences of developing pathways of care. Qual Health Care 1998; 7 (suppl):S30-6

Graban M. Lean hospitals, improving quality, patient safety and employee satisfaction . New York: Taylor & Francis, 2009

Womack JP, Jones DT. Lean thinking . 2nd ed. London: Simon & Schuster, 2003

Cite this as: BMJ 2010;341:c4078

Contributors: TMT designed the protocol and drafted the manuscript; TMT, MB, JH, and TH collected and analysed the data; all authors critically reviewed and contributed towards revision and production of the manuscript. TMT is guarantor.

Competing interests: MB is a senior faculty member carrying out research for the Lean Enterprise Academy and undertakes paid consultancies both individually and from Lean Enterprise Academy, and training fees for providing lean thinking in healthcare.

Provenance and peer review: Not commissioned; externally peer reviewed.

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patient journey surgery

Maximizing your glow: Ideas for embracing the patient journey

  • Ariel Frankeny | Freelance Writer
  • Thursday, August 31, 2023

embracing the patient journey in plastic surgery

Many patients are so hyper-focused on planning a plastic surgery procedure that they forget about preparing for one of the most important parts of the process – the recovery. The procedure can be life-changing, but how you recuperate can make a big difference in your end result.

It seems contrary, but you can achieve the best results much faster if you take the time to mend according to your surgeon's instructions. It is essential to prepare for recovery both mentally and physically before the procedure. This allows your body and your mind the adequate time and energy to focus on healing.

ASPS is here to set you up for success in the recovery process. We have reached out to two experts in the field – Ashley Howarth, MD , and Lisa Jewell, MD, FACS – for their insight and advice on the importance of recovery and how to maximize your results and glow.

The importance of mindfulness and healthy choices in recovery

It is vital to understand your plastic surgery journey starts before the actual operation.

"Preparing before a plastic surgery procedure is crucial to ensure success," said Howarth. "Physical and psychological preparation prior to surgery can significantly impact and improve the healing process, minimize complications and enhance outcomes."

Your journey really begins at your first meeting with the surgeon.

"This step is very important, and I spend a lot of time coaching my patients to set themselves up for a smooth recovery," said Jewell. "I start this process during their consultation. I try to be as accurate as possible with the recovery time required for each procedure."

Recovery from any plastic surgery procedure can benefit from switching to healthier lifestyle choices. This means getting enough sleep, hydrating and minimizing stress.

"Patients should avoid smoking, excessive alcohol and certain medications that can hinder recovery," said Howarth. "These items will always be discussed during your individualized pre-operative visit with your board-certified plastic surgeon. It is also important to maintain a peaceful environment without undue drama or stress in your life as you prepare for your operation."

Healthy lifestyle choices are key to a successful recovery, but it is also important not to make a drastic life change prior to surgery. You may think it will improve your overall health, but it can negatively affect your recovery.

"I typically advise patients to avoid making any major changes to their lifestyle, diet or supplement intake immediately before surgery," said Jewell. "More long-term changes, we try to address prior to surgery scheduling."

Another healthy practice that is easy to implement prior to surgery and stick with afterward is using mindfulness to reduce stress. Meditation or simple quiet time can allow you to reflect upon your thoughts and feelings or help you recenter yourself if you are beginning to feel overwhelmed.

"Visualize heading to your surgery, having surgery and recovering from surgery to help manage anxiety," said Howarth. "Practice self-care and do the things you love to do that help you manage stress."

How to set yourself up for a successful recovery

Here are a few key ways to prepare yourself and your space ahead of your surgery to maximize your recovery and your results.

Establish realistic expectations for your recovery

This may seem like common sense, but this step is often skipped when considering plastic surgery procedures. Make sure to keep in mind that you will need adequate rest and relaxation to recover properly and will not immediately go back to your day-to-day activities.

"It surprises me how many patients think that they will just hop on an airplane for work or vacation a week after a breast augmentation or tummy tuck," said Jewell. "They have no idea that trying to get a suitcase in the overhead bin is not going to happen safely within a week of those surgeries."

Keep an eye on what you are eating

Focus on establishing a healthy and nutritious diet leading up to and following the procedure.

"Key components of preparation are providing your body with vital nutrients from a healthy and well-balanced diet," said Howarth.

It is more than just generally eating healthy, though. Exactly what you eat makes a big difference.

"Protein requirements increase after surgery, so make sure that your diet contains adequate high-quality protein before and after surgery," said Jewell. "Set a goal of 1.6-2 grams per kilogram of body weight per day starting about one week prior to surgery."

Set your recovery space up ahead of time

The time following any procedure can be stressful. Prepare your recovery space ahead of time so there is less strain. Have everything you will need ready to go, including premade meals and a support system to assist you with day-to-day tasks.

Don't be afraid to ask for help

So many patients are used to being independent. They are often the person others rely on at home or the office and are afraid to ask for help. Make sure that you have a plan and help lined up to minimize stress and physical activity during your recovery.

"The single most important thing a patient can do to ensure a successful recovery is to overestimate how much help they will need," said Jewell. "It is much better to have too much than not enough."

Stay in touch with your surgeon

Your number one resource before and during your recovery process will be the surgeon and team that completed your procedure. They will be able to guide you on the steps to follow to set yourself up for success.

"Communication with your board-certified plastic surgeon sets the foundation for your successful recovery as you work together to prepare for surgery," said Howarth.

Be mindful throughout the process

Mindfulness can be a powerful tool to maximize your recovery and give patients the confidence they need to take the plunge on planning a procedure.

"Patients may find comfort in acknowledging that they have made a choice to have surgery and have the power to change their minds if the circumstances do not feel right," said Jewell. "Accepting that during and after surgery they may feel vulnerable, anxious and experience physical discomfort. Trusting their provider to help them achieve the benefits that surgery will have on their quality of life and self-esteem. Certainly, being present in the moment and listening to their body will help avoid making choices that may slow their recovery."

Maximize your glow

Proper planning for your plastic surgery recovery is critical in order to maximize your results. Start implementing healthy lifestyle choices ahead of time, prepare your space and practice mindfulness to keep yourself centered throughout the recovery process.

You can effectively maximize your glow and results by giving your body the time and space it needs to heal fully.

To find a qualified plastic surgeon for any cosmetic or reconstructive procedure, consult a member of the American Society of Plastic Surgeons. All ASPS members are board certified by the American Board of Plastic Surgery, have completed an accredited plastic surgery training program, practice in accredited facilities and follow strict standards of safety and ethics. Find an ASPS member in your area .

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  • Road to recovery: Patience in practice after plastic surgery
  • Change of heart? Reversing your plastic surgery results

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patient journey surgery

  • Open access
  • Published: 20 June 2017

Re-designing the pathway to surgery: better care and added value

  • Michael P. W. Grocott 1 , 2 , 3 , 4 ,
  • James O. M. Plumb 1 , 2 , 3 , 5 ,
  • Mark Edwards 1 , 2 , 3 , 5 ,
  • Imogen Fecher-Jones 1 , 2 , 5 &
  • Denny Z. H. Levett 1 , 2 , 3 , 4  

Perioperative Medicine volume  6 , Article number:  9 ( 2017 ) Cite this article

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The case for radical pathway re-design before surgery is in part driven by healthcare system pressures which are in turn the result of continuously rising demand in the face of tightly constrained resources. Such circumstances tend to drive revolutionary, rather than incremental, change. The current approach to preoperative assessment, that typically occurs in the weeks leading up to surgery, but is all too often only a few days before surgery, results in a lost opportunity for perioperative physicians to improve patient care. Re-engineering this process based on a patient-focused, pathway-driven vision of perioperative medicine offers a means of exploiting this opportunity. This review explores drivers for change, the opportunity offered by pathway re-design, and suggests a variety of strategies to add value in the preoperative pathway, each of which is facilitated by early engagement between perioperative physician and patient: collaborative decision-making, collaborative behavioural change, targeted comorbidity management as well as expectation management and psychological preparation for surgery including surgery schools.

Introduction

Contemporary healthcare is characterized by severe resource constraints in the face of unremitting increases in demand, in large-part due to demographic change. The 2007–2008 global economic crisis and the subsequent Great Recession of 2008–2012 resulted in fiscal tightening that in turn led to flat or falling healthcare spending, expressed as a proportion of Gross Domestic Product, in many countries (Health and care funding in a nutshell | the health foundation & Available from: http://www.health.org.uk/health-and-social-care-funding-explained#Future. Accessed 20 Dec 2016 ). At the same time, improvements in public health and medical care have led to increased life expectancy, but declines in mortality have not been matched by similar declines in morbidity; people are living longer with disease and the prevalence of multi-morbidity is rising (Newton et al. 2015 ; Barnett et al. 2012 ). Continuing healthcare innovation drives an additional and sustained cost pressure within healthcare budgets (Health and care funding in a nutshell | the health foundation & Available from: http://www.health.org.uk/health-and-social-care-funding-explained#Future. Accessed 20 Dec 2016 ). This progressive increase in burden in the context of tightly constrained resourcing is only sustainable through either degradation of service quality and/or scope, or radical improvements in efficiency and cost-effectiveness. In this context, slow incremental change may not provide credible solutions. Radical process re-design, based on a fundamental re-evaluation of goals from a patient perspective, may be needed: revolution, not evolution, may be the answer to this existential challenge.

Process re-engineering

The Institute of Health Improvement in the USA places healthcare cost reduction as a key dimension of the “Triple Aim” framework for optimizing health system performance and population health benefit (Stiefel & Nolan 2012 ). In modern healthcare, where resources are inevitably constrained, it is incumbent on clinicians seeking to change practice to demonstrate not only that a new approach improves clinical quality but also that it is of good value, defined by the relationship between cost and clinical effectiveness (Grocott & Mythen 2015 ). So how can anaesthetists and perioperative physicians add value to our patient’s pathway to surgery?

The concept of business process re-engineering (BPR) is commonly attributed to the 1990 Harvard Business Review article by Michael Harmer entitled “Reengineering work: don’t automate, obliterate” (Hammer 1990 ). Perhaps the most concise definition of this business management strategy is: “… the fundamental rethinking and radical re-design of business processes to achieve dramatic improvements in critical contemporary modern measures of performance, such as cost, quality, service, and speed” (Hammer & Champy 1993 ). BPR focuses on radical change, rather than continuous iterative improvement, and was introduced in the context of increasing use of information technology (IT) in industry. BPR sought to rethink the application of such technology, away from using IT to replace existing roles, towards fundamental system re-design, based on a comprehensive re-evaluation of process aims. Is it time to apply such thinking to the pathway our patients take towards surgery?

Value and perioperative medicine

Perioperative medicine is defined as the practice of patient-centered, multidisciplinary, and integrated medical care of patients from the moment of contemplation of surgery until full recovery (Grocott & Mythen 2015 ). Explicit to this definition is the patient and their pathway of care as the central focus. In contrast, traditional care models have tended to define themselves by “silos” of delivered care (e.g. operating room suite) or professional activity (e.g. administering anaesthetics). Such silo-based thinking is antithetical to modern concepts of improving value in healthcare, which emphasize the importance of considering value across the whole patient pathway. In the words of Michael Porter, the business thinker turned healthcare reform advocate “The proper unit for measuring value should encompass all services or activities that jointly determine success in meeting a set of patient needs.” (Porter 2009 ).

The pathway to surgery

For the patient, the pathway to surgery commences when they first contemplate surgery in primary care or a surgical clinic and culminates weeks to months later on the day of surgery. In most settings, anaesthetic engagement with patients prior to surgery commences, at best, with preoperative assessment. This typically occurs in the weeks leading up to surgery, however, is all too often only a few days before surgery (Fig.  1 ), and at worst does not occur at all. Consequently, any contribution perioperative physicians might have to improving patient preparation for surgery is profoundly limited by one key factor: the limited time available between meeting the patient for the first time and the date of surgery. This in turn minimizes anaesthetists’ capacity to provide patient benefit. Opportunities to optimize therapy or behaviours have been missed and by this time patient expectations about their approaching surgery are long established and firmly set. So why do perioperative physicians not engage with their patients earlier?

Traditional model of the journey from GP referral through to surgery

The preoperative pathway has two key functions: to ensure that the right decision is made in relation to the surgery and to ensure that the patient is as well prepared as possible in order to maximize their resilience to the physiological stress of surgery. Both of these functions are more readily achieved when the perioperative physician has the opportunity to engage with their patient earlier in the pathway to surgery (Fig.  2 ). Early engagement with patients, as soon as possible after the moment of contemplation of surgery, is probably best achieved through screening questionnaires administered during the first discussion of the possibility of surgery. Such engagement may occur at the time of initial diagnosis of pathology (e.g. cystoscopy clinic, colonoscopy clinic) or at the point where the patient chooses to contact a physician to discuss troubling symptoms (e.g. hip pain consultation in a GP practice). The content of these questionnaires might encompass basic demographic data, items to screen for comorbidities (e.g. diabetes, heart and lung disease) as well as questions about relevant behaviours (e.g. cigarettes, alcohol, activity and diet). The nature of these questionnaires may vary between settings, but substantial opportunities exist for the application of technological solutions, such as tablet or mobile telephone-based applications, in order to facilitate the rapid transmission of data to the perioperative care team. Patients may then be triaged by risk category to low-, medium- and high-risk pathways. Patients estimated to have a high risk of adverse outcome may benefit from early referral to specialist “high-risk” clinics and advanced investigations such as cardiopulmonary exercise testing (Levett & Grocott 2015 ). Patients estimated to have a medium-level risk of adverse outcome might follow a more conventional pathway, with additional educational opportunities afforded by “surgery schools” (see below). Patients estimated to have a low risk of adverse outcome might bypass pre-assessment arrangements entirely and simply be offered “surgery school” (Trust tests ‘surgery school’ to get patients fit for ops | news | nursing times & Available from: https://www.nursingtimes.net/news/research-and-innovation/trust-tests-surgery-school-to-get-patients-fit-for-ops/7011466.article. Accessed 20 Dec 2016 ; Surgery school for patients | medicine | university of southampton & Available from: http://www.southampton.ac.uk/medicine/news/ 2016 /10/surgery-school-to-get-patients-fit.page. Accessed 20 Dec 2016; Your surgery 3.Pdf, Available from: https://www.cmft.nhs.uk/media/1461701/your%20surgery.pdf. Accessed 20 Dec 2016 ). Surgery schools are multidisciplinary team (MDT)-delivered, predominantly classroom-based, interactive learning environments where patients come together as a group to learn more about their surgical journey and how they can improve it. A similar concept is seen in “antenatal classes” for expectant parents. Patients have the opportunity of meeting other patients going through the same journey along with members of the MDT and professionals involved with smoking/alcohol cessation, exercise and weight loss. Our experience of running such a school is that patients report benefit in the social, psychological and physiological domains.

The pathway “re-engineered”—a model of process evolution in perioperative pathways. This re-engineered model aims to shift the timing of pre-assessment to much earlier in the pathway using simple online risk stratification tools and then early staging using objective physiological assessments (namely CPET). The aim is to have detailed information prior to any decision to operate with true collaborative decision-making taking centre stage. Surgery school and any “bolt-ons” occur in conjunction aiming to have things optimized prior to final decisions regarding surgery

Opportunities to add value before surgery

Early engagement with patients before surgery, as soon as possible after the defining “moment of contemplation of surgery”, opens up many opportunities to improve the chances of meeting the twin aims of optimizing decision-making and maximizing resilience (see Table  1 and Fig.  2 ). Whilst surgeons may be expert in the prognosis estimates relating to the procedure type, anaesthetist/perioperative physicians may be better informed about the risks relating to functional status, chronic health and acute physiological deterioration. Risk factors for adverse outcome following surgery may be divided into fixed (e.g. age, gender) and modifiable (e.g. anaemia, physical fitness) (Table 1 ). Fixed and modifiable risk factors may be addressed during collaborative decision-making. Modifiable factors may be amenable to optimization through collaborative behavioural change and/or targeted comorbidity management (Table 1 ).

Collaborative (shared) decision-making

The evaluation of likely benefits and harms of surgery can proceed in parallel so that at the time of decision-making, patients may weigh the competing factors together and come to a well informed decision. Benefits from surgery derive almost exclusively from the primary therapeutic aim of the procedure (e.g. tumour removal). Harms from surgery derive in general from the unintended consequences of the necessary processes of perioperative and surgical care (e.g. tissue trauma, hypovolaemia, starvation). Benefits to the patient are characterized through careful evaluation of the primary pathology and the planned surgical procedure, for example through precision imaging of a tumour. Harms to the patient are best characterized by evaluating physiological resilience to the predictable pathophysiological challenges encountered around the time of surgery. Patients can only truly weigh these factors if they understand the outcome benefits associated with good “surgical outcome”, the spectrum of harms associated with limited physiological resilience, and how these factors interact with the context of their own life. Collaborative, or shared, decision-making provides the practice framework for achieving this goal (Glance et al. 2014 ). Value is added through reducing the incidence of “wrong patient surgery” (demand management) and as a consequence of the nature of the patients who choose to decline surgery. Those patients most likely to decide not to have surgery may well be those at greatest risk of complications following surgery. This is because those patients who are aware that they are at high risk for adverse outcome, and therefore where the harms of surgery may outweigh any benefit, are those patients most likely on balance to be those who decide against surgery. This is unlikely to be because patients intrinsically know their risk level, but rather is a product of full and effective communication of the harms and benefits of surgery. Patients who have complications following surgery incur costs that are two- to threefold higher than patients who avoid postoperative complications (Pradarelli et al. 2016 ; Birkmeyer et al. 2012 ; Vonlanthen et al. 2011 ). There are many other unrelated reasons why patients may decline surgery, which on occasions may seem unusual to the physician, but which make sense in the context of their personal beliefs and preferences. Exploring these beliefs and preferences and the options available in a collaborative manner enables a truly informed choice for the patient.

Collaborative behavioural change

Collaborative behavioural change offers the opportunity to beneficially modify patient risk profiles and increase resilience prior to surgery. Smoking, alcohol consumption, diet and physical activity levels, the so-called lifestyle factors, are all linked to outcome following major surgery. More importantly, each of these factors is amendable to modification through behavioural change on a timeframe that can be achieved between the moment of contemplation of surgery and the procedure itself (Levett & Grocott 2015 ). Whilst improving any of these factors might offer a health benefit at any time in a patient’s life, there is a good argument that the period of time immediately before surgery offers a unique “teachable moment” when patients are particularly susceptible to positive behavioural messaging. The emerging science of behavioural economics aims to “meet patients half way”. Recognizing that patients do not always make decisions that optimize their own welfare, the aim of the this approach is to encourage change within existing patterns of behaviour, rather than asking patients to modify their behaviour to something more health promoting (Volpp & Asch 2016 ). Value is added through reducing postoperative complications and therefore cost as well the possibility of long-term behavioural change and public health benefit. In order for this value proposition to be viable, the aggregate costs of the intervention should be less than the resulting aggregate cost reduction. The costs of such interventions range from minimal (e.g. simple advice) and largely ineffective, to more expensive (e.g. structured in-hospital exercise training) with improved effectiveness (West et al. 2015 ). The public health benefits of long-term behavioural change, sustained long after the immediate perioperative episode is completed, are more difficult to characterize but may still be important. For example, smoking cessation is well documented to improve outcomes in a range of specialties and the “teachable moment” that comes with major surgery has been shown to improve a wide range of outcomes (Goltsman et al. 2017 ; Er Dedekargınoğlu et al. 2016 ; Jackson & Devine 2016 ).

  • Comorbidity management

When identified and characterized early in the pre-surgical pathway, many comorbidities are amenable to management that can improve the patients physiological resilience to the surgical episode and thereby improve outcome following surgery. Specialist preoperative clinics delivered collaboratively by anaesthetists/perioperative physicians and relevant specialists are increasingly offering this service before surgery (e.g. perioperative anaemia clinics) (Guinn et al. 2016 ). Often these are virtual clinics, running efficiently without the requirement for patients to attend a physical place unless specific hospital-delivered therapy (e.g. intravenous iron) is required. Value may be added through reduced complications leading to improved outcomes and thereby reducing costs, and from more proximate measures. For example, the reduction in transfusion costs resulting from anaemia management may offset or even exceed the costs of an anaemia clinic (Evans et al. 2017 ; Froesslar et al. 2017 ; Froessler et al. 2016 ). In a recent study from Germany, economic modeling showed savings of €785.54 per anaemic patient treated with intravenous iron undergoing elective abdominal surgery due to a combination of reduction in blood transfusion and length of stay (Froesslar et al. 2017 ).

Psychological preparation for surgery

Finally, patients can be better prepared psychologically for surgery. Patient information, helping to manage expectations, has long been considered a key element of enhanced recovery pathways (ERPs) (Grocott et al. 2012 ) and has traditionally been delivered in surgical and anaesthetic pre-assessment clinics. More sophisticated psychological preparation for surgery, for example using cognitive behavioural education, may provide additional benefit (Rolving et al. 2016 ). As we dissect the functions of the various elements of the pathway to surgery it becomes clear that diagnosis, prognosis and shared decision-making do not have to be undertaken at the same time and place as preparation for surgery. Increasingly, the concept of a separate classroom-based “Surgery School” is being pursued as a group patient activity (Trust tests ‘surgery school’ to get patients fit for ops | news | nursing times & Available from: https://www.nursingtimes.net/news/research-and-innovation/trust-tests-surgery-school-to-get-patients-fit-for-ops/7011466.article. Accessed 20 Dec 2016 ; Surgery school for patients | medicine | university of southampton & Available from: http://www.southampton.ac.uk/medicine/news/ 2016 /10/surgery-school-to-get-patients-fit.page. Accessed 20 Dec 2016; Your surgery 3.Pdf, Available from: https://www.cmft.nhs.uk/media/1461701/your%20surgery.pdf. Accessed 20 Dec 2016 ). Value is added through driving behavioural change as well as through effectively preparing patients for early mobilization, eating and drinking after surgery.

Conclusions

Re-designing the pathway to surgery so that perioperative physicians encounter their patients earlier in the perioperative journey opens up many opportunities to improve patient care. Collaborative decision-making offers the means of ensuring that each patient makes the right decision about which treatment option they wish to choose, including surgery. Collaborative behavioural change offers a route to improving modifiable behavioural characteristics prior to surgery through active programmes of alcohol cessation, smoking cessation, activity/exercise and dietary intervention. Surgery schools offer the opportunity to share such knowledge with all patients and thereby guide them towards healthier behaviours. Surgery schools also offer the opportunity to manage expectations in relation to the in-hospital surgical journey and improve psychological preparation for surgery. Each of these interventions offers a particular value proposition based on their relative costs and outcome benefits. Together, these interventions offer an opportunity to optimize patient decision-making in relation to surgical interventions and to maximize our patients resilience to the physiological stress of surgery through targeted management of modifiable risk factors.

Abbreviations

  • Business process re-engineering

Cardiopulmonary Exercise Testing

Enhanced recovery pathways

Information technology

Multidisciplinary team

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Acknowledgements

No funding was required for this manuscript. All authors apart from IF work within the University of Southampton NIHR Respiratory Biomedical Research Unit, which received a portion of funding from the UK Department of Health Research Biomedical Research Units funding scheme. All funding was unrestricted.

Availability of data and materials

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.

Authors’ contributions

MG conceived and drafted the manuscript. ME, IF, JP & DL all contributed to the draft. ME produced the figures. JP collated the article including references. The final version was read and approved by all authors.

Competing interests

MG is a co-chair of the annual UK National Perioperative Cardiopulmonary Exercise Testing Meeting and a board member of CPX International. He has received honoraria for speaking for and/or travel expenses from BOC Medical (Linde Group), Edwards Lifesciences and Cortex GmBH. He leads the Fit-4-Surgery research collaboration and also leads the Xtreme-Everest oxygen research consortium, which has received unrestricted research grant funding from BOC Medical (Linde Group), Deltex Medical and Smiths Medical. MPWG is also funded in part from the British Oxygen Company Chair of the Royal College of Anaesthetists awarded by the National Institute of Academic Anaesthesia. Some of this work was undertaken at University Southampton NHS Foundation Trust – University of Southampton NIHR Respiratory Biomedical Research Unit, which received a portion of funding from the UK Department of Health Research Biomedical Research Units funding scheme. All funding was unrestricted. The funders had no role in study design, data collection and analysis, decision to publish or the preparation of the manuscript. JP has received financial support from Siemens Healthcare Limited for consumables and hardware for research into the measurement of haemoglobin mass (2015–2017) but is unaware of any direct or indirect conflict of interest with the contents of this paper or its related fields.

DL is course director for the UK Perioperative Cardiopulmonary Exercise Course and is a an executive board member of the Xtreme-Everest oxygen research consortium, who has received unrestricted research grant funding from (amongst others) BOC Medical (Linde Group) and Smiths Medical. Some of this work was undertaken at University Southampton NHS Foundation Trust – University of Southampton NIHR Respiratory Biomedical Research Unit, which received a portion of funding from the UK Department of Health Research Biomedical Research Units funding scheme. All funding was unrestricted. The funders had no role in study design, data collection and analysis, decision to publish or the preparation of the manuscript.

IF and ME declare that they have no competing interests.

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Grocott, M.P.W., Plumb, J.O., Edwards, M. et al. Re-designing the pathway to surgery: better care and added value. Perioper Med 6 , 9 (2017). https://doi.org/10.1186/s13741-017-0065-4

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The Patient's Voice | HCM: Understanding the Patient Journey From Diagnosis to Treatment

Cardiology Magazine

HCM: Understanding the Patient Journey From Diagnosis to Treatment

As with any disease, the first step towards treatment starts with a diagnosis. Along with feeling seen and heard, starting to have answers helps to relieve concerns and empowers patients to manage their symptoms. Unfortunately, for patients with hypertrophic cardiomyopathy (HCM), the gap between the onset of symptoms and official diagnosis can be long and frustrating. A survey of patients with diagnosed HCM conducted by the ACC and the Hypertrophic Cardiomyopathy Association (HCMA) offers a closer look at some of the challenges along the path to HCM diagnosis and management in an effort to close this gap and optimize care and outcomes.

According to estimates, between one in 500 and one in 250 patients have HCM, but only about 100,000 patients have been formally diagnosed with the disease. One reason could be the disparities in cascade or family screening, which could catch HCM before symptoms appear. Of the 608 patients surveyed, only 13% had pursued medical care because a family member was diagnosed with HCM or experienced a sudden cardiac arrest, while only 10% listed a family history of heart disease as their reason for seeking a medical appointment. Notably, only a very small number of those surveyed took part in cascade or family screening (3%) or genetic testing (14%).

In contrast, experiencing symptoms consistent with HCM was the most common reason (for 89%) for seeking medical care: dyspnea in 48%, heart murmur (36%), arrhythmia (35%), dizziness (35%), reduced exercise capacity (27%) and fatigue and weakness (27%). Chest pain/pressure when exercising as well as chest pain/pressure at rest were reported by about a quarter of respondents. About two-thirds said they had multiple symptoms.

Dyspnea was more commonly reported by women than men (52% vs. 39%) and those who reported worse health in the past year (57%). In addition, dyspnea was more frequently reported as the initial symptom by patients ultimately diagnosed with obstructive HCM and mid-cavity HCM.

Time to Diagnosis

According to estimates, between one in 500 and one in 250 patients have HCM, but only about 100,000 patients have been formally diagnosed with the disease.

From the start of symptoms to the time of HCM diagnosis, it took five years or more for nearly 50% of patients. Most patients (two-thirds) surveyed experienced symptoms by the time they were 40 years old, but only about 40% gained a diagnosis by that age.

Women were more likely than men to report a gap or delay of five years or more between initialing experiencing symptoms and being diagnosed (52% vs. 37%).

Once patients sought care for their symptoms, with the majority seeing a cardiologist (43%), followed by a family or primary care physician (33%), two-thirds reported receiving a correct diagnosis, with more than half saying it took less than one year. The data indicate a true opportunity to improve time to diagnosis for nearly a third of the patient community.

The majority of those surveyed noted that echocardiography and ECG were the most common tests conducted (72% and 66%, respectively), followed by Holter/event monitoring, exercise stress testing and cardiac MRI. Those who received genetic testing, cascade MRI or cascade screening were among those most likely to report a correct diagnosis.

Some 37% of patients noted receiving an incorrect diagnosis or no diagnosis at all. Of the incorrect diagnoses, heart murmur was the most common, followed by hypertension, anxiety/panic attacks and asthma.

Of note, a correct diagnosis of HCM was more likely for patients who first saw an HCM specialist (only 3% of those surveyed) or a cardiologist, than those who initially saw a primary care or internal medicine physician.

HCM Takes a Toll

The Hypertrophic Cardiomyopathy Association (HCMA) has been serving the HCM spectrum disorder community since 1996.

The survey conducted by the ACC/HCMA on the patient experience shows a high level of emotional and psychological toll on patients with HCM. While it is important to ensure patients have strong clinical support for their physical symptoms, we must also ensure support for the significant emotional burden of having a chronic genetic cardiac disease.

The HCMA has programs to support patients and their families through the uncertainty that life with HCM can present. Learn more about the HCMA at 4hcm.org .

The survey highlights important opportunities for continued clinician and patient education on HCM, whether it's understanding the many signs and symptoms which can be unpredictable or knowing when to seek screening based on risk factors like family history. Only 33% of those surveyed felt they could find a clinician who understands HCM and could treat it.

Developing tools to help friends, family and others support those living with HCM is also an opportunity for closing gaps in care. More than half of respondents said their friends and family do not understand the disease and how it affects daily life. Helping patients navigate diet and exercise is another area for growth. For example, while 81% of patients said they knew exercise is good for them, 62% were afraid of pushing their heart too much. This was especially true among women and those who had indicated worsening health status in the past year. The HCMA has been suggesting that exercise prescriptions by the physician for patients with HCM would contribute to teaching patients how to safely be active and that this may improve their overall quality of life.

Living with HCM is exhausting said half of respondents and managing stress and depression is challenging. For younger patients, it was more challenging to manage the risks, feel in control of the disease and to plan ahead, and they are concerned about sudden death, a lifetime of uncertainty, emotional distress, access to experts and the impact on children and family. Compared with the past year, a third of a patients said their health status was worse, while better outcomes were reported by patients who saw an HCM expert or went to a center of excellence.

According to one patient, "It has been confusing living with the symptoms (dyspnea, weight gain, tiredness/weakness). I, admittedly attributed the worsening symptoms to getting older, gaining weight, and COVID keeping me from getting out and going to the gym. I was shocked to find out there was a real reason for feeling the way I did. I am grateful to have a cardiologist who recognized HCM and who recommended surgery when the medicines no longer controlled the disease. It's a bit of a 'hidden disease' and I'm sure I'm not alone in saying that you tend to hide the symptoms and keep a lot of it to yourself. The HCMA has been a valuable resource navigating this disease."

Financial burdens are also great, with one-third of survey respondents noting HCM taking a toll on their pocketbooks as a result of high costs associated with medications, procedures and/or travel to see an expert. In the past six months alone, nearly half of all participants reported a major event that required either an urgent appointment with their physician, a trip to the emergency department, overnight hospitalization and/or missed work for 14%.

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Keywords: ACC Publications, Cardiology Magazine, Quality of Life, Cardiologists, Depression, Dizziness, Exercise Tolerance, Financial Stress, Friends, Panic Disorder, Physicians, Primary Care, Uncertainty, Cardiomyopathy, Hypertrophic, Echocardiography, Electrocardiography, Genetic Testing, Magnetic Resonance Imaging, Cine, Risk Factors, Emergency Service, Hospital, Psychological Distress, Patient Outcome Assessment, Internal Medicine, Hospitalization, Family, Heart Murmurs, Prescriptions, Primary Health Care, Weight Gain, Weight Gain, Surveys and Questionnaires, Arrhythmias, Cardiac, Chest Pain, Dyspnea, Anxiety, Asthma, Fatigue, Diet, Exercise

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patient journey surgery

The Patient Journey: What it is and Why it Matters

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Healthcare is under enormous pressure today.

Patient expectations about their service and experience have changed over the years. Patients have more choices about their care, and they’re more empowered with information about what they want their care experience to be. They expect you to interact with them on their terms, not yours. And with COVID-19 turning so much of our lives digital, this trend has only accelerated.

Having a robust marketing automation approach is critical to addressing these challenges in today’s environment. Meeting — and exceeding — patient expectations comes down to managing your patient’s engagement journey. 

How can patient journeys improve care?

What patient journeys can do is turn the healthcare experience from a primarily reactive experience to a proactive one.

By building out journeys for your patient personas, you can close gaps in care, establishing robust preventative routines that ultimately help your patients stay as healthy as possible for as long as possible.

Engaging consumers and patients where they are builds trust and confidence that keeps patients in the system and encourages them to refer their friends and family to your practice. According to the Beryl Institute , 70% of patients will share a positive experience with others. But your bigger risk is that 76% will share a negative one. And with a negative experience, 43% of patients won’t go back to that provider, with 37% finding a different doctor altogether.

What is the patient journey?

A patient journey represents the entire sequence of events that a patient experiences within a given healthcare system or across providers, from scheduling an appointment for a regular checkup to receiving treatment for an illness or injury. 

A patient journey is an ongoing process that incorporates all parts of the healthcare ecosystem, from hospitals to physicians, specialty care, and outpatient therapy.

While it is easy to think about a patient’s journey as those interactions you have with them before, during, and after an appointment, there are actually many other touchpoints that drive their overall journey. A comprehensive patient engagement strategy touches on all aspects of a patient’s relationship with a healthcare provider, including:

  • Onboarding and Access 
  • Diagnosis and Treatment
  • Adherence to Lifestyle or Behavioral Changes
  • Ongoing and Proactive Health (Wellness)
  • Referrals and Loyalty

How do I create the patient engagement journey?

Every single interaction with a patient is part of the patient engagement journey and a moment of truth for the health system or provider to add value.

In today’s value-based healthcare world, having that personalized experience is more important than ever. A patient engagement journey organizes those communication touchpoints and ensures you’re delivering the right information at the right time to the right person, and leveraging the appropriate communication channel. Millennials and Generation Z, for example, may be more likely to prefer a text, email, or chat to a phone call.

It’s about knowing your patients’ preferences — like that they prefer to be texted during the day while they’re at work or if they prefer an office vs. telehealth visit — and what’s going to make it easier for them, like sending automatic reminders the week and day before an appointment.

Whether it’s making sure you follow up with cardiac patients about weighing themselves daily after surgery to catch any water retention issues or asking colonoscopy patients whether or not they’ve been following post surgery protocols after discharge, it’s about continuity of care once a patient leaves the office or hospital so they have a quality outcome. From there, patients can more proactively drive their own wellness plan.

Here are important areas to focus on when creating your patient engagement journey:

Establish your patient personas

You need to know the different types of patients that are coming into your organization. You want to figure out:

  • What are the most relevant needs of your patients?
  • What are their communication and care preferences?
  • How do they want to engage with you?
  • What information do you already know about them?

To be able to craft the best possible patient experience, you first have to know more about your patients.

For example, there’s a well-known healthcare persona out there called the “Medical Mom” (which can, of course, be any individual taking care of themselves, their kids, their spouses, and may also be the caretaker for aging parents). 

Let’s say this individual has three children, and they book annual physicals at their pediatrician, which happens to have offices in the same building as their own primary care physician. Wouldn’t it be nice if the office sent them one email reminder to schedule all five appointments, rather than five different emails? And when they do call, scheduling those appointments back-to-back so everyone is in and out in one afternoon?

A spreadsheet is not going to be able to do that for you. Collecting and managing the data required to drive complex, interconnected patient journeys requires more than a spreadsheet. In order to succeed, you’ll need to pay close attention to the entire patient lifecycle.

Understand the entire patient lifecycle

An appointment reminder is a great start to engaging a patient, but it’s just one event in an ongoing patient lifecycle that begins with preventative care and includes diagnostics, delivery of care, and post-operations.

For example, how many patients show up for routine blood work at their physician office and you find out they haven’t fasted for the appropriate amount of time? Sending a patient home is frustrating for them and it’s frustrating for you. If the appointment is at 2:00 PM, then that appointment reminder should have been sent at dinnertime the previous evening, reminding them that they can’t eat anything after a 6:00 AM breakfast the next morning.

You’ll want to tailor your communications based on whether the patient is new or existing, what their preferences are, and whether they have any specific or chronic health issues. From there, you need to…

Understand the moments of truth

The healthcare system is complicated, even for those who have been a part of it for decades. The key to building a great foundation for your patient engagement strategy is to put yourself in a typical patient’s shoes. Most patients don’t engage with the healthcare industry unless they’re feeling sick. That means they’re rarely at their best, and they’re not only anxious about getting better, but about the costs associated with that.

The best healthcare providers understand the moments of truth — opportunities for a positive touchpoint that can alleviate their stress and anxiety and help them get on the road to recovery. Every time you interact with a patient is an opportunity for a moment of truth, whether that be in person or via other channels of communication.  It’s not only about establishing accurate moments of truth, but capitalizing on them.

It’s up to you to understand the places people need to be, how you want to communicate to them, and make every one of those touchpoints a positive experience. It doesn’t matter whether they’re physically in your office or not. Your patient engagement journey is what guides your patients to making the best possible decisions on their care so they get better. 

The easier you make it for them to engage with you, the higher quality their care will be.  Ultimately, you want your patients to be evangelists for your services based on their positive experiences. To do that, you’ll need to…

Get the data you need

Your patients expect personalization.

Personalization in healthcare used to mean created tailored treatment plans and clinical protocols. That’s still important, but patients expect more personalization around the entire experience, from access to communication to quality outcomes. It’s like turning on a light switch in your home: a patient just expects the light to turn on. 

Personalization today means being able to see at-a-glance a patient’s healthcare record, communication preferences, and social determinants that may be impacting their overall health to give you a 360-degree picture .

To do this, you need more than clinical data.

You may have patients that constantly miss their appointments. By storing questions that go beyond health risks — say, that they’re a smoker — but to understand that they don’t have a car to get to the appointment in the first place is becoming a more important part of the process. Part of empathetic, compassionate care is understanding these environmental factors that can help patients get the care they need, whether that’s calling a Senior Shuttle, caregiver, or arranging a telehealth appointment instead.

Once you have the data, you can…

Encourage referrals and loyalty

The first place people look for a new doctor isn’t the Internet. It’s their friends and family. In an ideal world, every patient you have should be able to say, “Oh, I loved my experience with…”

Doing that starts with the technology you have. Before a patient ever comes in for treatment, you need to make sure they have a seamless experience that builds trust and encourages referrals and loyalty. 

How do I get started with patient journey mapping?

It’s time to move away from the mindset to simply fill the top of the funnel with as many new potential patients and contacts with caregivers as possible. While this is still a requirement, it is just as crucial for organizations to get better at managing and growing relationships at every phase of the patient journey. Providers must engage with consumers in the marketplace to introduce them to their services of course, but it is of growing importance that they offer support throughout the entire diagnostic and treatment process. 

As a Salesforce Platinum Partner with deep industry expertise, we have created a Foundation for Patient Engagement package — a complete strategy that starts with Health Cloud and facilitates a 360-degree view of the patient , as well as a comprehensive communication strategy, CTI integration, and the use cases driving patient acquisition, engagement, and loyalty.

Learn more about building your patient journey with Silverline.

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  • v.27(7); 2020 Jul

The bird’s-eye view: A data-driven approach to understanding patient journeys from claims data

Katherine bobroske.

o1 Cambridge Centre for Health and Leadership Enterprise, University of Cambridge, Cambridge, United Kingdom

Christine Larish

o2 Research and Development, Evolent Health, Arlington, Virginia, USA

Anita Cattrell

Margrét v bjarnadóttir.

o3 Robert H. Smith School of Business, University of Maryland, College Park, Maryland, USA

Lawrence Huan

Associated data.

In preference-sensitive conditions such as back pain, there can be high levels of variability in the trajectory of patient care. We sought to develop a methodology that extracts a realistic and comprehensive understanding of the patient journey using medical and pharmaceutical insurance claims data.

Materials and Methods

We processed a sample of 10 000 patient episodes (comprised of 113 215 back pain–related claims) into strings of characters, where each letter corresponds to a distinct encounter with the healthcare system. We customized the Levenshtein edit distance algorithm to evaluate the level of similarity between each pair of episodes based on both their content (types of events) and ordering (sequence of events). We then used clustering to extract the main variations of the patient journey.

The algorithm resulted in 12 comprehensive and clinically distinct patterns (clusters) of patient journeys that represent the main ways patients are diagnosed and treated for back pain. We further characterized demographic and utilization metrics for each cluster and observed clear differentiation between the clusters in terms of both clinical content and patient characteristics.

Despite being a complex and often noisy data source, administrative claims provide a unique longitudinal overview of patient care across multiple service providers and locations. This methodology leverages claims to capture a data-driven understanding of how patients traverse the healthcare system.

Conclusions

When tailored to various conditions and patient settings, this methodology can provide accurate overviews of patient journeys and facilitate a shift toward high-quality practice patterns.

INTRODUCTION

Medical researchers have long pointed to the importance of understanding the realistic picture of the patient journey: the chronological sequence of how a patient seeks and receives care from the healthcare system. 1 , 2 Capturing an accurate overview of the patient journey can help identify sources of variability, evaluate why patients respond differently to the same overarching treatment plan, and compare how actual realizations of the treatment plan differ from standard clinical guidelines. However, in a fragmented healthcare system, it can be difficult to derive a comprehensive understanding patient journeys based on real utilization patterns.

Understanding the patient journey is especially important for highly variable, preference-sensitive conditions such as back pain. 3–5 Because back pain has numerous clinically acceptable therapeutic options, the trajectory of patient care can be highly variable and influenced by the severity of the condition, access to healthcare services, provider preferences, and the patient’s medical history. 5–7 Adding to this complexity, treatment for back pain often occurs across service locations (eg, primary care, emergency services, physical therapy). While significant effort has been placed on extracting and analyzing patient journeys from electronic medical records and clinical workflows, these data sources tend to be centered around a single healthcare provider. 8–10

To obtain a more comprehensive overview of the patient journey across various providers and locations, we propose a data-driven methodology based on medical and pharmaceutical claims data. In the U.S. healthcare system, administrative claims data from insurance providers offer a uniquely detailed retrospective account of how individual patients receive medical treatment. 11–13 Claims data contain date, diagnostic, procedural, and provider information, which, when strung together, create an overview of services provided by a collection of clinicians.

Compared with electronic health records, insurance claims are a useful platform to study longitudinal utilization and conditions that are treated across multiple locations. However, claims data are often inherently noisy, have duplicated information, and may not accurately identify a complete list of services provided to the patient. 14 , 15 With these challenges, to our knowledge, automatic detection of representative patient journey patterns from claims data has not been successfully completed at scale.

The proposed data-driven methodology uniquely combines and builds on tools leveraged elsewhere in healthcare informatics to develop an algorithmic approach to extract and understand patient journeys from claims data. 16–25 We represent the back pain–related events of the patient’s journey as a string of letters, in which each letter corresponds to a distinct encounter with the healthcare system. We then evaluate the similarities between the strings based on both their content and their ordering (with a dynamic sequence alignment algorithm), and finally cluster the patient journeys together (using ensemble clustering) to identify representative patterns. Applied together, using careful data modeling, these analytic elements create a data-driven understanding of the patient journey.

The proposed methodology to extract patient journey patterns from claims data combines and customizes techniques from sequence alignment and clustering. Applications of sequence alignment (such as the Levenshtein edit distance) have been successfully implemented within informatics to map laboratory text into a standardized medical vocabulary, identify duplications in electronic medical records, and normalize terms in clinical text. 16–19 Clustering has been shown to be effective at compressing large clinical datasets; techniques including k-means clustering are commonly applied to image processing in the context of radiology scans and skin tissue samples. 20–23

There is a large prior literature that focuses on understanding or extracting patient journey patterns from event logs, such as electronic medical record systems. 8 , 10 , 26 , 27 When patient journey data are organized into event logs or time stamps, process mining can discover a single process map (or set of maps) that shows how entities transfer from the beginning to the end of the system. 24 , 28 Even though noise reduction techniques have been developed to address challenges such as missing data and repeated events, the frequency of such occurrences in claims data makes it difficult to apply process discovery within the claims setting. 9 , 29 , 30 Furthermore, in conditions like back pain, in which it is appropriate to revisit or repeat events such as physical therapy, it may not be appropriate to conceptualize the patient journey as an end-to-end process.

When studying the patient journey using administrative claims, analyses typically limit the analysis to specific elements of the patient journey, for instance, categorizing the first-line treatment after condition onset, or looking at the first 3 events of the treatment pathway. 31 , 32 Claims have also been used to measure outcomes of pathway effectiveness, without being leveraged to create an understanding of the patient journey itself. 33 , 34 Other work identified common pathways by frequency, but this inherently biases the outputs to display the shortest and simplest patient pathways. 35 In contrast, our proposed methodology uses a data-driven approach to identify similarities between patient journeys and understand the main patterns across the patient’s full set of interactions with the healthcare system.

MATERIALS AND METHODS

There are 3 analytical steps to the proposed data-driven approach to extract the patient journeys: claims processing, sequence alignment, and journey clustering. Details of all clinical assumptions, including codes used to process the data, are provided in the Supplementary Appendix .

Claims processing

This research utilized a nationwide U.S. dataset that included medical and pharmaceutical claims from 29 different provider networks across 23 states and the District of Columbia. While not a nationally representative dataset, the patients were insured through commercial, Medicare Advantage, and Medicaid plans and represent a variety of patient demographics and comorbidities. The research was approved by the Ethics Committee at the University of Cambridge Judge Business School as a nonhuman subject study.

We analyzed all back pain–related claims between September 2012 and March 2019, in which back pain was broadly defined to encompass patients expected to follow conservative back pain guidelines, such as those released by the American College of Practitioners. 36 , 37 Following the related back pain literature, patients were excluded if they had a history of cancer, congenital abnormalities, or certain autoimmune conditions, or if they were being treated in end-of-life care, as the care for these patients is often medically justified to deviate from the general guidelines. 36–39

We identified a random sample of 10 000 back pain episodes (corresponding to 9981 unique patients) in which the patient had an initial back pain–related claim after a minimum 6-month clean period without back pain–related claims. 38 , 40 Patients were required to be fully eligible in the dataset for at least 12 months before the start of the episode and for 6 months after the index back pain claim. We then extracted the first 6 months of back pain claims for each episode, totaling 113 215 claims.

The claims processing stage uses clinical assumptions to group the medical and pharmaceutical claims into 14 event types (see Table 1 ). For each event type, we identified the set of diagnosis, procedure, revenue, service location, and clinician specialty codes that could be used to classify the claims. For some event types such as back pain surgery (coded as event letter “S”), the event is clearly defined and the codes used to identify claims are directly drawn from the medical literature. 4 , 38

Back pain episode event categories and event type descriptions

Within the back pain setting, the order of the table from top to bottom reflects a decreasing clinical importance of the events.

Other event types require a more knowledge-driven approach to identify the combination of characteristics that classify claims into events. For instance, the unplanned care event (coded as event letter “E”) looks for claims related to an emergency department visit (revenue code starting with 045, service location code 23, or Current Procedural Terminology code between 99 281 and 99 285) or urgent care visit (revenue code starting with 0516 or 0526, service location code 20, or Current Procedural Terminology code of S90088 or S9083). Further description of how we arrived at the code classification can be found in the Supplementary Appendix .

Once the claims are assigned to an event type, the claims within each event category are aggregated based on overlapping dates into distinct interactions with the health system. For example, if a physical therapy appointment generated more than 1 medical claim, these claims would be grouped together into a single “physical therapy” (T) event. Likewise, all medical claims associated with a multiday inpatient hospital stay would be grouped together into a single “inpatient admission” (A) event.

If an event contained claims that could be classified into different event types, the event is labeled according to the claim with the highest relative importance. For example, if a patient saw a surgeon (G) while admitted to the hospital (I), the event would be labeled as an inpatient admission (I). The order of importance of various events, also known as a clinical hierarchy, is represented from top to bottom in Table 1 , with higher importance events listed first. 41

Because combining claims into a single event only occurs within the partitions of an event category (eg, diagnostic imaging), it is possible that events from different categories occur on the same day. We also apply the clinical hierarchy from Table 1 to order these same-day events, such that the general medical interactions are ordered ahead of diagnostic imaging or prescriptions. This logic assumes that the clinician associated with the general medical interaction likely ordered the diagnostic imaging or prescription drugs.

Events are each assigned a letter and then strung together in consecutive order to form a longitudinal view of the patient journey for back pain across distinct specialty appointments, prescriptions, facility visits, and diagnostic tests. As an example, the string P-T-T-I-O-W is a potential patient journey. It represents a patient that first went to their primary care physician for back pain (P), had 2 physical therapy appointments (T-T), was given diagnostic imaging in the form of magnetic resonance imaging or a computed tomography scan (I), and then was prescribed an opioid (O). A time-spacing event (W) indicates that significant time has elapsed between events or marks the end of an episode.

Depending on the specific study context, the preprocessing stage can make a significant impact in reducing the dimensionality of the dataset. In our illustration, 113 215 back pain claims were reduced to 53 820 events (a 52.5% reduction in distinct data points), representing 2863 unique variations of the 6-month back pain patient journey. Figure 1 contains a visual representation of the first 4 back pain–related events across the patient sample.

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Variation in the first 4 events of the patient back pain journey. Because back pain is a preference-sensitive condition, high variation exists in the first 6 months of the patient journey. The letters in this Sankey chart correspond to the event types displayed in Table 1 . Of the patient back pain episodes, 74% contain 4 or fewer events; 89% are completed within 6 months.

Sequence alignment

For preference-sensitive conditions such as back pain, the treatment decisions (eg, whether the patient was prescribed opioids) as well as the order of treatment decisions (eg, whether the patient was sent for advanced imaging before or after attempting physical therapy) can substantially impact patient outcomes. 4 , 37 , 40 , 42 , 43 The next stage of our proposed algorithm assesses the similarity between pairs of patient journey sequences based on both content and order, without requiring researchers to explicitly define clinical rules.

Levenshtein’s edit distance algorithm aligns 2 sequences using a combination of edits: matches, insertions (or, equivalently, deletions), and substitutions. 44 For example, the sequences G-T-T-T-P and P-T-P could be aligned by substituting the G for P at the front of the string, and inserting 2 Ts into the middle of the second sequence (see Figure 2 ). In the standard Levenshtein algorithm, each match between the 2 sequences is awarded a value of 1 and each insertion or substitution is penalized with a value of –1. 45 As such, aligning G-T-T-T-P and P-T-P as described previously (substitute + match + insert + insert + match) with the Levenshtein edit costs would result in an alignment score of −1.

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Example of sequence alignment. Our adaption of Levenshtein’s edit distance maximizes the total score of aligning 2 sequences using matches, substitutions, insertions, and transpositions. Because multiple possible alignments exist for any 2 strings, dynamic optimization is applied to maximize the sequence alignment score based on the given edit values.

Our algorithm relies on 2 expansions of the Levenshtein algorithm. First, we allow for transpositions, such that O-P and P-O could be aligned by swapping the last 2 characters instead of applying the insert-match-insert sequence. 46 This is important in the back pain context because small changes in the order of patient actions (eg, filling a prescription and getting an x-ray) are often due to scheduling constraints and are of little consequence to the patient’s overall pattern of care. Second, unlike in the Levenshtein algorithm, in which all edits are penalized with a value of 1, our algorithm customizes the edit values based on both the type of editing action and the event being edited. 19 For instance, transposing 2 letters may be awarded a smaller edit value compared with matching on the same 2 letters.

Assigning edit values can be data-driven, involve the input of medical experts, or a combination of both. 47 For back pain patients, some rarer treatment options, such as surgery, can be a defining aspect of the patient journey. Therefore, instead of weighting a match on surgery equal to a match on a primary care visit, we assign the value of matching events in proportion to the rareness of the event (which we refer to as rareness weighting). With match values scaled between 1 and 10 in our dataset, A (inpatient admission), which makes up 0.1% of events, has a match edit value of 10.0, while P (primary care visits), which makes up 11.7% of events, has a match edit value of 2.2. See the Supplementary Appendix for a complete list of edit values and the corresponding sensitivity analyses.

As each pair of sequences may be aligned with multiple sets of edit actions, we utilize dynamic optimization to efficiently calculate the highest possible alignment score. The dynamic program is based on the principle that the maximum alignment score of strings i and j must be some combination of an action (eg, substitution) on the last letter(s) of 1 or both the sequences and the optimal score before that action. Specifically, we define s i , j * ( y , z ) to represent the maximum score of aligning the first y elements of patient journey i (where 1 ≤ y ≤ i _ len ,   the number of elements in sequence i ) with the first z elements of patient journey j (where 1 ≤ z ≤ j _ len ,   the number of elements in sequence j ). The value of the yth element of i is designated as i [ y ] and the zth element of j as j [ z ] .

The values ( v ) associated with each potential edit operation are v mtc   (match), v sub (substitution), v ins (insertion), and v tns (transposition). The dynamic optimization problem to maximize similarity score s i , j * y , z can be expressed through the following formulation:

Subject to:

Where [1] inserts letter j z into string i , [2] inserts letter i y into string j , [3] matches letter i y = j z , [4] substitutes letter i y for j z , [5] transposes letters i y - 1 : y with j z - 1 : z , and [6] indicates that a transposition between i y - 1 : y and j z - 1 : z is not valid.

After obtaining the optimal similarity score, we calculate the minimum ( scale _ min i j ) and maximum ( scale _ max i j ) scores that could have been generated for the given pair of strings i , j (see Supplementary Appendix for calculation). We then transform the optimal value of aligning the 2 complete strings s i , j * ( i _ len , j _ len ) into a normalized similarity score s i , j , where 0 represents no similarity between strings and 1 implies the strings are identical:

The algorithm thus assigns high similarity scores to similar patient journeys (eg, P-X-O-W and P-X-O-O-W have a similarity score of 0.81) and lower scores to less similar journeys (eg, P-X-O-W and E-R-P-W have a similarity score of 0.21). The similarity scores s i , j for each pair of journeys are compiled into a similarity matrix (see Figure 3 ).

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Sample of the n -by- n similarity matrix. The matrix is populated using the normalized similarity scores. The index [ i , j ] in the similarity matrix s corresponds to the similarity score between patient journey i and patient journey j . Note that diagonal entries all have a normalized similarity score of 1 (as a given patient journey is identical to itself), and the lower diagonal is a reflection of the upper diagonal scores (because s i , j = s j , i ).

Journey clustering

The goal of the clustering is to summarize the main patterns of the patient journeys. As it is important for the methodology to scale to large patient samples, we leverage k-means clustering, an effective approach when classifying objects within large datasets. 21 The basic k-means algorithm (1) chooses k objects to be cluster centers, (2) assigns all other objects to their nearest cluster center, and (3) re-evaluates the center of the cluster. Steps 2 and 3 are repeated until the algorithm converges and no reassignments are made.

To choose the cluster centers, we leverage the “k-means++” seeding technique, an approach that encourages starting seeds to be widely spread across the sample. 48 After the first center K is randomly chosen, the next center is chosen by assigning a probability based on the squared distance between K and the other objects.

Then, because k-means clustering can be sensitive to its initialization, we aggregate the results from multiple iterations of k-means using ensemble clustering. Ensemble clustering forms more stable clusters, with improved robustness and less distortion. 21 , 22 , 49 After the k-means algorithm is run with different values of k and starting seeds, we calculate the percentage of times that patient journey i has been clustered together with patient journey j . These percentages are populated into what is called a co-association matrix.

Researchers can then choose the single-link threshold t , which represents the minimum percentage that a patient journey i must have been clustered together with 1 (or more) of the patient journeys j in the final data partition C n for patient journey i to be added into   C n . In the example illustrated in Figure 4 , higher thresholds (eg, 90%) yield smaller and more homogenous clusters, whereas lower thresholds (eg, 50%) yield larger and more diverse clusters.

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Aggregating k-means results using ensemble clustering. A single-link method partitions the outputs from multiple iterations of k-means into the final patient journey clusters C n . When the minimum threshold t is set to 90%, 2 clusters form: POWPO-POWPRO and GWGIGW-GXIGW; the other 4 patient journeys drop out as “noise.” When t  =   70%, patient journeys are categorized into 1 of 3 clusters: GWGIGW-GXIGW-GXIW, POWPO-POWPRO-PPRW, or EOXW-EPOPW. When t  =   50%, 2 clusters merge, resulting in 2 more heterogeneous clusters: POWPO-POWPRO-PPRW-EOXW-EPOPW and GWGIGW-GXIGW-GXIW.

The chosen threshold t should balance the specificity of the clusters (to focus on specific sets of patients) with the cluster size (to gain enough “power” for any subsequent interpretations, regressions or analyses). To gain an overview of the main patient journey patterns in this study, clinicians selected a threshold of 50% to extract 12 main patient journey patterns from the data. As detailed in the Supplementary Appendix , this threshold is appropriate for this study context in gathering a comprehensive overview of the first 6 months of back pain treatment; setting t to higher thresholds resulted in more, smaller partitions appropriate for studying more detailed clinical questions.

Using the proposed data-driven methodology, the 10 000 patient journeys were reduced into 12 primary patient journey clusters. The resulting clusters displayed in Table 2 show the distribution of patient episodes between diagnosis and treatment pathways, along with example patient journey sequences that make up each cluster.

Back pain patient journey clusters

The highest proportion of patients (17.0% in cluster 1) visit a primary care practitioner and are directed to a low-acuity next step that may include waiting at least 4 weeks, getting an x-ray diagnosis, or a physical or occupational therapy appointment. Patients in cluster 1 appear to closely follow clinical guidelines that promote noninvasive, nonopioid care after initial onset of back pain. 36 , 43 Patients in clusters 5 and 7 also begin their back pain episode in the primary care setting; however, most patients fill prescriptions (either opioid or nonopioid) as their first-line treatment.

The second most common cluster is comprised of patients who make an unplanned visit to an emergency or urgent care center and receive an x-ray (16.0% in cluster 2). In 9.7% of episodes (cluster 3), we observe a self-referral to physical or occupational therapy, in which the patient proceeds to have approximately 3-5 additional therapy appointments. There also exist small, well-defined clusters such as cluster 8 (5.7% of episodes in which patients are primarily treated with facet or epidural injections) and cluster 12 (5.0% of episodes in which pain medicine specialists are consulted but do not administer epidural or facet injections).

As described in the Materials and Methods, patient journeys were clustered solely on the sequence of the patient’s back pain events without considering the patient’s comorbidities or demographics. However, as seen in Table 3 , there is a high level of variability between clusters in terms of patient characteristics.

Cluster summary statistics

For example, patients in cluster 6 (who receive 10 or more physical or occupational therapy sessions) or clusters 9, 11, and 12 (who obtain care from specialists) are more likely to live in areas with higher average salaries compared with patients who follow different patient journeys. Meanwhile, the lowest average salaries within the sample are associated with clusters 2 and 10 (seeking care from the emergency room) or cluster 7 (being prescribed opioids by a primary care physician). The alternative medicine cluster (cluster 4) is associated with the youngest average age of the sample, whereas cluster 8 (invasive pain management procedures) is associated with the highest average age.

Driven largely by our use of rareness-weighted edit values, there is a high level of diversity between clusters in terms of the key back pain outcomes such as early advanced imaging and surgical rates. 37 For example, high rates of back pain surgery are concentrated among the patients whose initial starting encounter is a surgeon (cluster 9 at 9.1%), compared with patients who enter the system though other clinical entry points. Episodes in cluster 8 (invasive pain management procedures) average 10.1 times higher medical costs than episodes in cluster 1. In cluster 7, in which the patient’s first point of contact is typically the primary care physician, 91.2% of patients are prescribed and fill opioids within the first 6 weeks of the start of their episode. This opioid fill rate in this primary care cluster even exceeds that of clusters 2 and 10, in which patients seek care in emergency or urgent care settings.

Although early advanced imaging within 6 weeks of onset of pain is considered a major contributor to overtreatment and inappropriate medical spending, 89.8% of the patients in cluster 10, who seek care in an emergency or urgent care setting, receive magnetic resonance imaging or a computed tomography scan within 6 weeks of their index back pain claim. 4 Despite the high cost associated with this cluster, the episodes appear short-lived, with 93.4% of patients ceasing treatment for back pain within the first 6 weeks compared with the overall rate of 88.9% across the sample. An additional 27.8% of patients who seek care from a surgeon (cluster 9) receive advanced imaging within the first 6 weeks, as do 17.3% of patients whose care is managed by nonprocedural specialists (cluster 12). Although they jointly comprise only 23.4% of episodes in the sample, clusters 8-12, which rely heavily on specialists, procedures, and imaging, make up 43.2% of overall back pain spending.

While claims data have been touted as having the potential to provide a bird’s-eye view of a patient’s healthcare records and of healthcare utilization at the population level, studies have often fallen short of that goal. Claims data are notoriously noisy (owing to, for example, variation in medical coding) and are not generated for research purposes. 11–15 The proposed methodology effectively used a combination of data processing, sequence alignment, and ensemble clustering to identify primary patient journey patterns in the highly variable, preference-sensitive condition of back pain.

When a group of primary care providers in a large multispecialty clinic were presented with the preliminary cluster outputs using the group’s own data, they initially voiced concerns about the validity of the treatment pathways. However, within a short time of reviewing the outputs, the clinicians moved beyond their own recollections of individual patient cases to a more objective discussion treatment options within the context of real-life complexities. In addition to engaging with an overview of care plans, clinicians leveraged the outputs to better understand variability between outcomes and inform future medical research into how patients and providers interact to create high-quality care.

This study is the result of a close collaboration between healthcare informatics researchers and clinicians. Medical expertise on back pain was instrumental in designing an objective with clinical relevance and informing the patient sample criteria. Clinicians also helped define event types, set edit value assumptions, and interpret cluster results. While not used directly in this research, standardized logics, such as SNOMED CT (Systematized Nomenclature of Medicine Clinical Terms), can aid informatics researchers when translating clinical assumptions into corresponding diagnosis codes. 50

There are multiple opportunities to expand this methodology in future work. First, the methodology could be adapted to study longitudinal healthcare events such as chronic conditions or the patient experience at the end of life. Doing so may require researchers to adjust the preprocessing steps such that the patient journey is represented in blocks of time instead of as a string of distinct events.

Second, researchers could consider different methods of assigning edit values. For instance, the rareness-weighting method of assigning edit values was developed when clinicians identified that the Levenshtein edit values caused insufficient differentiation of journeys with rare, high-cost events. In other research contexts that have well-established guidelines, a weighting strategy could assign edit values based on which events are recommended as first-line or second-line therapies.

Third, the methodology could be adjusted based on the size of the dataset. The sequence alignment step can be computationally intensive as it compares each pair of patient journeys to obtain the full matrix of similarity scores. In comparison, conformance checking in process mining uses sequence alignment to compare event-log data to a single, predetermined understanding of the process map. 19 , 24 While the conformance checking approach anchors the analysis to prior, potentially biased knowledge of the system, there likely exists a balance between its limited comparisons and our methodology that lets patterns emerge fully from the data. Researchers could also compare the efficiency of the presented clustering method to techniques such as spectral clustering.

Finally, we have not yet explored techniques used in other applications of data science and sequence alignment, including the trace-back method that identifies sources of deviations along pairs of sequences. 51 In the context of preference-sensitive conditions, the trace-back method could allow researchers to isolate key discrepancies between journeys that may have led to variation in outcome measures. The resulting clusters can also be combined with prediction algorithms to identify patients who should be targeted for early intervention. For example, certain patterns in the beginning of the journey may signal that a patient is at elevated risk for aggressive opioid prescribing or for a low-quality procedure.

Despite the clinically relevant results, we acknowledge that this study has several limitations. We used a very broad definition of back pain that captured most patients presenting new general back pain symptoms. The purpose of this definition was to identify patient episodes typically expected to follow a conservative care route, as outlined by the American College of Physicians, and to understand population-level deviation from clinical recommendations. 36 , 37 It is not known how well our selected population reflect all patients who present with back pain, as claims data were not supplemented by other data sources such as hospital notes or psychologic evaluations. Additionally, while patients are geographically dispersed throughout the United States, the sample is not nationally representative; thus, the breakdown of patient episodes into clusters may not represent national trends.

Compared to clinical guidelines that represent a top-down picture of patient behavior, the outputs from this methodology reveal a data-driven understanding of how patients traverse the healthcare system. Using a limited set of assumptions, the methodology is particularly effective in analyzing conditions with high levels of variability in patient care and those treated across service locations. In the preference-sensitive condition of back pain, we observed that treatment choices are associated with patient characteristics and procedure rates, thereby highlighting the potential public health impact of related future studies based on this methodology. When tailored to various care settings, this methodology can provide the medical community with an accurate overview of the current state of patient care and facilitate a shift toward high-quality practice patterns.

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sector. It was supported internally by Evolent Health.

AUTHOR CONTRIBUTIONS

All authors were involved in revising the work for intellectual content and approved the manuscript. KB, AC, and LH made substantial contributions to the original study design. KB developed the algorithm, contributed to data analysis, interpretation, and writing the manuscript. CL contributed to data analysis, interpretation, and writing the manuscript. AC contributed to data acquisition and revising the manuscript. MB refined the algorithm and contributed to data interpretation, writing, and revising the manuscript. LH served as the primary contact with provider groups during algorithm development and contributed to clinical assumptions, data interpretation, and revising the manuscript.

SUPPLEMENTARY APPENDIX

Supplementary Appendix is available at Journal of the American Medical Informatics Association online.

Supplementary Material

Ocaa052_supplementary_data, acknowledgments.

The authors gratefully acknowledge the following individuals for their contributions: Rich King, Malcolm Charles, and Michael Freeman who advised on algorithm development; Madina Bram who provided administrative support on the project; Feryal Erhun, Stefan Scholtes, Nico Lewine, Matthias Weidlich, and Jenny Wang who provided valuable feedback and suggestions to the development and framing of this research. The authors also thank the JAMIA review team for their constructive and encouraging comments, as well as the clinicians who participated in discussions on the back pain assumptions and outputs.

CONFLICT OF INTEREST STATEMENT

None declared.

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  • [Download Free Template] How to create a patient journey map

Patient Journey Mapping

Patient journey mapping is a process that helps you—as healthcare providers—to visualize the complete experience of your patients who seek and use your care services.  

This includes every single touchpoint (whether online or offline) that a patient encounters in the process of finding a care provider, scheduling an appointment, to having the consultation, and even post-care interactions. 

A good understanding of a patient journey map, and all the pitfalls that the patient can encounter while seeking care, can help you pre-emptively improve your operations to deliver a delightful and consistent patient experience . 

In this article, we’ll dive deeper into various aspects of patient journey mapping, stages of a patient journey, how to create a patient journey map and the benefits you can realize by using the right tools. 

If you’d rather jump to the steps to create a patient journey map, you can do that as well. Go to:

What is patient journey mapping? 

Patient journey mapping is the process of visualizing the connection between various interactions and touchpoints patients have during their relationship with a healthcare practice.  

Mapping healthcare journeys helps providers understand:  

  • What is the patient going through? 
  • What are the patient’s primary concerns? 
  • Is the patient able to cope with their diagnosis? 
  • Is information regarding the patient’s diagnosis easily accessible? 
  • Is the patient able to reach you to book a consultation easily? 
  • Is the patient satisfied with the care they’re receiving?   

With this knowledge, providers can spot inconsistencies, find operational bottlenecks, and devise strategies to improve them.

Healthcare providers need to be obsessed with patient journey. The journey begins way before a patient visits the healthcare facility to interact with the provider, and it ends a lot after their treatment. A good patient journey map integrates various virtual and physical touchpoints. Uzodinma Umeh, Chief Medical Officer, Zuri Health

Before we get into the steps to create a journey map, let’s look at the stages a patient goes through before any consultation. 

5 crucial stages of a patient journey 

The 5 stages common in most of the patient journeys are: 

Stages of a patient journey

1. Awareness  

The patient recognizes a need for care at this point and starts looking for providers.  

The patient evaluates their symptoms, does research, thinks about potential medical issues that might need treatment, and may even interact with message boards. 

It begins the moment when the patient experiences a symptom. Most of the time, they go online to find a treatment or a solution to their pain. Healthcare providers need to use this opportunity to position themselves virtually by offering a solution, allowing them to research treatments, and book appointments with ease. Uzodinma Umeh, Chief Medical Officer, Zuri Health

Online searches, review websites, advertising initiatives, networking, and friends/family referrals are a few examples of how patients find out about healthcare services.   

However, patients may face certain challenges at this stage. Such as: 

  • Lack of information about their condition
  • Inability to find a provider nearby who they think could help
  • Feelings of fear and anxiety regarding their concerns

The key to reaching patients at this stage lies in your online presence. You can help your patients by: 

  • Publishing posts about the treatments you provide
  • Publishing educational blogs posts on your website about the conditions and how to manage them 
  • Getting yourself listed on GoogleMyBusiness 

It goes without saying, you should monitor the results of your efforts by using website analytics tools and collect patient feedback through surveys . 

Baptist Health South Florida has nailed this stage by introducing an online triage tool on their website. It asks patients a series of questions around their symptoms and accordingly directs them to e-visit, ER, urgent care, or physician’s office.  

Baptist Health South Florida - online triage tool to guide patients to the right care during their journey

2. Consideration  

The patient analyzes their options to see if your healthcare facility can satisfy their needs. Referrals, coverage and perks, suggestions, accessibility, and ratings and reviews are all things that patients take into account during this stage.   

When it comes to healthcare reviews and recommendations, 83% of patients trust their friends and family, while 62% trust reviews online from people they haven’t even met. This is exactly why healthcare businesses need to collect feedback and reviews physically and virtually to bring in patients from referrals. Chantelle Fraser, Vice President – Africa Sales, LeadSquared

Patients frequently interact with your website and social media accounts and call or email you. Additionally, if you are hard to get in touch with, they will go on to the next applicant. 

At this point, you can find out more about your potential patient, specifically about their preferred method of communication, and make sure you provide it. For instance, if a patient prefers communicating via email, you should reach them on this platform.  

Tools you can use to better connect with patients at this stage are:  

  • Email marketing solutions that help automate emails that reach the right person at the right time,  
  • Tools that help you segment visitors and create targeted ad campaigns,
  • Chatbots help you reach patients with concerns in real time and get a deeper understanding of their concerns.   

3. Acquisition 

Direct patient contact with your organization is the first indicator of the acquisition stage.  

As part of the booking and new patient acquisition process, you will interact with patients via phone calls, the user portal, texts, and emails.   

The patient generally arranges a meeting and visits a doctor or takes a telehealth consultation for a preliminary checkup.  

Common challenges patients face at this stage are: 

  • Lack of access to appointment booking portals and websites 
  • Inability to reach providers at odd hours (e.g., 2 AM in the morning) 
  • No-shows because of no reminder communications 
  • Lengthy wait times at hospitals
  • Extensive paperwork before consultation 

At this point, providers can use software to improve communications with patients. Such as: 

  • Appointment scheduling solutions that help providers and patients find convenient timings for consultations.  
  • Email automation tools that send notifications to patients before appointments to reduce the chance of no-shows.  
  • Patient intake tools help them fill out forms and answer pertinent questions before they visit the facility.   

4. Service  

The stage of service delivery has to do with the medical care you administer to your patients. The medical consultation itself, check-in and check-out, registration and discharge, and payment are all components of this step.   

The type of service you provide will determine the patient’s satisfaction from your practice. 

Common challenges providers face at this stage are: 

  • Difficulty locating comprehensive patient information across different touchpoints at the facility.   
  • Administering the necessary treatment and meeting patient expectations.  
  • In cases where the patient opts for home care, the inability to monitor and track their progress poses a significant challenge to the treatment process.  

The bulk of patient issues is rarely solved in the medical office. The patient’s experience persists into the treatment phase after assessment and any related procedures. They might receive an in-patient or out-patient plan or receive medicine and get discharged.   

At this point, you want to go beyond just calling to see how the patient is doing with their medicine and use the knowledge you have collected about them to deliver personalized care.  

Tools that can help providers at this stage are: 

  • Billing and payment software that enables the speedy processing of invoices and collection of money through the patient or insurer.  
  • A tool that unifies patient data and offers visual reports on a healthcare dashboard that is easy to use and accurate in its data collection and analysis.  
  • A communication tool that allows patients to contact their healthcare provider whenever necessary and update their status as it changes.  
  • Feedback collection tools like patient satisfaction surveys and questionnaires to gather information and testimonials for future use.   

5. Loyalty (on-going care) 

The best way to retain and nurture patients over time is to carry out post-visit follow-ups and keep track of their recovery.  

The patient journey also includes post-operation and post-visit care for your patients. You can use technology to take care of your patients by sending visit reminders, notify them of when their next vaccination is due, schedule house calls and much more. Collecting feedback and implementing it on a macro-level is another important post-visit step. Uzodinma Umeh, Chief Medical Officer, Zuri Health

Most healthcare providers often overlook this phase of the patient’s journey. Regardless of whether a patient’s treatment goes well or not, it is still necessary for the provider to follow up with them thereafter.   

Challenges hospitals face at this stage are:   

  • Difficulty keeping in touch with patients as they recover or face issues during the aftercare process 
  • Measuring patient satisfaction and their response to the treatment  
  • Offering the necessary information to speed up recovery and keep patients aware of different reactions they may have when receiving care 

Providers must keep an eye on the patient’s aftercare and monitor their interactions with them. This phase is crucial because it guarantees the patient’s long-term welfare and lowers the likelihood of readmission.  

Tools that can help at this stage are:  

  • Tools that track and monitor the patient’s progress, like a healthcare smartwatch or diagnosis tools 
  • CRMs that help send notifications to patients to update them on recurring appointments and consultations 

Note that these stages may differ from one patient to another. This is why it is vital to create patient journey maps to understand gaps in your service and meet patient needs.

How to create a patient journey map

Journey maps are mainly of the following four types: 

  • Current state : Useful for illustrating what your patients do, think, and feel as they interact with your practice with your present system. 
  • Future state : Useful for illustrating your patient experiences with your practice in the future (usually goes well with your plans to implement a new system/technology). 
  • Day in the life : This journey map illustrates what your patients do, think, and feel with or without your product or service. 
  • Service blueprint : It is generally a roadmap with action items and support processes. 

Creating all four types of journey maps may not be required for your practice, especially when your goal is to understand your current standing. In the following section, we’ll learn how to create a patient journey map using the current state journey map. 

Create a patient journey map in 7 simple steps

FullStory has come up with a simple and easy-to-remember technique for creating journey maps. It includes 7 D’s, which are as follows: 

  • Define: business goals 
  • Describe: personas or customer attributes 
  • Determine: touchpoints 
  • Design: the journey (lay out the steps a customer takes while buying a product/service from your brand) 
  • Designate: tag milestones, motivations, frustrations 
  • Decide: Flag events that need action 
  • Deploy: people, process, and technology to act upon 6 

We’ll apply this technique with some modifications to create journey maps for the healthcare sector. 

Step 1: Define your goals  

Why do you want to create a journey map?  

You might be facing certain challenges for which mapping a patient journey seems like a good starting point. For example,  

  • To reduce no-shows 
  • To increase retention 
  • To increase patients from referral sources 
  • To increase intake, and so on. 

Answering the “ why ” part will give you clarity on the purpose of creating a patient journey map and help you sketch the journey in a definitive direction. 

Step 2: Define your patient attributes  

You must be getting leads from your outreach, marketing, or referral programs. You’ll need to know whether you’re attracting the right patients to whom you can serve.  

Mapping patient attributes with the services you provide will help you tune your marketing, outreach, and referral programs. Lay out every single bit of information you have about your patients. Such as: 

  • Demographic info : location, age, gender, ethnicity, education, employment, etc. 
  • Engagement : appointment history, communication channels, feedback/satisfaction score, etc. 
  • Health goals : challenges, conditions, treatment history, barriers to getting care, etc. 

Create an ideal patient profile based on the information you have about your patients. You can also use your CRM data to gain insights into how they came to know about you, their interactions with your facility, and more. 

Healthcare HIPAA Compliant-CRM

Explore LeadSquared’s Healthcare CRM

Purpose-built to increase patient intake, engagement, and retention.

Note: Create separate journey maps for each patient profile you create. It will help you analyze patient experiences more deeply.   

Step 3: Determine touchpoints  

Touchpoints are the ways in which patients interact with your practice. They can be online like scheduling apps, websites, ads, etc., or offline interactions like phone calls, OPD walk-ins, etc. 

Some of the common touchpoints in the healthcare patient journey are: 

  • Appointment scheduling : WhatsApp, text messaging, phone calls, patient portals, mhealth platforms, provider’s healthcare apps, etc. 
  • Pre-check-in : appointment confirmations and reminders on email, WhatsApp, app notifications, text messages, phone calls 
  • Check-in and during care : intake process (digital or physical), video consultation, telehealth, insurance verification, etc. 
  • Post-visit : diagnosis notes, follow-up consultation scheduling, reminders, feedback via email, WhatsApp, app notifications, and text messages.  

Depending on the nature of your practice the touchpoints will vary. The idea is to note down all the possible sources of interactions with your patients. 

Step 4: Design a visual journey  

Once you’ve identified the touchpoints, it’s time to create a visual journey that your team can easily understand. 

You can plot: 

  • Journey stages 
  • Customer interactions and actions 
  • Your patient’s needs and pains 
  • Touchpoints 
  • Their sentiments during those interactions 

Concurrently, mark the areas of improvement and who can own them.  

Also, keep your ideal patient profile and goal cards side by side to ensure you’re moving in the right direction. 

Patient Journey Map Template

You can bookmark this page or download an editable PDF patient journey mapping template: 

Step 5: Designate milestones, motivations, frustrations  

This step of a patient journey highlights various kinds of friction a patient may encounter while contacting you for your product/service. 

For example, patients may not book an appointment because of one of the following reasons: 

  • UI issues – If the interface through which they’re trying to schedule a consultation is not working at that time, patients may not be able to book an appointment. 
  • Cognitive load – If the UI (User Interface) is not intuitive enough or too complex to understand, or the patients find it difficult to navigate to the services they see, they may drop off.  
  • Emotional friction – What patients are feeling at that moment will determine their action on opting for your services. 

This exercise helps the admin understand what to fix and how to fix it. 

Step 6: Decide on the actions you need to take  

Until step 5, the journey was looked upon through the patient’s lens. Now that there’s better clarity on patient experiences and hesitations, it’s time to look at the back-office tasks that can be improved. 

It involves identifying the areas of improvement and how that can be done.  

Step 7: Deploy people, process, and technology to achieve your goals  

In this final step of creating a patient journey map, you assign roles, delegate tasks, and procure tools to act on the areas of improvement identified. 

Best practices to follow while creating a patient journey map 

When you’re just starting off, learn the journey mapping fundamentals and research existing journey maps for healthcare. 

Here are some helpful resources: 

  • Neilsen Norman Group’s Journey Mapping 101  
  • Atlassian’s team playbook on Customer Journey Mapping  
  • Understanding Patient Journey webinar by LeadSquared 

Once you’ve understood the basics, follow these best practices to create a patient journey map. 

  • Set clear goals . Define what you wish to achieve from your patient journey map. 
  • Do not mix all the information in one map. Create different journey maps for different patient profiles . 
  • Involve different stakeholders. Do not restrict it to one team or department for sharing their inputs. 
  • Keep it simple . You may not need fancy tools or lots of graphics and colors; a simple spreadsheet can do the work. 
  • Make it an iterative process. You may not have perfect journey mapping from the very first time. Take feedback, act on it, and improve all the way up.  

Benefits you can realize by mapping patient journeys correctly 

The goal of patient journey mapping is to improve patient experience across all touchpoints and derive better outcomes. In a nutshell, 

Investing in patient experience essentially takes away the cost of advertising and acquisition. It also boosts referrals, recommendations, and NPS at the same time. Uzodinma Umeh, Chief Medical Officer, Zuri Health

Here’s the drill-down of benefits you get by mapping patient journeys efficiently. 

1. Spot inefficiencies

Every time a patient expresses frustration or uncertainty about her next steps toward recovery, it’s an obvious sign that there are friction spots or unmet gaps in the healthcare system. A patient journey map can effectively battle such challenges and create a clear path for a patient’s progress.   

2. Improve communication

Importance of Patient Journey Mapping

By mapping patient journeys providers can understand the drop-offs occurring because of communication gaps and take measures to rectify their strategies. 

3. Increase profitability 

Net margins for hospitals that provide “excellent” patient care are typically 50% higher than those for hospitals that offer “average” patient care. 

With a patient journey map, practitioners can identify the scope of improvement in operations and help their staff focus more on interacting with patients and caregivers. 

4. Reduce wait time for patients 

The average ER wait time in America is 145 minutes (even higher in some states; e.g., 228 minutes in Maryland, 195 minutes in Delaware, 176 minutes in Arizona, and so on). In India and other countries as well, it may take hours to get emergency admissions . These delays happen due to one or more of the following reasons: 

  • Examination of patient 
  • Time taken for consultation 
  • Emergency investigations or imagining 
  • Unavailability of vehicles for transport 
  • Lengthy admission procedures 

By knowing what exactly is causing the delays and taking steps to correct them, providers can reduce waiting times for patients to a great extent. 

5. Improve patient outcomes 

A healthcare journey map can help identify the touchpoints where essential and relevant information can be shared with patients. Educating patients and keeping them abreast of their illnesses can lower their anxiety and bring better outcomes 

Tools to create a patient journey map 

As a matter of fact, you can use any UI design tool (e.g., Figma , Sketch , FullStory , etc.) to create a journey map.  

However, there are dedicated tools to create journey maps with ready-to-use templates to make your work faster and easier. Some of which are: 

  • Creately  
  • TheyDo  
  • Custellence  
  • Miro  
  • LeadSquared  

On a final note, you’ll be able to map your patient’s journey effectively when you’ve ample information about their interactions with your practice.  

Healthcare CRM software is the best tool to collect and manage patient interaction data and make them accessible for various purposes like creating a journey map. 

If you’re looking for one such tool, 

A patient journey is the series of steps patients take to book an appointment, consult a physician, and pursue treatment with your practice. It involves both online and physical interactions.

Patient journey mapping helps you understand your customers’ experiences while interacting with your practice. With this exercise, you get to know their pain points, identify opportunities for improvement, and take measures to improve your services.

Padma Ramakrishna

Padma is a Content Writer at Leadsquared. She enjoys reading and writing about various financial and educational topics. You can connect with her on LinkedIn or write to her at [email protected].

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“I am a Cincinnatian, and I’ve known about UC’s expertise for a long time,” Melinda shares.

Melinda's familiarity with UC's exceptional medical care traces back to the early 1980s when her sister, now a nurse practitioner, received treatment for a severe head injury sustained in a car accident. Witnessing UC Health’s dedication to excellence during her sister's recovery instilled in Melinda a profound trust in our capabilities.

A long-time hair designer, Melinda’s day-to-day life for years was physically demanding, with hours spent on her feet making movements that, over time, put significant strain on her back. Several years ago, Melinda turned to another hospital in Cincinnati for answers to begin addressing her pain.

“They said I was just basically going to be living with back pain; I continued to suffer and suffer.”

A pivotal moment occurred in November 2022 during a routine but extensive grocery trip for a Thanksgiving food drive. The next day, while loading comforters into her washing machine, Melinda experienced excruciating pain radiating from her lower back down to her ankle. It became evident that her condition necessitated specialized care beyond what she had previously received.

“I woke up with a pain that I thought was a Charlie horse, but it was a disc that had finally slipped.”

Through a series of fortuitous connections, Melinda ended up under the expert care of Owoicho Adogwa, MD, MPH, at the UC Gardner Neuroscience Institute. Dr. Adogwa is an esteemed Assistant Professor in the Department of Neurosurgery renowned for his expertise in treating spinal diseases. He is one of the few surgeons in the country who is cross-trained in orthopedic spine surgery and neurosurgery.

A Personalized Approach: Spinal Anesthesia and Patient-Centric Care

Dr. Adogwa's approach was marked by thoroughness and compassion as he meticulously reviewed her case, explained MRI findings, and discussed treatment options with genuine concern.

“My husband and I met with Dr. Adogwa, and he was just wonderful. I loved him. From the time he walked into the room, I felt comfortable. I could tell I was in really good hands. He explained everything on my MRI, and I had never had a doctor do that before, to really spend the time.”

Physical therapy at the UC Gardner Neuroscience Institute emerged as a cornerstone of Melinda's recovery journey, with dedicated therapists guiding her through tailored exercises to alleviate pain and enhance mobility throughout the winter of 2023. Melinda completed her therapy treatments and put in the work at home, but ultimately, surgery was needed. But she had just one hesitation.

“We started talking about surgery. I had confidence in him and knew he would get me out of pain. The thing that I was the most afraid of was that when I had general anesthesia, I was so sick. I would throw up the night of surgery…and would feel sick for weeks after. I feel like I’ve been poisoned.”

But at UC Health, we don’t settle for good enough. We pursue options that may not have been tried before. A pivotal breakthrough came from a groundbreaking spinal anesthesia technique proposed by Dr. Adogwa for awake spine surgery, marking a significant innovation in the field. Opting for an epidural with propofol instead of general anesthesia, Dr. Adogwa sought to minimize post-operative discomfort, a common issue following conventional anesthesia.

Melinda would be the first “awake” spinal surgery patient at UC Health. Although she was the first to do this here, Dr. Adogwa has years of experience with this approach.

Melinda recalls, “I thought, ‘Oh my gosh, I’m not going to be sick.’ I’m going to be out of pain and not sick.”

On the day of surgery, Melinda experienced a mix of anticipation and relief. Dr. Adogwa's careful planning and the use of minimally invasive surgery techniques, in collaboration with the anesthesiology team, expertly led by Dr. Jessica Garrett, ensured a smooth and comfortable experience. As soothing music played through her earbuds, the surgical team worked diligently to address the underlying cause of her pain.

“It was so quick. I couldn't feel my legs anymore; I was relaxed. I knew I had the team behind me. Dr. Garrett was wonderful, and I’m grateful she was willing to do it…I was face down and just listening to music. Think about it as the same level of sedation as a colonoscopy. I didn’t hear anything; I just fell asleep. It was peaceful.”

Melinda's Story: Experiencing the Benefits of Awake Spine Surgery

Experiencing the Benefits of Minimally Invasive Awake Surgery

Following surgery, Melinda noticed a profound difference. Freed from the debilitating effects of general anesthesia, she experienced minimal discomfort and was able to resume normal activities sooner than anticipated.

“I was eating after surgery; I never threw up; I was walking around, not sick at all. I came home and ate a full meal.”

With the guidance of Dr. Adogwa and his team, Melinda embraced a comprehensive rehabilitation program designed for enhanced recovery after surgery, encompassing physical therapy, cardio exercises, and mindful practices like yoga. This holistic approach significantly contributed to her faster recovery, allowing her to regain strength and mobility quickly.

A New Horizon in Spinal Health and Recovery

Today, Melinda is a testament to the transformative power of personalized care and innovative medical interventions. Her journey with UC Health embodies the intersection of expertise, compassion, and a commitment to pioneering advancements in patient-centric spine surgery, spotlighting the institution's dedication to patient well-being and faster recovery.

“My care was unbelievably beautiful, thoughtful, compassionate. It was patient-focused. It was outcome-focused. It was a team effort…Dr. Adogwa is a pioneer in many ways but humble…I’m just grateful.”

As she continues her path to recovery, Melinda remains deeply grateful for the unwavering support of Dr. Adogwa, Dr. Garrett, and the entire care team at UC. Through their dedication and expertise, she has regained her physical well-being and discovered renewed hope and resilience in adversity. As the first patient to receive this innovative approach, she paves the way for others.

“When I met with Doctor Adogwa recently, he said I’m the first, but because of how this all came to be, now other patients can benefit because we have paved the way for others to have the opportunity when they may not have otherwise.”

As for Dr. Adogwa, he continues to look forward.

“The implementation of an awake spinal surgery protocol, complemented by genotype-guided opioid therapy post-surgery, is a pivotal component of our holistic approach aimed at providing tailored, patient-centric spinal healthcare services within Cincinnati and beyond.

This approach is underpinned by the collaborative efforts of a multidisciplinary team, boasting expertise across a spectrum of disciplines, all dedicated to enhancing the well-being and quality of life of individuals afflicted with back pain and spinal pathologies.

Our overarching objective is to establish the UC Gardner Neuroscience Institute as the nation's preeminent center for spinal care, distinguished not only by our innovative surgical methodologies but also by our commitment to achieving high patient satisfaction rates.”

Featured Expert:

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UC Gardner Neuroscience Institute

At UC Health, we lead the region in scientific discoveries and embrace a spirit of purpose – offering our patients and their families something beyond everyday healthcare. At UC Health, we offer hope.

For more information, call:

513-475-8000

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UK patient finds relief after 25 years of shoulder pain

Bryan Gibson, 54, finally feels healed after 25 years of shoulder pain. Photo provided by Bryan Gibson.

LEXINGTON, Ky. (March 26, 2024)  — When asked to describe his pain on a scale from one to 10, there were no numbers that could describe the agony Bryan Gibson felt in his shoulder.

Gibson, who lives in Somerset, Kentucky, underwent six surgeries on his right shoulder before finally having hope that his recovery would be different this time.

Gibson was 29 years old when he had his first shoulder surgery after being stationed in Korea serving in the U.S. Army. He didn’t know that his surgery in 1999 would take him on a 25-year journey to find healing and pain relief.

Initially, Gibson underwent a capsular shrinkage on his shoulder. This is a surgery that tightens the loose ligaments and capsules of the shoulder joint. The procedure is typically intended for patients with very loose shoulder joints leading to dislocations.

“When I had my first shoulder surgery, it lasted about six months, and then I went back and they had to repair the rotator cuff,” said Gibson. “Then about a year later, I had already torn it again.”

This turned into a vicious cycle for Gibson. Constantly in and out of different surgeries and procedures trying to repair his shoulder. Overwhelmed with constant pain, his sleep was impacted, he couldn’t lift everyday items and he experienced numbness throughout his arm.

“I would stand in the shower for a long time and increase the water temperature just to try to get rid of some of the pain,” said Gibson. “I had ice packs, I would eat Tylenol and ibuprofen, whatever I could just to relieve the pain a little bit.”

Gibson was not feeling like his normal self while suffering from shoulder pain.

“It changed my attitude, of course,” said Gibson. “I would snap because I was in pain, but nobody understood the pain that I was in.”

Gibson was persistent in finding relief. After years of trying to treat his pain, he was willing to do anything to be healed – even if it meant a full shoulder replacement.

In March 2023, Gibson was referred to Srinath Kamineni , M.D., an orthopaedic surgeon at UK HealthCare who specializes in shoulder surgery.

“Dr. Kamineni grabbed a hold of my right arm and moved it around identifying the shoulder joint itself was good, but the tendons and ligaments and everything else in there were torn up,” said Gibson. “That was a real relief because everybody else that I was seeing was telling me that I was going to have to have a full shoulder replacement, which I was ready for.”

However, since Gibson is only 54 years old and lives an active lifestyle, Dr. Kamineni took a different approach to repair his shoulder.

“It brought me to tears, to be honest, because what I thought was going to be a shoulder replacement wasn’t and instead, he performed a life-changing surgery,” said Gibson.

Instead of a replacement, Gibson underwent a detailed revision shoulder stabilization with a partial rotator cuff repair.

“When I perform revision surgeries of this nature, I find it very important to first identify the relevant tissues that need to be repaired and mobilize them in their entirety, before deciding their reparability,” said Dr. Kamineni. “Making the right decision for any particular patient is vital. In this case, I removed the scar tissue and fixed the labrum and rotator cuff in place with anchors.” 

In April 2023, Gibson received his sixth and final shoulder surgery. He says he has never had a faster recovery. He now has more range of motion and less pain than ever before.  

“He broke out his wand and did something in my shoulder,” said Gibson.

 He can lift and reach things a lot easier now, and the pain is gone. He doesn’t have to worry about keeping his arm still or in a sling position all day, he can relax and keep his arm neutral.

It was a long journey to finding the right treatment, but Gibson never gave up on finding the right care. He advocated for himself and knew he wanted to maintain an active lifestyle.

“His motivation to get back to normal was a very important factor in his outcome,” said Dr. Kamineni. “The patient is always the most important part of the team for dealing with the problem and getting the best possible outcome. Seeking out the right physician and asking relevant questions increases the chances of success.”

Dr. Kamineni and his UK HealthCare team were able to help give Gibson his life back.

“He went in and he saw what the problem was,” said Gibson. “He figured out what needed to be done and fixed it, and my shoulder works great.”

UK HealthCare is the hospitals and clinics of the University of Kentucky. But it is so much more. It is more than 10,000 dedicated health care professionals committed to providing advanced subspecialty care for the most critically injured and ill patients from the Commonwealth and beyond. It also is the home of the state’s only National Cancer Institute (NCI)-designated Comprehensive Cancer Center, a Level IV Neonatal Intensive Care Unit that cares for the tiniest and sickest newborns, the region’s only Level 1 trauma center and Kentucky’s top hospital ranked by U.S. News & World Report.

As an academic research institution, we are continuously pursuing the next generation of cures, treatments, protocols and policies. Our discoveries have the potential to change what’s medically possible within our lifetimes. Our educators and thought leaders are transforming the health care landscape as our six health professions colleges teach the next generation of doctors, nurses, pharmacists and other health care professionals, spreading the highest standards of care. UK HealthCare is the power of advanced medicine committed to creating a healthier Kentucky, now and for generations to come. 

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Sask. residents can now track the status of their upcoming surgery online

Saskatchewan residents will soon have more access to surgical information online including scheduled dates and their surgeon’s name with the launch of a new feature on MySaskHealthRecord accounts.

The province says the Surgical Procedures feature will be available to everyone who has a MySaskHealthRecord account, with patients currently waiting for surgery already able to see information about their upcoming procedure.

The feature, which the province claims is the first of its kind in Canada, will make available the date of the scheduled procedure, the specialist or surgeon’s name, the name of the procedure, location and status, a government news release said.

  • Download the CTV News app for Sask. top stories and breaking news alerts on your smartphone 

“When patients can easily access information ahead of time, it allows us to make good use of the time we have together. We spend less time on scheduling details and can focus on discussing their individual journey toward timely surgical care,” Dr. Michael Kelly said in a release.

MySaskHealthRecord was first launched in the fall of 2019 . It provides people in Saskatchewan online access to their lab test results and other health records such as clinical visit history, medical imaging reports, prescription history and immunization history.

A mobile app version of the program was also launched in May of 2023, with an average of 10,000 people downloading it each month, according to the province.

Saskatchewan residents who want to register for a MySaskHealthRecord account need to be at least 14-years-old, have a valid provincial driver’s licence of photo ID and have an active Saskatchewan health card as well as an email address.

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A Terrorist Attack in Russia

The tragedy in a moscow suburb is a blow to vladimir v. putin, coming only days after his stage-managed election victory..

This transcript was created using speech recognition software. While it has been reviewed by human transcribers, it may contain errors. Please review the episode audio before quoting from this transcript and email [email protected] with any questions.

From “The New York Times,” I’m Sabrina Tavernise, and this is “The Daily.”

A terrorist attack on a concert hall near Moscow Friday night killed more than 100 people and injured scores more. It was the deadliest attack in Russia in decades. Today, my colleague Anton Troianovski on the uncomfortable question it raises for Russia’s president, Vladimir Putin. Has his focus on the war in Ukraine left his country more vulnerable to other threats?

It’s Monday, March 25.

So Anton, tell us about this horrific attack in Russia. When did you first hear about it?

So it was Friday night around 8:30 Moscow time that we started seeing reports about a terrorist attack at a concert hall just outside Moscow. I frankly wasn’t sure right at the beginning how serious this was because we have seen quite a lot of attacks inside Russia over the last two years since the full scale invasion of Ukraine, and it was hard to make sense of right away. But then within a few hours, it was really looking like we were seeing the worst terrorist attack in or around the Russian capital in more than 20 years.

On Friday night, Crocus City Hall was the venue for a concert by an old time Russian rock group called Picnic. It was a sold-out show. Thousands of people were expected to be there. And before the start of the concert, it appears that four gunmen in camouflage walked into the venue and started shooting.

We started seeing videos on social media, just incredibly awful graphic footage of these men shooting concertgoers at point blank range. In one of the videos, we see one of them slitting the throat of one of the concertgoers. And then what appears to have happened is that they set the concert hall on fire. Russian investigators said they had some kind of flammable liquid that they lit on fire and basically tried to burn down this huge concert hall with wounded people in it.

Some of these people ended up trapped as the building burned, as eventually, the roof of this concert hall collapsed. And it seems as though much of the casualties actually came as a result of the fire as opposed to as a result of the shooting.

The actual attack, it looks didn’t take more than 15 to 30 minutes. At which point, the four men were able to escape. They got into a white Renault sedan and fled the scene.

It took the authorities clearly a while to arrive. The attackers were able to spread this horrific violence for, as I said, at least 15 minutes or so. So among other things, there’s a lot of questions being raised right now about why the official response took so long.

And you said the perpetrators got away. What happened next?

So it looks like they were caught at some point hours after the attack. On Saturday morning, the Kremlin said that 11 people had been arrested in connection to the attack, including all four perpetrators. They were taken into custody according to the Russian authorities in the Bryansk region of Russia, roughly a five-hour drive from the concert hall in southwestern Russia, also pretty close to the border with Ukraine.

Obviously, we have to take everything that the Russian authorities are saying with a grain of salt. And as we’ve been reporting on this throughout the weekend, we have very much tried to verify all the claims that the Russian authorities are making independently. And so our colleagues in the visual investigations unit of the times have been working very hard on that.

And what we can say based on the footage of the attack that was taken by many different individuals and posted to social media, it very much looks like the four men who were detained who Russia says were the attackers, in fact, are the same people who were seen doing the shooting in those videos of the attack judging by their clothes, judging by their hairstyle, judging by their build and other identifying characteristics that our colleagues have been looking at. So it does appear that by Saturday morning, the men who directly carried out this attack had been taken into custody.

Wow. So the Russian government actually apprehended the perpetrators, according to our reporting work that our colleagues have done. So who are these guys?

We don’t know much about them. The Russian government says that none of them are Russian citizens. After the arrest, throughout the weekend, videos, short clips of interrogations of these men have been popping up on the Telegram social networks, clearly leaked or provided by Russian law enforcement. You see these men bloodied, hurt.

And is this Russian interrogators abusing them?

Yes. That is very much what it looks like. And it’s also notable that the Russian authorities aren’t even hiding it. Two of the suspects in those videos are heard speaking Tajik. So that’s the language spoken in Tajikistan, a Central Asian country, but also in some of the surrounding countries, including Afghanistan.

At the end of the day, this is still very much a developing situation, and there’s a ton that we don’t know. But hours after the attack, the Islamic State, ISIS, took responsibility. And they then really tried to emphasize this by even releasing a video on Saturday showing the attack taking place as it was filmed apparently by one of the attackers. And US intelligence officials have told our colleagues in Washington that they indeed believe this to be true, that they believe that this ISIS offshoot did carry out this attack.

Wow. So the Americans actually think that ISIS, the extremist group that we know so well from Iraq and Syria, carried out this attack.

Yes. And all of this is really remarkable because just a few weeks ago, on March 7, the United States actually warned publicly that something just like this could happen. The US embassy in Moscow issued a security alert, urging US citizens to avoid large gatherings over the next 48 hours. They said that the embassy is monitoring reports that extremists have imminent plans to target large gatherings in Moscow to include concerts.

Crazy. That is a very specific warning.

Absolutely. And of course, the statement mentioned that specific 48-hour time frame. But nevertheless, it feels really significant.

And did the Russian authorities respond to that?

They did, and frankly, they responded mostly by ridiculing it. This is all obviously happening against the backdrop of the worst conflict between Moscow and the West since the depths of the Cold War. And so Vladimir Putin actually publicly dismissed this warning. He called it blackmail in a speech that he gave just three days before the attack last Tuesday.

So despite the specificity publicly at least, the Russian authorities did not take it seriously.

That is remarkable. And so three days later, this huge attack happens. Where is Putin in all of this? And who is he blaming? What’s his version of events?

So he’s coming off this Russian election season, as you know, where he declared this very stage managed victory and after that had been taking a victory lap of sorts. But Putin doesn’t appear on camera until around 19 hours after the attack. At that point, Russian state television airs a five-minute speech by Putin.

[NON-ENGLISH SPEECH]

He’s sitting at this nondescript desk surrounded by two Russian flags, but it’s not clear where he is located at that point. It doesn’t look like he’s at the Kremlin.

And Anton, what does he say?

So he describes the horror of this attack. He declares Sunday a national day of mourning. He says the most important thing is to make sure that the people who did this aren’t able to carry out more violence.

He also says that the four men who carried out the attack were captured as they were moving toward Ukraine. And he claims that based on preliminary information, as he put it, there were people on the Ukrainian side who were going to help these men cross the border safely. And remember, this is an extremely dangerous militarized border given that Russia and Ukraine have been in a state of full scale war for over two years now.

And as he ends the speech, He. Says that Russia will punish the perpetrators, whoever they may be, whoever may have sent them.

So what’s important about all that is first of all, that Putin did not mention the apparent Islamic extremist connection here that Western officials have been talking about, and that is in front of all of us given that Islamic State has claimed responsibility for the attack. But he does set the stage for blaming Ukraine for this horrific tragedy, even though it seems that Putin and the Russian government may be alone in thinking that.

We’ll be right back.

So Anton, the Islamic State has claimed responsibility for this attack, but Putin ignores that and kind of obliquely points the finger at Ukraine. What do we actually know about who did this?

Well, let’s start with the group that claimed responsibility for this attack. That’s ISIS, the Islamic State. And in particular, US officials are talking about a branch of ISIS called ISIS-K or Islamic State Khorasan, which is an Islamic State affiliate that’s primarily active in Afghanistan and that in recent years has gained this reputation for extreme brutality.

They might be best known in the US for being the group behind the Kabul Airport bombing back in 2021 right after the Taliban took over when thousands of Afghans were trying to escape. That was a bombing that killed 13 American troops and 171 civilians, and it really raised ISIS case profile.

So this terrorist group is mainly based in Afghanistan. What do they want with Russia?

So what’s notable is our colleague Eric Schmitt in Washington talked to an expert over the weekend who said ISIS-K has really developed an obsession with Russia and Putin over the last two years. They say Russia has Muslim blood on its hands.

So it looks like the primary driver in this enmity against Russia is Russia’s alliance with Bashar al-Assad, the Syrian president, who is also a sworn enemy of ISIS. And Russia intervened, of course, on Assad’s behalf in the Syrian civil war starting back in 2015. But it’s not just Syria. So the experts we’ve talked to say that in the ISIS-K propaganda, you also hear about Russia’s wars in the Southern region of Chechnya in the 1990s and the early 2000s.

And also even about the Soviet Union’s war in Afghanistan throughout the 1980s. There’s this really long arc of Russia’s and the Soviet Union’s wars in Muslim regions that appears to be driving this violent hatred of Russia on the part of ISIS-K.

OK. So ISIS-K is pointing not only to Russia’s actions in Syria but actually further back into Russian history, even Soviet history, to its war in Chechnya and then to the Soviet’s war in Afghanistan. Yet Putin in his speech ignores the group entirely and instead points in the direction of Ukraine. Is there a chance that this attack could have been carried out by Ukraine?

Well, look. It is true that Ukraine has carried out attacks inside Russia that put Russian civilians at risk. There have been several bombings that American officials have ascribed to parts of the Ukrainian government. Perhaps most famously, there was the bombing that killed Darya Dugina, the daughter of a leading Russian ultranationalist back in the summer of 2022.

That was a bombing that happened just outside Moscow. And of course, there have been various drone strikes by Ukraine against things like Russian energy infrastructure even just in the last few weeks. But we really don’t see any evidence right now of any connection of the Ukrainian state to this attack. US officials tell us they don’t see anything, and we haven’t in our own reporting come across such a connection either.

And there is, of course, the context of the US has said very clearly that they don’t want to see Ukraine carrying out big attacks inside Russia. American officials have said that doing so is counterproductive, could lead to the risk of greater escalation by Putin in his war. And we’re in an extremely sensitive time right now when it comes to US support for Ukraine.

The US, of course, has given all these weapons, tens of billions of dollars in aid to Ukraine. But right now, $60 billion in aid are stuck in US Congress. And you would think that Ukraine wouldn’t want to do anything right now —

That could risk that.

That could risk that. Exactly. I mean, also, let’s just say, I mean, this was an incredibly horrific attack, and we haven’t seen anything from Ukraine in the way they’ve carried themselves in defending against Russia in this war that would make us think they would be capable of doing something like this.

Anton, just to step back for a moment. I mean, it’s interesting because this attack, it really doesn’t remotely fit into Putin’s obsession about where the threat is coming from in the world to Russia, right? His obsession is Ukraine. And this kind of short circuits that.

Absolutely. I mean, Russia has had a real Islamic extremism problem for decades going back to the 1990s to those brutal wars against Chechen separatists that were a big part of Putin coming to power and developing his strongman image.

So it’s really remarkable how we’ve arrived at this turning point here for Putin where he used to be someone who really portrayed himself as the man keeping Russians safe from terrorism. Now the threat of terrorism coming from Islamic extremists doesn’t really fit into that narrative that Putin has because now Putin’s narrative is all about the threat from Ukraine and the West and that the most important thing to do now for Russian national security is to win the war against Ukraine.

And does the security failure here have anything to do with Russia actually being obsessed with Ukraine? Like it’s kind of taken its eye off the ball?

Well, look. The Russian domestic intelligence agency, the FSB, they’re the ones who are supposed to keep the country safe from terrorism. But that has also been the agency that has been charged with asserting control over the territories in Ukraine that Putin has occupied, and the FSB has been spending all this time hunting down dissidents of Putin.

Just a few hours before the attack on Friday, Russia officially classified the so-called LGBT movement, as they put it, on their list of terrorists and extremists. So terrorists in the current Putin narrative are anyone who disagrees with him, who criticizes the war, and who doesn’t fit into the Kremlin’s conception of so-called traditional values, which has become such a big Putin talking point.

So the FSB has been pretty busy but not in terms of Islamic terrorism. In terms of its own people.

Exactly. We don’t know for sure obviously how the FSB is apportioning its resources, but there’s a lot of reason to believe that as the leadership of that organization has been looking at Putin’s priorities in Ukraine and in terms of cracking down on dissent domestically, they could well have lost sight of the risks of actual terrorism inside Russia.

Which is pretty remarkable, right, Anton? Because you and I know and we’ve spoken a lot about on the show, a big part of the reason that Putin actually appeals, his argument to Russians is that he’s the security guy. Think what you will about him. He’s the guy who’s fundamentally going to keep you safe. And here we have this attack.

That’s right. And so he needs to continue making the case that he knows how to keep Russia safe. And that’s why my colleagues and I have been watching a lot of Russian state TV this weekend. And this ISIS claim of responsibility barely comes up. And when it does come up, it’s often being referred to as fake news. Instead, Russian propaganda is already assuming that it was Ukraine and the West that did this. We’ll see if the Russian public buys that.

But if you look at the way the last two years have gone in Russia, I think you have to draw the conclusion that Russian propaganda is extremely powerful. And I think if this message continues, it’s quite likely that very many Russians will believe that Ukraine and the West had something to do with this attack.

And so the worry now, as we look ahead, is that Putin could end up using this to try to escalate his war even further, which shows us why this is such a tenuous and perilous moment because at the same time, this attack reminds us that Russia faces other security risks. And as Putin deepens that conflict with the West, he may be doing so at the cost of introducing even more instability inside the country.

Anton, thank you.

Thank you, Sabrina.

Late Sunday night, the four men suspected of carrying out the concert hall attack were arraigned in a court in Moscow and charged with committing an act of terrorism. All four are from Tajikistan but worked as migrant laborers in Russia. They range in age from 19 to 32 and face a maximum sentence of life in prison. Also on Sunday, Russian authorities said that 137 bodies had been recovered from the charred remains of the concert hall, including those of three children.

Here’s what else you need to know today.

In January, I underwent major abdominal surgery in London, and at the time, it was thought that my condition was non-cancerous. The surgery was successful. However, tests after the operation found cancer had been present.

In a video message on Friday, Catherine, Princess of Wales, disclosed that she’d been diagnosed with cancer and has begun chemotherapy, ending weeks of fevered speculation about her absence from British public life.

This, of course, came as a huge shock, and William and I have been doing everything we can to process and manage this privately.

In her message, Middleton did not say what kind of cancer. She had or how far it had progressed but emphasized that the diagnosis has required meaningful time to process.

It has taken me time to recover from major surgery in order to start my treatment. But most importantly, it has taken us time to explain everything to George, Charlotte, and Louis in a way that’s appropriate for them and to reassure them that I’m going to be OK.

Today’s episode was produced by Will Reid and Rachelle Bonja. It was edited by Patricia Willens, contains original music by Dan Powell and Marion Lozano, and translations by Milana Mirzayeva and was engineered by Alyssa Moxley. Special thanks to Eric Schmitt and Valerie Hopkins. Our theme music is by Jim Brunberg and Ben Landsverk of Wonderly.

That’s it for “The Daily.” I’m Sabrina Tavernise. See you tomorrow.

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Hosted by Sabrina Tavernise

Featuring Anton Troianovski

Produced by Will Reid and Rachelle Bonja

Edited by Patricia Willens

Original music by Dan Powell and Marion Lozano

Engineered by Alyssa Moxley

Listen and follow The Daily Apple Podcasts | Spotify | Amazon Music

Warning: this episode contains descriptions of violence.

More than a hundred people died and scores more were wounded on Friday night in a terrorist attack on a concert hall near Moscow — the deadliest such attack in Russia in decades.

Anton Troianovski, the Moscow bureau chief for The Times, discusses the uncomfortable question the assault raises for Russia’s president, Vladimir V. Putin: Has his focus on the war in Ukraine left his country more vulnerable to other threats?

On today’s episode

patient journey surgery

Anton Troianovski , the Moscow bureau chief for The New York Times.

In the foreground is a large pile of flowers. In the background is a crowd adding more flowers to the pile.

Background reading

In Russia, fingers point anywhere but at ISIS for the concert hall attack.

The attack shatters Mr. Putin’s security promise to Russians.

There are a lot of ways to listen to The Daily. Here’s how.

We aim to make transcripts available the next workday after an episode’s publication. You can find them at the top of the page.

Translations by Milana Mazaeva .

Special thanks to Eric Schmitt and Valerie Hopkins .

The Daily is made by Rachel Quester, Lynsea Garrison, Clare Toeniskoetter, Paige Cowett, Michael Simon Johnson, Brad Fisher, Chris Wood, Jessica Cheung, Stella Tan, Alexandra Leigh Young, Lisa Chow, Eric Krupke, Marc Georges, Luke Vander Ploeg, M.J. Davis Lin, Dan Powell, Sydney Harper, Mike Benoist, Liz O. Baylen, Asthaa Chaturvedi, Rachelle Bonja, Diana Nguyen, Marion Lozano, Corey Schreppel, Rob Szypko, Elisheba Ittoop, Mooj Zadie, Patricia Willens, Rowan Niemisto, Jody Becker, Rikki Novetsky, John Ketchum, Nina Feldman, Will Reid, Carlos Prieto, Ben Calhoun, Susan Lee, Lexie Diao, Mary Wilson, Alex Stern, Dan Farrell, Sophia Lanman, Shannon Lin, Diane Wong, Devon Taylor, Alyssa Moxley, Summer Thomad, Olivia Natt, Daniel Ramirez and Brendan Klinkenberg.

Our theme music is by Jim Brunberg and Ben Landsverk of Wonderly. Special thanks to Sam Dolnick, Paula Szuchman, Lisa Tobin, Larissa Anderson, Julia Simon, Sofia Milan, Mahima Chablani, Elizabeth Davis-Moorer, Jeffrey Miranda, Renan Borelli, Maddy Masiello, Isabella Anderson and Nina Lassam.

Anton Troianovski is the Moscow bureau chief for The Times. He writes about Russia, Eastern Europe, the Caucasus and Central Asia. More about Anton Troianovski

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Politics latest: Keir Starmer asked if he's a 'Tory in disguise' - as Labour leader accuses Rishi Sunak of 'bottling' calling election

Labour leader Sir Keir Starmer and deputy leader Angela Rayner launch Labour's local elections campaign in the West Midlands. Listen to the latest Electoral Dysfunction podcast as you scroll.

Thursday 28 March 2024 15:23, UK

  • Starmer says PM wants 'one last drawn out summer tour with his beloved helicopter'
  • Rob Powell: Starmer offers solution to age-old problem, but there's a central tension at the heart of his remedy
  • Starmer reveals 'frustration' at Johnson's 'unforgivable' failure to deliver levelling up
  • He says he has not seen legal advice given to Rayner over tax affairs
  • Could Tory instability bounce Sunak into a summer election?
  • Explained: How Tory MPs can get rid of PM - and who could replace him
  • Live reporting by Ben Bloch

The Labour leader has told Sky News that he will not provide a "lump sum cash injection" to shore up the financial positions of local councils.

Many face a serious financial crunch, with one in five council bosses saying they are likely to go bankrupt in the next 15 months, and £4bn needed to keep basic services afloat.

But speaking to our political editor Beth Rigby , Sir Keir Starmer said that although he is "very concerned about councils of all political colours struggling as much as they are", he "can't turn on the spending taps".

In the long term, Sir Keir said the funding settlement for councils should last three years instead of one, the economy could be stabilised to reduce inflation which has been "a big drag for councils", and also banning no-fault eviction to reduce housing pressures on councils.

He added: "At the end of an incoming Labour government, councils will be better funded, more sustainable, and able to deliver their services than they are now."

Pushed on the more immediate funding crisis and how he will solve that, he said: "What it means is not a lump sum cash injection, but it does mean reducing the burden on councils who are spending money on things like homelessness, spending money on interest rates, spending money inefficiently. We can do that straight away."

But he said this issue of councils on the brink is "the central problem in politics at the moment", saying that after 14 years of Tory government, "almost everything is broken".

Asked why he won't raise taxes to bring in the money needed to fix public services, the Labour leader told Beth: "We've already got the highest tax burden since the Second World War, and we have to grow our economy.

"But you could equally put to me the broken state of our health service, the broken state of social care, the broken state of childcare, the broken state of all of our public services, all of which after 14 years are on their knees."

His party's job, he said, will be to "not make promises we can't keep" and "build these institutions, public services up".

We reported earlier this morning that Angela Rayner has said she will not publish the "personal tax advice" she received on the sale of her council house.

This is despite police confirming they are "reassessing" their initial decision not to investigate allegations made about her living arrangements.

Labour's deputy leader told BBC Radio 4's Today programme she was "confident" she had done "absolutely nothing wrong" with regards to the sale of her council house and whether she should have paid capital gains tax on it ( more here ).

Sir Keir Starmer gave his deputy his full support earlier today, saying he is "satisfied" that she has "not broken any rules" ( see post at 10.58 ).

But speaking to our political editor Beth Rigby  following that statement, the Labour leader revealed he has not seen the legal advice given to Ms Rayner, saying there's "no need to" and it is "not appropriate" for him to ask to see it.

"She answered no end of questions from the media on this," he said.

"And she's been very clear - should the authorities want any more information, she's more than happy to provide it for them. I have full confidence and full support in her."

Sir Keir said both his and Ms Rayner's team have seen the advice, and he is not worried about offering her his full backing without having seen it.

"I have faith in Angela Rayner's answers," he said.

"My team has looked at it. Her team's looked at it. There is no need for me personally to look at it, nor is it appropriate to do so."

He added: "But I do think, standing back, it's a sign of how desperate the Tories have got that they want to make this the issue in a local election, which should be about their failure of delivery."

 Sir Keir Starmer has told Sky News of his "frustration" with Boris Johnson for not delivering on levelling up, and has accused Rishi Sunak of having "strangled levelling up at birth".

Speaking to our political editor Beth Rigby , the Labour leader said it is "unforgivable" the ex-PM "failed to do the hard yards" of delivering on his promise, which is "why people feel even more let down".

He was speaking to Beth following the launch of his party's local elections campaign in the West Midlands, where he unveiled plans for much more devolution of powers to local authorities, and hit out at the Tories for not addressing regional inequalities.

After his keynote address, the Labour leader told Sky News: "I think Rishi Sunak strangled levelling up at birth because he wouldn't put the funding behind it, and we know what the consequences are."

He said the "idea of levelling up" and eliminating regional inequalities has been "around for years" - but achieving it requires "a viable plan".

"I'm afraid neither Boris Johnson nor Rishi Sunak have had either a viable plan or put in the hard yards."

Sir Keir continued: "My frustration with him is I actually think the idea of levelling up that was put before the electorate in 2019 by Boris Johnson was right. I will say that."

But he accused the Conservatives of "preying on people's hopes" that levelling up would be delivered, saying: "What's unforgivable about Boris Johnson is having made that the focus, he then didn't do the hard yards of delivery, and that's why people feel even more let down."

He said Mr Johnson "wasn't prepared or didn't have the wherewithal to see it through".

Over a year ago, Rishi Sunak made five pledges for voters to judge him on.

The prime minister met his pledge to halve inflation by the end of 2023.

However, as evidenced by the latest figures on small boat crossings ( more here ), and the fact that the UK economy is in recession ( see post at 7.06 ), he is faring less well with his other pledges.

With the general election approaching, how is Mr Sunak doing on delivering on his promises?

You can see the progress for yourself below.

By Beth Rigby , political editor

There is an edict in our democracy that politics and royalty must not mix.

Sure, we live in a "constitutional monarchy" where King Charles is head of state, wading through government papers and meeting the prime minister weekly.

But when it comes to the task of setting the political direction and framing our nation's political debate, the Royal Family has to zip it and remain entirely neutral.

And just as the royals don't stray into political territory, political editors like myself and politicians don't talk much about the Royal Family.

In fact, politicians actively swerve any questions inviting them to comment on the latest tabloid drama around the royals.

But this week on Electoral Dysfunction, we've broken with our own conventions to discuss the Princess of Wales's announcement that she has cancer, and ask whether this might be a moment when the cultural and social role the Royal Family play in our national life takes a more political tilt.

Read more below - and listen to Electoral Dysfunction wherever you get your podcasts .

Email Beth, Jess, and Ruth at [email protected] , post on X to @BethRigby , or send a WhatsApp voice note on 07934 200 444. 

By Siobhan Robbins , Europe correspondent

In a hostel in northern France, the atmosphere was tense.

A father and his family were waiting for a call, a sign sea conditions were right and it is finally time to go.

After fleeing from Kurdistan, they've paid around €8000 (£6,850) to cross the Channel on a dinghy provided by smugglers who value money over life.

"We don't have any other option except this dinghy. The surveillance for the trucks [crossing the Channel] is very strong and that is why we have to take this journey. We will either die or succeed," Mohammed said ahead of the journey.

To tell their story safely, all the family's names have been changed.

The UK wasn't their destination of choice; for years Germany was their home but then, after a failed asylum bid and threatened with deportation last month, they ran.

If they stayed, Mohammed says they would have been sent back home where he fears he could be killed.

But after years of making friends and plans, overnight his family's lives changed.

Read the full story here:

By Jennifer Scott , political reporter

A former ethics adviser to Boris Johnson broke the rules in the House of Lords by "assisting an outside organisation in influencing" government officials at the Ministry of Defence, a watchdog has ruled.

A report from the Lords Commissioner for Standards said Lord Geidt - who advised the former prime minister between April 2021 until he quit in June 2022 - gave introductory remarks at a meeting in May 2021 between the officials and Theia Group Inc, which employed him as an adviser.

Despite claims from the peer that his only role had been to make sure the firm's contact with the department "were conducted properly" and that he had been hired to advise them due to his previous experience, rather than his seat in the Lords, the commissioner said he had gone against a rule stopping peers providing "parliamentary services" in return for payment.

Lord Geidt appealed against the decision, but it was dismissed by the Lords Conduct Committee, which said while they accepted the peer "sought at all times to behave honourably and to comply with the rules", he had still broken them.

The first three months of this year have seen the highest number of small boat arrivals ever at 4,644, according to provisional Home Office figures.

Not by very much. The number for the first three months of 2022 was 4,548 - 96 fewer.

A few days of poorer weather could have swung it the other way, but the point is it's moving in the wrong direction for a prime minister who promised to "stop the boats".

If you promise to reduce the numbers as one of your key pledges, then you get blamed for every failure to do so.

Former immigration minister Robert Jenrick, who resigned from the government last year , described his party's immigration policy in a tweet as "the triumph of hope over experience".

As Tories head off on the local election campaign trail in glum spirits, the message from Downing Street is that this "migration emergency" can only be solved by getting flights to Rwanda.

And the legislation which might - possibly - allow that to happen won't be debated again until after Easter following a string of defeats by peers .

Time is ticking down.

Read Tamara's full analysis here:

Dame Esther Rantzen has hailed "historic" assisted dying legislation that has been introduced at Holyrood on Thursday.

The veteran broadcaster, who has revealed she is considering travelling to Switzerland for an assisted death after being diagnosed with stage four lung cancer, said those who are terminally ill should have the "right to choose".

Liberal Democrat MSP Liam McArthur has published a bill at the Scottish parliament that, if passed, will allow people living in Scotland with a terminal illness to be given help to end their life.

Dame Esther said: "I want to congratulate the Scottish parliament for prioritising this debate so that they can carefully consider this crucial issue and scrutinise this historic assisted dying bill.

"The current law is cruel, complicated and causes terrible suffering to vulnerable people."

Read her full comments here:

While the Royal Family have faced a challenging few weeks, our political editor Beth Rigby , Jess Phillips, and Ruth Davidson explore the points where royalty and politics meet, and what the family will say publicly about the state of cancer care following the King and the Princess of Wales's diagnoses.

Plus, is deputy prime minister Oliver Dowden someone likely to be feeling on top this week after calling out China-backed cyberattacks and announcing sanctions against two individuals and a company? Beth, Jess, and Ruth discuss the extent of the Chinese threat.

And they go through more of your messages and questions.

Listen here:

👉 Tap here to follow Electoral Dysfunction wherever you get your podcasts 👈

Email Beth, Jess, and Ruth at [email protected], post on X to @BethRigby, or send a WhatsApp voice note on 07934 200 444.

Warning: some explicit language.

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    With regard to surgery, patients agreed that the surgery room environment itself generates fear and was described as "intimidating", and they feared the appearance of complications during surgery (including death). ... an exploratory study using patient journey mapping. Patient Exp J. 2018; 5 (3):97-107. doi: 10.35680/2372-0247.1273 ...

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    The type of surgery and stage of the patient journey formed the analysis groups. The study was part of a larger hospital project to redesign the orthopaedic patient journey for hip or knee replacement surgery, here starting with the patient experience [19, 21]. In particular, the data collected by the hospital management to assess the quality ...

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    The term patient journey (also referred to as patient pathway, clinical pathway, patient flow, and care pathway) has become a key topic when addressing the challenges in healthcare. ... Initial planning of the case study revealed the need to develop two typical patient scenarios, one for emergency surgery and one for elective surgery. The ...

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    Process mapping enables the reconfiguring of the patient journey from the patient's perspective in order to improve quality of care and release resources. This paper provides a practical framework for using this versatile and simple technique in hospital. Healthcare process mapping is a new and important form of clinical audit that examines how we manage the patient journey, using the ...

  10. Exploring the hospital patient journey: What does the patient

    Purpose To understand how different methodologies of qualitative research are able to capture patient experience of the hospital journey. Methods A qualitative study of orthopaedic patients admitted for hip and knee replacement surgery in a 250-bed university hospital was performed. Eight patients were shadowed from the time they entered the hospital to the time of transfer to rehabilitation ...

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    Patients have the opportunity of meeting other patients going through the same journey along with members of the MDT and professionals involved with smoking/alcohol cessation, exercise and weight loss. ... Value is added through reducing the incidence of "wrong patient surgery" (demand management) and as a consequence of the nature of the ...

  13. PDF The patients journey

    The patient's journey. So you can put the operation into context for the patient, here is a typical "patient journey" for elective or planned surgery: G.P. referral: the patient's General Practitioner decides that the patient has a condition that may require surgery and refers the patient to the hospital (usually a few days or weeks later).

  14. The Patient's Voice

    The survey conducted by the ACC/HCMA on the patient experience shows a high level of emotional and psychological toll on patients with HCM. While it is important to ensure patients have strong clinical support for their physical symptoms, we must also ensure support for the significant emotional burden of having a chronic genetic cardiac disease.

  15. The Patient Journey: What It Is and Why It Matters

    Your patient engagement journey is what guides your patients to making the best possible decisions on their care so they get better. The easier you make it for them to engage with you, the higher quality their care will be. Ultimately, you want your patients to be evangelists for your services based on their positive experiences.

  16. Patient Journey & Resources

    Our cardiac ICU nurses are all specialized surgical nurses with expertise in cardiothoracic disease. They take care of you as your recovery begins, providing 24-hour monitoring. Depending on your specific health needs, your hospital stay may vary. In general, you can expect to stay in the cardiac ICU for one to two days.

  17. Patient Journey

    Patient Journey. We understand the road to transplant can seem overwhelming for patients. So we've created a series of videos to help explain the transplant journey from evaluation to waitlisting, and from pre- to post-transplant. Our dedicated team is here for you every step of the way. Hear from our experts on what to expect.

  18. The bird's-eye view: A data-driven approach to understanding patient

    Assigning edit values can be data-driven, involve the input of medical experts, or a combination of both. 47 For back pain patients, some rarer treatment options, such as surgery, can be a defining aspect of the patient journey. Therefore, instead of weighting a match on surgery equal to a match on a primary care visit, we assign the value of ...

  19. The patient journey: ophthalmic practices and refractive cataract surgery

    Empathy for the patient and understanding the patient's perspective represent essential elements of refractive cataract surgery. Seeing one's own practice (and one's self) from another's vantage point can present many challenges, but is well worth the effort. Cataract surgery embodies both a therapeutic intervention and a refractive ...

  20. [Download Free Template] How to create a patient journey map

    Learn. Healthcare. [Download Free Template] How to create a patient journey map. Patient journey mapping is a process that helps you—as healthcare providers—to visualize the complete experience of your patients who seek and use your care services. This includes every single touchpoint (whether online or offline) that a patient encounters in ...

  21. Exploring the hospital patient journey: What does the patient experience?

    Therefore, hospitals can significantly improve the quality of the ser-vice provided by exploring and understanding the individual patient journey [12-14]. Many tools may be used to measure and understand patient experience [15, 16]. Surveys are the methods mainly used to capture the patient experience and to evaluate the quality and safety of ...

  22. Improve surgery patient journey with Patient Journey App

    Surgery & Patient Journey App. Inform your patients and prepare them for the various appointments (initial consultation, briefings, check-up appointments, etc.). Ensure the best possible support in the time after discharge from the hospital with rehab programmes. Send push-notifications including information and reminders in preparation for the ...

  23. Patient Journey : Mark O'Donnell Vascular Surgery

    Patient Journey Professor O'Donnell believes that communication and its ability to reduce a patient's stress is absolutely paramount in clinical practice. ... Due to the complexity of arterial surgery which is indicated for the prevention of strokes, aortic aneurysm rupture or to improve lower limb blood supply, such procedures or surgeries ...

  24. Awake Spine Surgery: Patient-Centric Approach To Conquering Back Pain

    Her journey with UC Health embodies the intersection of expertise, compassion, and a commitment to pioneering advancements in patient-centric spine surgery, spotlighting the institution's dedication to patient well-being and faster recovery. "My care was unbelievably beautiful, thoughtful, compassionate. It was patient-focused.

  25. Nextech Demos Patient Journey Innovations with Artificial

    Nextech services more than 16,000 physicians and over 60,000 office staff members in the clinical specialties of Dermatology, Med Spa, Ophthalmology, Orthopedics, and Plastic Surgery.

  26. UK patient finds relief after 25 years of shoulder pain

    Gibson was 29 years old when he had his first shoulder surgery after being stationed in Korea serving in the U.S. Army. He didn't know that his surgery in 1999 would take him on a 25-year journey to find healing and pain relief. Initially, Gibson underwent a capsular shrinkage on his shoulder.

  27. Sask. surgeries, more patient info available online

    Saskatchewan residents will soon have more access to surgical information online including scheduled dates and their surgeon's name with the launch of a new feature on MySaskHealthRecord accounts.

  28. A Terrorist Attack in Russia

    The tragedy in a Moscow suburb is a blow to Vladimir V. Putin, coming only days after his stage-managed election victory.

  29. Politics latest: Keir Starmer asked if he's a 'Tory in disguise'

    Labour leader Sir Keir Starmer and deputy leader Angela Rayner launch Labour's local elections campaign in the West Midlands. Listen to the latest Electoral Dysfunction podcast as you scroll.