An action-research study examines a patient journey model to improve patient-centred care and the collaboration needed for the project’s success
Sue Baron, BSc, RN, is research assistant, School of Health and Social Care, Bournemouth University.
Baron, S. (2009) Evaluating the patient journey approach to ensure health care is centred on patients. Nursing Times; 105: 22, early online publication.
Background: In order to become more patient-focused, the City Hospitals Sunderland NHS Foundation Trust developed the ‘patient journey’ approach, which was a ‘comprehensive practice development/service improvement’ model.
Aim: For an ‘outsider’ (a newly qualified nurse with personal experiences as a patient) to implement a new patient journey in an unrelated hospital trust, to enable an impartial and independent evaluation of the model.
Method: This was an action-research study, with data collected through a variety of sources such as matrix sampling, project team meetings, mapping and semi-structured qualitative interviews.
Results: Participants spoke extremely highly of the care received, while interviews revealed more insightful and sometimes distressing information. A number of changes to service delivery were made as a result, including the introduction of a dedicated telephone line giving patients direct contact with the vascular nurse practitioner.
Discussion: The most notable attributes of the patient journey approach are: giving patients a ‘voice’; enhancing collaborative multidisciplinary teamwork; shared ownership and decision-making; providing evidence to substantiate change; and achieving results.
Conclusion: The City Hospitals Sunderland patient journey approach is an effective, patient-centred, collaborative service improvement model.
Keywords: Patient journey, Patient experience, Action research
This article has been double-blind peer reviewed
The following are examples of recommendations produced during this project that could have broader implications for practice:
- Improved information systems are needed between primary and acute care to reduce the risk of patients falling through the net, for example in GP referrals, patient discharge and outpatient follow-up;
- NHS uniforms should be standardised to enable everyone to readily identify staff;
- A centralised patient record should be introduced – one place for interprofessional documentation to reduce risks to patients from misinformation or lack of information. This would also reduce duplication and time wasted searching for information;
- NHS management should have a higher profile through talking to staff and patients – for example with ‘walkabouts’;
- Greater recognition should be given to the value of the patient’s voice.
Campbell et al (2004), from the City Hospitals Sunderland NHS Foundation Trust (CHS), designed their ‘patient journey’ model in response to the NHS modernisation programme.
A directive in The NHS Plan advocated that ‘the NHS must be redesigned to be patient-centred – to offer a personalised service’ (Department of Health, 2000). This initiative comprised a six-month multidisciplinary service improvement/practice development model.
If it was to become more patient-centred, the trust believed that ‘the insider perspective of the illness experience’ (Thorne and Paterson, 2000) and patients’ views and experiences should be taken into account as a fundamental part of service redesign.
The CHS created its patient journey approach from aspects of the integrated care pathway process, but with a greater emphasis on patient involvement and partnership.
It recommended that project team membership should be drawn from the broad range of disciplines linked to patients’ healthcare journey.
The CHS described its patient journey as ‘a dynamic, locally agreed, patient-centred process, which crosses organisational and primary/secondary care boundaries. The pathway is developed by the multidisciplinary team, which includes strong patient/carer involvement, using the best evidence to guide practice’ (Campbell et al, 2004).
By 2005, the trust had piloted more than 20 patient journeys and completed 16 in the patient groups shown in Box 1.
Campbell et al (2004) said the approach was ‘explicit, different and making a difference to patients’.However, at that time no formal or independent evaluation of its effectiveness had been carried out.
Box 1. Patient groups for journeys
- Acute coronary syndrome
- Prostate cancer
- Acute myocardial infarction
- Acute child admissions
- Ovarian cancer
- Lung cancer – two journeys
- Percutaneous endoscopic gastrostomy (PEG)
- Head injury
The vision of high-quality, patient-centred, evidence-based health care has been at the heart of NHS reforms for many years.
Numerous government directives all argue that the NHS must deliver high-quality, safe and personalised, patient (person)-centred health care (DH, 2007; 2005; 2004; 2000).
Yet, even now, in spite of ever-increasing emphasis on providing personalised NHS health care, and numerous frameworks and models to enable its delivery, excellence in patient-centred health care continues to evade many areas of the NHS.
Evidence to support this view is readily available from the media (BBC News, 2008; Open2.net, 2007), the literature, or through personal observation or experience.
It could be argued that one reason for this is that many of these initiatives still appear to fail to reach or include front-line staff.
Of those projects that do include practitioners – such as integrated care pathways and the Productive Ward initiative (NHS Institute for Innovation and Improvement, 2007) – none appear to include feedback from patient interviews in service redesign.
Neither do they seem to draw on membership from the broad range of disciplines linked to patients’ healthcare journey.
Furthermore, it could be argued that trying to improve healthcare services without learning more about patients’ experiences or asking what they really want may explain why excellence in patient-centred care delivery still eludes many areas of the NHS.
Providing personalised health care is a complex, diverse and multi-faceted issue. It is influenced by many factors, on both the actual delivery of health care and patients’ expectations and perceptions of their experiences.
In light of this, it could be argued that it is imperative to take into account both patients’ and healthcare providers’ views if the NHS is to fulfil its vision of personalised, patient-centred health care.
Goodrich and Cornwell (2008), Richards and Coulter (2007), Scott and Caress (2005) and Wales (2005) supported this view. They recognised that patient-centred care requires effective interprofessional relationships based on shared visions and a clear understanding of patients’ needs and their individual perspectives.
Furthermore, Bauman et al (2003) argued that efficient, effective collaboration between NHS management and healthcare professionals was vital in achieving excellence in health care. Campbell et al (2004) said these factors were central to the CHS patient journey approach.
Interestingly, despite the government’s focus on the NHS becoming patient-centred and offering a personalised service (DH, 2000), the government has not provided a single, succinct definition of ‘patient-centred’.
This is surprising, given there are over 1.2 million staff across more than 600 NHS trusts expected to provide patient-centred services to the millions of people needing health care every year (NHS Choices, 2009).
In view of this and to avoid confusion, the term ‘patient-centred’, in the context of this study, refers to health care that fulfils the individual needs and expectations of the whole person, rather than merely the ‘patient’.
This review also highlighted that there were different interpretations and uses of the term ‘patient journey’, most commonly associated with a person’s health trajectory or the process of mapping the patient’s journey through healthcare organisations.
In the context of this study, the term ‘patient journey’ refers to a process. This is a practice development/service improvement model that incorporates the patient’s journey, the individual’s lived experience and views of health care.
Although CHS had piloted more than 20 patient journeys, in 2005 no independent or written evaluation of the model existed.
Furthermore, all these projects had been run or overseen by team members who had been involved in developing the patient journey approach, understood the process, and were employed by and held positions of authority within CHS.
The main aim of this qualitative, action-research study was for an ‘outsider’ (a newly qualified nurse with personal experiences as a patient) to this approach and the trust to implement a new patient journey.
It was carried out in an unaffiliated NHS hospital trust in the South West of England, to enable the approach to be independently and impartially tested and evaluated.
Action research was chosen for this study because of its natural affinity with the anticipated cyclical and constantly evolving nature of the CHS patient journey model (Campbell et al, 2004).
This research method involves a qualitative, collaborative approach (Coghlan and Brannick, 2001).
The trust recommends that each patient journey should be conducted as an individual research project and, as such, must meet NHS research governance procedures.
Full ethical and research and development approval was obtained before implementing the new patient journey.
The active phase of the project ran from May to December 2007, during which time monthly project team meetings were held.
The activities outlined in Box 2 were carried out in accordance with the CHS patient journey model.
Box 2. Activities for patient journey model
- Recruiting multidisciplinary project team – key roles assigned
- Matrix sampling
- Process mapping
- Interviews with patients
- Identifying issues and solutions (based on feedback from interviews and mapping)
- Action planning/proposals for service improvement
Recruiting multidisciplinary project team
The vascular patient journey project team comprised the following: vascular consultants; consultants specialising in care of older patients; anaesthetists; director of nursing; service improvement managers; nurse practitioner; matron; practice development lead nurse; divisional general manager (surgery); general manager (surgery); vascular specialist nurse; clinical nurse specialist (primary care); ward sisters; occupational therapists; physiotherapist; pharmacist; superintendent radiographer; medical secretaries; senior social worker; and waiting list coordinator.
Key roles were agreed at the first meeting in accordance with the CHS patient journey model:
- Vascular patient journey chair – director of nursing;
- Clinical champion – vascular consultant surgeon;
- Local facilitator – nurse practitioner;
- Patient journey facilitator – researcher.
The vascular patient journey project team used matrix sampling, which is similar to purposive or stakeholder sampling, as recommended by CHS (Campbell et al, 2004).
The method enabled the team to determine and agree which criteria would facilitate the selection of patients who best represented their sample group.
In this instance, they were identified as patients with peripheral vascular disease who had undergone surgery for a femoral bypass graft in the previous six months. From a list of 25 eligible patients, 11 participants were finally recruited for interview.
Three process mapping sessions were held between June and late August 2007 and run by a service improvement manager with expertise in this area.
The patients’ journeys, for elective and emergency admissions, were mapped from the point of referral/admission through to 1–2 days post surgery. This is a lengthy process because of this group’s complex needs.
The information was transferred onto a detailed flow chart, with each step on the chart numbered and accompanied by explanatory notes. The final map (flow chart) of the current patient journey was produced after consultation and agreement with the project team.
Semi-structured interviews with patients and relatives/carers
Participants were aged 45–80 years, and there were six men and five women. Six participants had a spouse/partner/relative present.
All gave written, informed consent before the interviews, which took place in their homes between August and November 2007.
The in-depth, informal interviews started with participants being invited to give an account of their healthcare experience: ‘Please tell us about your care. What did we do well? How could we make it better?’
Recorded interview data was transcribed and the key themes identified and categorised as follows:
- Time from initial GP appointment to vascular consultant appointment;
- Telephone contact with hospital;
- Communication and information;
- Short notice/emergency admission;
- Relationships with healthcare professionals;
- Nurse workloads;
- Healthcare delivery;
- Privacy and dignity;
- Cleanliness/infection control;
- Hospital catering;
- Hospedia (Patientline at the time of the study);
- Car parking;
- Outpatient appointments/follow-up care.
Verbatim, anonymised extracts from participants’ transcripts were amalgamated into a 34-page themed report and distributed to project team members.
Identifying issues and solutions
Issues were identified for action from the patient interview feedback and the mapping exercises.
These were amalgamated into an issues and solutions document, containing 75 issues for further discussion and prioritisation by the project team.
Action planning/proposals for service improvement
After prioritising the issues and discussing possible solutions, the project team jointly agreed and assigned actions to be taken.
The issues ranged in complexity from ensuring that skimmed milk was available for patients on the wards to purchasing diagnostic imaging equipment.
The most powerful element of the patient journey process was undoubtedly the feedback gathered from patients and carers during the interviews.
The project team commented on how much they had valued learning about the actual experiences and views of their patients.
Furthermore, they acknowledged that, had this information been collected by more traditional means such as surveys or questionnaires, the data would not have been so detailed and informative, and was unlikely to have created the same impact.
For instance, overall participants spoke extremely highly of the care they received. Comments included: ‘Swiftness at admission was amazing’ and ‘Care in hospital was fantastic’. They were keen to express their gratitude to staff: ‘They’ve all done a good job…excellent’ and ‘She’s wonderful’.
Had these views on health care been collected by a more structured method, it could have been possible that patients’ responses might have yielded ‘satisfied’ or ‘very satisfied’ results only. It was only as the interviews progressed that the deeper, more insightful and sometimes distressing information was revealed, as shown by the examples in Box 3.
The vascular patient journey project team placed a high value on learning about these experiences, being aware of strengths and weaknesses in service delivery and having the opportunity to discuss, review and jointly plan the way ahead.
Many members reported how working in this way – and especially learning about their patients’ experiences and expectations – had ‘opened their eyes’ and ‘broadened their thinking’.
They observed how this was likely to have a positive influence on their future practice.
Box 3. Examples of patient experience
- ‘The nursing staff worked very hard and were very busy but were in control of what they were doing and instilled confidence…super care.’
- ‘I didn’t like to use the call bell; I could see them rushing around with so much to do.’
- ‘The anaesthetist was very nice…he gave good information…even drawing a sketch of the operation.’
- ‘The doctors…they talk to you but sometimes they talk over you, you know what I mean? You don’t know what they’re on about.’
- ‘They’ve all done a good job…excellent; but the psychological side – nobody tells you about the sense of isolation, the highs, the lows, the mood swings…the tiredness, the possible after-effects of anaesthesia and surgery.’
- ‘She undressed me totally…went off…left curtains ajar and I couldn’t do anything …I felt terrible.’
- ‘Hard bit of being in a side room…you don’t see a soul…you lose the human contact.’
- ‘The nurse said, “Why didn’t you tell us about this before?” and I said, “Well I did, I’ve been saying something all night” (Nurse) “Well, nobody told me…”’ (patient readmitted to theatre, post-operative bleed).
The following are examples of some of the results achieved in response to the issues identified during this patient journey project:
- Inter-hospital access to IT diagnostic imaging results is now possible for consultants;
- The short-notice surgical admission notification procedure was changed – vascular patients are now only contacted by medical staff/nurse practitioner for short-notice admissions;
- A dedicated telephone line/answer phone was installed, giving patients direct contact to the vascular nurse practitioner;
- Angioplasties became available as day-case procedures for suitable patients from January 2008 in an attempt to reduce delays;
- Clearer information and guidelines on medications before hospital admission for surgery are now available for patients, in a revised patient information sheet on this topic;
- Pre-operative medication and fasting procedures were clarified in a revised nil-by-mouth policy and distributed to ward staff;
- Skimmed milk is available on wards on request;
- Patient information leaflets for surgical patients are being reviewed, after a patient requested information on the possible psychological/emotional effects following anaesthesia/surgery;
- Funding has been obtained for a portable head for the duplex scanner (the results of a further bid for an extra duplex scanner are awaited).
Despite a number of setbacks before and during the project, these examples show how the patient journey process can be an effective, evidence-based catalyst for change when supported by a fully engaged interprofessional project team.
In this instance, the tenacity of those allocated key roles to ensure a positive outcome – specifically the local facilitator, clinical champion and patient journey facilitator – was a major contributory factor to the project’s success.
During the evaluation, team members said how much they had valued their involvement in the project through comments such as:
- ‘Felt empowered by the experience and my involvement’;
- ‘Increased my profile’;
- ‘Identification of issues that are important to patients’;
- ‘Privilege of reading about the patients’ experience’;
- ‘Identification of issues that as a team we can try to put right for the benefit of patients’.
Correspondingly, the four strongest features of the approach were identified as:
- Patient involvement – enabling healthcare professionals to hear what patients really want from their caregivers;
- The opportunity the patient journey provides for interprofessional teambuilding from trust management to clerical staff and acute to primary care – project team participants considered this to be of significant value;
- Collecting evidence to support change/service improvement;
- Achieving results - this in turn can lead to increased staff morale and improve motivation.
This study and previous pilot studies show the CHS patient journey approach is an effective, patient-centred, collaborative service improvement model that can yield varied and tangible results.
The model also enhances the knowledge, understanding and interprofessional working practices of those involved.
The approach may be adapted for specific patient groups diagnosed with acute or long-term conditions – or both, as in this example.
The learning from a project such as this is invaluable and extends far beyond that which can be described in this article.
Perhaps the strongest aspect of this approach is the opportunity to hear the patient’s voice, to really learn about their experiences and expectations.
This is information which, if gathered through more traditional forms such as questionnaires or surveys, might have yielded results indicating only that these patients and their partners/carers were satisfied or very satisfied with their health care.
If the government’s vision of the NHS becoming patient-centred is to be realised, it is essential that both service users’ and service providers’ views are taken into account.
In addition, it is vital to give interprofessional working the opportunity to flourish.
Bauman, A.E. et al (2003) Getting it right: why bother with patient-centred care? The Medical Journal of Australia; 179: 5, 253–256.
BBC News (2008) Nurses raise ‘dignity’ concerns.
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Coghlan, D., Brannick, T. (2001) Doing Action Research in Your Own Organization. London: Sage Publications.
Department of Health (2007) Our NHS, Our Future: NHS Next Stage Review Interim Report. London: DH.
Department of Health (2005) Creating a Patient-led NHS: Delivering the NHS Improvement Plan. London: DH.
Department of Health (2004) The NHS Improvement Plan:Putting People at the Heart of Public Services. London: The Stationery Office.
Department of Health (2000) The NHS Plan: A Plan for Investment, a Plan for Reform. London: The Stationery Office.
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