post visit phase

Deconstructing the Patient Journey: The Post-Visit

Learn more about how patient loyalty and treatment compliance can be swayed by a good or bad post-visit experience.

Understanding the patient journey means setting aside the preconceived notion that the patient is traveling along a healthcare path alone. A successful patient journey also involves payers and providers that are pursuing their own clinical and financial journeys, which interact and interweave with the patient’s.

In the previous two articles on this topic ( 1 ,  2 ), we have focused on the pre-visit and visit stages of the patient journey. This article examines the post-visit period and the priorities present for each stakeholder.

Preserving loyalty is essential

Depending on where you sit in the healthcare ecosystem, the goal of the post- visit is to engender loyalty. For this article, loyalty is broadly defined as when consumer decision-making aligns with the objectives an entity is trying to realize. For example, will a patient choose to seek care at the same facility again? Will they meet their financial responsibilities? Will they take the next steps to continue their care? Will they remain members of a health plan year over year?

It has  been shown  that a 5% increase in customer retention can increase a company’s profitability between 25% and 95%.  Consequently, ensuring post-visit processes and procedures are designed to cultivate loyalty is crucial for long-term financial viability and success.

Remain vigilant about the patient experience

As the patient journey winds down, it may be tempting to shift focus away from the patient experience and toward processes for collecting reimbursement and mitigating revenue loss. However, organizations should not take their foot off the gas here. There have been a lot of well-documented friction points with patients regarding their healthcare bills and wrapping up their financial obligations during this stage. Payers and providers need to provide easy-to-read statements, patient-friendly communications, and responsive customer service. This is the last opportunity payers and providers have to interact with a patient, and it is important to leave a lasting, positive impression. Patient loyalty and treatment compliance can be swayed by a good or bad post-visit experience, and many financial and clinical outcomes are determined by the effectiveness of post-visit processes.

The critical part that payers play

From a financial standpoint, payers assume an outsized role during the post-visit phase as the onus falls on them to efficiently review claims and associated documentation, and render payment decisions and reimbursement. When payers and providers collaborate to streamline documentation submission, enable electronic information exchange, and minimize the sending and receiving of unnecessary information, payers can become more efficient in adjudication. Better processes yield more consistent decisions, reduce risk, and allow the payer to get payments out faster.

From a clinical perspective, both payers and providers must be able to promptly and effectively share patient health information during this stage without sacrificing privacy and security. Whether it’s connecting clinical decision makers who aren’t necessarily within the same institution or sending attachments between payers and providers to justify medical necessity, it is vital that information exchange be smooth and efficient—and ideally embedded into existing workflow. Payers and providers must also readily share information with post-acute providers to get them the information they need to continue care without lapses or miscommunications.

Creating an infrastructure that encompasses diverse viewpoints

As with the other stops along the patient journey, it is critical for providers and payers to work with innovative technology that sits at the juncture of patient, provider, and payer perspectives. These tools can enable a smooth post-visit experience for all stakeholders. The interdependencies at this stage are substantial, yet if the different entities operate in siloes, they can miss key opportunities to preserve loyalty, reduce risk, and ensure financial viability. When organizations use smart technologies like artificial intelligence and blockchain, they can make processes in this phase more efficient, data-driven, and accurate, removing tedious manual components and freeing staff to focus more directly on value-added activities.

Don’t get left behind: the time for innovation is now

Across the three articles in this series we’ve demonstrated that optimizing the patient journey requires more than just enhancing patient engagement. Providers and payers must elevate and enrich their own clinical and financial journeys while determining how they impact and influence the patient. Delivering a high level of performance given the various interconnected and interwoven processes can be a tall order. But it is necessary for organizations to pursue a new way of thinking and acting to compete in today’s competitive healthcare marketplace. To hold onto market share and remain competitive, traditional providers and payers must commit to transformation and seek comprehensive and future-facing solutions that span all perspectives, incorporate emerging technologies, and are designed to help healthcare entities make meaningful progress toward a new standard of healthcare delivery during the pre-visit, visit, and post-visit phases of the journey.

Read part I in this series: The Pre-Visit

Read part II in this series: The Visit

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Kansas Home Visiting

Steps for Conducting a Home Visit

Establishing Trust and Connection

Meeting the family on its home ground may contribute to their sense of control and active participation in planning and achieving health goals.

Phases/Activities of a Home Visit

Initiation Phase

• Identify source of referral for visit
• Clarify purpose for home visit
• Share information on reason and purpose of visit with family

Pre-Visit Phase

• Initiate contact with mother/family
• Establish shared perception of purpose with mother/family
• Determine mother/family’s willingness for home visit
• Schedule home visit
• Review referral and/or family record

In-Home Phase

• Introduction of self and identity
• Social interaction to establish rapport
• Establish relationship
• Implement educational materials and/or make referrals
• Review visit with family
• Plan for future visits as needed

Post-Visit Phase

• Record visit and plan for next visit
• Follow-up with educational materials and/or referrals

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Patient Journey Mapping: What it is, Benefits and 5 Steps to Do it

In the rapidly evolving landscape of healthcare, patient-centered care has emerged as a crucial paradigm shift. As hospitals strive to deliver exceptional patient experiences and improve outcomes, understanding the patient journey has become paramount. 

A customer journey map is a powerful tool that shares patients’ path from their first encounter with a healthcare facility to their final discharge. By visualizing this complex expedition, hospitals can gain invaluable insights into patient needs, pain points, and opportunities for enhancement, thereby revolutionizing the delivery of care. 

The following article delves into the significance of patient journey maps for hospitals and their importance in optimizing patient experiences, streamlining processes, and ultimately elevating the standard of healthcare.

What is a Patient Journey Map?

A patient journey is a methodology that enables the analysis of a healthcare provider’s processes and value chain but from the patient’s viewpoint. This includes their possible solutions, pain points, emotions, touchpoints and user actions throughout the journey.

The patient journey map employs visual representation to gain deeper insights into how patients engage with a healthcare facility throughout their care journey. This unique approach is an evolution of the customer journey map , tailored specifically to the healthcare context. By employing this method, healthcare providers can unravel the intricacies of patient interactions, uncovering valuable information to enhance the quality of care provided.

The concept of the Patient Journey Map mirrors that of the Customer Journey Map, seeking to uncover areas of enhancement in patient care across various healthcare providers, including hospitals, fertility centers, and more.

Just as a skilled cartographer carefully crafts a map to navigate uncharted territories, patient journey maps chart the course of a patient’s experience, revealing hidden insights, unveiling opportunities for improvement, and ultimately guiding healthcare providers toward a destination of unparalleled patient satisfaction . 

What are the benefits of implementing a Patient Journey Map?

Engaging in the patient journey proves immensely valuable as it enables us to provide patients with an optimal experience, meeting the very expectations that arise when seeking healthcare services. 

The emotional aspect tied to the Patient Journey Map can be profoundly impactful, considering the inherent uncertainties often associated with visiting a healthcare facility.

Considering the unique personalities, fears, behaviors, and attitudes of different patient archetypes play a pivotal role in creating a tailored and pleasant experience for them. Thus, the patient journey map becomes a valuable tool benefiting both patients and healthcare service providers.

● Enhanced Communication with Patients:

By understanding the patient journey, healthcare providers can establish effective and continuous communication throughout the entire care process, addressing any doubts or uncertainties. Keeping patients well-informed and updated through appropriate channels reinforces the quality of care provided.

● Elimination of Blind Spots:

Clear comprehension of each stage of the patient journey helps bridge the gaps between patients and services. From the initial appointment request to discharge and follow-up, identifying and addressing potential blind spots ensures consistent and satisfactory solutions tailored to each patient’s unique situation.

● Streamlined Resolution of Pain Points:

Mapping the patient journey and defining archetypes enables a deeper understanding of patient concerns, particularly identifying which aspects of the service have the most negative impact. Pain points such as waiting times, unclear explanations, lack of empathy, or impersonalized treatments can be simplified and resolved more effectively.

Learn About: Complaint Resolution

● Process Optimization:

A well-defined patient journey optimizes workflow and allows for more efficient handling of all processes. Staff members become better equipped to anticipate and address patient issues promptly, offering alternatives that instill confidence and satisfaction.

● Continuous Improvement:

Implementing a Patient Experience model involves measuring patient experiences through a feedback system . Continuously updating the database with relevant information about patient journeys and their experiences leads to ongoing improvement in response times, customer service processes, and overall service quality .

What is a Patient Persona?

The patient persona represents an imaginary profile that encapsulates potential patients’ needs, goals, illnesses, conditions, emotions, behaviors, and knowledge. 

By creating patient personas, healthcare providers can enhance the accuracy and anticipation of care and diagnosis processes, ultimately improving the experience of individuals seeking healthcare services.

5 Steps to Build Your Own Patient Journey Map

1. define the experience to map:.

Before diving into the Patient Journey Map, it is crucial to determine the specific experience you intend to outline. By establishing your objectives and identifying the type of information you seek to gather and how it will be utilized, you can ensure a more efficient mapping process right from the start.

2. Identify your Ideal Patient:

The majority of data used to construct the customer patient care journey will come directly from patient-clients. Thus, a key step is identifying the patient persona, which can be singular or multiple. You must decide whether the map will encompass various patient profiles or if separate maps will be created for each target patient.

To create the patient persona(s), gather feedback directly from patients and analyze their behaviors and data. Pose questions such as:

• What initially led the patient to seek your services?
• Which competitors did they research?
• How did they discover your website or company?
• What factors differentiated your brand from others? What influenced their decision (or lack thereof) to choose your services?
• What are their expectations when interacting with your company?
• Can they articulate what they appreciate about your company and what frustrates them?
• Have they ever contacted customer service? If so, how was their experience?

Once you have defined the patient persona(s), you can identify the distinct stages of the customer journey when engaging with your company.

3. Divide the Phases of the Customer Journey:

Throughout the customer-patient care journey, patient-clients progress through several discernible stages.

Phase #1: Pre-Visit

● DISCOVERY:

The patient journey initiates with a phase characterized by learning and concern. Patients embark on their healthcare journey upon recognizing a need or developing a concern related to a health issue.

For instance, if an individual experiences symptoms associated with being overweight, they may begin researching options for scheduling an appointment with a medical specialist. At this point, potential patients discover their specific needs and commence the process of investigating suitable solutions. They may turn to the internet, seek recommendations from friends and family, or explore other avenues. During this stage, it is recommended healthcare systems should provide educational support to aid individuals on their journey of understanding.

● CONSIDERATION:

Following their research, patients reach the consideration stage, having discovered your service. At this point, they possess some knowledge about your healthcare facility’s location and offerings, leading them to believe it could meet their needs. However, patients have also explored your competitors and are contemplating multiple options.

During the consideration stage, potential patients meticulously assess the information they come across, including service descriptions, pricing, contact pages, online inquiries, and reviews. They also evaluate the ease of accessing relevant information before scheduling an appointment and the availability of operating hours, among other factors.

Phase #3: Visit

● APPOINTMENT & ENGAGEMENT:

Having gathered sufficient information and progressed through the consideration phase, the patient ultimately chooses your service. This marks their first contact with the health center, which can occur in person, over the phone, via chat, email, or other means of communication.

During this stage, the patient schedules their appointment. The company must streamline the application process and maintain effective and proactive communication. It is crucial for this phase to be completed without complications.

● SERVICE DELIVERY:

Within the visit phase is the service delivery stage, where patients interact with various service providers at the health center. From the moment the patient enters the premises, the company must ensure an exceptional service experience.

Service delivery encompasses multiple micro-moments, necessitating comprehensive attention throughout the entire journey. Every interaction matters, from the reception care and waiting times to the core service itself—meeting the patient’s objective of being evaluated by a doctor or specialist.

Phase #3: After the Visit

● RETENTION:

The Patient journey doesn’t conclude after the initial visit. A crucial third phase occurs post-encounter, where efforts should be dedicated to fostering patient retention and encouraging their return for subsequent visits. Building strategies that monitor the patient experience is essential in designing loyalty programs to ensure patients return for future services.

● RECOMMENDATION:

Part of the post-visit phase involves patient recommendations, which heavily depend on the overall patient journey experience provided by the company. If patients have had a positive service encounter, they are likely to recommend it to others, benefiting your business. 

However, it is important to remember that negative experiences are equally shared, and if patients are dissatisfied, they may spread negative feedback. 

Promptly addressing any negative comments is crucial to resolving issues and preventing unfavorable recommendations.

Phase #4: Identify Touchpoints

An additional vital step in mapping the customer-patient care journey is identifying the various touchpoints between the patient and the healthcare facility. These interactions occur at different stages throughout the patient journey, and understanding these touchpoints aids in developing strategies that facilitate effective communication.

• Seeking information about healthcare centers: discovering the existence of the healthcare provider and the services it offers.

Investigation:

• Reviewing patient-client feedback: researching comments and feedback from other patients about their visit experiences at the health center.
• Exploring promotions: searching for economic benefits such as discounts, promotions, and bundled service packages.

Acquisition :

• Appointment Request: Contact or visit the health center to schedule an appointment.
• Provision of Personal Data: The health center will request personal information to finalize the appointment booking.
• Appointment Confirmation: After providing the required data, the appointment for the agreed date and time is confirmed.
• Patient Reception: The patient arrives at the health center at their scheduled appointment time.
• Waiting Room: The staff guides the patient to the designated waiting area.
• Consultation: The patient’s turn to be attended by the specialist.
• Payment: The process of settling the payment for the service, which may occur at any point during the service phase, depending on the health center’s policies.
• Patient Recommendations: Patients offer positive or negative feedback about the health center and its services.
• Loyalty Program: Incentives such as offers, promotions, discounts, or a points system to encourage future visits.

Recommendation:

• Complaint: If the patient has had a negative experience, they may file a complaint with the health center.
• Online Reviews: Patients share comments or criticisms about the service by posting reviews on the internet.

4. Identify Contact Channels

Patients engage with the health center through various channels throughout the patient journey. These channels, such as the health center itself, can be physical or online, including social media, email, applications, websites, and online forms.

Identifying the most utilized contact channels at each stage of the customer-patient care journey is crucial. This allows for the development of tailored strategies for each channel, meeting patient expectations at each phase.

Working on the patient journey is crucial for healthcare providers to deliver a high-quality experience to patients. By mapping their interactions, providers gain a deeper understanding of their patient personas, allowing them better to comprehend patient needs, desires, and circumstances to provide the desired care.

You can explore Patient Experience Software to measure your patient journey. QuestionPro published a blog about it very recently!

Patient Journey Map Example 

To better understand what a Patient Journey Map is, we have created this fictitious example using one of the most reputable medical institutions in the healthcare sector, the Massachusetts General Hospital, as a reference.

In this example, we have included some generic touchpoints that are usually the most common in the interaction between a hospital and a patient.

Through this example, it would be possible to visualize the points of interaction between both parties and the perception that patients have of them, which can be positive or negative. This serves as a clear indicator for making adjustments and learning from what has been done well.

The Office of Patient Experience plays a vital role in facilitating initiatives to assess and enhance the quality of care experienced by patients and their families. They are responsible for evaluating each of these touchpoints and ensuring that appropriate actions are taken.

The Mass General Hospital is a benchmark not only in terms of service level but also in the implementation of methodologies and actions that guarantee the satisfaction of their patients. A clear example of this can be seen in the results of their annual HCAHPS survey, where they score above the national average in various aspects.

Willingness to Recommend Hospital Scores below show the percentage of patients who would “definitely recommend” Mass General to their friends and family.

To see the complete study, we invite you to visit their website and learn about it.

More Examples of Patient Journey Maps

Seeking inspiration to craft your own Patient Journey Map? Your search ends here!

Explore a collection of remarkable examples from top-notch brands, unveiling their initiatives that delight customers and foster loyalty.

Get set to revolutionize your own Patient Journey!

Mass General Hospital is renowned for providing exceptional care and taking special care in understanding the perspective of its patients. They achieve this through different tools, such as satisfaction surveys, internal and external feedback, and  HCAHPS surveys .

Mayo Clinic is characterized by its focus on patient satisfaction and its extensive technical deployment to gather user and prospect feedback.

Cleveland Clinic is often ranked among the best hospitals in the United States. This recognition is not only due to its incredible facilities, global expansion, and well-prepared staff but also because of its remarkable focus on the experience they provide to its patients and clients.

Singapore General Hospital is one of the largest and oldest hospitals in Singapore. It has been a major healthcare institution providing a wide range of medical services and treatments since 1821.

Johns Hopkins Medicine has long recognized the significance of a positive patient and family experience during hospitalization, which is why they maintain a specific focus on  patient satisfaction  to achieve an optimal experience.

How can you enhance your Patient Journey Map based on your acquired knowledge?

The insights and recommendations shared above are likely to have sparked ideas about the potential impact of these initiatives across various industries, not just healthcare.

The first crucial step is to embrace a customer-centric approach, keeping their needs and expectations at the forefront. By doing so, the actions you take will have a meaningful impact on your customers and yield multiple benefits for your business.

At QuestionPro, we offer a range of tools and features specifically designed to help you achieve this objective.

QuestionPro SuiteCX is a Customer Journey Mapping Software that simplifies the process of creating your customer journey. 

With a vast selection of templates and the ability to personalize user/buyer personas while incorporating your own data, you can conduct precise visual analyses at every touchpoint throughout your patient journey.

Start delighting your customers today!

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7 Principles to Improve Patient Experience (Best Practices & Examples)

Table of contents

The journey of potential patients to selecting a quality doctor involves an online search and finding a hospital that meets their expectations. Patients value convenience and quality care more than anything. It all comes down to providing a meaningful and positive patient experience.

72% of patients are willing to change their providers to get a desirable care experience.

Healthcare industry is striving to create a positive patient experience to improve healthcare outcomes by developing new strategies, such as digital tools for better patient engagement and communication.

Creating a positive patient experience is more important than ever. Not only is it the right thing to do, but it also leads to better health outcomes. And that’s a win for both healthcare providers and their clients. In fact, as the healthcare industry develops new strategies for optimizing patient communications and engagement, other industries can benefit from the resulting best practices.

What is Patient Experience (and Why It Matters)?

Patient experience refers to all types of interactions that a patient encounters along the entire healthcare journey, including care from their physician, nurses, staff, and health care facilities.

Understanding patient experience is a key step in moving toward patient-centered care. By looking at various aspects of patient experience, one can assess the extent to which patients are receiving care that is respectful of and responsive to individual patient preferences, needs and values. Evaluating patient experience along with other components such as effectiveness and safety of care is essential to providing a complete picture of healthcare quality.

Significance of an elevated patient experience :

Better Health Outcomes : Patients who are truly engaged with the care team are likely to be more confident about their treatment approach. Care experience tailored towards their active participation increases compliance and results in positive health outcomes.

Higher Patient Satisfaction: Patients who receive respect, support and are timely communicated will be eager to follow the plan throughout their continuum of care. It not only builds trust with the providers but elevates their satisfaction.

Boost Your Bottomline: A better patient experience affects other aspects of a hospital such as superior safety records, better technical quality and less readmission rates.

Improve Your Online Reputation: The National Research Corporation identified a strong link between the patient care experience and the organization reputation. Experience of former patients shapes the thoughts and perception of potential patients who may have never been to the clinic.

Patient Experience vs Patient Satisfaction

Patient satisfaction is a term that is often confused with patient experience.

Patient experience is measured by gaining insights from patients as to what is important in a healthcare setting, such as behavior of the provider or communication skills.

On the other hand, patient satisfaction demonstrates to what extent the patient needs and expectations were fulfilled during the healthcare journey. For example, two patients can have different preferences about their care services based on which they will have different satisfaction ratings.

Measures of Patient experience include:

• A holistic approach throughout their continuum of care
• Attention is given to multiple factors associated with care services    
• Focus on areas that specifically affect patient
• Questions designed around actual or relevant issues (For example, long waiting time during clinical visits)

Measures of Patient satisfaction include:

• A one-dimensional approach around hospital performance
• Attention is given to only few specific aspects of healthcare services
• Focus is to meet the providers goal or agenda
• Measures patient perspective regarding their health care encounter (For example, a fair or good rating about the staff’s communication skill does not provide clarity what aspect requires improvement)

How to Improve Patient Experience in Your Healthcare Organization (Best Practices & Examples)

The key to improving patient experience depends on the efforts and providers willingness to enhance quality services and make patients their top priority.

These are the main steps to improve patient experience and satisfaction.

1. Map Out Your Patient Journey

Patient experience includes a wide range of interactions that patients have within the healthcare settings, such as with their doctors, nurses, staff, and healthcare facilities. When so many interactions are involved, it is difficult to understand where to start.

Remove the barriers

Understand patients from their point of views. Assess each and every step that a patient encounters when interacting with the hospital.  For example,

• How and when did the patient first contact the hospital?
• Did the patient experience any difficulty while booking appointments?
• Did the patient experience long waiting periods?
• Did the patient experience problems during discharge? (Such as billing, filling forms, or understanding the treatment)

Once the challenges and barriers are correctly identified, put efforts to create a smooth and better patient experience

Make efforts to provide a personalized touch

Patient’s healthcare experience is not just limited to the hospital walls. Try to improve care services even when the patient makes the first contact through phone or website. Answering the phone by merely shifting from an automated voice recognition to an actual human can make a drastic shift. Individuals are more likely to be engaged in their care plans if they are given appointments timely, communicated clearly, and have access to information with ease.

2. Streamline Patient Engagement with an Omnichannel Approach

Omnichannel approach has the potential to create a smooth, and simple process. A systematic approach during the pre-visit, clinical visit or post-visit phase of a patient’s journey strengthens the patient’s trust.

Robust technology has become one of the most critical elements for boosting patient engagement channels.

In order to build new digital tools hospitals require an integrated system. Focus on few important components such as:

Patient Engagement Software

Use an omnichannel patient communication solution help to promote a patient centric approach with a high personalization level. For example, if a patient is planning to visit the hospital for a pile problem, then a series of automated messages and services can be sent that inform the patient about lifestyle modifications, and treatment options to keep them engaged. Once the patient visits the clinic they will already have a positive perception about the clinic services.

Integration with Electronic Health Records (EHR)

Inclusion of EHR makes it better to streamline the fragmented medical history. Patients as well as the provider can easily access the information related to the treatment processes.

3. Use AI Virtual Assistants for Customer Support Automation

Healthcare staff receive more than 2 million calls every year , according to a report by Boston’s Children Hospital. Handling so many calls can become painful and unpleasant for an administrative person.

Automated customer support provides solutions to patient problems without requiring human interaction. A dedicated AI virtual assistant tailored to customer support helps patients to contact 24/7. Patients can ask their concerns, raise queries or register their complaints.

However, just including an AI virtual assistant is not enough when a patient requires immediate assistance.  For emergency cases patients require human interaction Therefore, the quality assurance team can evaluate where the virtual assistant is getting stuck. Real-time monitoring will help to understand the issues so that AI is equipped in a better way to manage patient interactions.

Patient’s details can be connected to a single, individualized location. AI virtual assistants can extract relevant medical history details, contact details and patient’s preferences to provide information that they are looking for.

4. Offer Online Appointment Bookings

Patients are looking for a convenient booking option. In fact, more than 80% of patients are willing to switch their doctors just to find the easiest option . By offering online bookings patients can select the schedule and method that works best for them.

Send appointment confirmations and reminders

Online scheduling of appointments enables patient complete accessibility across different touchpoints of their treatment journey. The online scheduling system can send appointment reminders and confirm bookings.

It has several benefits such as:

• Appointment confirmation reminders via email or text improve the on-time arrivals.
• Reduces no-shows and cancellations which in turn saves clinician’s time and resources.
• Less inconvenience as more patient follow the appointment schedule

Automated recall and recare

Online scheduling software ensures that patients do not miss out on their routine follow-up appointments.  System can regularly track the patients who missed their recall booking, or simply remind them through a text, voice call or email to go for the visit.

5. Automate Your Fragmented Processes across Patient Journey

Patients feel safe and comfortable when they can ask questions without being judged. Virtual assistants provide a safe, discrete environment. AI-powered assistants can conduct surveys to track a patient’s healthcare journey .  Monitoring  patient feedback will provide information to the hospitals that will guide them to make changes in the existing care services.

AI virtual assistants can reduce the pressure on medical system in various ways:

• Screening of critical patients
• Limiting the number of patients requiring clinical visit
• Providing specialist recommendations
• Scheduling online appointments
• Depending on patient’s symptoms connect to the right specialist

Automate clinical or administrative workflow

For example, robotic process automation (RPA)—software robots that have machine-learning capabilities—can be used to automate functions ranging from admissions to billing. And natural language processing (NLP)—a branch of AI that helps computers understand and process human language—can automate workflows for administrative documentation, including the creation of transcripts and patient-case summaries.

6. Gather and Execute on Data Insights

Evaluate patients experience in real-time

With the introduction of remote patient monitoring tools healthcare systems are able to provide a better patient experience where data is given to the providers in real time. Healthcare settings have quickly adapted to the remote patient monitoring technologies since the pandemic arrived.

Patient data collection has become more efficient, removing the logistical disruptions associated with improved patient experience.

Develop platform that supports EHR integration

Cumbersome and cluttered EHR impairs the systematic workflow, leading to undesirable outcomes (such as loss of patient data). Interoperability is the most important factor when it comes to sharing of patient information between different clinicians.

Building a platform that not only takes care of regular administrative activities, but also prioritizes healthcare needs of patients will strengthen the healthcare system.

7. Create a Patient Centric Workplace Culture

Patient experience is largely influenced by the manner they are treated. Healthcare sector is dependent on human interactions. Doctors and the entire team members can shape patient experience by making it a positive one.

Patients should be treated with respect, empathy and compassion even when they become difficult to manage. Prompt actions centered towards patient needs will develop a strong sense of care in patients. Happy and satisfied patients pass on their positive emotions to their staff, who are willing to go the extra mile to improve patient outcomes

Although changing an organization’s culture is challenging, the team members should be held accountable for their actions. Ensure to expose them to guidelines, procedures and protocols before they are implemented.

Reinforce the tasks and messages in meeting sessions. For example, qualities such as compassion and accountability can be embedded in their job descriptions or linked to their performance reviews.

An Exciting Future for Healthcare Patient Experience

The healthcare industry has seen several transformation in the past decade. With this pace, it is clearly evident that healthcare organizations need to have a sole aim to provide a better patient experience.

A positive patient experience boosts patient satisfaction, patient retention and treatment outcomes. Identification of patient journey, adopting omnichannel approach with automation, and creating a patient-centric environment is essential to enhance healthcare experience of patients.

AI’s Role in Elevating Patient-Reported Outcome Measures (PROMs)

Alleviating Errors in Healthcare Appointment Bookings with AI

Streamlining IVF Treatments with Artificial Intelligence

Patient visits can be more effective if much of the information gathering is done ahead of time.

CHRISTINE A. SINSKY, MD, FACP, THOMAS A. SINSKY, MD, FACP, AND ELLIE RAJCEVICH

Fam Pract Manag. 2015;22(6):30-38

Author disclosures: Christine Sinsky is an adviser for Healthfinch, a company that develops prescribing software. No other relevant financial affiliations disclosed.

When you walk in to see your next patient, is all of the necessary information assembled, organized, and ready? Or do you spend the first five to 10 minutes of each appointment determining who the patient is, why he or she is here, which performance measures are due, and what care the patient may have received from another provider, the emergency department, or an urgent care center since his or her last visit?

In our own practice, if the first time we think about a patient is when he or she checks in, we are already behind. 1 – 3 There is a lot to be done at each appointment. Consider that the average family medicine patient age 65 or older presents with four problems per visit and, in our experience, one or more care gaps needing to be addressed. 4 This is more work than a physician can typically handle alone yet is too important to leave to chance.

Pre-visit planning can help make your patient visits run more smoothly, giving you time to focus on what matters most to the patient and even a little time to spare to simply visit with the patient. Furthermore, you may be able to head home an hour earlier, feeling satisfied with the day and a job well-done, knowing that your patients and staff feel the same.

IN THE AUTHORS' OWN WORDS

Dr. Thomas Sinsky and Debra Althaus, RN, discuss some of the benefits that pre-visit planning provides for their practice.

Pre-visit planning

The objective of pre-visit planning is to help the patient and physician conduct the face-to-face visit more effectively by gathering and organizing information ahead of time so they can devote more attention during the visit to interpreting, discussing, and responding to that information.

Pre-visit planning takes place in several steps:

1. Plan forward, or “The next appointment starts today.” 5 The most efficient form of pre-visit planning begins near the end of the previous visit. As the visit draws to a close, the physician and patient decide on next steps, such as planning any lab tests that might be needed before the follow-up appointment. The physician is already familiar with the patient's conditions and medications, so it should take very little time to identify the appropriate tests for the next visit. The patient then may schedule these appointments immediately instead of having to remember to call back in several months to set them up.

In our practice, we use a checklist to help us plan for the next visit. The checklist is part of a form that also includes the date of the patient's last annual exam as well as any upcoming appointments and labs that are already scheduled. This format allows the physician to put today's care and the next visit's care within the context of the patient's ongoing care. The checklist features lab and other test options in three sections: those to be done before the patient leaves today; those due before the next follow-up visit; and those due before the next annual visit. The patient is then given the option at check-out of receiving an automated reminder phone call, text message, or letter closer to the time of the appointment. (The "Post-appointment order sheet" is available in the FPM Toolbox ).

In an effort to be more patient-centered, we've also found that asking the patient when he or she would like to return is an effective way to share decision-making and give patients an active role in their own care. We also believe this approach, combined with the reminder system and pre-visit labs, have helped lower our no-show rate, which is less than 4 percent.

2. Look back . Some practices do not begin pre-visit planning at the end of the current visit. Instead, it starts a week or so before the next visit when a nurse or other staff member looks back over a patient's record and orders any tests indicated by protocol based on the patient's conditions or medications, as well as any instructions the physician left in his or her documentation from the previous visit. Practices that rely on physicians to enter future orders into the electronic health record (EHR) on the day of the visit will sometimes also employ this “look back” process by the clinical staff. Physicians may feel they cannot spare extra minutes at the end of the visit inputting orders when other patients are waiting, so the look-back process ensures the work has been done.

Reviewing the patient's record outside of the office visit requires more time than planning forward, but it is still more efficient than not doing any pre-visit planning.

3. Pre-visit lab testing . Pre-visit lab testing saves time, improves patient engagement in health management, and reduces the amount of work needed to report and respond to results. Some practices arrange for patients to come in several days before the appointment for lab testing. Others arrange for patients to have their blood drawn 15 minutes to an hour before their scheduled appointment and then use point-of-care testing or rapid turnaround of standard lab testing. In both cases, the goal is to time the tests so that the results are available to the patient and physician at the face-to-face visit.

By having the results available during the appointment, patients can be part of the ensuing decision-making and are more likely to adhere to the treatment recommendations than if they received those recommendations later by phone or letter. In addition, the physician and patient can avoid playing phone tag or engaging in several rounds of email after the visit to resolve unanswered questions. One practice found that pre-visit labs saved $25 in overhead per patient visit. 6

Pre-visit labs can also aid safety. Because patients are able to review their test results together with their physician at the appointment, it is less likely that an important result will be overlooked or lost in the system.

4. Pre-visit phone call . Calling the patient ahead of his or her visit can help the clinical team prepare more thoroughly by clarifying the patient's agenda, anticipating any special needs, and completing many of the tasks usually performed during rooming, such as reviewing medications or screening for depression or falling. Some practices reserve pre-visit phone calls for complex patients. A pharmacist or pharmacy technician may also call these patients for in-depth medication reconciliation. In some cases, this process is aided by access to an all-payer claims database, which staff can use to see what medications the patient has actually filled. You can identify and address nonadherence to medication in a non-judgmental way with this approach.

5. Visit preparation . On the day of or the day before a visit, the medical assistant or nurse can do a quick review of the patient's record to see what needs the patient may have during the appointment. For example, they can identify if the patient needs an immunization, a cancer screening, or other prevention measures and close these “care gaps” during the rooming process. Conducting visit prep can be an effective tool in panel management and can positively affect the health of the entire patient population.

6. Pre-visit questionnaire . A pre-visit questionnaire is a list of questions the patient completes either on paper in the waiting room or through an online patient portal from home. See the questionnaire our practice uses .

PRE-VISIT QUESTIONNAIRE

Questions explore the reason for the visit (“What are you hoping to accomplish today?” and “Is there anything else you'd like to work on to improve your health?”), which prevents the situation in which a patient's main goal is revealed just as the physician is about to leave the exam room. Standardized questions applicable to the particular practice, such as screening questions for falls, depression, or domestic abuse, can also be asked. The questionnaire can also be used to update the patient's past, family, and social histories, as well as to conduct a complete review of systems. All of these uses can save the staff, physician, and patient time during the actual visit.

In our own practice, we have a separate pre-visit questionnaire for the Medicare Annual Wellness Visit that mirrors the template in our EHR, which makes it easier for the nurses to upload the information. Some EHRs are designed so that the patients' answers to the pre-visit questionnaire can be imported into the visit note, reducing the amount of data entry required of physicians and clinical staff.

7. Mini-huddle . The nurse or medical assistant often learns important medical and social information during his or her interaction with the patient during rooming. We have found that a brief “mini-huddle” with the physician before the physician meets with the patient can be helpful. The nurse can alert the physician to the patient's concerns (“She is afraid she will lose all strength in her arm”), a change in social situation (“His wife was recently diagnosed with breast cancer, and he is worried”), or a teachable moment (“Her sister just developed diabetes, so she is willing to work more on diet and exercise to prevent this from happening to her”).

Although we have not found many studies measuring the overall financial savings of pre-visit planning, our personal experience is that pre-visit planning definitely reduces the time spent on a patient's care during or after the visit. A rough estimate is that pre-visit planning takes about an hour of nursing time per day and saves about an hour of physician time and up to two hours of nursing time. It also increases the quality of care by identifying agenda items and care needed at the appointment, such as immunizations or cancer screening.

We have received mostly supportive feedback from our patients regarding pre-visit planning. When they leave an appointment, we reserve a time for their next appointment, which they can plan around. We plan ahead to make that next visit meaningful to them. They don't have to wait after the appointment for lab results or instructions based on those results, and they can speak with their physician about those management decisions.

Finding the right strategy for you

Pre-visit planning can take many forms, and practices can choose the ones that make sense for them. Each component adds efficiency and supports a rapid understanding of why the patient is visiting and what his or her comprehensive needs are. An organized system to manage this complexity and volume will allow physicians to relax and truly listen to patients, knowing that the standardized, predictable work of the practice happens correctly by default and resting assured that they have minimized the chance of overlooking an important piece of data.

You can read more about pre-visit planning, pre-visit labs, huddles, pre-appointment questionnaires, and building a culture of team-work at the American Medical Association's practice transformation website .

Sinsky CA, Sinsky TA, Althaus D, Tranel J, Thiltgen M. Practice profile. ‘Core teams’: nurse-physician partnerships provide patient-centered care at an Iowa practice. Health Aff (Millwood) . 2010;29(5):966-968.

Sinsky CA. Improving office practice: working smarter, not harder. Fam Pract Manag . 2006;13(10):28-34.

Kravitz RL. Improvement happens: an interview with Christine Sinsky, MD. J Gen Intern Med . 2010;25(5):474-477.

Beasley JW, Hankey TH, Erickson R, et al. How many problems do family physicians manage at each encounter? A WReN study. Ann Fam Med . 2004;2(5):405-410.

Phrase coined by ThedaCare Health System, a community health system based in Appleton, Wis.

Crocker JB, Lee-Lewandrowski E, Lewandrowski N, Baron J, Gregory K, Lewandrowski K. Implementation of point-of-care testing in an ambulatory practice of an academic medical center. Am J Clin Pathol . 2014;142(5):640-646.

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• Open access
• Published: 04 April 2024

Adaptation and qualitative evaluation of the BETTER intervention for chronic disease prevention and screening by public health nurses in low income neighbourhoods: views of community residents

• Mary Ann O’Brien   ORCID: orcid.org/0000-0001-6093-1040 1 ,
• Aisha Lofters 1 , 2 , 3 , 4 ,
• Becky Wall 5 ,
• Regina Elliott 5 ,
• Tutsirai Makuwaza 2 ,
• Mary-Anne Pietrusiak 5 ,
• Eva Grunfeld 1 , 6 ,
• Bernadette Riordan 5 ,
• Cathie Snider 5 ,
• Andrew D. Pinto 1 , 4 , 7 , 8 ,
• Donna Manca 9 ,
• Nicolette Sopcak 9 ,
• Sylvie D. Cornacchi 10 ,
• Joanne Huizinga 5 ,
• Kawsika Sivayoganathan 7 ,
• Peter D. Donnelly 4 , 11 ,
• Peter Selby 1 , 12 ,
• Robert Kyle 5 ,
• Linda Rabeneck 4 ,
• Nancy N. Baxter 13 ,
• Jill Tinmouth 14 &
• Lawrence Paszat 14  

BMC Health Services Research volume  24 , Article number:  427 ( 2024 ) Cite this article

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The BETTER intervention is an effective comprehensive evidence-based program for chronic disease prevention and screening (CDPS) delivered by trained prevention practitioners (PPs), a new role in primary care. An adapted program, BETTER HEALTH, delivered by public health nurses as PPs for community residents in low income neighbourhoods, was recently shown to be effective in improving CDPS actions. To obtain a nuanced understanding about the CDPS needs of community residents and how the BETTER HEALTH intervention was perceived by residents, we studied how the intervention was adapted to a public health setting then conducted a post-visit qualitative evaluation by community residents through focus groups and interviews.

We first used the ADAPT-ITT model to adapt BETTER for a public health setting in Ontario, Canada. For the post-PP visit qualitative evaluation, we asked community residents who had received a PP visit, about steps they had taken to improve their physical and mental health and the BETTER HEALTH intervention. For both phases, we conducted focus groups and interviews; transcripts were analyzed using the constant comparative method.

Thirty-eight community residents participated in either adaptation ( n  = 14, 64% female; average age 54 y) or evaluation ( n  = 24, 83% female; average age 60 y) phases. In both adaptation and evaluation, residents described significant challenges including poverty, social isolation, and daily stress, making chronic disease prevention a lower priority. Adaptation results indicated that residents valued learning about CDPS and would attend a confidential visit with a public health nurse who was viewed as trustworthy. Despite challenges, many recipients of BETTER HEALTH perceived they had achieved at least one personal CDPS goal post PP visit. Residents described key relational aspects of the visit including feeling valued, listened to and being understood by the PP. The PPs also provided practical suggestions to overcome barriers to meeting prevention goals.

Conclusions

Residents living in low income neighbourhoods faced daily stress that reduced their capacity to make preventive lifestyle changes. Key adapted features of BETTER HEALTH such as public health nurses as PPs were highly supported by residents. The intervention was perceived valuable for the community by providing access to disease prevention.

Trial registration

#NCT03052959, 10/02/2017.

Peer Review reports

Screening rates for cancers and other chronic diseases are suboptimal in Ontario, Canada [ 1 , 2 ]. Moreover, studies show higher rates of chronic disease and lower rates of chronic disease prevention and screening (CDPS) activities in low income areas in Canada [ 3 , 4 ]. For example, increased smoking and exposure to second-hand smoke are associated with lower income [ 4 ].

Canadians living with low income are more likely to develop chronic diseases compared to those with higher income. For example, Roberts et al. found that among Canadians in the 35–49 year age group, people in the lowest versus highest income quintile had an adjusted odds ratio of 7.5 [95% CI: 4.0–13.7] for multi-morbidity [ 5 ]. For people in the 50–64 year age group, the adjusted odds ratio for multi-morbidity was 5.9 [(95% CI: 4.4–7.9] in the lowest versus highest income quintile [ 5 ].

There is some evidence that specific interventions may reduce barriers to accessing preventive services in disadvantaged populations. For example, in a systematic evidence review aimed at achieving health equity in ten preventive services Nelson et al. found that patient navigation improved screening rates for breast, cervical, and colorectal cancers [ 6 ]. Other effective interventions for specific cancer screening included telephone calls and point-of-care prompts (colorectal cancer) as well as reminders from lay health workers (breast cancer) [ 6 ].

In Canada, the Building on Existing Tools to Improve Chronic Disease Prevention and Screening (BETTER) intervention has been shown to increase the uptake of CDPS activities in primary care in urban [ 7 , 8 , 9 , 10 ] as well as in rural and remote settings [ 11 ]. Briefly, the original BETTER intervention consisted of a one-time 1:1 visit between a specially-trained prevention practitioner (PP) and a patient (40–65 years). During the visit, the PP and patient reviewed recommended CDPS activities and through principles of brief action planning and shared decision-making, the PP assisted the patient to identify one to three personal goals [ 7 , 8 , 9 , 10 ].

Although the BETTER intervention has been shown to be effective, it has been conducted in primary care settings with full access to electronic medical records, in which study participants were already connected to a family physician. Moreover, in the original BETTER trial, about half of the participants had an income of $100,000 (CAD) or higher [ 7 ]. Since a large number of Canadians do not have access to a primary care practitioner [ 12 ] and it was unknown if the BETTER intervention would be effective for people living with low income, we adapted the BETTER intervention to a public health setting (without access to electronic or paper medical records from any source) with public health nurses as PPs, and conducted a cluster randomized controlled trial (cRCT) that compared the adapted BETTER intervention to a wait-list control [ 13 , 14 ]. We previously reported that six months after the prevention visit participants in the intervention arm met 64.5% of actions for which they were eligible versus 42.1% in the wait-list arm (rate ratio 1.53 [95% confidence interval 1.22–1.84]) [ 14 ]. In that cRCT, more than 90% of participants had an annual household income of less than $60,000 (CAD) [ 14 ].

This paper describes two study phases, 1) the process for adapting the intervention from primary care to a public health setting; and 2) the post-visit qualitative evaluation by community residents. We refer to the adapted intervention as ‘BETTER HEALTH’, the first implementation of the BETTER intervention outside of a primary care setting. Details of the adaptation process could be useful to others who are interested in implementing the BETTER HEALTH intervention in their own setting for individuals who may not have access to a primary care practitioner. We also conducted a qualitative evaluation of the intervention by community residents. We undertook this evaluation to complement the results of the cRCT to understand how residents viewed the intervention and how they made lifestyle changes to reduce their risk of chronic disease. Widespread implementation of the BETTER HEALTH intervention in a public health setting may contribute to a reduction in health inequities by facilitating access to prevention services and lifestyle advice.

Durham Region is located within the eastern portion of the Greater Toronto Area in Ontario and comprises eight municipalities with an estimated population (2018) of 683,600 [ 15 ]. Population health assessments by the Durham Region Health Department (DRHD) showed high rates of chronic disease and smoking, and low cancer screening rates in seven neighbourhoods with low-income levels, deemed as priority health neighbourhoods [ 16 ]. For example, the health neighbourhood of Downtown Oshawa had a breast cancer screening rate of 55.3, cervical cancer screening rate of 52.5 and rate of overdue for colorectal cancer screening of 58.1 (2016 age-standardized rates per 100) [ 16 ]. By comparison, Ontario age-standardized rates for breast cancer screening, cervical cancer screening, and overdue of colorectal cancer screening were 64.5, 62.0, and 38.1 respectively [ 17 ].

The public health setting was an appropriate fit for the adapted intervention since chronic disease prevention and well-being are part of the Ontario Public Health program standards [ 18 ].

In preparation for adaptation of BETTER from primary care to public health, principles of community-based participatory research (CBPR) were used to design a community engagement strategy [ 19 , 20 ]. Key elements included close collaboration with public health partners to identify a range of community stakeholders, creating the study Community Advisory Committee (CAC) ( n  = 14) that included representation from public health ( n  = 5), service agencies/social services ( n  = 4), primary care ( n  = 2), and residents of low income neighbourhoods ( n  = 3). We also received advice from a Primary Care Engagement Group ( n  = 9) that included family physicians (FPs), a nurse practitioner (NP), and public health staff to provide advice on the adaptation of BETTER, recruitment strategies and approaches to community engagement. The CAC was engaged throughout the study period and met in-person approximately three times per year. They provided advice on all aspects of the study design especially for recruitment in low-income neighbourhoods and fit with existing community services. For example, the community resident members of the CAC reinforced the importance of being treated with respect, the value of recruitment in public spaces such as libraries, and provided suggestions for helping with referrals (if desired by participants). Other examples of CAC involvement included connections to not-for-profit housing and access to a food bank for recruitment. The Primary Care Engagement Group helped identify local family physicians or a nurse practitioner willing to accept new referrals for study participants (if desired). They also helped connect the study to other primary care practitioners in the region [ 13 ].

In both study phases, we used purposeful sampling [ 21 , 22 ]. This approach is appropriate in a qualitative research study when the purpose is to obtain information from participants who are knowledgeable about the topic under investigation [ 21 , 22 ].

Adaptation phase

We used the ADAPT-ITT model ( A ssessment, D ecision, A dministration, P roduction, T opical Experts – I ntegration, T raining, T esting) for the adaptation [ 23 ]. Table 1 summarizes how the steps were applied. Briefly, the research team conducted an initial assessment by reviewing the recruitment strategies and components of the PP visit and BETTER toolkit (educational materials, a ‘Prevention Prescription’, ‘Bubble Diagram’ and “Goals Sheet”), and then made preliminary adaptations. For example, we revised the BETTER toolkit to include community resources such as support for income and food insecurity. Public health nurses were identified as PPs instead of practitioners from within primary care practices. Next, eligible community residents reviewed the adapted intervention during focus groups and interviews and provided feedback, as did the CAC. We incorporated community resident and CAC recommendations and further refined recruitment strategies such as displays at local community events. The PP training was based on the adapted features. Key adaptations included recruitment via numerous community facilities and events rather than by primary care practices; baseline data collection by self-report and collected by a supportive research assistant during an interview; participants in both arms received the standard educational materials from the DRHD; the prevention meeting and interaction with the PP was adapted to include a 'warm hand off' referrals for CDPS; and the location of the baseline and outcome assessment and the prevention meeting were all at the venue chosen by the resident.

Inclusion criteria

Community residents 40 to 64 years old were eligible for inclusion in adaptation focus groups and interviews if they lived in identified priority health neighbourhoods and were English speaking. We chose the age range of 40 to 64 years for the adaptation so that we would obtain views from people who were in the same age range as those who would be eligible to receive the PP visits. We reasoned that it was preferable to make any adaptations to the visits or program materials if recommended by people in the same age range rather than by those younger or older who might not be eligible for a given screening test.

Recruitment

Residents were recruited through flyers and posters distributed at libraries, community drop-in centers, community kitchens, community events, libraries, and shelters. Recruitment also occurred at in-person presentations in the community, via advertisements in local newspapers, and by word of mouth.

Post-visit qualitative evaluation phase

Community residents were eligible to participate if they were part of the study intervention arm, and had completed the PP visit and 6-month data collection. Community residents who participated in the adaptation phase were not eligible for the visits or the post-visit qualitative evaluation.

Residents who had enrolled in cRCT intervention arm and agreed to be contacted for participation in the qualitative evaluation were approached by email and/or telephone.

Data collection

For both adaptation and post-visit qualitative evaluation phases, we conducted focus groups and interviews (adaptation, June to September 2017; evaluation, March to July 2019). We first recruited residents to focus groups, aiming for 4–8 members in each group [ 24 ]. When a resident wanted to participate but could not attend any of scheduled focus groups, we offered an individual interview instead. Interviews took place in a location chosen by the resident such as their home or a community space. All focus groups took place in a meeting room in a library or community centre that was accessible by public transportation. For each phase, we created a focus group and interview guides that were based on the study objectives then pre-tested by community residents living in low income areas who were members of the CAC. During all focus groups and interviews, we asked residents about their physical and mental health, impressions of their neighbourhoods, and their knowledge of and access to community resources and primary care. We also asked about the proposed visit structure, and appropriateness and completeness of the PP tools. For the post-visit evaluation, we asked residents about their views of the adapted BETTER HEALTH intervention including the administered survey and PP visit. All sessions were recorded, transcribed verbatim and anonymized. Sessions were conducted in-person by experienced qualitative researchers (MAO and TM) and lasted between 24 and 110 min. Community residents received a $25.00 (CAD) grocery gift card and two transit tickets in recognition of their time.

The adaptation and post-visit evaluation data were analyzed separately then combined. An inductive approach using the constant comparative method was used to analyze data [ 25 , 26 ]. Initially, three team members (MAO, TM and SC) independently coded two transcripts, then met to compare coding, discuss differences and develop consensus on codes. Subsequently, two team members coded the remaining transcripts using the coding guide. We compared initial codes to each other within the same transcript and across transcripts in the adaptation phase and then in the post visit evaluation. As we developed the emerging themes from the coded data, we compared themes within a transcript then across transcripts looking for supporting as well as disconfirming instances. Team members met periodically with co-investigators DPM and NS to review and refine the coding manual, interpret findings, develop emerging themes and ensure consistency. NVivo 10 (QSR International) software was used for data management. An audit trail was used to ensure transparency of major analytic decisions [ 27 ].

We provide additional details about the qualitative methods in the ‘Consolidated criteria for reporting qualitative studies’ (COREQ) checklist [ 28 ]. (online Supplemental File 1 ).

This study was approved by the Research Ethics Boards of the University of Toronto (# 33340), Sunnybrook Health Sciences Centre (REB 222—2016), St. Michael’s Hospital (REB #16–231) and Ethics Review Committee of the DRHD (ERC #20160802–002). Written informed consent was provided by all community residents prior to their interview or focus group. We also provide sample interview and focus group guides online in Supplemental File 2 .

A summary of the key features of BETTER that were adapted for the BETTER HEALTH cRCT is provided in Table  1 .

Adaptation and post-visit focus groups and interviews

During adaptation, 4 focus groups and 5 in-person interviews were conducted over four months (14 community residents, 64% female; average age 54 y [range: 42 – 62 y]). For the post-visit qualitative evaluation, 6 focus groups and 2 in-person interviews were held over five months (24 community residents, 83% female; average age 60 y [range: 43–63 y]). On average, the focus groups and interviews were held 10 months after the visit. Three participants withdrew in the adaptation phase: one participant dropped out after a focus group because they decided it was not useful to them. Two potential participants declined to proceed with a focus group prior to its start because they did not wish to be identified on the consent form. No participants withdrew from the post-visit qualitative evaluation. All participants lived in one of the priority health neighbourhoods in the town of Whitby or city of Oshawa, ON, Canada.

Major themes

We integrated the adaptation and post-visit results since community resident views of their health challenges were similar. We identified five themes and associated subthemes. The major themes were: 1) Significant intersecting health and social challenges in coping with everyday life; 2) Personal desire to change and readiness for change were key to improving health behaviours; 3) Value of accessible community programs and resources; 4) PPs enabled residents to change health behaviours through a client-centred education and goal setting approaches; and 5) Feeling listened to and being understood were critically important when interacting with PPs. See Table  2 for exemplar supporting quotes for each theme. We provide additional illustrative quotes in the sections below.

Significant intersecting health and social challenges in coping with everyday life

Participants described five significant challenges that affected their health: a) living in poverty, b) coping with stressful lives including difficult work or social environments, c) being socially isolated and experiencing loneliness, d) living with depression and anxiety, and, e) living with addictions to alcohol or drugs. Residents described the effects of living in poverty such as not having enough money to buy nutritious food, for example fresh fruits and vegetables, and feeling stressed by having insufficient resources to make ends meet. They also perceived other intersecting influences in their lives such poor living conditions, mental illness and unemployment which could lead to drug or alcohol addiction and ignoring health problems when they occurred.

“There’s a lot of homeless in my area, mental health issues. People can’t fix themselves if you don’t have good medical around or money to go to it… Because if you don't have food and you don’t have money, you go into depression.” (Adaptation, Interview 1)

Subtheme: disease prevention was a lower priority

As a result of health and social challenges, residents described that disease prevention was a lower priority. They described that they were likely to wait until they became ill, rather than pre-emptively engage in disease prevention. Other residents said they had to be in a “good place” before they could take steps to improve their health.

“And I really think that people don’t take preventive maintenance that readily… I really don’t think so. …not until they get it [illness]…. that’s me personally.” (Adaptation, Focus Group (FG) 3)

Subtheme: different attitudes toward disease prevention in men compared to women

Both men and women said that men were less likely than women to focus on disease prevention. Generally men did not want to admit to ill health which they perceived as a weakness. Men were also skeptical about the value of disease prevention and less likely than women to think that it should be a priority.

Subtheme: social influences on health—the “company you keep”

Throughout both phases, residents described how social connections influenced their health. Being engaged in the community, and finding purpose in life were associated with taking steps toward better health. Others described how their circle of friends had negative influences on health behaviours by encouraging smoking and alcohol habits. As a consequence of choosing healthier behaviours, some residents described that their circle of friends had diminished.

“I was going to say – the company you keep, right? … Yeah, it makes a big difference. Right? Because if your friends are drinking, you will drink. If your friends are smoking, you may smoke. And even if you’re not smoking, you’re inhaling that smoke, right. So it makes a difference.” (Post-Visit, FG5)

Personal desire to change and readiness for change were key to improving health behaviours

During both phases, residents described the importance of motivation and readiness to change.

They described that: a) it is difficult to change behaviours, b) the desire for better health is a motivator, c) that readiness to change is an important factor in changing health behaviours, d) the timing when they were primed to change was important and e) that a “wake-up call” may provide motivation to change. Several residents described internal motivation as important in making changes — that one had to make a choice to change their behaviour. Lack of motivation was identified as one reason why people do not change; people may know what to do to improve their health, yet often do not modify their behaviour. At the same time, residents acknowledged that it is very difficult to change behaviours that contribute to poor health. For example,

“I know I have to get healthy. …It’s very difficult. My obstacle is my big stomach. It’s hard to get motivated to get started.” (Adaptation, FG2)

During both phases, residents reported on previous attempts to improve their health if they had experienced a health scare or what was often referred to as a “wake-up call” that motivated them to make changes. For instance, several residents became aware that their blood pressure was elevated or that they had gained more weight than they had expected. During adaptation, residents described having taken different strategies to improve health such as walking, biking, and using community gardens for fresh vegetables. Walking and biking activities were described as essential since most residents could not afford a car. In the post-visit phase, residents described that wanting better health for themselves was a significant motivator to join the study, and some had already started to make changes prior to the PP visit. For many, the right timing was identified a key contributor to motivation – participants became aware of BETTER HEALTH at a pivotal time in their lives when they were primed for change.

Value of accessible community programs and resources

During adaptation, residents mentioned different community programs including food banks, community kitchens, libraries and community centres that provided much-needed resources (e.g. food and clothing) and referrals to service agencies such as John Howard Society (a non—profit organization focused on education and community service pertaining to criminal justice systems), Legal Aid, and the Canadian Mental Health Association. The perception was that educational programs and community resources helped people in the neighbourhood become healthier.

“And yes, you can eat well. [Name of city] is very good for that if you put your mind to it and get into their time schedules. The churches once a month do a soup and sandwich right there on [name of street] right, like right across from the library. (Adaptation FG3)

Importantly some residents did not know about community programs and many residents had difficulty obtaining relevant and accurate information about chronic disease prevention and health care outside of the PP visit.

Subtheme: valuing guidance and assistance to connect to resources

During adaptation, residents perceived that they needed someone to help them to navigate health care and social systems by assisting them to connect with health or social resources and getting appropriate referrals e.g., for help with mental health issues. Some residents described positive experiences of receiving help from both peers and professionals, and getting connected to local services.

“I just found out I can see a psychologist to deal with my head issues for free as long as it’s a referral from [name of clinic]. (Adaptation FG2)

Prevention Practitioners (PPs) enabled residents to change health behaviours through a client-centred approach to education and goal setting

In both adaptation and post-visit phases, residents perceived the PP as a health professional with knowledge and skills to support disease prevention. In adaptation, residents also liked that PP visit would be private since confidentiality was important. Residents reported that: a) their health behaviour changed, and b) that the PP enabled them to make changes.

Residents in the post-visit phase described making positive lifestyle changes as a result of the PP visit such as exercising more often, quitting smoking, and making more social connections. The majority of participants said they had immediate follow through on some goals. Sustained follow through was mixed; some had not continued with their goals but wanted to get back on track while others had continued to maintain behaviour changes. Residents appreciated the assistance with setting small goals that were tailored to them. The PPs supported residents to identify barriers and strategies to overcome them such as access to low cost or free programs, which was seen as an important step.

“I actually learned a lot as well about how she [PP] handled the goal setting… she would say, “Okay, are there any challenges that would get in the way of you doing this?” And then I said, well, actually yes, you know, these three things would probably stop me. She said, “Now, let’s figure out how we get over those.” And I thought that was really important.” (Post-visit FG5)

Shared goal setting with the PP was also important as residents felt involved in decision- making about their own health. PP tools were perceived as accessible, easy to use and provided good follow-up reminders for residents. The offer of home visits was considered an enabler of participation since residents had limited transportation options. Moreover, residents spoke positively about DRHD and public health nurses as trusted sources of health information. PPs were also viewed as knowledgeable about existing community resources and were able to link participants to them. Residents saw BETTER HEALTH as an asset for the community because it addressed a disease prevention gap.

Feeling listened to and being understood were critically important when interacting with PPs about their health

In the post-visit phase, residents said it was important to feel heard and understood when engaging with a professional about their health issues.

“I found she listened so well… Like before giving me advice, she took the time to listen to everything that I had to say. So I felt very understood.” (Post-visit FG5)

Residents felt listened to by both the research assistant (RA) during baseline data collection and by the PP. The RA interview was identified by residents as the first step of building trust and rapport as it prompted reflection and inspired changes in behaviour. Residents also described the PP as having good listening skills, being professional and non-judgmental, and that they felt cared for, respected, and understood. The PP visit was described as private and comfortable and participants did not feel rushed.

In this study, we adapted the original BETTER intervention for a cRCT (BETTER HEALTH) directed toward community residents living in low income neighbourhoods and with a public health nurse as the PP. In both adaptation and the post-visit evaluation phases, we found that residents faced significant intersecting health and social challenges in coping with everyday life. A substantial contributor to stress was perceived to be living with poverty, coping with previous or current mental health issues or addictions, loneliness, and social isolation. Consequently, it was important that the adapted intervention incorporated resources for social and income support, food security support, and other resources (e.g., community social programs, community kitchens, mental health supports). PPs assisted participants to access these resources since many residents did not know how to access them.

We also found that disease prevention was not a priority for some community residents due to health and social challenges; they could only consider making lifestyle changes when their life was in a stable place. Similarly, Crooks et al. (2021) found that chronically ill residents from low income neighbourhoods reported only seeking medical care at walk-in clinics and emergency departments when they hit a “crisis point” rather than practicing disease prevention [ 29 ]. In our study, the supportive PP visits that incorporated health promotion and shared decision-making served as a “wake-up call” for many residents and helped them plan concrete strategies to improve their health.

Our research highlighted that feeling listened to was especially important when interacting with PPs. This finding supported the appropriateness of having public health nurses with strong skills in trust-building as PPs. Dupéré et al. (2012) reported that men living in deep poverty in Montreal were reluctant to seek needed medical care or social services; many had experienced significant abuse and victimization which led to difficulties expressing their feelings and trusting others [ 30 ]. Other researchers also reported that a lack of trust in other people was an important barrier for chronically ill patients with complex social needs to engage with health care services [ 31 ].

We found that residents valued accessible community programs and the BETTER HEALTH approach of using established community resources. PPs referred residents to existing community resources within the region and avoided duplication of services. In this context, the role of the PP is an educator and a navigator with extensive knowledge of relevant community resources.

The BETTER HEALTH intervention based in the community and delivered by public health nurses as PPs was positively perceived by residents. The PPs helped residents to make lifestyle changes by focusing on achievable short-term goals which contributed to the success of the intervention. The results of qualitative evaluation were consistent with the results of the cRCT which showed that residents in the intervention arm achieved more eligible actions compared to those in the waitlist arm [ 14 ].

Numerous community-based interventions have attempted to increase cancer and cardiovascular disease (CVD) screening and improve health outcomes [ 32 , 33 , 34 , 35 , 36 , 37 ]. Some interventions were targeted specifically toward those who might experience systemic barriers to accessing healthcare such as those living in rural areas [ 36 ]. Systematic reviews have found that multicomponent interventions which include one-on-one and/or group education sessions through various community settings (e.g. faith-based organizations, public health, community health centres), utilizing community health workers/volunteers or nurses have been successful in increasing screening rates for cancer and CVD with some studies also showing improvements in patient health outcomes [ 32 , 33 , 34 ]. Krantz et al. (2013) and Shlay et al. (2011) both successfully used community health workers to improve patient CVD-related outcomes (e.g., diet, weight and blood pressure) through one-on-one interventions in public health settings that consisted of motivational interviewing and goal-setting, patient navigation and referrals to medical /community resources [ 36 , 37 ]. While both of these previous studies focused on CVD outcomes, BETTER and the BETTER HEALTH adaptation are unique in effectively providing an evidenced-based comprehensive approach to CDPS, including associated lifestyle factors [ 7 , 14 ].

The results of our qualitative evaluation are consistent with a previous evaluation of the BETTER intervention that was conducted with patients in primary care living in urban, rural or remote communities in Newfoundland and Labrador [ 10 , 11 ]. This previous evaluation reported that patients valued the PP visit which was perceived as personalized and comprehensive, the PPs were viewed as professional and had strong interpersonal skills, and patients were concerned about access to disease prevention [ 10 ]. Our study provides additional information about the perceived health of community residents living in low income neighbourhoods including stress and loneliness, the role of personal motivation, and the positive influence of the PP visit in helping residents achieve their personal health goals. The new PP role was largely consistent with the chronic disease prevention mandate of the public health department that participated in the study but was delivered in a one-to-one visit. The role of the PP public health nurse as an educator and a navigator allowed a more targeted approach focused on those most at need.

A particular strength of our study was the engagement of community stakeholders especially the community residents living in low income neighbourhoods who participated both as members of the CAC and in the adaptation phase of the study. The adapted intervention that was subsequently tested in the cRCT incorporated key features recommended by community residents such as having private and confidential visits with PPs who listened to concerns and helped residents to create personal goals that were meaningful. We speculate that this input from the community contributed to the positive results of the adapted intervention. The community residents also reinforced that the adapted intervention helped to fill a prevention gap in the community.

Limitations

We acknowledge that many of the community residents who participated in focus groups or interviews may already have taken some steps to improve their health. These individuals may represent community members already empowered around health issues and who had the motivation to make lifestyle changes or to connect to community services. We do not know if individuals who felt unable to make lifestyle changes would have had the same positive views of the PP visit. Additionally, our study included community residents who volunteered to participate and we cannot be certain that the views of residents who did not participate would be similar. However, we recruited individuals from all eligible priority neighbourhoods in an effort to obtain a range of views and reached informational saturation of themes during the analysis [ 38 ]. In the post-visit evaluation, we enrolled about one-third of study participants who received the PP visit. We chose to include only those who had received a PP visit so we could obtain their impressions of the visit; however, it might have useful to have included residents who were eligible and consented but did not attend the visit. In doing so, we might have gained information about additional barriers that were unique to these individuals. In addition, only five men in the adaptation phase and four in the post-visit phase participated. As a result, we do not know whether we might have missed important information about the program. For example, we might have identified other opportunities to share information about BETTER HEALTH with men who might be otherwise reluctant to attend a PP visit. Another limitation is that we did not explore the cultural differences and approaches to behaviour change at the familial or community level beyond those identified by participants [ 39 ]. Therefore, our findings provide information about individual versus collective approaches to illness and health. A final limitation relates to the application of our intervention to a virtual setting. All PP visits were conducted in-person. Given that the onset of the Covid-19 pandemic and the switch to more virtual care, we are uncertain if our findings would be applicable in a virtual care setting.

The adaptation phase was crucial to learn from community residents about their perceived health and to gauge acceptability of the BETTER HEALTH intervention. Significant challenges faced by community residents included those pertaining to mental health, loneliness and social isolation and living with poverty. Resources that addressed social needs were important additional components of the adapted intervention.

The post visit qualitative evaluation by community residents helped us understand key relational aspects of the PP visit including resident’s sense of being respected and understood. Residents perceived that help with setting personal and achievable goals empowered them to make changes. We also learned that the BETTER HEALTH intervention was viewed as providing access to chronic disease prevention in the community.

Availability of data and materials

We are not able to publicly share the transcripts because we do not have consent from participants to do so. The analytic codes are available from the corresponding author upon reasonable request.

Abbreviations

A ssessment, D ecision, A dministration, P roduction, T opical Experts – Integration, T raining, T esting

Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Family Practice

Community Advisory Committee

Community-based participatory research

Chronic disease prevention and screening

Community Health Centre

Canadian Mental Health Association

Durham Regional Health Department

Primary Care Engagement Group

Prevention practitioner

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Acknowledgements

The research team wishes to thank the study participants for giving their valuable time. We acknowledge the contributions of members of the Community Advisory Committee to this research. They were integral in advising the research team, providing unique insights into the communities where the research was being conducted and brokering collaborations between the research team and community partners.

The adaptation phase is one component of a study funded as a grant proposal entitled 'Advancing Cancer Prevention Among Deprived Neighbourhoods' by the Canadian Cancer Society Research Institute grant #704042 and by the Canadian Institutes of Health Research Institute of Cancer grant OCP #145450. Aisha Lofters is supported by a CIHR New Investigator Award, as a Clinician Scientist by the Department of Family and Community Medicine, University of Toronto, and as Chair in Implementation Science at the Peter Gilgan Centre for Women’s Cancers at Women’s College Hospital in partnership with the Canadian Cancer Society. Dr. Andrew Pinto holds a Canadian Institutes of Health Research Applied Public Health Chair and is supported as a Clinician-Scientist in the Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, and supported by the Department of Family and Community Medicine, St. Michael’s Hospital, and the Li Ka Shing Knowledge Institute, St. Michael’s Hospital. He is also the Associate Director for Clinical Research at the University of Toronto Practice-Based Research Network. Lawrence Paszat is supported by a Clinician Scientist award funded by the Ontario Ministry of Health and Long Term Care. The funding sources played no role in the design, conduct, or reporting of this study.

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Contributions

MAO, AL, BW, RE, TM, MAP, EG, BR, CS, ADP, DM, NS, KS, PDD, PS, RK, LR, JT, NNB and LP took part in the planning process of adapting and conducting the qualitative evaluation of the BETTER HEALTH intervention. MAO, AL, BW, RE, TM, MAP, BR, CS, ADP, JH, KS, LP adapted the intervention. MAO, DM, NS, TM and SDC collaborated on the analysis and interpretation of data collected from community resident focus groups and interviews. MAO, TM and SDC led manuscript preparation and all authors contributed to manuscript review and revision.

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Correspondence to Mary Ann O’Brien .

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All procedures performed in studies involving human participants were in accordance with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

The study was approved by the following research ethics boards (REB) or committee: Sunnybrook Health Sciences Centre (REB 222—2016), St. Michael’s Hospital (REB #16–231), the University of Toronto (# 33340), and the Ethics Review Committee (ERC) of the Durham Region Health Department (ERC #20160802–002). Informed consent was obtained from all individual participants included in the study.

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Regina Elliott, Tutsirai Makuwaza and Mary-Anne Pietrusiak: Indicates affiliation at the time of the study.

Sylvie D Cornacchi: At the time of the study, Sylvie Cornacchi was affiliated with the Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, 500 University Ave, Fifth Floor, Toronto, ON, Canada M5G 1V7.

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O’Brien, M.A., Lofters, A., Wall, B. et al. Adaptation and qualitative evaluation of the BETTER intervention for chronic disease prevention and screening by public health nurses in low income neighbourhoods: views of community residents. BMC Health Serv Res 24 , 427 (2024). https://doi.org/10.1186/s12913-024-10853-z

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• The Patient Journey: Meaning & How To Map It Out

Introduction

The term, patient journey is similar to a customer experience journey, which refers to offering a service in a way that fixes the customer’s pain points, with a focus on ensuring a positive experience, across all touch points through which a customer interacts with your brand. The focus here is to consolidate all the emotional drivers of engagements, to ensure that patients have positive experiences, that propel them to keep interacting with your brand.

Over time, the customer experience has evolved to also include patient experience, which can be managed by mapping out the patient journey. 

In this post, we share all you need to know about the patient journey map and how to create one.

What is Meant by Patient Journey?

The patient journey is a word used to describe the experience of an individual receiving or seeking medical care. In this case, the individual is referred to as a patient. The patient journey includes all aspects of an individual’s experience within a hospital or medical care environment.

It begins with the consultation stage, where a patient seeks to find out more about their health condition. Before this event, there is a stage called the pre-visit stage. This occurs because patients can now find out more about their conditions and organizations suited to handling them, via the web, social media, etc.

The online research stage is what determines the actual physical or online location that they visit.

The second phase is now the earlier mentioned consultation where they meet the medical personnel for in-depth insight into their medical concern and subsequent diagnosis.

The third phase is the treatment stage which involves subsequent visits based on the diagnosis.

It is somewhat similar to the customer journey map with a few notable differences, as illustrated below.

The goal of a patient journey map is to provide maximum satisfaction to the patient, by identifying and proffering custom-fit solutions to the patient’s pain points, while paying attention to the patient’s experience at each stage. 

Hence one of the easiest ways to do this is to create a map, showing and interpreting the patient’s experience in other to improve it.

The Patient Journey vs. The Patient Experience

The patient journey is the different phases that impact their experience. The journey is a series of activities geared towards helping the patient meet their goal and most times a patient journey follows a sequential order.

A patient experience on the other hand is everything, every emotion a patient feels as they navigate the patient journey. Every credible organization would love to retain and attract more patients or simply become a go-to solution for medical occurrences in the patient’s life.

However, they sometimes fail to realize that the key to this is a mixture of all the activities and the experience gained that often leads them to choose one organization over the other. 

How To Conduct Patient Journey Mapping

The key to creating an effective patient journey map is not a one size fits all approach, but a personalized solution subject to patients’ individual interaction with the different aspects of your organization.

A patient journey map is a visual illustration of all the steps a patient undergoes as they interact with your organization. Therefore it should include the pre-visit stage and the post-visit phase. 

The first step to doing this is, to begin with, an inventory or collection of all the areas or touch points where you gather feedback, even as you pay attention to the specific patient personas, demography, and health conditions.

This step is essential because creating a valuable personalized experience in the healthcare world is not negotiable. Hence, tailoring the map to the specific requirement of each patient class is key. 

A patient journey map helps you to tick all the boxes up to the mode of communication touchpoints and ensure that the appropriate channel is employed to deliver the right information in a time-efficient manner.

Therefore, knowing or discovering the preference of your patient, their choices, such as their preferred time or channel of communication, the necessary steps they need to undergo repeatedly to ensure that they get optimal care, etc. is an important aspect when conducting your patient journey.

Let us look at some definitive steps to conducting a patient journey map:

Define The Various Patient Personas

This step is perhaps the most important step that allows you to place your patient in the right groups. It involves knowing the following;

• What does your patient require the most?
• What is their preferred mode of communication?
• What kind of care do they want or is suitable for their condition?
• How much information have you gathered about them?

The more insight you have about your patient the better your patient journey experience.

• Own The Entire Patient Lifecycle

In other to conduct a patient journey map, you must own the process and this means having first-hand knowledge or a thorough understanding of the patient life cycle for each patient category. While an appointment reminder for an expectant mother to come in for their test is great, it would be frustrating to see that they forgot to bring a test sample as required. 

In this instance, when sending reminders, it’s best done a day or more before emphasizing that they come in with the required sample while stating any specific instructions like the time of collection, etc.

Understanding a patient’s pain point involves putting yourself in the shoes of your patient. Being able to fully understand and feel all the emotions your patient experiences when engaging with your brand is key in your journey map. 

Your ability to walk literally in the shoes of your patient would help build an effective patient engagement strategy. Addressing concerns like how they feel, the strong desire to get better quickly, the fear of the associated cost that comes with healthcare, payment plan options, and the like is a great way to get their loyalty and have them become promoters of your brand.

Gather Insightful Data

Customized service in healthcare is just like rabbits to carrots. The two go hand in hand. Customization means creating personalized treatment plans suitable for each individual based on their diagnosis. 

To make this happen, you need to gather medical/personal data that provides insight into the patient’s condition. This data can also include their preferred mode of communication, social factors that affect their health, the nature of their career, and more. 

All of this data helps you offer a more personalized treatment plan that would ensure their well-being and ultimate loyalty.

How Do I Get Started With Patient Journey Mapping?

   You can get started with your patient journey mapping by outlining all the patient’s touchpoints at each stage in their care journey. This would help you create an experience that improves patient engagement, satisfaction, and retention or loyalty.

To do this successfully you begin by capturing and addressing these 6 major stages in the patient journey:

• Pre-Visit Awareness

This refers to the stage at which the patient is surfing the internet, making research about their condition in other to get the best facility to manage their concerns.

• First Contact

At this, the patient has made a decision and contacts your organization via emails, a call, or an actual visit to your location.

• Consultation/Care

Here, the patient interacts with a healthcare provider for accurate diagnosis and proposed care options.

This is the commencement of the actual treatment phase, such as tests and medication prescriptions, counseling, or proposed changes in lifestyle.

• Follow-up Care

At this stage, there is follow-up care to ensure that the patients take the recommendations to make the required changes in their behavior and lifestyle for their well-being and full recovery.

• Continued Care/Support/Check-up

This is the patient retention phase, where periodic visits are set up to monitor the patient’s well-being, review symptoms, and generally foster engagement between the patient and physician to ensure a full recovery. 

Here you get feedback on the treatments or medication offered and any other information. This feedback would be used to improve the patient journey map and overall experience.

Benefits of Patient Journey Mapping

The patient journey mapping process provides benefits like ;

Helping you give a personal and human touch to your treatment plans through personalized care. This is so because the patient journey map gives you a deep understanding of your patient’s unique needs and preferences.

With a journey map, missed opportunities and gaps are highlighted in each stage of interaction with your healthcare system. and you can get a first-hand insight into the emotions patients experience when going through your touchpoints.

Knowledge of these gaps helps you address them swiftly 

Boosting your customer retention ratio is one of the benefits of this process. This is so because it fosters improved communication between patients and healthcare providers. That way you get firsthand feedback from your patients, which allows you to see how well or poorly you are doing based on their perspectives.

Moreso, with a journey map you monitor the post-treatment stage of your patients through close supervision. This way, you get to provide personalized support to your patients during the post-treatment phase.

Most importantly, with a patient journey map you get to improve the functionality of your online channels, such as your websites, socials, mobile apps, call centers, etc.

In summary, a patient journey map is an ideal tool that transforms your patient’s experience from reactive to proactive, simply because you preempt their every step and go ahead to remove any gridlock even before they occur.

Using Patient Journey Data

The idea behind the patient data is to see the end from the beginning. Once you have been able to create a visual picture of this process, you go ahead to do the following in other to use the patient journey data successfully;

• Collect The Appropriate Data

Data must be collected from every touch point in the patient journey. This would help you understand the experiences of your patients as they interact with certain aspects of your organization. 

For instance, their experience with the customer service desk, the pharmacy, the x-ray or laboratory experiences, and even their experience with your website, scheduling appointments, to mention a few.

Paying attention to this through data collection would unveil the pain points patients experience and you can use this information to address the concerns uncovered.

Read Also –  Customer Journey Touchpoints: The Complete Guide

• Analyze The Data

Analytics using smart tools can uncover trends and subsequent pain points in the patient journey. In-depth analytics would provide the insight necessary to improve the overall patient experience.

• Use Your Data To Initiate Action

The smartest way to use your data is to take action. Every data gleaned from your patient journey should result in tangible actions, that would provide maximum results in a way that directly impacts the patient experience positively.

For instance, if a patient provides negative feedback about getting a test done, follow up with the patient to understand why this is happening and reach a resolution by ensuring they have their test done. Subsequently, actively monitor the test department to ensure that no other patient has the same negative experience that would require escalation to resolve.

A patient journey map is a visual illustration of the activities patients get involved in as they interact with an organization to receive medical care. Having a patient journey map is essential to creating a favorable experience with patients that would make them unsolicited promoters of your organization. 

Ideally, a patient journey map should capture all the steps taken before a visit to your website or physical location and all the straps taken after care has been provided and administered. 

The results are not just the commercial success of your brand but the fulfillment that comes with knowing that you gave your best to each patient and they attest to that.

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• Customer Experience
• customer journey
• customer journey map
• customer touchpoints
• patient experience
• patient journey map
• Angela Kayode-Sanni

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Description and preliminary experience with Virtual Visit Assessment (ViVA) during the COVID-19 pandemic, a structured virtual management protocol for patients with multiple sclerosis

Affiliations.

• 1 Multiple Sclerosis Center, IRCCS Mondino Foundation, via Mondino 2, 27100, Pavia, Italy.
• 2 Novartis Farma S.P.A, Origgio, VA, Italy.
• 3 Bip Life Sciences, Milan, Italy.
• 4 Multiple Sclerosis Center, IRCCS Mondino Foundation, via Mondino 2, 27100, Pavia, Italy. [email protected].
• PMID: 34131815
• PMCID: PMC8205205
• DOI: 10.1007/s10072-021-05371-3

In people with multiple sclerosis (PwMS), strict follow-up is essential. Telemedicine has the potential to overcome many of the difficulties in routine management. Herein, we present a structured protocol that can be used to remotely manage patients with MS, describing in detail the steps to be taken and exams needed at each stage. A working group was established which developed a tailored protocol that can be adapted to a variety of settings. The overall protocol consisted of 5 phases: enrolment, document sharing phase, pre-evaluation, virtual visit, and post-visit phase, which was divided into 14 individual steps. As of October 2020, 25 virtual visits have been carried out, all via Skype. The patient's caregiver was present during visits and had an active role. The average duration of the virtual visit was 24 min, and that of the pre-visit and post-visit were around 15 min each. Overall satisfaction as rated by physicians was considered high (8.0 ± 0.5). Using the system usability scale (SUS), patients also favorably rated the virtual visit (96.6 ± 6.1). In 20% of cases, the virtual visit was not sufficient to provide adequate information and an in-person clinical visit was recommended. The described protocol has the potential to provide benefits for the healthcare system as well as patients and their caregivers both during and beyond COVID-19 pandemic.

Keywords: COVID-19; Management; Multiple sclerosis; Protocol; Telemedicine.

© 2021. The Author(s).

• Multiple Sclerosis* / diagnosis
• Multiple Sclerosis* / epidemiology
• Multiple Sclerosis* / therapy
• Telemedicine*

• Postoperative Phase

The  postoperative phase  of the surgical experience extends from the time the client is transferred to the recovery room or postanesthesia care unit (PACU) to the moment he or she is transported back to the surgical unit, discharged from the hospital until the follow-up care.

During the postoperative period, reestablishing the patient’s physiologic balance, pain management and prevention of complications should be the focus of the nursing care. To do these it is crucial that the nurse perform careful assessment and immediate intervention in assisting the patient to optimal function quickly, safely and comfortably as possible.

• Maintaining adequate body system functions.
• Restoring body homeostasis .
• Pain and discomfort alleviation.
• Preventing postoperative complications.
• Promoting adequate discharge planning and health teaching.

The mnemonic “POSTOPERATIVE” may also be helpful:

• P – Preventing and/or relieving complications
• O – Optimal respiratory function
• S – Support: psychosocial well-being
• T – Tissue perfusion and cardiovascular status maintenance
• O – Observing and maintaining adequate fluid intake
• P – Promoting adequate nutrition and elimination
• A – Adequate fluid and electrolyte balance
• R – Renal function maintenance
• E – Encouraging activity and mobility within limits
• T – Thorough wound care for adequate wound healing
• I – Infection Control
• V – Vigilant to manifestations of anxiety and promoting ways of relieving it
• E – Eliminating environmental hazards and promoting client safety

Patient Care during Immediate Postoperative Phase: Transferring the Patient to RR or PACU

Patient Assessment

Special consideration to the patient’s incision site, vascular status and exposure should be implemented by the nurse when transferring the patient from the operating room to the postanethesia care unit (PACU) or postanesthesia recovery room (PARR). Every time the patient is moved, the nurse should first consider the location of the surgical incision to prevent further strain on the sutures. If the patient comes out of the operating room with drainage tubes, position should be adjusted in order to prevent obstruction on the drains.

• Assess air exchange status and note patient’s skin color
• Verify patient identity. The nurse must also know the type of operative procedure performed and the name of the surgeon responsible for the operation.
• Neurologic status assessment. Level of consciousness (LOC) assessment and Glasgow Coma Scale (GCS) are helpful in determining the neurologic status of the patient.
• Cardiovascular status assessment. This is done by determining the patient’s vital signs in the immediate postoperative period and skin temperature.
• Operative site examination. Dressings should be checked.

Positioning

Moving a patient from one position to another may result to serious arterial hypotension . This occurs when a patient is moved from a lithotomy to a horizontal position, from a lateral to a supine position, prone to supine position and even when a patient is transferred to the stretcher. Hence, it is very important that patients are moved slowly and carefully during the immediate postoperative phase.

Promoting Patient Safety

When transferred to the stretcher, the patient should be covered with blankets and secured with straps above the knees and elbows. These straps anchor the blankets at the same time restrain the patient should he or she pass through a stage of excitement while recovering from anesthesia . To protect the patient from falls, side rails should be raised.

Safety checks when transferring the patient from OR to RR:

• S – Securing restraints for I.V. fluids and blood transfusion.
• A – Assist the patient to a position appropriate for him on her based on the location of incision site and presence of drainage tubes.
• F – Fall precaution implementation by making sure the side rails are raised and restraints are secured well.
• E – Eliminating possible sources of injuries and accidents when moving the patient from the OR to RR or PACU.

Postoperative Nursing Care

• Keep airway in place until the patient is fully awake and tries to eject it . The airway is allowed to remain in place while the client is unconscious to keep the passage open and prevents the tongue from falling back. When the tongue falls back, airway passage obstruction will result. Return of pharyngeal reflex, noted when the patient regains consciousness, may cause the patient to gag and vomit when the airway is not removed when the patient is awake.
• Suction secretions as needed.
• B – Bilateral lung auscultation frequently.
• R – Rest and place the patient in a lateral position with the neck extended, if not contraindicated, and the arm supported with a pillow. This position promotes chest expansion and facilitates breathing and ventilation .
• E – Encourage the patient to take deep breaths. This aerates the lung fully and prevents hypostatic pneumonia .
• A – Assess and periodically evaluate the patient’s orientation to name or command. Cerebral function alteration is highly suggestive of impaired oxygen delivery.
• T – Turn the patient every 1 to 2 hours to facilitate breathing and ventilation.
• H – Humidified oxygen administration. During exhalation , heat and moisture are normally lost, thus oxygen humidification is necessary. Aside from that, secretion removal is facilitated when kept moist through the moisture of the inhaled air. Also, dehydrated patients have irritated respiratory passages thus, it is very important make sure that the inhaled oxygen is humidified.

Circulation

• Obtain patient’s vital signs as ordered and report any abnormalities.
• Monitor intake and output closely.
• Recognize early symptoms of shock or hemorrhage such as cold extremities, decreased urine output – less than 30 ml/hr, slow capillary refill – greater than 3 seconds, dropping blood pressure , narrowing pulse pressure, tachycardia – increased heart rate .

Thermoregulation

• Hourly temperature assessment to detect hypothermia or hyperthermia .
• Report temperature abnormalities to the physician.
• Monitor the patient for postanethesia shivering or PAS. This is noted in hypothermic patients, about 30 to 45 minutes after admission to the PACU. PAS represents a heat-gain mechanism and relates to regaining the thermal balance.
• Provide a therapeutic environment with proper temperature and humidity. Warm blankets should be provided when the patient is cold.

Fluid Volume

• Assess and evaluate patient’s skin color and turgor, mental status and body temperature.
• Monitor and recognize evidence of fluid and electrolyte imbalances such as nausea and vomiting and body weakness .
• Recognize signs of fluid imbalances. HYPOVOLEMIA: decreased blood pressure, decreased urine output, increased pulse rate , increased respiration rate, and decreased central venous pressure (CVP). HYPERVOLEMIA: increased blood pressure and CVP, changes in lung sounds such as presence of crackles in the base of both lungs and changes in heart sounds such as the presence of S3 gallop.
• Avoid nerve damage and muscle strain by properly supporting and padding pressure areas.
• Frequent dressing examination for possible constriction.
• Raise the side rails to prevent the patient from falling.
• Protect the extremity where IV fluids are inserted to prevent possible needle dislodge.
• Make sure that bed wheels are locked.

GI Function and Nutrition

• If in place, maintain nasogastric tube and monitor patency and drainage.
• Provide symptomatic therapy, including antiemetic medications for nausea and vomiting .
• Administer phenothiazine medications as prescribed for severe, persistent hiccups.
• Assist patient to return to normal dietary intake gradually at a pace set by patient (liquids first, then soft foods, such as gelatin, junket, custard, milk, and creamed soups, are added gradually, then solid food).
• Remember that paralytic ileus and intestinal obstruction are potential postoperative complications that occur more fre-quently in patients undergoing intestinal or abdominal surgery .
• Arrange for patient to consult with the dietitian to plan appealing, high-protein meals that provide sufficient fiber, calories, and vitamins. Nutritional supplements, such as Ensure or Sustacal, may be recommended.
• Instruct patient to take multivitamins, iron, and vitamin C supplements postoperatively if prescribed
• Observe and assess behavioral and physiologic manifestations of pain.
• Administer medications for pain and document its efficacy.
• Assist the patient to a comfortable position.
• Presence of drainage, need to connect tubes to a specific drainage system, presence and condition of dressings

Skin Integrity

• Record the amount and type of wound drainage.
• Regularly inspect dressings and reinforce them if necessary.
• Proper wound care as needed.
• Perform hand washing before and after contact with the patient.
• Turn the patient to sides every 1 to 2 hours.
• Maintain the patient’s good body alignment.

Assessing and Managing Voluntary Voiding

• Assess for bladder distention and urge to void on patient’s arrival in the unit and frequently thereafter (patient should void within 8 hours of surgery).
• Obtain order for catheterization before the end of the 8-hour time limit if patient has an urge to void and cannot, or if the bladder is distended and no urge is felt or patient cannot void.
• Initiate methods to encourage the patient to void (eg, letting water run, applying heat to perineum).
• Warm the bedpan to reduce discomfort and automatic tightening of muscles and urethral sphincter.
• Assist patient who complains of not being able to use the bedpan to use a commode or stand or sit to void (males), unless contraindicated.
• Take safeguards to prevent the patient from falling or fainting due to loss of coordination from medications or orthostatic hypotension .
• Note the amount of urine voided (report less than 30 mL/h) and palpate the suprapubic area for distention or tenderness, or use a portable ultrasound device to assess residual volume.
• Continue intermittent catheterization every 4 to 6 hours until patient can void spontaneously and postvoid residual is less than 100 mL.

Encouraging Activity

• Encourage most surgical patients to ambulate as soon as possible.
• Remind patient of the importance of early mobility in preventing complications (helps overcome fears).
• Anticipate and avoid orthostatic hypotension (postural hypotension: 20-mm Hg fall in systolic blood pressure or  10-mm Hg fall in diastolic blood pressure, weakness , dizziness, and fainting)
• Assess patient’s feelings of dizziness and his or her blood pressure first in the supine position, after patient sits up, again after patient stands, and 2 to 3 minutes later.
• Assist patient to change position gradually. If patient becomes dizzy, return to supine position and delay getting out of bed for several hours.
• When patient gets out of bed, remain at patient’s side to give physical support and encouragement.
• Take care not to tire patient.
• Initiate and encourage patient to perform bed exercises to improve circulation (range of motion to arms, hands and fin-gers, feet, and legs; leg flexion and leg lifting; abdominal and gluteal contraction).
• Encourage frequent position changes early in the postoperative period to stimulate circulation. Avoid positions that compromise venous return (raising the knee gatch or placing a pillow under the knees, sitting for long periods, and dangling the legs with pressure at the back of the knees).
• Apply antiembolism stockings, and assist patient in early  ambulation . Check postoperative activity orders before get-ting patient out of bed. Then have patient sit on the edge of bed for a few minutes initially; advance to ambulation as tolerated

Gerontologic Considerations

Elderly patients continue to be at increased risk for postoperative complications. Age-related physiologic changes in respi-ratory, cardiovascular, and renal function and the increased incidence of comorbid conditions demand skilled assessment to detect early signs of deterioration. Anesthetics and opioids can cause confusion in the older adult , and altered pharmacokinetics results in delayed excretion and prolonged respiratory  depressive effects. Careful monitoring of electrolyte, hemoglo-bin, and hematocrit levels and urine output is essential because the older adult is less able to correct and compensate for fluid and electrolyte imbalances. Elderly patients may need frequent reminders and demonstrations to participate in care effectively.

• Maintain physical activity while patient is confused. Physi-cal deterioration can worsen delirium and place patient at increased risk for other complications.
• Avoid restraints, because they can also worsen confusion. If possible, family or staff member is asked to sit with patient instead.
• Administer haloperidol (Haldol) or lorazepam (Ativan) as ordered during episodes of acute confusion ; discontinue these medications as soon as possible to avoid side effects.
• Assist the older postoperative patient in early and progressive ambulation to prevent the development of problems such as pneumonia , altered bowel function, DVT , weakness, and functional decline; avoid sitting positions that promote venous stasis in the lower extremities.
• Provide assistance to keep patient from bumping into objects and falling. A physical therapy referral may be indicated to promote safe, regular exercise for the older adult.
• Provide easy access to call bell and commode; prompt void-ing to prevent urinary incontinence .
• Provide extensive discharge planning to coordinate both professional and family care providers; the nurse, social worker, or nurse case manager may institute the plan for continuing care.

Patients in PACU are evaluated to determine the client’s discharge from the unit. The following are the expected outcomes in PACU:

• Patient breathing easily.
• Clear lung sounds on auscultation.
• Stable vital signs.
• Stable body temperature with minimal chills or shivering.
• No signs of fluid volume imbalance as evidenced by an equal intake and output.
• Tolerable or minimized pain, as reported by the patient.
• Intact wound edges without drainage.
• Raised side rails.
• Appropriate patient position.
• Maintained quiet and therapeutic environment.

To Surgical Unit

Patient Care during Immediate Postoperative Phase: Transferring the Patient from RR to the Surgical Unit

To determine the patient’s readiness for discharge from the PACU or RR certain criteria must be met. The parameters used for discharge from RR are the following:

• Uncompromised cardiopulmonary status
• Stable vital signs
• Adequate urine output – at least 30 ml/ hour
• Orientation to time, date and place
• Satisfactory response to commands
• Minimal pain
• Absence or controlled nausea and vomiting
• Pulse oximetry readings of adequate oxygen saturation
• Movement of extremities after regional anesthesia

Most hospitals use a scoring system to assess the general condition of patient in RR or PACU. Observation and evaluation of the patient’s physical signs is based on a set of objective criteria.

The evaluation guide used is a modification of the APGAR scoring system used for newborns. Through this, a more objective assessment of the patient’s physical condition is guaranteed while recovering the RR or PACU.

The perfect possible score in this modified APGAR scoring system is 10. To be discharge from RR or PACU the patient is required to have at least 7 to 8 points.

Patients with score less than 7 must remain in RR or PACU until their condition improves. Areas of assessment in PACU or RR evaluation guide are:

• Respiration – ability to breathe deeply and cough .
• Circulation – systolic arterial pressure >80% of preanesthetic level
• Consciousness Level – verbally responds to questions or oriented to location
• Color – normal skin color and appearance: pinkish skin and mucus
• Muscle activity – moves spontaneously or on command
• Perioperative Nursing
• Preoperative Phase
• Intraoperative Phase

8 thoughts on “Postoperative Phase”

Excellent work, very interesting and useful information for students and nurses

do you have any questions on pre and post operative

,very good work indeed, very helpful. Thank you.

As a student nurse I have benefited, this information it very useful and it has helped me alot thank you so much 🙏

Thank you so much!!!!!!! This has calmed my nerves for sim lab tomorrow!

Hello Nurseslabs, I must say am glad about what I have read from your page. It’s awesome, and a source of learning. I have been practicing as a Nurse in the Surgical unit for quite some time now. With this new information that I came across, I think my strength has been upgraded. Thanks so much for this write-up. I Am rating your work on 5/5

My experience must be unique. This sounds like run of the mill standard nursing for any post op patient. The minimum pain comment certainly is misleading. My patient was screaming and/or crying for hours. The additional emphasis on protecting perineal area (Turn on left/right only, not supine; Use foam wedge, not pillow; do not sit without wedge to keep off chair) is missing entirely.

Hi James, Really appreciate you pointing out those specifics, especially about managing severe pain and the extra care needed for the perineal area. It’s a reminder of how diverse post-op needs can be. I’ll keep your insights in mind for our content updates. Any other tips or experiences you want to share are always welcome!

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A Plan to Remake the Middle East

While talks for a cease-fire between israel and hamas continue, another set of negotiations is happening behind the scenes..

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 New York Times, I’m Michael Barbaro. This is The Daily.

[MUSIC CONTINUES]

Today, if and when Israel and Hamas reach a deal for a ceasefire fire, the United States will immediately turn to a different set of negotiations over a grand diplomatic bargain that it believes could rebuild Gaza and remake the Middle East. My colleague Michael Crowley has been reporting on that plan and explains why those involved in it believe they have so little time left to get it done.

It’s Wednesday, May 8.

Michael, I want to start with what feels like a pretty dizzying set of developments in this conflict over the past few days. Just walk us through them?

Well, over the weekend, there was an intense round of negotiations in an effort, backed by the United States, to reach a ceasefire in the Gaza war.

The latest ceasefire proposal would reportedly see as many as 33 Israeli hostages released in exchange for potentially hundreds of Palestinian prisoners.

US officials were very eager to get this deal.

Pressure for a ceasefire has been building ahead of a threatened Israeli assault on Rafah.

Because Israel has been threatening a military offensive in the Southern Palestinian city of Rafah, where a huge number of people are crowded.

Fleeing the violence to the North. And now they’re packed into Rafah. Exposed and vulnerable, they need to be protected.

And the US says it would be a humanitarian catastrophe on top of the emergency that’s already underway.

Breaking news this hour — very important breaking news. An official Hamas source has told The BBC that it does accept a proposal for a ceasefire deal in Gaza.

And for a few hours on Monday, it looked like there might have been a major breakthrough when Hamas put out a statement saying that it had accepted a negotiating proposal.

Israeli Prime Minister Benjamin Netanyahu says the ceasefire proposal does not meet his country’s requirements. But Netanyahu says he will send a delegation of mediators to continue those talks. Now, the terms —

But those hopes were dashed pretty quickly when the Israelis took a look at what Hamas was saying and said that it was not a proposal that they had agreed to. It had been modified.

And overnight —

Israeli troops stormed into Rafah. Video showing tanks crashing over a sign at the entrance of the city.

— the Israelis launched a partial invasion of Rafah.

It says Hamas used the area to launch a deadly attack on Israeli troops over the weekend.

And they have now secured a border crossing at the Southern end of Gaza and are conducting targeted strikes. This is not yet the full scale invasion that President Biden has adamantly warned Israel against undertaking, but it is an escalation by Israel.

So while all that drama might suggest that these talks are in big trouble, these talks are very much still alive and ongoing and there is still a possibility of a ceasefire deal.

And the reason that’s so important is not just to stop the fighting in Gaza and relieve the suffering there, but a ceasefire also opens the door to a grand diplomatic bargain, one that involves Israel and its Arab neighbors and the Palestinians, and would have very far-reaching implications.

And what is that grand bargain. Describe what you’re talking about?

Well, it’s incredibly ambitious. It would reshape Israel’s relationship with its Arab neighbors, principally Saudi Arabia. But it’s important to understand that this is a vision that has actually been around since well before October 7. This was a diplomatic project that President Biden had been investing in and negotiating actually in a very real and tangible way long before the Hamas attacks and the Gaza war.

And President Biden was looking to build on something that President Trump had done, which was a series of agreements that the Trump administration struck in which Israel and some of its Arab neighbors agreed to have normal diplomatic relations for the first time.

Right, they’re called the Abraham Accords.

That’s right. And, you know, Biden doesn’t like a lot of things, most things that Trump did. But he actually likes this, because the idea is that they contribute to stability and economic integration in the Middle East, the US likes Israel having friends and likes having a tight-knit alliance against Iran.

President Biden agrees with the Saudis and with the Israelis, that Iran is really the top threat to everybody here. So, how can you build on this? How can you expand it? Well, the next and biggest step would be normalizing relations between Israel and Saudi Arabia.

And the Saudis have made clear that they want to do this and that they’re ready to do this. They weren’t ready to do it in the Trump years. But Mohammed bin Salman, the Crown Prince of Saudi Arabia, has made clear he wants to do it now.

So this kind of triangular deal began to take shape before October 7, in which the US, Israel, and Saudi Arabia would enter this three way agreement in which everyone would get something that they wanted.

And just walk through what each side gets in this pre-October 7th version of these negotiations?

So for Israel, you get normalized ties with its most important Arab neighbor and really the country that sets the tone for the whole Muslim world, which is Saudi Arabia of course. It makes Israel feel safer and more secure. Again, it helps to build this alliance against Iran, which Israel considers its greatest threat, and it comes with benefits like economic ties and travel and tourism. And Prime Minister Benjamin Netanyahu has been very open, at least before October 7th, that this was his highest diplomatic and foreign policy priority.

For the Saudis, the rationale is similar when it comes to Israel. They think that it will bring stability. They like having a more explicitly close ally against Iran. There are economic and cultural benefits. Saudi Arabia is opening itself up in general, encouraging more tourism.

But I think that what’s most important to the Crown Prince, Mohammed bin Salman, is what he can get from the United States. And what he has been asking for are a couple of essential things. One is a security agreement whose details have always been a little bit vague, but I think essentially come down to reliable arms supplies from the United States that are not going to be cut off or paused on a whim, as he felt happened when President Biden stopped arms deliveries in 2021 because of how Saudi was conducting its war in Yemen. The Saudis were furious about that.

Saudi Arabia also wants to start a domestic nuclear power program. They are planning for a very long-term future, possibly a post-oil future. And they need help getting a nuclear program off the ground.

And they want that from the US?

And they want that from the US.

Now, those are big asks from the us. But from the perspective of President Biden, there are some really enticing things about this possible agreement. One is that it will hopefully produce more stability in the region. Again, the US likes having a tight-knit alliance against Iran.

The US also wants to have a strong relationship with Saudi Arabia. You know, despite the anger at Mohammed bin Salman over the murder of the Saudi dissident Jamal Khashoggi, the Biden administration recognizes that given the Saudis control over global oil production and their strategic importance in the Middle East, they need to have a good relationship with them. And the administration has been worried about the influence of China in the region and with the Saudis in particular.

So this is an opportunity for the US to draw the Saudis closer. Whatever our moral qualms might be about bin Salman and the Saudi government, this is an opportunity to bring the Saudis closer, which is something the Biden administration sees as a strategic benefit.

All three of these countries — big, disparate countries that normally don’t see eye-to-eye, this was a win-win-win on a military, economic, and strategic front.

That’s right. But there was one important actor in the region that did not see itself as winning, and that was the Palestinians.

[MUSIC PLAYING]

First, it’s important to understand that the Palestinians have always expected that the Arab countries in the Middle East would insist that Israel recognize a Palestinian state before those countries were willing to essentially make total peace and have normal relations with Israel.

So when the Abraham Accords happened in the Trump administration, the Palestinians felt like they’d been thrown under the bus because the Abraham Accords gave them virtually nothing. But the Palestinians did still hold out hope that Saudi Arabia would be their savior. And for years, Saudi Arabia has said that Israel must give the Palestinians a state if there’s going to be a normal relationship between Israel and Saudi Arabia.

Now the Palestinians see the Saudis in discussions with the US and Israel about a normalization agreement, and there appears to be very little on offer for the Palestinians. And they are feeling like they’re going to be left out in the cold here.

Right. And in the minds of the Palestinians, having already been essentially sold out by all their other Arab neighbors, the prospect that Saudi Arabia, of all countries, the most important Muslim Arab country in the region, would sell them out, had to be extremely painful.

It was a nightmare scenario for them. And in the minds of many analysts and US officials, this was a factor, one of many, in Hamas’s decision to stage the October 7th attacks.

Hamas, like other Palestinian leaders, was seeing the prospect that the Middle East was moving on and essentially, in their view, giving up on the Palestinian cause, and that Israel would be able to have friendly, normal relations with Arab countries around the region, and that it could continue with hardline policies toward the Palestinians and a refusal, as Prime Minister Benjamin Netanyahu has said publicly, to accept a Palestinian state.

Right. So Michael, once Hamas carries out the October 7th attacks in an effort to destroy a status quo that it thinks is leaving them less and less relevant, more and more hopeless, including potentially this prospect that Saudi Arabia is going to normalize relations with Israel, what happens to these pre-October 7th negotiations between the US, Saudi Arabia, and Israel?

Well, I think there was a snap assumption that these talks were dead and buried. That they couldn’t possibly survive a cataclysm like this.

But then something surprising happened. It became clear that all the parties were still determined to pull-off the normalization.

And most surprisingly of all, perhaps, was the continued eagerness of Saudi Arabia, which publicly was professing outrage over the Israeli response to the Hamas attacks, but privately was still very much engaged in these conversations and trying to move them forward.

And in fact, what has happened is that the scope of this effort has grown substantially. October 7th didn’t kill these talks. It actually made them bigger, more complicated, and some people would argue, more important than ever.

We’ll be right back.

Michael, walk us through what exactly happens to these three-way negotiations after October 7th that ends up making them, as you just said, more complicated and more important than ever?

Well, it’s more important than ever because of the incredible need in Gaza. And it’s going to take a deal like this and the approval of Saudi Arabia to unlock the kind of massive reconstruction project required to essentially rebuild Gaza from the rubble. Saudi Arabia and its Arab friends are also going to be instrumental in figuring out how Gaza is governed, and they might even provide troops to help secure it. None of those things are going to happen without a deal like this.

Fascinating.

But this is all much more complicated now because the price for a deal like this has gone up.

And by price, you mean?

What Israel would have to give up. [MUSIC PLAYING]

From Saudi Arabia’s perspective, you have an Arab population that is furious at Israel. It now feels like a really hard time to do a normalization deal with the Israelis. It was never going to be easy, but this is about as bad a time to do it as there has been in a generation at least. And I think that President Biden and the people around him understand that the status quo between Israel and the Palestinians is intolerable and it is going to lead to chaos and violence indefinitely.

So now you have two of the three parties to this agreement, the Saudis and the Americans, basically asking a new price after October 7th, and saying to the Israelis, if we’re going to do this deal, it has to not only do something for the Palestinians, it has to do something really big. You have to commit to the creation of a Palestinian state. Now, I’ll be specific and say that what you hear the Secretary of State, Antony Blinken, say is that the agreement has to include an irreversible time-bound path to a Palestinian state.

We don’t know exactly what that looks like, but it’s some kind of a firm commitment, the likes of which the world and certainly the Israelis have not made before.

Something that was very much not present in the pre-October 7th vision of this negotiation. So much so that, as we just talked about, the Palestinians were left feeling completely out in the cold and furious at it.

That’s right. There was no sign that people were thinking that ambitiously about the Palestinians in this deal before October 7th. And the Palestinians certainly felt like they weren’t going to get much out of it. And that has completely changed now.

So, Michael, once this big new dimension after October 7th, which is the insistence by Saudi Arabia and the US that there be a Palestinian state or a path to a Palestinian state, what is the reaction specifically from Israel, which is, of course, the third major party to this entire conversation?

Well, Israel, or at least its political leadership, hates it. You know, this is just an extremely tough sell in Israel. It would have been a tough sell before October 7th. It’s even harder now.

Prime Minister Benjamin Netanyahu is completely unrepentantly open in saying that there’s not going to be a Palestinian state on his watch. He won’t accept it. He says that it’s a strategic risk to his country. He says that it would, in effect, reward Hamas.

His argument is that terrorism has forced a conversation about statehood onto the table that wasn’t there before October 7th. Sure, it’s always in the background. It’s a perennial issue in global affairs, but it was not something certainly that the US and Israel’s Arab neighbors were actively pushing. Netanyahu also has — you know, he governs with the support of very right-wing members of a political coalition that he has cobbled together. And that coalition is quite likely to fall apart if he does embrace a Palestinian state or a path to a Palestinian state.

Now, he might be able to cobble together some sort of alternative, but it creates a political crisis for him.

And finally, you know, I think in any conversation about Israel, it’s worth bearing in mind something you hear from senior US officials these days, which is that although there is often finger pointing at Netanyahu and a desire to blame Netanyahu as this obstructionist who won’t agree to deals, what they say is Netanyahu is largely reflecting his population and the political establishment of his country, not just the right-wingers in his coalition who are clearly extremist.

But actually the prevailing views of the Israeli public. And the Israeli public and their political leaders across the spectrum right now with few exceptions, are not interested in talking about a Palestinian state when there are still dozens and dozens of Israeli hostages in tunnels beneath Gaza.

So it very much looks like this giant agreement that once seemed doable before October 7th might be more important to everyone involved than ever, given that it’s a plan for rebuilding Gaza and potentially preventing future October 7th’s from happening, but because of this higher price that Israel would have to pay, which is the acceptance of a Palestinian state, it seems from everything you’re saying, that this is more and more out of reach than ever before and hard to imagine happening in the immediate future. So if the people negotiating it are being honest, Michael, are they ready to acknowledge that it doesn’t look like this is going to happen?

Well, not quite yet. As time goes by, they certainly say it’s getting harder and harder, but they’re still trying, and they still think there’s a chance. But both the Saudis and the Biden administration understand that there’s very little time left to do this.

Well, what do you mean there’s very little time left? It would seem like time might benefit this negotiation in that it might give Israel distance from October 7th to think potentially differently about a Palestinian state?

Potentially. But Saudi Arabia wants to get this deal done in the Biden administration because Mohammed bin Salman has concluded this has to be done under a Democratic president.

Because Democrats in Congress are going to be very reluctant to approve a security agreement between the United States and Saudi Arabia.

It’s important to understand that if there is a security agreement, that’s something Congress is going to have to approve. And you’re just not going to get enough Democrats in Congress to support a deal with Saudi Arabia, who a lot of Democrats don’t like to begin with, because they see them as human rights abusers.

But if a Democratic president is asking them to do it, they’re much more likely to go along.

Right. So Saudi Arabia fears that if Biden loses and Trump is president, that those same Democrats would balk at this deal in a way that they wouldn’t if it were being negotiated under President Biden?

Exactly. Now, from President Biden’s perspective, politically, think about a president who’s running for re-election, who is presiding right now over chaos in the Middle East, who doesn’t seem to have good answers for the Israeli-Palestinian question, this is an opportunity for President Biden to deliver what could be at least what he would present as a diplomatic masterstroke that does multiple things at once, including creating a new pathway for Israel and the Palestinians to coexist, to break through the logjam, even as he is also improving Israel’s relations with Saudi Arabia.

So Biden and the Crown Prince hope that they can somehow persuade Bibi Netanyahu that in spite of all the reasons that he thinks this is a terrible idea, that this is a bet worth taking on Israel’s and the region’s long-term security and future?

That’s right. Now, no one has explained very clearly exactly how this is going to work, and it’s probably going to require artful diplomacy, possibly even a scenario where the Israelis would agree to something that maybe means one thing to them and means something else to other people. But Biden officials refuse to say that it’s hopeless and they refuse to essentially take Netanyahu’s preliminary no’s for an answer. And they still see some way that they can thread this incredibly narrow needle.

Michael, I’m curious about a constituency that we haven’t been talking about because they’re not at the table in these discussions that we are talking about here. And that would be Hamas. How does Hamas feel about the prospect of such a deal like this ever taking shape. Do they see it as any kind of a victory and vindication for what they did on October 7th?

So it’s hard to know exactly what Hamas’s leadership is thinking. I think they can feel two things. I think they can feel on the one hand, that they have established themselves as the champions of the Palestinian people who struck a blow against Israel and against a diplomatic process that was potentially going to leave the Palestinians out in the cold.

At the same time, Hamas has no interest in the kind of two-state solution that the US is trying to promote. They think Israel should be destroyed. They think the Palestinian state should cover the entire geography of what is now Israel, and they want to lead a state like that. And that’s not something that the US, Saudi Arabia, or anyone else is going to tolerate.

So what Hamas wants is to fight, to be the leader of the Palestinian people, and to destroy Israel. And they’re not interested in any sort of a peace process or statehood process.

It seems very clear from everything you’ve said here that neither Israel nor Hamas is ready to have the conversation about a grand bargain diplomatic program. And I wonder if that inevitably has any bearing on the ceasefire negotiations that are going on right now between the two of them that are supposed to bring this conflict to some sort of an end, even if it’s just temporary?

Because if, as you said, Michael, a ceasefire opens the door to this larger diplomatic solution, and these two players don’t necessarily want that larger diplomatic solution, doesn’t that inevitably impact their enthusiasm for even reaching a ceasefire?

Well, it certainly doesn’t help. You know, this is such a hellish problem. And of course, you first have the question of whether Israel and Hamas can make a deal on these immediate issues, including the hostages, Palestinian prisoners, and what the Israeli military is going to do, how long a ceasefire might last.

But on top of that, you have these much bigger diplomatic questions that are looming over them. And it’s not clear that either side is ready to turn and face those bigger questions.

So while for the Biden administration and for Saudi Arabia, this is a way out of this crisis, these larger diplomatic solutions, it’s not clear that it’s a conversation that the two parties that are actually at war here are prepared to start having.

Well, Michael, thank you very much. We appreciate it.

On Tuesday afternoon, under intense pressure from the US, delegations from Israel and Hamas arrived in Cairo to resume negotiations over a potential ceasefire. But in a statement, Israel’s Prime Minister Benjamin Netanyahu made clear that even with the talks underway, his government would, quote, “continue to wage war against Hamas.”

Here’s what else you need to know today. In a dramatic day of testimony, Stormy Daniels offered explicit details about an alleged sexual encounter with Donald Trump that ultimately led to the hush money payment at the center of his trial. Daniels testified that Trump answered the door in pajamas, that he told her not to worry that he was married, and that he did not use a condom when they had sex.

That prompted lawyers for Trump to seek a mistrial based on what they called prejudicial testimony. But the judge in the case rejected that request. And,

We’ve seen a ferocious surge of anti-Semitism in America and around the world.

In a speech on Tuesday honoring victims of the Holocaust, President Biden condemned what he said was the alarming rise of anti-Semitism in the United States after the October 7th attacks on Israel. And he expressed worry that too many Americans were already forgetting the horrors of that attack.

The Jewish community, I want you to know I see your fear, your hurt, and your pain. Let me reassure you, as your president, you’re not alone. You belong. You always have and you always will.

Today’s episode was produced by Nina Feldman, Clare Toeniskoetter, and Rikki Novetsky. It was edited by Liz O. Baylen, contains original music by Marion Lozano, Elisheba Ittoop, and Dan Powell, and was engineered by Alyssa Moxley. Our theme music is by Jim Brunberg and Ben Landsverk of Wonderly.

That’s it for The Daily. I’m Michael Barbaro. See you tomorrow.

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• May 3, 2024   •   25:33 The Protesters and the President
• May 2, 2024   •   29:13 Biden Loosens Up on Weed
• May 1, 2024   •   35:16 The New Abortion Fight Before the Supreme Court
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Hosted by Michael Barbaro

Featuring Michael Crowley

Produced by Nina Feldman ,  Clare Toeniskoetter and Rikki Novetsky

Edited by Liz O. Baylen

Original music by Marion Lozano ,  Elisheba Ittoop and Dan Powell

Engineered by Alyssa Moxley

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

If and when Israel and Hamas reach a deal for a cease-fire, the United States will immediately turn to a different set of negotiations over a grand diplomatic bargain that it believes could rebuild Gaza and remake the Middle East.

Michael Crowley, who covers the State Department and U.S. foreign policy for The Times, explains why those involved in this plan believe they have so little time left to get it done.

On today’s episode

Michael Crowley , a reporter covering the State Department and U.S. foreign policy for The New York Times.

Background reading :

Talks on a cease-fire in the Gaza war are once again at an uncertain stage .

Here’s how the push for a deal between Israel and Saudi Arabia looked before Oct. 7 .

From early in the war, President Biden has said that a lasting resolution requires a “real” Palestinian state .

Here’s what Israeli officials are discussing about postwar Gaza.

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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.

Michael Crowley covers the State Department and U.S. foreign policy for The Times. He has reported from nearly three dozen countries and often travels with the secretary of state. More about Michael Crowley

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