ARCHIVED - Addressing Wait Times with Information Technology

Report 2

Submitted To: Dr. Brian Postl
Submitted By: Canada Health Infoway
Date: March 21, 2006

Executive Summary

Timely access to care is critical to optimizing health, health outcomes, and improving patient satisfaction. With increasing wait times for many health care services, monitoring and management of wait times has become a focus for governments in Canada and internationally.

Wait time initiatives in Canada have varied from the web-based reporting of wait times in selected surgical and diagnostic procedures to more focused investments in increasing capacity and redesigning system processes. Information and communication technologies have demonstrated value in many of the efforts to date and will increasingly become crucial to supporting clinicians providing timely and equitable access to quality health care for Canadians.

This document frames the wait time issue in terms of a patient's journey through the health care system. The use of information and communication technologies will result in the following benefits:

Access

  • Support timely delivery of care - solutions to improve referral and scheduling processes and overall case management will help providers decrease the overall time between identification of need and treatment.
  • Support equitable distribution of care - solutions for prioritization of resource usage will help ensure that care is delivered appropriately on the basis of need.

Quality

  • Improve appropriateness of care - standardized assessment and wait time prioritization will help providers ensure that the wait time is appropriate for the patient.
  • Improve effectiveness of care - more timely access to physicians, specialists, diagnostic tests, surgical procedures, as well as after care services will provide for improved health outcome and reduced pressure on the system.

Productivity

  • Improve provider productivity - information technology will impact provider productivity in many ways, from ease of access to information to improved efficiencies (e.g. reduced call backs, reduced duplicate tests).
  • More efficient resource use - solutions for scheduling will help managers optimize the use of scarce human and physical resources.
  • Improve coordination of care - case management will allow a virtual team of providers to more easily coordinate the successful completion of a patient's treatment plan.

In order to capitalize on these benefits there is need to leverage and integrate information and communication technologies for wait time management with the pan-Canadian electronic health record infostructure currently being implemented across the country.

The additional information and communication technologies envisioned to better manage wait times will require investment in referral management, scheduling, case management and wait time monitoring and reporting systems as well as additional investment in location registry, physician electronic medical records and patient portal technologies. The pan-Canadian costs for wait time related information and communication technologies are estimated at approximately $400 million, and the physician electronic medical record and patient portal costs are estimated at approximately an additional $2.0 billion.

Table of Contents

1 Introduction

1.1 The Challenge of Health Care Renewal

Over recent years, a broad consensus has emerged on the priorities for health care renewal in Canada. Building on seminal reports produced by the Honourable Roy Romanow, Senator Kirby, Messrs. Mazankowski, Clair and Fyke, the First Ministers' have identified key areas for improvement, including primary health care, home care, public health, health human resources, patient safety, pharmaceuticals, innovation, aboriginal health, accountability, as well as access and wait times. The 2004 Ten Year Plan to Strengthen Health Care further identified access to timely care across Canada as the biggest concern and a national priority.

Wait times in Canada are a symptom of the underlying challenges faced by the health care system as it strives to meet the increasing service demands of an aging population. The Ten Year Plan provides the national foundation for wait time improvement, while the recommendations from Romanow, the Health Council of Canada and others, set a stage for action that is directed at

  • information and systems to better understand and manage wait times
  • fair and effective distribution of resources to serve those waiting
  • appropriate and effective use of health human resources
  • coordination of the patient journey among many different clinicians and care settings

Access to accurate and complete health information to support clinical practice and patient management is fundamental to the success of health care renewal.

"Many of the health care reforms committed to by the First Ministers depend upon rapid transmission of accurate patient information among health care providers working in different locations...Accurate patient information electronically transmitted in a timely fashion is a cornerstone of the future integrated system. Efforts to 'wire' the country need to be aggressively supported so that primary care providers can do their jobs. "

Figure 1 - The integrating role of information and communication technologies in health care renewal

Figure 1 - The integrating role of information and communication technologies in health care renewal

Health Council of Canada, Health Care Renewal in Canada: Accelerating Change, January 2005

All governments across Canada are making significant investments in creating a pan-Canadian health infostructure. This investment needs to be further leveraged to support and integrate all health care renewal activities, including the effective management of wait times. Failure to do so will result in a series of "silo" initiatives that will not provide full value that patients, clinicians and health care managers' desire.

1.2 Managing Wait Times is Very Complex

Managing health and providing healthcare services can be viewed from the perspective of 3 key actors - the patient, healthcare providers (e.g. physicians) and healthcare managers (e.g. policy makers, administrators). Figure 2 depicts, at a summary level, the primary business processes for each actor, specifically:

  • the patient - the processes to manage one's health
  • the healthcare provider - the processes to provide healthcare services to patients
  • the healthcare manager - the processes necessary to manage the healthcare delivery system

Wait times involves all three actors and are impacted by all their business processes. As a result, the management of wait times is very complex. It requires information and communication technologies that can effectively bridge patients, healthcare providers and healthcare managers so they can make informed decisions about accessing care, providing healthcare services and managing wait times. Information technology alone will not solve the problem of wait times. Redesign of healthcare provider business processes will be required. Information technology solutions will need to enable and support these new processes.

Figure 2 - Business context for wait time management

Figure 2 - Business context for wait time management

2 The Patient Journey and Wait Time Improvement Opportunities

2.1 A Hip Replacement Scenario

To understand the complexity of wait times in detail requires an understanding of the patient journey through the Canadian healthcare system today. In this regard, a patient scenario has been developed for a fictitious patient, named Betty Smith. Betty is a 70 year old woman requiring a hip replacement who, 78 weeks after presenting with hip pain, receives the treatment she needs.

Betty's care is in the hands of many healthcare providers. The timing of her services is dependant upon a complex set of resource availabilities and priorities, managed by a diverse set of actors. Information is the common currency of all of these transactions, and Betty's case helps to illustrate the role that information and communications technologies can potentially play in improving wait times.

As the Canadian health care system has evolved "a number of concerns emerged, including: The disjointed way the various parts of the health care system worked with each other, often leaving patients to move between different providers and institutions."

Health Council of Canada, Health Care Renewal in Canada: Accelerating Change, January 2005

Figure 3 - The Health Council of Canada's Patient Journey

Figure 3 - The Health Council of Canada's Patient Journey

 

The Betty Smith scenario is based on an analysis completed by the Health Council of Canada in its document Health Care Renewal in Canada: Accelerating Change, January 2005 which has identified 16 places where waiting occurs - see figure 3. In some cases waiting may be appropriate; in others, it may be unwarranted and possibly detrimental.

In addition, included in Appendix A, is the detailed patient journey scenario for Betty Smith and the associated flow diagrams detailing the journey and the opportunities where wait times can be improved.

The opportunities identified through the analysis of the patient journey are described as a set of tools for patients, providers and managers. Each of the 10 tools has process and workflow implications and potential impacts on wait times.

2.2 Standardized Assessment Tools

Physicians use a standardized assessment tool to determine the patient's need and relative priority level for referral and surgery. The assessment tool will have clinical decision support capabilities to assist the physician in planning treatment. The assessment will be integrated with the electronic health record and wait list management systems, allowing providers across the continuum of care to review and update the assessment to reflect changes in a patient's condition over time.

  • Anticipated Improvement: Physicians can choose the most appropriate therapeutic strategy for the patient at that time. Specialists avoid inappropriate referrals. Patients who are most in need of care can be granted faster access to specialist, diagnostic and surgical services.

2.3 Order Entry and Results Reporting Tools

Physicians are able to order diagnostic tests electronically using computerized order entry and view the results through the electronic health record. Radiologists use the electronic health record to remotely review and report results.

  • Anticipated Improvement: Physicians order diagnostic tests quickly and legibly. Physicians make clinical management decisions more quickly since the image is available to the radiologist immediately and the subsequent report can be accessed from the electronic health record as soon as it is posted.

2.4 Advanced Scheduling Tools

Patients' appointments with family practitioners, specialists, and specialty services are scheduled through an electronic scheduling application. Advanced scheduling features will help find the most appropriate appointment, enable complex scheduling tasks such as sequenced or clustered appointments, schedule resources across organizations and include no-show functionality, such as reminders. Centrally coordinated scheduling could also be enabled if required to fit jurisdictional plans to rationalize resource use across a jurisdiction.

  • Anticipated Improvement: Patients receive more timely and appropriate appointments and multiple appointments are more streamlined. Patient schedules are transparent, improving satisfaction. Providers avoid empty slots, as patients are reminded of appointments and those who habitually miss appointments are identified. Health care managers are able to effectively spread demand across available resources and reduce overall wait times. Patients move more quickly to post-operative services, rehabilitation and home care, freeing acute care capacity

2.5 Electronic Referral Tools

Physicians create referrals using an electronic referral template, which contains a minimum data set of key information about the patient needed for referral. The referral is transmitted electronically, either to a referral service function, or to the specialist directly. The specialist uses an electronic referral response, allowing him or her to accept, decline it or revise the referral.

  • Anticipated Improvement: The specialist saves time, by receiving legible, specified information necessary to both triage the patient and assist the specialist during the consultation. The physician and patient receive feedback quickly about the case; and can either prepare for the specialist visit or use the feedback in continuing to manage the patient's condition.

2.6 Case Management Tools

All providers involved in a patient's case can develop, review and coordinate his or her treatment plan and the related scheduled events. Case management tools will assist providers in streamlining tasks across an episode of care, and will support the development of treatment plans which make the most effective use of high demand provider time. . A case also holds key documents related to a treatment plan.

  • Anticipated Improvement: Providers save time by easily monitoring cases, and by having effective use made of their services. Patients' treatment plans are more streamlined and available to all relevant clinicians, reducing the overall wait time while improving the efficiency of healthcare delivery. Cases may be prioritized for access to high demand services.

2.7 Provider Electronic Health Record Tools

Providers across the continuum of care can access relevant healthcare information. Assessment results, diagnostic test results, medication profile, medical history and other clinical information are available to clinicians, as appropriate.

  • Anticipated Improvement: Providers can easily access a complete and current history on the patient. Providers save time searching for information. Physicians avoid duplicating diagnostic tests, which also avoid delays in treatment.

2.8 Patient Electronic Health Record Tools

Patients can access all details regarding their health record and their care, including medical history and scheduled events. Patients also have access to resources to self-manage including disease information, support services and information about wait times in their jurisdiction.

  • Anticipated Improvement: Patients' treatment plans are transparent and they are well informed and supported, so they can actively participate and are better positioned to deal with wait times. Patients also have access to resources to self-manage including disease information, support services and information about wait times in their jurisdiction.

2.9 Wait Time Monitoring and Reporting Tools

Waiting times at a procedure, surgeon and individual level (from primary care through rehabilitation) are available and reported as appropriate. The waiting list can be reviewed and physicians are automatically alerted to inappropriate wait times or cases in need of re-assessment.

  • Anticipated Improvement: Patient's whose wait will be too long are identified and can be addressed. Physicians and health care managers have the information they need to plan and manage the system. Patients have more information about waits, and are better equipped to self-manage.

3 The Information Technology Solution

The opportunities for improving the patient journey by reducing wait times and ultimately supporting healthcare renewal can only be realized by implementing a broad vision for a pan-Canadian health infostructure. All jurisdictions, supported by Canada Health Infoway investments are making significant progress in this regard by laying the technology foundation to successfully deploy the tools necessary to improve wait times.

Figure 4 - Wait Time Solution Architecture

Figure 4 - Wait Time Solution Architecture

The wait time information and communications technology architecture is simply an extension of the pan-Canadian electronic health record infostructure being deployed across Canada today and consists of:

Registries Data and Services - client, provider, location and terminology registries.

EHR Data and Services - diagnostic imaging, laboratory, drug, hospital, communicable disease and immunization data.

Health Information Data Warehouse - for retrospective analyses and reporting.

Wait Time Data and Services - referral management, scheduling, case management, wait time monitoring and reporting.

HIAL and Longitudinal Record Services - communications network, common services like consent and security and longitudinal record services to support the sharing of records across the continuum of care.

Point of Service Applications - the software used by healthcare providers, including information systems in hospitals, diagnostic centres, laboratories, pharmacies, specialist's clinics and physician offices. This would include point of service applications specific to wait time management, such as case management and scheduling.

EHR Viewers - the software that easily allows clinicians to view the electronic health record if they have no means to do so - typically via a provider portal. EHR viewers are also available as a portal for the patient to view their electronic health record.

By leveraging the pan-Canadian electronic health record infostructure all jurisdictions across Canada will be able to significantly lower the total cost of ownership of adding wait time management data and services.

When viewed at the next level of detail (see figure 5) the wait time solution architecture starts to reveal the technical complexities associated with managing wait times and the interfaces with electronic medical records for all providers which support primary care reform, drugs and patient safety, public health surveillance, and to date some limited wait time management.

For a provider, patient or healthcare manager to utilize any one of the proposed tools for improving wait times, data will need to be sourced from multiple repositories in the registries services, the electronic health record services, as well as the wait time management services. That data will then be transported through a common network to point of service applications that will be used by the provider (e.g. a physician office electronic medical record), a patient (e.g. a patient portal) and a healthcare manager (e.g. wait time monitoring and reporting).

Figure 5 - Electronic health record infostructure with wait time management

Figure 5 - Electronic health record infostructure with wait time management

4 The Implementation Strategy

Deploying interoperable wait time management solutions as part of a pan-Canadian electronic health record infostructure has to be based on a common technology architecture. That architecture exists today as the Infoway EHRS Blueprint and has been adopted by every jurisdiction across Canada.

4.1 Implementation Staging

The implementation of a pan-Canadian interoperable wait time management solution can be achieved in five steps

Step 1: Requirements Definition - all jurisdictions working collaboratively to create a common set of functional and technical requirements for the wait time management solution. This will take 6 months.

Step 2: Standards Definition - develop the national interoperability standards for wait time management. It is anticipated that these standards will be based on the HL7v3 messaging format leveraging work already completed by the National Health Service in England. This will take 6-9 months.

Step 3: National Reference Solution - develop a reference solution that can meet the functional requirements of all stakeholders and support the interoperability requirements with the pan-Canadian electronic health record infostructure. The reference solution will likely consist of a mixture of commercially available solutions (e.g., case management, referral management, scheduling, electronic medical records) and some custom components (e.g. implementation of wait time management and reporting), all integrated into a complete system.

Step 4: Jurisdiction Planning and Implementation - the national reference solution provides a "menu" of components that can be used, as needed, by each jurisdiction. Each province will establish their priorities and select the best approach to implementing the national reference solution, in whole or in part. In this way, legacy systems in a jurisdiction can still be fully leveraged when there is no requirement to have them replaced.

Given the size and complexity of the wait time management it is likely the reference solution will be implemented in an iterative approach over 2-3 years.

  • Prototype demonstrations (<6 months):
    Demonstrate working prototypes, leveraging existing initiatives that can show in part the improvements in wait times that are possible through the use of information and communication technologies

  • First iteration (12-18 months):
    1. Location Registry
    2. Case Management - core functions
    3. Physician EMR - limited initial rollout
    4. Wait Time Reporting
    5. Integration of physician EMR, case management, wait time reporting, location registry and the electronic health record

  • Second iteration (18-24 months):
    1. Case Management - enhanced set of functions
    2. Referral Management - initial set of functions
    3. Physician EMR - accelerated rollout
    4. Integration of referral management with case management, physician EMR, wait time reporting, location registry and the electronic health record

  • Third iteration ( >24 months):
    1. Referral Management - complete set of functions
    2. Centralized Scheduling - complete rollout
    3. Physician EMR - complete rollout
    4. Patient Portal - complete rollout
    5. Integration of centralized scheduling and patient portal with referral management, case management, physician EMR, wait time reporting, location registry and the electronic health record

Step 5: Evaluation - after 2-3 years in production the wait time management system needs to be evaluated in terms of the results (i.e. and the benefits (i.e. implementation, integration, interoperability, utilization and sustainability) and the benefits (i.e. the measured impact on access, quality and productivity).

4.2 Other Implementation Considerations

Achieving the desired impacts and benefits will require a number of implementation initiatives beyond the procurement and installation of the technology solution. For example, the end-users - providers, patients and managers - must adopt the solution and use it effectively. This will require a significant change management program be put in place.

The following additional initiatives will support jurisdictions with successful implementation.

Collaborative Leadership

The implementation of a pan-Canadian wait time management system will require strong collaborative leadership from all jurisdictions within a national forum. There is an opportunity to implement a single integrated bilingual wait time management system (i.e. there may be many instances of the single solution) across Canada. The initiative requires participation from a diverse mix of actors - family physicians, specialists, administrators, patients, as well as information technology professionals - for it to be successful. Each jurisdiction has a senior governance group for jurisdiction-wide information systems and it is anticipated that these groups would continue to provide leadership within the province or territory.

Process Redesign

The proposed systems will need to accommodate process flexibility. For example jurisdictions will use a combination of referral processes - referral to a provider and/or referral to a service. Some of the long-term objectives may require complete process redesign. These present an opportunity for tailoring information systems not just to wait time management but also to support improved healthcare delivery and national initiatives like primary care reform.

Physician Engagement

This solution must provide physicians, as well as other providers and their support staff with tools that meet their needs. Changing referral and scheduling processes may involve a significant change in business practice. The information technology solution must be tailored to these new business practices. Full physician leadership and engagement throughout these steps is critical if the initiative is to be successful.

Physician Office Systems

To enable the full range of wait time management services to be implemented requires that physician offices have local electronic medical record systems. These systems will be integrated into the electronic health record infostructure and are certainly a key component to improving the referral management, case management processes and scheduling processes. Where physicians do not have an electronic medical record system, or where the electronic medical record system cannot send/receive standard messages to/from the electronic health record infostructure then a physician has the option to use an Electronic Health Record Viewer. This will provide the physician with the ability to retrieve a patient's electronic health record for viewing only. Some vendors have extended their Electronic Health Record Viewer products to carry out basic case management and referral management

Hospital and Diagnostic Clinic Information Systems

To integration of Hospital Information Systems (e.g. tertiary, community and Children's' hospitals) in acute care facilities and diagnostic clinics (e.g. DI clinics) is also a fundamental requirement for a wait time management strategy to be successful. At a minimum this includes integration with registration systems (e.g. hospital ADT systems) to the jurisdiction client registry and the integration of enterprise scheduling systems with hospital and clinic scheduling systems (e.g. OR booking systems). All are complex undertakings.

Change Management

Change management is a proactive, systematic process to achieving defined outcomes. To maximize "value", the change process needs to be effectively designed, planned, managed and sustained to ensure a solution is effectively used by relevant providers, patients and mangers alike. It is a best practice to rollout new processes, business practices and systems concurrently.

Privacy and Security

Health information privacy is an important issue in wait time management - it involves identifiable health information. The electronic health infostructure, including the privacy and security components of it have been defined in detail and it supports the health information privacy legislation in place across Canada (e.g. different rules for managing consent). The wait time management solution would leverage this infostructure, rather than building it from scratch.

Policy / Legislation

This wait time management solution, and the initiatives which it supports (wait time reduction, primary care reform and healthcare renewal in general) may require policy and/or legislation changes.

Electronic Health Record Infostructure

The wait time management solution needs to leverage the electronic health record infostructure that is being implemented in every jurisdiction. To re-create this infostructure, in whole or in part, would not be a duplicate investment. Jurisdictions are at different stages in the implementation of this infostructure, and either have it already in place today or will have it available in the next 3 years. The development of the wait time management system can occur in parallel with the implementation of the electronic health record infostructure.

4.3 Costs

The pan-Canadian costs for a wait time management system are estimated at $401 million. The more significant costs are for the physician electronic medical record and the patient portal, together estimated at $2.014 billion.

The pan-Canadian costs for a wait time management system

The following assumptions were used in costing:

  • An electronic health record Infostructure is in operation in all jurisdictions and are not included in the costs
  • Hospitals are connected to at least one electronic health record service
  • Implemented technology will leverage current wait time management solutions
  • Hospital information systems, operating room and clinic scheduling systems are not included in the costs
  • Upgrades to existing hospital information systems are not included in the costs

The costing methodology combines hardware and software cost estimates from project budgets and vendor input, with industry-standard cost ratios for integration, implementation, standards and change management.

5 Benefits from a Wait Time Management Solution

Information systems in support of wait time initiatives and broader healthcare renewal objectives are a critical tool for achieving a measurable reduction in wait times. Specific benefits include:

5.1 Access

  • Support timely delivery of care - solutions to improve referral and scheduling processes and overall case management will help providers decrease the overall time between identification of need and treatment.
  • Support equitable distribution of care - solutions for prioritization of resource usage will help ensure that care is delivered appropriately on the basis of need.

5.2 Quality

  • Improve appropriateness of care - standardized assessment and wait time prioritization will help providers ensure that the wait time is appropriate for the patient.
  • Improve effectiveness of care - more timely access to physicians, specialists, diagnostic tests, surgical procedures, as well as after care services will provide for improved health outcome and reduced pressure on the system.

5.3 Productivity

  • Improve provider productivity - information technology will impact provider productivity in many ways, from ease of access to information to improved efficiencies (e.g. reduced call backs, reduced duplicate tests).
  • More efficient resource use - solutions for scheduling will help managers optimize the use of scarce human and physical resources.
  • Improve coordination of care - case management will allow a virtual team of providers to more easily coordinate the successful completion of a patient's treatment plan.

Appendix A - Patient Journey Scenario

Patient Scenario

  1. Betty Smith is a 70 year old woman. She lives with her husband, John, in a rural town about 2 hours from the nearest city. Betty was diagnosed with type II diabetes and hypertension about 5 years ago and has been managed by her family physician, Dr. Leblanc. Betty's husband John, 75, had a stroke last year and she has become the primary care giver for him. In her spare time, Betty likes to bake, bowl and play bingo.
  2. Betty has noticed increasing pain in her left hip. She has had the pain off and on for at least a year, but it has become worse over the last three months. It has reached the point where she is having difficulty bowling and looking after John. She has been taking acetaminophen, but this has had little effect. Betty decides that it is time to get in to see Dr. Leblanc. She calls his office to make an appointment and is scheduled for three weeks later. Betty keeps her appointment with Dr. Leblanc. He takes a history and does a physical examination and determines that she likely has osteoarthritis in the hip.
  3. Dr. Leblanc prescribes a non-steroidal anti-inflammatory medication and orders an x-ray. Betty presents for her x-ray at the local community hospital later that day. Dr. Leblanc receives the x-ray report three days later. The radiologist noted advanced arthritic changes in the hip joint but also queried a stress fracture.
  4. Dr. Leblanc chooses to order a CT scan to determine if a stress fracture is present. He calls Betty to inform her of the finding and the upcoming CT scan and has his receptionist book the scan. Betty is notified of her appointment date by the Diagnostic Imaging department of the nearest city's hospital. The CT scan will be done in four weeks. Betty has her CT scan on the appointed date. The radiologist reviews the images and generates her report. That day, Betty books an appointment to follow up with Dr. Leblanc in five days.
  5. Betty returns to see Dr. Leblanc. He informs her that there is no stress fracture, but there are advanced arthritic changes in the left hip joint. He counsels her about osteoarthritis and they discuss her treatment options. Betty wants to try the medication and work harder on losing some weight. Over the next three months Betty notices a progression of her pain. She has been unable to lose any weight and the anti-inflammatory medication upset her stomach. She is now losing sleep because of pain, has had to stop bowling and is struggling to help John with his daily care. She calls for an appointment with Dr. Leblanc and is booked in for one week later.
  6. Dr. Leblanc and Betty discuss her symptoms and they decide to refer her to an orthopedic surgeon to consider joint replacement surgery. Dr. Leblanc prepares a referral letter to Dr. Os, which is faxed later that day. Two months later Betty receives a call from Dr. Os' office informing her that her appointment will be in three months.
  7. Betty sees Dr. Os at the scheduled time at the hospital outpatient clinic. He reviews her history and does a physical examination. He chooses to repeat her x-rays and reviews the films. Dr. Os discusses surgical treatments with Betty and they decide to proceed with total hip replacement. Dr. Os has his nurse book the procedure with the Operating Room booking office. The procedure is not booked immediately; Betty will wait two months to receive a procedure date an additional seven months away. Because of Betty's diabetes, Dr. Os also refers her to the diabetes clinic for a pre-operative assessment.
  8. Four weeks later Betty attends the diabetes clinic. She is assessed by an internist, a dietician and a diabetes teaching nurse. A number of lab investigations, including fasting blood sugar, HbA1C and an EKG are ordered and Betty is to return in two weeks. Betty returns to the diabetes clinic in two weeks. The internist reviews her lab results and her home glucose testing values. She makes some minor changes to the doses of the medications and arranges to follow Betty while she is in hospital. Betty returns periodically for follow-up.
  9. About six months later Betty receives a call from the hospital asking her to come to the Pre-Admission Clinic for her pre-operative assessment. The anaesthetist reviews Betty's history along with the information from the Diabetes clinic. Betty goes for her Hip surgery on the appointed date. The procedure goes very well and she progresses through her rehabilitation in hospital. Prior to her discharge the rehabilitation team decides Betty will require home care and orders it for her.

Appendix B - Patient Journey Flowchart

Appendix B - Improving the Journey: Week 1 to Week 8

Appendix B Continued

Appendix B Continued - Improving the Journey: Week 9 to Week 30

Appendix B Continued

Appendix B Continued - Improving the Journey: Week 42 to Week 80
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