Despite well-defined care pathways and referral processes, patients’ journeys are rarely linear and always unique. In the patient’s mind, they may often start well before an episode of care, and continue on after their discharge.

The concept of the journey has implications for nurses at both a systemic and practice level and forms part of the current suite of patient-oriented approaches that also includes patient experience and patient engagement.

Health Service Redesign

One common methodology gaining momentum is lean thinking inspired by Toyota, who devised it as a way of removing waste and inefficiency from their car production processes. Lean principles have been adopted globally by health services; in Australia, they are supported by an inter-industry network and specialised training.

Process mapping (Trebble et al. 2010) translates lean into practice and looks backwards to improve forwards, using a clinical audit process to identify problems and suggest improvements. It aims to reconfigure the journey from the patient’s perspective to improve the quality of care and free up resources.

Data collection is the key. A holistic approach includes multidisciplinary meetings, re-enacting the patient’s journey, walking the journey alongside the patient, and patient's self-reported experiences. Not only are patients heard, but also staff - especially frontline nurses who understand the system (or even just their part of it) but are rarely asked to contribute to global change processes.

The resulting collation - sometimes called a value stream map - identifies and quantifies both value and non-value steps in the journey. Comprehensive maps have been especially useful in reducing two of the biggest wastes in healthcare: waiting times (for patients) and underusing staff skills.

Experience-Led Approach

In contrast, the Fifteen Steps Challenge (NHS 2012) imagines from a carer’s perspective what kind of journey their loved one will experience just by taking the first fifteen steps into their healthcare environment. It originated from a parent in the UK who synthesised her many ‘first impressions’ of mental health wards into a checklist to guide services about the impact of sensory elements on a patient’s admission and subsequent care.

The challenge is not a clinical audit or performance management tool, but instead augments existing quality and continuous improvement initiatives. Services are not forewarned, allowing participants - often including nursing staff and patient and carer representatives - to record their impressions under five domains that consider whether the environment was:

Welcoming;
Safe;
Caring and involving;
Well organised; and
Calm.

These subjective experiences are reviewed by service management and compiled into a rapid feedback summary that is timely, constructive and courteous for their team to help reduce their anxiety and foster positive changing practice.

A Successful Combination

While both approaches can be conducted simultaneously and complement one another, they will only work if healthcare providers are committed to change and prepared to ‘hear’ a variety of views. However, if conducted with rigour and honesty, both allow nurses to continue their strong tradition of advocacy by promoting the value of listening to and learning from the one constant throughout the whole journey: their patient.

References

NHS Institute for Innovation and Improvement 2012, The Fifteen Steps Challenge, NHS, viewed 17 November 2016, https://webarchive.nationalarchives.gov.uk/20121102164054/https://www.institute.nhs.uk/productives/15stepschallenge/15stepschallenge.html
Trebble, T M, Hansi, N, Hydes, T, Smith, M A & Baker, M 2010, ‘Process Mapping the Patient Journey: An Introduction’, The British Medical Journal, vol. 341, viewed 17 November 2016, https://www.bmj.com/content/341/bmj.c4078

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