Figure 1
Example of value exchange.
Table 1
Examples of transaction content and value attributes.
| Transaction content | Value attribute | ||
|---|---|---|---|
 | Advice |  | Satisfaction |
 | Reassurance |  | Comfort |
 | Information |  | Control (over) |
 | Feedback |  | Quality |
Table 2
Sample of interviewees.
| Actor | Function | Involved in the pathway’s | ||
|---|---|---|---|---|
| early development | implementation | continuous development(1) | ||
| Operational process | ||||
| Patient A | Subject of the outpatient THA care pathway. | × | × | × |
| Patient B | Subject of the outpatient THA care pathway. | × | × | × |
| Anaesthetist | Examines the patient to prescribe the right anaesthesia. | √ | √ | √ |
| Nurse | Ensures the health and safety of patients at the ward. | × | × | × |
| O.R. Nurse | Assists the orthopaedic surgeon during surgery. | × | × | × |
| Orthopaedic consultant | Informs and educates patient about medical procedures, and ensures that the right arrangements are made at their homes. | √ | √ | √ |
| Orthopaedic surgeon | Performs the outpatient THA surgeries and discharges the patient. Introduced the caregivers and hospital to the idea of fast-track surgery and outpatient THA; had a crucial role in ensuring the acceptance and implementation of the care pathway. | √ | √ | √ |
| Physician assistant | A specialist nurse who is able to execute certain tasks of the orthopaedic surgeon at the outpatient clinic, such as post-operative checks. The chairperson of the different meetings. Has a central role in managing and disseminating the developments in the care pathway. Is often consulted for information by other actors in the care pathway. | √ | √ | √ |
| Physiotherapist | Assists in the postoperative recovery process of patients. | √ | √ | √ |
| Ward doctor | An orthopaedist in training who diagnoses patients at the outpatient clinic and visits patients at the ward. | × | × | × |
| Managerial process | ||||
| Care manager | Manager of various business units including orthopaedics. | √ | √ | √ |
| Head of nursing | Manages the orthopaedic nursing department on a day-to-day basis. | √ | √ | √ |
| Manager orthopaedics | Manages the orthopaedic partnership on a day-to-day basis. | √ | √ | √ |
| External process | ||||
| Biomet consultant | Consults healthcare organisations on optimising their care pathways. | × | × | √ |
| Biomet sales representative | Assists healthcare organisations with the use of products and sells products. | × | × | √ |
| Health insurer | In charge of selecting care for their insured. | × | × | × |
| (1) | Every four to six months, meetings are held with the different caregivers involved in the pathway. Problems are discussed, projects are initiated and progress is tracked on ongoing projects. | |||
Table 3
Organisation problems and inefficiencies.
| Care pathway | |
|---|---|
| Poor communication on the implementation of changes in the outpatient THA care pathway. | √ |
| Lack of information-sharing and transparency between caregivers causing problems in the provision of care. | √ |
| The ward doctor alternates monthly between specialists in training, which requires time to adjust and settle in the role of preparing, examining and prescribing the right medications to the patient. | |
| The different actors of the care pathway do not feel responsible for the pathway’s development, as a result of which problems are neglected, making it difficult to improve the care pathway. | √ |
| Model phase 1 | |
| The information provided to the patient (education) is outdated, repetitive, excessive and generic. | |
| Inefficient consultations with the orthopaedic consultant, long and redundant. | √ |
| Patient does not always prepare for the orthopaedic consultation by reading the information folder. | |
| Many patients do not visit the group information session pre-operatively. | √ |
| High number of pre-operative patient transactions and hospital visits, which is very time-consuming, especially for patients traveling from afar. | √ |
| The anaesthetist has not always enlisted the medication in the patient’s file at the time the patient visits the ward doctor pre-operatively; this results in that the ward doctor is unable to provide a patient prescription, causing issues at a later time. | √ |
| Model phase 4 | |
| The recovery time from spinal anaesthesia varies per patient, making it difficult to predict when mobilisation can take place. | |
| Misunderstanding between caregivers on the patient treatment. The agreement is that only the first two patients may be discharged on the day of surgery. Even if the third patient meets the discharge criteria he or she cannot go home. | |
| The ward doctor’s presence is needed at both the ward and outpatient clinic. However in the afternoon the ward doctor is at the outpatient clinic and rarely visits the ward, which means the patients only get to see a doctor at discharge. | √ |
Figure 2
Model phase 1 diagnosis and preparation, as-is (left), optimised design (right).
Table 4
Value exchanges of care pathway model design phase 1.
| No. | Involved actors | Transaction content | Value attribute |
|---|---|---|---|
| Patient visit 1 | |||
| 1 | Radiologist, Patient | The radiologist takes an x-ray of the patient’s hip and provides the patient with information about the procedure. The patient answers any clarifying questions from the radiologist. | Patient: quality Radiologist: efficiency |
| 2 | Orthopaedic surgeon, Patient | The orthopaedic surgeon examines and questions the patient for diagnosis. The patient is provided with information about his or her condition, treatment options are advised and discussed, and the patient is reassured. The patient asks any questions he or she has and both actors exchange and discuss their expectations concerning the procedure and the post-operative recovery. Finally the orthopaedic surgeon conducts a physical examination and motivates the patient to recover. | Orthopaedic surgeon: insight, control, quality Patient: insight, satisfaction |
| Patient visit 2 | |||
| 3 | Anaesthetist, Patient | The anaesthetist questions the patient about his or her health and gathers medical data (e.g. drug use, blood pressure). The patient is reassured and discusses the anaesthetic procedure with the anaesthetist. The patient answers and asks questions. | Anaesthetist: insight, safety Patient: comfort |
| 4 | Physiotherapist, Patient | During the physiotherapeutic consultation the recovery process and expectations of the patient are discussed. The physiotherapist provides the patient with information and advice. During the consultation the patient is taught to walk with crutches. | Physiotherapist: insight Patient: insight |
| 5 | Pharmacist, Patient | The pharmacist phones (dotted line) the patient to check which drugs the patient uses. The patient provides the pharmacist with the needed information. | Pharmacist: safety Patient: comfort |
| 6 | Nurse specialist, Patient | The nurse specialist conducts the medical anamnesis by questioning the patient and ensures that the appropriate arrangements are made at home to support discharge on the day of surgery. These are, for example, the availability of an informal caregiver for support on the first day and moving the bed to avoid excessive use of stairs. The nurse specialist prescribes the medication needed after discharge so that it is already available when the patient returns home. The patient provides the needed information and asks questions to remove any uncertainties. | Nurse specialist: quality Patient: comfort, insight |
| 7 | Informal caregiver, Patient | continuous The informal caregivers are (generally) present at all value exchanges involving the patient. They reassure the patient, while the patient provides information to the informal caregivers about the care pathway. | Informal caregiver: satisfaction Patient: comfort |
| 8 | Patient information application, Patient | continuous The patient information application informs the patient throughout the entire pathway about his or her journey, preparing the patient on what to expect and when. The patient is able to ask urgent questions via the application. The date of surgery is scheduled via this application. | Patient information application: quality, efficiency Patient: insight, comfort |
Figure 3
Model phase 4 mobilisation and discharge, as-is (left), optimised design (right).
Table 5
Value exchanges of care pathway model design phase 4.
| No. | Involved actors | Transaction content | Value attribute |
|---|---|---|---|
| 1 | Nurse, Informal caregiver | The nurse phones the informal caregivers to inform them that the patient has returned to the ward. Any questions the informal caregivers have are answered. | Nurse: quality Informal caregiver: reliability |
| The following transactions are not listed in a strict successive order, but strong dependencies exist. | |||
| 2 | Nurse, Patient | continuous The nurse is the main contact person for the patient and supports him or her at the ward by checking in regularly, asking questions and monitoring the patient's health. In turn the patient provides information to the nurse and both asks and answers questions. This transaction is dynamic and occurs multiple times (blue colour). The nurse handles the discharge of the patient, informs him or her about do's and don'ts and arranges all the needed paperwork at discharge. | Nurse: safety Patient: comfort |
| 3 | Nurse, Physiotherapist | The nurse informs the physiotherapist when the patient has returned to the ward. Relevant medical patient data and information about how the patient feels is exchanged to determine when mobilisation of the patient could take place. At a later point in time the physiotherapist informs the nurse regarding progress in mobilisation. Both actors inform each other to track progress and coordinate whether the patient can be safely discharged. | Nurse: quality Physiotherapist: quality, insight |
| 4 | Physiotherapist, Patient | (twice) The physiotherapist supports the patient’s mobilisation on two separate occasions, providing advice and reassurance. The patient asks questions and gives feedback on mobilisation. The patient uses a walker for support during the first mobilisation. During the second, the patient uses crutches to meet the functional discharge criteria. | Physiotherapist: satisfaction, safety Patient: mobility, comfort |
| 5 | Doctor, Patient | The doctor visits the patient twice after surgery to check progress. The doctor explains how the surgery went and asks the patient how he or she is doing. The patient provides information on how he or she feels and asks any questions he or she still might have. Lastly the doctor reassures and motivates the patient. If the patient meets the functional discharge criteria and both the physiotherapist and nurse agree, the patient is discharged. | Pharmacist: safety Patient: comfort |
| 6 | Doctor, Nurse | The doctor asks the nurse how the patient is doing and whether the patient is able to go home. The nurse bases the response on medical data and information about the patient. Finally, the doctor notifies the nurse when patient discharge is approved. | Nurse specialist: quality Patient: comfort, insight |
| 7 | Doctor, Physiotherapist | The physiotherapist exchanges information with the doctor, and the doctor asks questions to discuss the state of health of the patient in order to determine whether it is safe to discharge the patient. | Informal caregiver: satisfaction Patient: comfort |
| 8 | Informal caregiver, Patient | continuous The informal caregivers are (generally) present at all value exchanges involving patients. They reassure the patient, while the patient provides information to the informal caregivers about the care pathway. | Informal caregiver: satisfaction Patient: comfort |
| 9 | Patient information application, Patient | continuous The patient information application informs the patient throughout the entire pathway about his or her journey, preparing the patient for what to expect and when. The patient can ask urgent questions via the application. The date of surgery is scheduled via this application. | Patient information application: quality, efficiency Patient: insight, comfort |