hospital visit meaning

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Dos and Don'ts for Visiting Patients in the Hospital

JGI / Tom Grill / Getty Images

It might surprise you to know that hospital visitors can be safety hazards who potentially introduce problems to the patients they hope to cheer or assist. The problems may be directly related to physical harm, or may even be mental or emotional.

It can be difficult to visit a patient in the hospital, but you can have a positive influence on your friend or loved one's recovery if you follow some simple visitor guidelines. Knowing the dos and don'ts may give you the confidence you need.

Ask for permission to visit

Wash your hands

Consider allergies and restrictions on decorations and gifts

Turn off cell phone

Keep visit short

Leave if doctor or provider arrive

Visit if you might be contagious

Bring young children

Bring food without checking on restrictions

Cause stress

Avoid visiting

Smoke before or during visit

Dos for Hospital Visitors

Do ask the patient's permission to visit before you arrive . Ask them to be candid with you, and if they prefer you not visit, ask them if another day would be better, or if they would prefer you visit once they get home. Many patients love visitors, but some just don't feel up to it. Do the patient the courtesy of asking permission.

Do wash or sanitize your hands . Do this before you touch the patient or hand the patient something. After touching any item in the room, wash or sanitize your hands again. Infections come from almost any source and the pathogens can survive on surfaces for days. Don't risk being responsible for making your favorite patient even sicker than they already are.

Do wear a mask . Regardless of current hospital rules, wearing a face mask can help protect both the patient and visitor from airborne viruses. If you do not have a mask, the hospital should be able to provide you with one.

Do check before bringing balloons or flowers . If your patient shares a hospital room, you won't want to take either, because you don't know if the roommate has an allergy. Most solid color balloons are latex rubber, and some people are allergic to latex . When in doubt, take mylar balloons or don't take any at all.

Do consider alternative gifts . A card, something a child has made for you to give to the patient, a book to read, a crossword puzzle book, even a new nightgown or pair of slippers are good choices. The idea isn't to spend much money; instead, it's about making the patient feel cared for without creating problems that might trigger an allergic reaction.

Do turn off or silence your cell phone . Different hospitals have different rules about where and when cell phones can be used. In some cases, they may interfere with patient-care devices, so your patient can be at risk if you don't follow the rules. In other cases, it's simply a consideration for those who are trying to sleep and heal and don't want to be annoyed by ringtones.

Do stay for a short time . It's the fact that you have taken the time to visit, and not the length of time you stay, that gives your patient the boost. Staying too long may tire them out. Better to visit more frequently but for no more than a half hour or so each time.

Do leave the room if the doctor or provider arrives to examine or talk to the patient . The conversation or treatment they provide is private, and unless you are a proxy, parent, spouse, or someone else who is an official advocate for the patient, that conversation is not your business. You can return once the provider leaves.

Do follow all hospital policies and staff instructions . Most hospitals have set visiting hours, limits on the number of visitors in the room, and other rules you are expected to follow. Check the hospital's visiting hours and other policies prior to visiting.

Don'ts for Hospital Visitors

Don't enter the hospital if you have any symptoms that could be contagious . Neither the patient nor other hospital workers can afford to catch whatever you have. If you have symptoms like a cough, runny nose, rash or even diarrhea, don't visit. Make a phone call or send a card instead.

During flu season , it is not uncommon for hospitals to restrict visitors to spouses, significant others, family members over 18, and pastors, so it is worthwhile to call the hospital before your visit.

Don't take young children to visit unless it's absolutely necessary . Check with the hospital before you take a child with you. Many hospitals have restrictions on when children may visit.

Don't take food to your patient unless you know they can tolerate it . Many patients are put on special diets while in the hospital. This is especially true for those with certain diseases or even those who have recently had anesthesia for surgery. Your goodies could cause big problems.

Don't visit if your presence will cause stress or anxiety . If there is a problem in the relationship, wait until after the patient is well enough to go home before you potentially stress them by trying to mend that relationship.

Don't expect the patient to entertain you . They are there to heal, not to talk or keep you occupied. It may be better for them to sleep or just rest rather than carry on a conversation. If you ask them before you visit, gauge their tone of voice as well as the words they use. They may try to be polite, but may prefer solitude at this time instead of a visit.

Don't stay home because you assume your friend or loved one prefers you not visit . You won't know until you ask, and your friend or loved one will appreciate the fact that you are trying to help by asking the question.

Don't smoke before visiting or during a visit, even if you excuse yourself to go outdoors . The odor from smoke is nauseating to many people, and some patients have a heightened sense of smell while taking certain drugs or in the sterile hospital environment. At most, it will cause them to feel sicker, and if your friend is a smoker, you may cause them to crave a cigarette.

Johns Hopkins Medicine. Patient safety and quality .

By Trisha Torrey  Trisha Torrey is a patient empowerment and advocacy consultant. She has written several books about patient advocacy and how to best navigate the healthcare system. 

Being Admitted to the Hospital

• Registration |
• What to Bring to the Hospital |
• After Admission |

Hospitals provide extensive resources and expertise that enable doctors to rapidly diagnose and treat a wide range of diseases.

However, a hospital can be a frightening and confusing place. Often, care occurs quickly and without explanation. Knowing what to expect can help people cope and actively participate in their care during their stay. Understanding more about what hospitals do and why they do it can help people feel less intimidated by their hospital experience, more in control, and more confident about their health when they are discharged.

People are admitted to a hospital when they have a serious or life-threatening problem (such as a heart attack). They also may be admitted for less serious disorders that cannot be adequately treated in another place (such as at home or in an outpatient surgery center). A doctor—the primary care doctor, a specialist, or an emergency department doctor—determines whether people have a medical problem serious enough to warrant admission to the hospital.

The main goal of hospitalization is

To restore or improve health so that people can be safely discharged

Thus, hospital stays are intended to be relatively short and to enable people to be safely discharged to home or to another health care setting where treatment can be completed.

For many people, hospital admission begins with a visit to the emergency department. Knowing when and how to go to an emergency department is important. When people do go to the emergency department, they should bring their medical information .

Children may require a parent or other caregiver to stay at the hospital most of the time.

Registration for Hospital Admission

The first step in admission is registration. Sometimes registration can be done before arriving at the hospital. Registration involves filling out forms that provide the following:

Basic information (such as name and address)

Health insurance information

Telephone numbers of family members or friends to contact in case of an emergency

Consent to be treated

Consent to release information to insurance companies

Agreement to pay the charges

People are given an identification bracelet to be worn on the wrist. They should check to make sure the information on it is correct and should wear it at all times. That way, when tests or procedures are done, staff members can make sure that they have the right person. In many hospitals, the identification bracelet has a unique, personal barcode that health care providers scan prior to giving medications or other treatments or doing tests to ensure the proper care is given to the right person at the right time.

In the United States, a federal law called the Health Insurance Portability and Accountability Act (HIPAA) applies to most health care institutions and clinicians. The act sets detailed rules regarding privacy, access to information, and disclosure of individually identifiable health information, referred to as protected health information.

What to Bring to the Hospital

Whether people are admitted to the hospital through the emergency department or by their doctor, they should bring their medical information.

The most important things people should bring are

A list of all medications they are taking and the doses of the medications (the list should include over-the-counter medications, prescription medications, and dietary supplements, such as vitamins, minerals, and medicinal herbs)

A list of any medication allergies

Any written instructions from their doctor

If people do not have this information or they are too ill to communicate, family members or friends should provide it if possible, and they should bring all bottles of medications they can find at home so that the hospital staff can make a list of those medications for the medical record.

People should also bring a copy of their most recent medical summary and records of recent hospital stays. However, many people do not have these records. In such cases, the hospital staff typically obtains the information from the primary care doctor, the hospital records department, or both.

Hospitals recommend that people also bring advance directives and any legal forms that indicate who can make medical decisions for them in case they cannot make decisions for themselves ( durable power of attorney for health care ).

People should give all of this information to the nurse responsible for getting them settled into a hospital room.

Personal items

People should also bring the following:

Toiletries, including a razor if used at home

Eyeglasses, hearing aids, and dentures (if they are used at home)

A CPAP (continuous positive airway pressure) machine to help with breathing (if they use one)

A few personal items, such as photographs of loved ones, to make them feel more comfortable, and, if they wish, something to read

Cell phone and cell phone charger

If a child is being hospitalized, parents should bring a comforting object, such as a favorite blanket or stuffed toy.

Because items often get lost in the hospital (especially when changing rooms), all personal items should be marked or labeled. Valuables (such as a wedding ring or other jewelry, credit cards, and large sums of money) should not be brought to the hospital.

Current prescription medications

Many people bring their own medications to the hospital so that they can use their own supply. However, to ensure patients are receiving the correct type and dose of medication, people are instead given the same or similar medications from the hospital's supply. If people bring medications to the hospital for the doctor or staff to review, the medications are usually returned home by a family member or friend after the medications are recorded in the medical record.

Therefore, in general, prescription medications should be left at home. Exceptions are expensive, unusual, or hard-to-obtain medications. These medications should be brought because the hospital may not be able to provide equivalent medications immediately. Such medications include rare chemotherapy drugs and experimental medications. In these cases, the medication is given to the hospital pharmacist who inspects and verifies it before it is given. During the person's hospital stay, the medication is kept in a storage area, and the nurse gives each dose of the medication to the person.

After Admission

After admission, people may be taken for blood tests or x-rays or go immediately to a hospital room. Before performing any invasive test or providing medical treatment, doctors must obtain permission from the patient or an authorized surrogate decision maker by explaining the potential harms and benefits of the tests and/or treatments. The process is known as informed consent . 

Hospital rooms may be private (one bed) or semi-private (more than one bed). Even in a private room, privacy is limited as staff members frequently go in and out of the room, and although they usually knock, they may enter before people can respond.

Various tests, such as blood or urine tests, may be done to check for problems. Staff members may ask questions to determine whether people are likely to develop problems in the hospital or to need extra help after discharge from the hospital. People may be asked about eating habits, mood, vaccinations, and drugs taken. They may be asked a standard series of questions to evaluate mental function (see table Mental Status Testing ).

Intravenous (IV) lines

An IV line is placed in almost every person who is admitted the hospital. An IV line is a flexible tube (catheter) inserted into a vein, usually a vein in the crook of the arm. IV lines can be used to give people fluids, medications, and, if needed, nutrients.

If people stay in the hospital for more than a few days, the IV line may have to be moved to a different place in the arm to avoid irritating the vein.

Preferences for resuscitation

All people admitted to the hospital are asked if they have a living will that documents their preferences for resuscitation and what their preferences for resuscitation are, even when they are in the hospital for minor problems and are otherwise healthy. Therefore, people should not assume that this question means they are seriously ill.

Resuscitation measures include the following:

Cardiopulmonary resuscitation (CPR)

Electric shocks to the heart

Use of certain medications

Insertion of a breathing tube in the throat (intubation) and use of a machine to help with breathing ( mechanical ventilation )

Insertion of a feeding tube into the stomach to give nutrition

The decision about resuscitation measures is very personal and depends on many factors, including the person's health, life expectancy, goals, values, and religious and philosophical beliefs and on family members' thoughts. Ideally, people should decide on their own after discussing the issues with their family members, doctors, and others. They should not allow others to make this decision for them.

People may decide against resuscitation if they are older and feel they have lived a full life or if they have a serious disorder with a short life expectancy or a disorder that makes their quality of life poor. Doctors may suggest that people consider deciding against resuscitation measures if they have a terminal disorder or a disorder that makes returning to an acceptable quality of life unlikely after resuscitation. If people decide against resuscitation, doctors write do-not-resuscitate (DNR) or do-not-attempt-resuscitation (DNAR) orders on their chart.

The decision against resuscitation measures does not mean no treatment. For example, people who have a DNR or DNAR order are still treated for all disorders they have until their heart stops or until they stop breathing. Comfort care and treatment for pain are always provided and become a primary focus for health care professionals as people near the end of life.

Did You Know...

If people indicate that they do not know how to answer, doctors assume that they want all resuscitation measures.

People can change their decision about resuscitation measures at any time by telling their doctor. They do not have to explain why they changed their mind.

Ideally, resuscitation measures would restore the body's normal functions, and assistance with breathing and other support would no longer be needed. However, in contrast to what is typically portrayed in the media, these efforts have varying degrees of success, depending on the person's age and overall condition. These efforts tend to be more successful in younger, healthier people and are much less successful in older adults and in people with a serious disorder. However, there is no sure way to predict who will have a successful outcome after resuscitation and who will not.

In addition, resuscitation can cause problems. For example, rib fractures can result from chest compressions, and if the brain does not get enough oxygen for a while before people are resuscitated, they may have brain damage.

If people indicate that they do not want to be resuscitated (a DNR or DNAR order), a plastic bracelet is applied to their wrist and kept in place during the hospital stay to indicate their preference. Also, a doctor fills out a form called a portable medical order or Provider Orders for Life-Sustaining Treatment (POLST) to indicate that they do not want to be resuscitated. People are given this form for their records. Then, after discharge, those who have a serious illness can post this form prominently at home (for example, on the refrigerator) in case they are found at home unconscious by medics. Formal POLST and similar programs do not exist in every state or community, but their development is spreading rapidly.

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Outpatient visit

Measured differently in the following data systems:

American Hospital Association

Defines outpatient visits as visits for receipt of medical, dental, or other services at a hospital by patients who are not lodged in the hospital. Each appearance by an outpatient to each unit of the hospital is counted individually as an outpatient visit, including all clinic visits, referred visits, observation services, outpatient surgeries, and emergency department visits.

National Hospital Ambulatory Medical Care Survey

Defines an outpatient department visit as a direct personal exchange between a patient (not currently admitted to the hospital) and a physician or other health care provider working under the physician’s supervision for the purpose of seeking care and receiving personal health services.

(Also see Sources and Definitions, Emergency department or emergency room visit ; Outpatient department .)

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Inpatient vs. Outpatient: Comparing Two Types of Patient Care

More than ever, patients are engaged in their medical care, which is encouraging when you consider most medical school mission statements emphasize patient communication and education. It’s also worth noting that research shows providers are able to drive positive patient outcomes using a teach-back method that involves caring and clear language. Yet even well-informed individuals lack some knowledge, such as the distinction between inpatient versus outpatient care.

So what’s the difference, and why does it matter? This overview can help you advance your health literacy.

Inpatient vs. outpatient: Distinguishing the differences in care

What is an inpatient ? In the most basic sense, this term refers to someone admitted to the hospital to stay overnight, whether briefly or for an extended period of time. Physicians keep these patients at the hospital to monitor them more closely.

With this in mind, what is outpatient care? Also called  ambulatory care , this term defines any service or treatment that doesn’t require hospitalization. An annual exam with your primary care physician is an example of outpatient care, but so are emergent cases where the patient leaves the emergency department the same day they arrive. Any appointment at a clinic or specialty facility outside the hospital is considered outpatient care as well.

While there’s a clear difference between an inpatient and an outpatient, there is a little bit of gray area as well. Occasionally, physicians will assign a patient  observation status while they determine whether hospitalization is required. This period typically lasts for no more than 24 hours.

Also note that the location itself doesn’t define whether you’re an inpatient versus outpatient. It’s the duration of stay, not the type of establishment, that determines your status.

Inpatient vs. outpatient: Comparing services

You’re probably starting to get a sense of the varying circumstances that fit under each category. To further recognize the difference between inpatient and outpatient care, review the below treatments and services that are common for these two types of care.

Inpatient care examples

• Complex surgeries, as well as some routine ones
• Serious illnesses or medical issues that require substantial monitoring
• Childbirth, even in cases that don’t require a cesarean section
• Rehabilitation services for psychiatric illnesses, substance misuse, or severe injuries

Outpatient care examples

• X-rays, MRIs, CT scans, and other types of imaging
• Lab tests, such as bloodwork
• Minor surgeries, particularly ones that use less invasive techniques
• Colonoscopies
• Consultations or follow-ups with a specialist
• Routine physical exams
• Same-day emergent care, often treated at an urgent care facility versus the ER
• Chemotherapy or radiation treatment

Inpatient vs. outpatient: The providers in each setting

Primary care physicians  have traditionally been considered outpatient providers, while specialists are thought of as inpatient physicians. But that’s really an oversimplification, particularly when you consider that  hospitalists bridge the gap  by providing general medical care to inpatients. Effective care requires that doctors work together and effectively leverage health care technology , regardless of their specialties and settings.

Many physicians also divide their time between inpatient and outpatient services. OB/GYNs , for example, provide inpatient care when delivering babies and outpatient care when consulting with pregnant women during prenatal checkups.

Generally speaking, inpatients have contact with a larger group of providers. During a hospital stay, you could interact with physicians, nurse practitioners, lab technicians, physical therapists, pharmacists, and physician assistants.

Inpatient vs. outpatient: Cost considerations

The difference between inpatient versus outpatient care matters for patients because it will ultimately affect your eventual bill.

Outpatient care involves fees related to the doctor and any tests performed. Inpatient care also includes additional facility-based fees. The most recent cost data included in the Healthcare Cost and Utilization Project from the Agency for Healthcare Research and Quality (AHRQ) shows the average national inpatient charges can vary considerably depending on the length of stay and the treatment involved. The exact amount you pay also hinges on your insurance.

Things get a little more complicated  if you have Medicare . Outpatient care and physician-related services for inpatient care are covered by Part B. Hospital services like rooms, meals, and general nursing for inpatients are covered by Part A.

But if you stay overnight in the hospital under observation status, Medicare still considers you an outpatient and will not cover care in a skilled nursing facility. It can certainly be confusing, so don’t be afraid to ask the medical team about your status. They’re used to these types of questions.

Expand your medical knowledge

Hopefully, you now have a little more clarity concerning the definition of inpatient versus outpatient. It can go a long way towards helping you understand what you should expect during and after any sort of medical treatment.

You can further deepen your understanding of the health care world by reading our article “50 Must-Know Medical Terms, Abbreviations, and Acronyms .”

*This article was originally published in June 2019. It has since been updated to reflect information relevant to 2021.

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Exploring the hospital patient journey: What does the patient experience?

Raffaella gualandi.

1 Department of Nursing, Università Campus Bio-Medico di Roma, Rome, Italy

Cristina Masella

2 Department of Management Economics and Industrial Engineering, Politecnico di Milano, Milan, Italy

Daniela Viglione

Daniela tartaglini, associated data.

All relevant data are within the paper and its Supporting Information files.

To understand how different methodologies of qualitative research are able to capture patient experience of the hospital journey.

A qualitative study of orthopaedic patients admitted for hip and knee replacement surgery in a 250-bed university hospital was performed. Eight patients were shadowed from the time they entered the hospital to the time of transfer to rehabilitation. Four patients and sixteen professionals, including orthopaedists, head nurses, nurses and administrative staff, were interviewed.

Through analysis of the data collected four main themes emerged: the information gap; the covering patient-professionals relationship; the effectiveness of family closeness; and the micro-integration of hospital services. The three different standpoints (patient shadowing, health professionals’ interviews and patients’ interviews) allowed different issues to be captured in the various phases of the journey.

Conclusions

Hospitals can significantly improve the quality of the service provided by exploring and understanding the individual patient journey. When dealing with a key cross-functional business process, the time-space dynamics of the activities performed have to be considered. Further research in the academic field can explore practical, methodological and ethical challenges more deeply in capturing the whole patient journey experience by using multiple methods and integrated tools.

Introduction

In the healthcare knowledge-based system, literature has given increasing attention over time to improving clinical knowledge, including by making use of the patient's insider perspective [ 1 – 3 ]. In particular, patient experience of healthcare and the delivery of care is emerging as an important area of knowledge, but one that is sometimes overlooked [ 4 , 5 ].

The Beryl Institute defines patient experience as “the sum of all interactions, shaped by an organization’s culture, that influence patient perceptions, across the continuum of care”[ 6 ]. Wolf et al. specify that interactions are “The orchestrated touchpoints of people, processes, policies, communications, actions, and environment” and patient perceptions are “what is recognized, understood and remembered by patients and support people”[ 7 ].

In the last few years, emphasis on the emotional drivers of engagements has led many authors to enhance the customer experience starting from an analysis of the customer journey [ 8 ]. In the hospital context, the patient journey is a key cross-functional business process where patient and providers share action and information flows between people and systems across various touchpoints. Providers aim to manage hospital patient flow in order to provide safe and efficient patient care while ensuring the best use of hospital resources (i.e.: beds, operating theatres, clinics and specialized staff). Poor patient flow may result in decreasing levels of productivity, increasing risk of harming patients and decreasing levels of quality perceived by patients [ 9 – 11 ]. Patients aim to receive the best care together with a high quality of service. As a matter of fact, the patient is the only actor who experiences the whole path by connecting each step of the journey. Therefore, hospitals can significantly improve the quality of the service provided by exploring and understanding the individual patient journey [ 12 – 14 ].

Many tools may be used to measure and understand patient experience [ 15 , 16 ]. Surveys are the methods mainly used to capture the patient experience and to evaluate the quality and safety of various clinical processes [ 17 , 18 ]. However, questionnaires or traditional static observation may not be well-suited to reveal all the aspects of patient experience [ 19 ]. In the complex hospital environment, multiple factors can affect the patient experience, including the time-space dynamics of the activities performed and the patients’ perceptions and emotions lived at the time of the experience [ 20 ]. Moreover, some authors emphasize that what the patient remembers is different from what he/she experiences in real-time, depending on the length of the recall period [ 21 , 22 ]. Therefore, as what the patient remembers may change over time, gathering accurate and immediate data on the experience lived also depends on the time of the interview.

A recent study reports how the use of unstructured diaries completed in a patient’s own words can capture the hospital-stay experience from the patient’s own perspective. However, it is not clear how real-time experiences are reported in relation to high-emotional situations or clinical activities that can interfere with the patient’s ability and willingness to write (i.e. during the transfer to the operating theatre or in the post-operative period, immediately after surgery). Furthermore, the authors show how study participants with a tertiary education wrote more in their diaries than those without [ 23 ]. This could potentially eliminate important aspects of the experience lived by vulnerable people.

Some authors have emphasized the value of shadowing for phenomenological research, by giving a more complete picture of the phenomenon in the real-time context of an organization [ 24 , 25 ]. Patient shadowing may have an especially valuable role in gaining insights into complex cross-hospital processes, in particular when dealing with vulnerable people who could be excluded from interview studies [ 26 , 27 ]. Furthermore, some studies have reported how, through shadowing methodology, it is possible to assess the lived experience of patients in a patient-centred perspective [ 28 , 29 ]. However, methodological and ethical issues of shadowing still need to be explored in greater depth [ 25 , 30 ].

While on the one hand patient experience is increasingly considered as a driver for health services improvement, on the other it is still not clear how to capture the whole patient experience in traversing hospital services [ 31 – 33 ]. Therefore, this study seeks to explore which aspects of the hospital patient journey experience may be captured by the three different standpoints: patient shadowing, health professionals’ interviews and patients interviews. Accordingly, it aims to answer the following questions: what does the patient experience through the hospital journey? How can it be captured?

Materials and methods

Study design.

This study was a qualitative study with a phenomenological‐hermeneutic approach using participant interviews and patient shadowing [ 34 , 35 ]. The Consolidated Criteria for Reporting Qualitative Research—COREQ checklist was used as a guideline to report the study data [ 36 ]. The study was undertaken in a 250-bed Italian academic teaching hospital. Orthopaedic patients undergoing total hip (THA) or knee arthroplasty (TKA) were selected in order to analyse a standard clinical path ( Fig 1 ). Urgently admitted patients were excluded due to the different clinical path they have to follow. The unit of analysis was the hospital patient’s journey starting from the first outpatient visit and concluding with the first follow-up visit. The study was approved by the Hospital Ethics Committee.

Data collection

Between August 2016 and April 2017, a total of twelve patients and sixteen key professionals were invited to participate and all agreed. There were no prior relationships between researchers and patients; two researchers knew some healthcare professionals because they worked in the same hospital, though in different units and without patient care roles. The possibility of coercion was minimized by guaranteeing data anonymity, by requesting voluntary participation in the study and by dealing with issues on which the researchers had no power to influence anything or anyone at hospital managerial level.

A convenience sample of patients was selected based on whether their inpatient admission and follow-up visit fell within the observation period. Inclusion criteria were: patients scheduled to undergo surgery for THA or TKA, for the shadowing phase; patients who had had a THA or TKA ad were in follow-up, for the interviews. Exclusion criteria were: <18 years, inability to understand, not wanting to participate, inability to read/speak Italian. Patients were asked to participate in the study at the time they arrived in the hospital. The first author invited patients to participate in the study when they met at the hospital for preoperative tests or on the day of admission. Patients accepting the invitation were provided with further information about the project by the first author, and were asked to sign their consent to participate in the study and to the anonymous use of their data.

Eight patients admitted between August and September 2016 were selected for the shadowing phase. A shadowing methodology was used in order to provide an embodied understanding of patients’ experiences in context [ 26 ]. Two female students from the nursing and industrial engineering degree courses, with no roles in the delivery of patient care, were trained for data collection by the first author. In this way, the risk of not reporting negative feedback during the study by the participants, and subjective interpretations by the authors in capturing data, was minimized. Patients were shadowed from the time of hospital admission to the time of discharge, with the shadower observing the patient during daytime hours and completing a data collection form prepared by the research group. This involved recording every step of the hospital journey process, by analysing each touchpoint and including time, patient, caregiver, activity, shadower’s observations, and impressions. In particular, touchpoint observations indicated where patients and families go (setting), with whom they come into contact, how long the experience at each touchpoint takes (time), what patients and caregivers do, and a description of any comments of the patient and family, including any observable emotional state of the patient. By considering patients’ emotion as consistent responses to internal or external events, the Plutchik’s model was used as framework to understand its intensity in a positive or negative characterization [ 37 ]. In particular, Plutchik suggests emotions are low, medium or high-intensity, and if left unchecked, they can intensify. Accordingly, the patient's emotional journey was also assessed in reference to external events that altered the patient's emotional level.

Patient care procedures were not noted because they were not relevant for the current research objectives. The shadower observed the patients during all hospital transfers and entered the patients’ rooms only to verify their general state and to gather any statements about their experience. The shadower was mainly passive during the observation, but was active in informal conversations. This level of proximity made it possible for the patients not to perceive shadowers as intrusive or disrespectful of their privacy.

Between September 2016 and April 2017, four patients and sixteen healthcare professionals participated in face-to-face open interviews lasting 30–45 minutes and performed by the first and the third author. A few main open questions were identified by the research group in order to analyse the main steps of the patients’ journeys, the patients’ experiences, and their reported emotions. Patients were interviewed at the first outpatient follow-up visit ( Fig 1 ), scheduled one month after discharge from the ward, in order to include their perceptions of discharge.

In order to capture viewpoints representing various different roles, a collaborative purposive sampling technique was used among professionals with different level of professional experience who take care of orthopaedic patients. In particular, according to Benner’s stages of clinical competence [ 38 ], two nurses with experience of at least five years, identified as expert nurses by their managers, and three nurses with experience of up to four years, identified as competent nurses, were selected. In addition, two orthopaedic surgeons and one medical doctor under training were involved. Finally, three members of the administrative staff, the director responsible for the quality of care processes, and the head nurses of the units involved in the patient journeys (i.e.: two Ward Units, one Surgery Room, one Rehabilitation Unit), were interviewed.

All interviews were audio-recorded and transcribed verbatim with participant permission. Data from the field notes and the interviews were transferred to an Excel spreadsheet database to systematize them and for the subsequent analysis.

Data analysis

Data analysis was performed on three levels as suggested by Ricoeur [ 30 ]: a naïve reading, a structural analysis and a critical analysis and discussion. The first author performed a thematic analysis of the text material. In the structural analysis, the units of meaning (what was said) were reflected in units of significance (what the texts were talking about) from which the key themes emerged ( Table 1 ). Patients’ emotions, reported or observed, were classified according to Plutchik’s Wheel of Emotions [ 37 ]. After that, a critical analysis was carried out by the researchers in order to analyse the coding process, the categories and the meanings that emerged.

The main characteristics of the participants involved in the study are reported in Table 2 . Patients involved ranged in age from 56–78 years with an average age of 67.3 years, and they were hospitalized on average 4.4 days. All had a regular clinical trajectory with no noteworthy complications. Healthcare professionals ranged in age from 29–61 years with an average age of 38.8 years and a work experience average of 10.6 years.

* TKA = total knee arthroplasty; THA = total hip arthroplasty

**LOS = Length of Stay

The hospital patient journey

In the patient hospital journeys studied, seven main phases and forty-four consequent steps were traced by shadowing patients and interviewing the main actors. Table 3 shows which steps were identified from the interviews and which from the shadowing. In particular, the patient shadowing enabled more accurate reconstruction of all the steps, compared to what patients narrated after a period of time. This information can be obtained from the health professionals' interviews only by summarizing their different points of view. Furthermore, through shadowing it was possible to detect that within the hospital the patient went through eighteen different places and was in contact with more than fifty different health professionals. The patients’ emotions as reported by the health professionals corresponded to what was observed by shadowing, but they did not match the general state of serenity reported by patients when interviewed.

The three different standpoints, (i.e.: patient shadowing, healthcare professional interviews and patient interviews) allowed different issues to be captured at the various phases of the journey. In particular, the shadowing was able to capture the 'connections' between one stage and another of the journey, such as movement from admissions to the ward and transport from the ward to the operating theatre, while the journey narrated by each professional and patient allowed the most significant touchpoints to be identified ( Table 3 ).

When interviewed about a month after discharge, patients remembered a generally positive experience, linked specifically to the success of surgery and to a good relationship with the professionals. They showed appreciation and satisfaction and they declared that there were no major problems to deal with. One patient reported "I was fine , look , I have to say the night of the surgery I was fine , the next day they also made me get up . They made me sit in the chair , my head was spinning a little , so it's not that ehm … then nothing else , everything else went well” (Patient 1); Another reported “What can I say ? Better than that I don't think it is; that… we may be worse , but I have not found that I was worse , and I have only good things to say about the professor and all his assistants” (Patient 3).

However, when shadowed, some discrepancies emerged. When going independently to the ward patients experienced confusion and anxiety, due to not having clearly understood indications, and to the waiting times before entering the assigned ward (Patient 5, 6, 7, 8, 9,12). Another critical step was the transfer and waiting in the operating theatre. They felt 'lost' when they were transferred and emotions of fear and anxiety emerged (Patient 10; 11). These experiences also emerged from the interviews with professionals (Healthcare professional 4, 6, 8, 12, 14 16).

Some other interesting points, detected by the shadowing, reveal how the hospital environment and management of patient flow can affect the patient experience, in particular on the day of admission. After the administrative acceptance, one patient took the wrong elevator and did not immediately reach the indicated ward. When arriving at the entrance of the ward, he found it difficult to use the intercom. When entering the ward, he was dissatisfied with the lack of staff to welcome him. When waiting in the room for surgery he showed apprehension and he reported a desire to have more information and to have a family member nearby (Patient 9). Another patient reported having received incorrect information to reach the ward and that the hospital directional signs were too small and difficult to read (Patient 1).

During the journey it is possible to identify some key steps, though with different levels of importance from patients’ and professionals’ perspectives. From the patient perspective and by shadowing the journey, the day of hospitalization was the most critical, and they experienced mainly negative emotions (Patient 5, 6, 7, 8, 9,12). From the interviews with the professionals it emerges that when returning to the ward after surgery patients were calm (Healthcare professional 7, 8, 16) but in the following days, they began to experience a lack of autonomy and this could make them nervous (Healthcare professional 13). Professionals involved in the pre-hospitalization phase report that waiting in the days before hospital admission can negatively affect patient experience. Patients can feel abandoned, if no one gives them information on the outcome of the outpatient clinic examination, or if all the procedures related to hospitalization are not properly programmed (Healthcare professional 1, 9).

Through analysis of the data collected four main themes emerged underlying both the shadowing and the interviews: the information gap; the covering patient-professionals relationship; the effectiveness of family closeness; and the micro-integration of hospital services.

The most significant issues are reported below.

The information gap

When interviewed, patients did not mention any problems with the information received in the course of their hospital journey. However, when patients were shadowed on arrival at the hospital, they did not seem to be aware of any information regarding their hospitalization (e.g. visiting hours for family members, the hospital route to the ward), but asked the first professionals they met. The patients seemed lost, especially after going through the admission process and on looking for their assigned wards. Moreover, when they arrived in the ward they needed information about their hospitalization, but healthcare professionals did not immediately assist them (Patient 5, 6, 9). This seemed to contribute to their state of anxiety about the surgery. This issue is confirmed by what the professionals reported. When they arrive at the hospital, patients put the same questions to any professional they come into contact with (Healthcare professional 4, 6). A nurse reports how each patient has "so many anxieties , fears , uncertainties , questions , as soon as he steps into the ward and I follow him , until he leaves the ward" (Healthcare professional 1). A head nurse reports "Family members also ask many questions . Many times it seems that what was already explained by the doctor , actually , has not sunk in ( … ) And so here they repeat the same questions many times , in different ways . What worries them a lot ( … ) is what will happen after discharge , when ‘I find him at home or in a rehabilitation clinic’” (Healthcare professional 13). Apprehension before surgery was observed in one patient, even though the patient claimed to have received very good information on how the surgery would be performed (Patient 2).

The time of waiting while the patient is in the operating theatre seems endless for family members, and waiting without information is a cause of anxiety (Healthcare professional 6). Professionals recognize the importance of informing the patient and family members about procedures, clinical pathways and pain management, before surgery (Healthcare professional 1, 2, 4, 7).

The covering patient-professionals relationship

The relationship between patient and professionals is a key issue for the quality of the service perceived by the patient, even when the health care provider fails to respond immediately to the patient's needs. Indeed, as many as 35 touchpoints occur throughout the patient journey ( Table 3 ). What the patient thinks and feels on this topic, emerges especially from the interviews, while the shadowing is not able to immediately capture thoughts or observations re-elaborated by the patient. In particular, when interviewed the patients remember, even after some time, some aspects of the relationship with professionals that are not directly related to clinical care, but which are perceived as being of value for the patients, since in these they receive attention as an individual. Even after some time, a patient remembered: “Early in the morning the nurse came to say goodbye before she went off duty , because I was being discharged later that day , so she wouldn't see me again . Really good . ” (Patient 3). A patient also remembered a rough response to a request for help to get dressed after the X-ray during outpatient clinic examination (Patient 2). Moreover, a patient pointed out how reassuring the relationship with the surgeon could be just before the surgery (Patient 3). One of the key moments appears to be the contact with the anaesthesiologist and the surgeon while the patient is waiting in the operating theatre: “Then the anaesthesiologist told me ‘Don’t worry , my dear , we do the epidural , we will sedate you’” (Patient 1). From the professionals’ perspective, the relationship with the patient is a key point to "buffer" a series of disruptions in the hospital journey and to reassure the patient: “ Patients always thank us because even if there is a gap in the organization and the patient has to wait a little , we apologize in the best way , with a smile" (Healthcare professional 3). As the nurse is the first person patients encounter when entering the ward, she knows she has the important role of reassuring patients by explaining to them how to orientate themselves in the ward and which procedures will be carried out, even if patients should already have been informed about all these things (Healthcare professional 4). Professionals recognize the importance of calming patients through interaction with the surgeon especially when they are waiting just before surgery (Healthcare professional 3, 13). An orthopaedist reports, “When you check or welcome the patient in the operating surgery where the surgeon and the anaesthesiologist are , the patient sees them and this helps him or her a lot , and so one thing that I think is in our favour ( … ) is communication , the possibility of having a point of reference” (Healthcare professional 3).

The effectiveness of family closeness

Family closeness is felt to be important for both patients and professionals, if programmed at the right times of the clinical journey. From the patient interviews and from shadowing it emerges that patients like family members to stay with them when waiting for surgery (Patient 4, 9). Once the surgery has been performed, when fears are diminished and pain is controlled, patients do not consider the presence of family members necessary, in particular immediately after returning to the ward from the operating theatre (Patient 1, 4). From the shadowing it emerges that after the first few days, when patients have recovered from the post-operative stage and close assistance has diminished, they then like to be with their family without interruptions for clinical-assistance reasons (Patient 10).

For professionals, family presence is important especially shortly before and after surgery, to reassure family members that the patient is doing well (Healthcare professional 5, 7, 13). When possible, professionals try to facilitate this, even outside regular visiting hours (Healthcare professional 13). In the days after surgery, “It is mainly relatives who come from outside the city who logically stay here , maybe in a hotel or some bed & breakfast , and would like to stay in the room all day; because they say–quite rightly , as I realize– : ‘But I have nothing else to do; my husband , my wife , my son is there . I'm with him’” (Healthcare professional 12). At this stage of the clinical journey, professionals do not see the closeness of family members as a need of the patient. Immediately after surgery, patients prefer to rest rather than having many people in their room. Conversely, the presence and closeness of family can greatly affect the patient experience in the rehabilitation period, especially when it comes to discharging elderly patients (Healthcare professional 15).

The micro-integration of hospital services

Even for a relatively simple routine surgical pathway, patients go through multiple stages. The behind-the-scenes coordination remains invisible to them and they are able to capture only some of the effects related to it. By contrast, professionals emphasize many critical issues in the management of the patient journey that affect the patient's experience.

When interviewed, patients reported the difficulty of having to move from one clinic to another during the outpatient clinic examination (Patient 1). Before hospital admission, an admissions office administrator shows how necessary it is to “decrease calls to the patient ( …), also depending on their age which is on average quite advanced …. cut out some calls that often from their point of view are unconnected . For instance , on one day I call you for admission , then the doctor calls you for blood tests , then another doctor calls you to arrange the meeting ( …), then if you take cardioaspirin the doctor calls you to give you information on cardioaspirin … All these calls could be grouped into maybe one by the doctor and one by the administrative staff” (Healthcare professional 10). At the time of hospital admission some critical points are revealed by the shadowing. After arriving at the hospital, patients waited an average of 21 minutes before being taken in charge by the Administrative Office to carry out admission procedures. At the end of the administrative registration procedures, patients made their own way to the ward, taking an average of 11 minutes. In this time, patients could get lost; they experienced anxiety about not getting to the right place, and waited outside the closed door of the ward without knowing what to do (Patient 5, 6, 7, 9). During their hospitalization, patients reported a lack of communication: a drug intolerance reported in their previous admissions had not been recorded in the notes. Orthopaedists reported critical issues concerning the management of operating theatres, such as delays in transporting patients from the ward to the operating theatre or delays in preparing the operating theatre for the next operation (Healthcare professional 2, 3). The accumulation of such delays could lead to the cancellation of the last scheduled patient, with a negative impact on the patient who had been waiting in a state of anxiety for many hours (Healthcare professional 2). A head nurse reported that waiting for transport to and from the radiology department for the post-operative radiography could slow down all the care processes, make the patient wait unnecessarily, and increase the pain, due to the temporary suspension of the continuous-infusion pain-killer (Healthcare professional 12). Finally, a patient reported that she was offered no choice when she was transferred to the rehabilitation unit recommended by the doctors, and she expressed the desire for a follow-up visit by the same doctor who had operated on her (Patient 1).

Exploring the individual patient journey can lead healthcare organizations to improve patient experience by focusing on the patient perspective, rather than the provider perspective [ 39 ]. Understanding what organizations can do to improve patient experience is critical [ 40 ]. However, the literature is still exploring the best methods to capture the patient's experience [ 17 , 23 , 30 ]. This study deals with the lived experience of orthopaedic patients by capturing the different points of view of patients and professionals on individual hospital patient journeys. Patients’ reported experience is analysed by shadowing them during hospitalization and by interviewing them at the end of the whole journey.

Historically, researchers and health care managers have focused on the study of how to achieve effective care through the definition of clinical pathways and by increasing patient adherence to treatment. However, reducing the patient's path to the clinical perspective may fail to reveal aspects that are relevant to patients, that influence their experience and their perception of quality of service [ 42 , 42 ]. In this study on patients’ hospital journeys, some important issues emerged through the shadowing of the hospital journey of the patients, and interviews with the key players. With the integrated use of these methods it was possible to identify which touchpoints are most critical for the patient, when family closeness is most effective, and how professionals can provide for the needs shown by patients over the entire journey. If on one hand the study of clinical pathways is now heading towards the active involvement of patients in decisions related to their own health issues [ 43 ], on the other hand the analysis of the hospital journey from a patient perspective can lead organizations to improve cross-hospital processes by creating procedures and focusing healthcare professionals on overall patient experience.

In line with Liberati's analysis [ 30 ], the shadowing method can contribute to patient-centredness by considering all the aspects of service delivery, not just the clinical one. In this study, both interviews and shadowing are able to “see the world from someone else’s point of view” [ 24 ]. However, the patient’s observations, focused on the whole service experienced, can reveal areas of potential improvement of the patient experience not otherwise identifiable. Shadowing highlights what the patient experiences in the different contexts and when going through one service and on to another, which professionals do not see since this falls outside the scope of their direct responsibility. Moreover, unlike using diaries completed by patients [ 23 ], this methodology allows the patient to be observed in the moment and in the spaces in which the relationship with the professionals takes place. However, this necessarily determines a subjective interpretation of what the researcher observes with respect to what the patient affirms.

Unlike what was pointed out by Gill [ 44 ], when dealing with the patient journey perspective, shadowing has an important potential for revealing invisible steps and spaces of the journey, more than intimate spaces and micro-processes of the decision. It is true that even now, in the healthcare sector, the provider establishes the patient path, while the patient is 'carried forward' through processes designed and managed by others.

In this study, when interviewed after time, patients focused on the overall clinical experience, forgetting other issues related to their hospitalization. For example, when interviewed, patients reported that they had had all the information they needed, while when shadowed shortly before the surgery the same patients appeared lost and asked for information from all the professionals they met. These data are also confirmed by interviews with professionals, who reported how highly emotional touchpoints, such as telling the patient they needed an operation, or the time immediately before transfer to the operating theatre, may affect patients’ perceptions and the effectiveness of the information [ 41 , 45 ]. As suggested by Ziebland, there is a difference between what patients said they experienced and what they actually experienced in real-life settings [ 20 ]. In this sense, the use of shadowing helps to understand the experience in a real time context. Moreover, it is always useful to evaluate whether the tools and information methods used for giving information to patients are effective, and which is the best moment for each patient to receive all the information they need, by considering their ability to absorb the information in a stressful situation [ 46 – 48 ].

In this study, both patients and professionals recognized the value of a personalized relationship in improving patient experience. Moreover, professionals report how a good relationship with the patient can compensate for the organization's inefficiencies. Interaction with the patient is especially important in the perceived patient-critical touchpoints. However, relevant steps of the journey are different from patients’ and from professionals’ points of view. From the patient’s point of view, the most critical steps occur when entering the hospital and just before surgery, where their emotional involvement is greater. On the other hand, from the professionals’ point of view, planning hospitalization and preparing patients for surgery is one of the most critical steps that affect patient experience. Indeed, patients, when interviewed, seem not to perceive critical issues in what happens ‘behind the scenes’, while professionals are able to identify issues related to the organization that can positively or negatively affect patients’ experience. These results highlight how frontline professionals are the key players in transforming organizational procedures into personalized care pathways, but the misalignment of views should be considered when improving the hospital journey by including the patients’ perspective.

The study has important limitations with respect to the sample and the setting considered and therefore its potential for generalization may be limited. The issues that emerged would need to be studied in depth in different care settings and with other types of patients to allow comparison of data and methodologies.

Patients’ experiences have become increasingly central to assess the performance of healthcare organizations and to redesign the services around the real needs of patients [ 20 , 41 , 42 , 45 , 49 ]. In this study, the analysis of the hospital journey from the patient perspective and the integration of three different standpoints, patient shadowing, healthcare professional interviews and patient interviews, highlights important areas of improvement otherwise hidden by the analysis of the clinical pathway only.

The nature of the study and its originality by subject matter and methods adopted can stimulate both academics and healthcare managers to explore important new fields. On the one hand, it is important to further investigate methodologies for capturing the patient experience and use it deeply and effectively at various organizational levels. In this way, shadowing seems to give a more patient-centric perspective, but it raises questions about its effectiveness as a single methodology for gathering the whole patient experience within a complex hospital process. On the other hand, the results of this study are a starting-point for healthcare managers who want to improve a key cross-functional hospital process in which the patient is the main actor. By considering the overall patient experience, as well as services performance and clinical pathways, they will able to create a distinctive value both for the patient and for the organization.

Acknowledgments

We are grateful to Eugenia Di Sabatino and Michela Ceri for their contribution to data collection.

Funding Statement

The author(s) received no specific funding for this work.

Data Availability

• PLoS One. 2019; 14(12): e0224899.

Decision Letter 0

30 Aug 2019

PONE-D-19-19443

Exploring the hospital patient journey: how can we capture the patient’s experience?

Dear Dr. Gualandi ,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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Please address reviewer comments as well as the following:

Literature review - further detail on the theoretical basis of shadowing and rationale for it's use.

Data collection - was there any prior relationship between the researcher and potential participants?  How were issues of possible coercion dealt with?

Please provide further information on shadowing and how the field notes were dealt with

Much greater detail is required in reference to Plutchik's Wheel of Emotions and the rationale for its use as a framework in this study.

Line 146 include "with participant permission"

Please include some minimal demographic characteristics of participants.

Please provide a better link between the text and Table 2

The data presented seems to come from the interviews - where is the data from the shadowing included?

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Reviewer #1: Title: Exploring the hospital patient journal: how can we capture the patient’s experience?

Manuscript number: PONE D 19 19443

General comments

Your title is Exploring the patient journey: how can we capture the patient experience?

And the research questions are Which aspects of hospital patient journey experience may be captured by 3 different standpoints – shadowing, professional and patient interviews. What does the patient experience through the hospital journey and how can it be captured?

The complexity and number of steps in the patient journey decoded by your research is very interesting as were other findings of patient journey. I commend you for using an ethnographic approach to try to capture the lived experiences of the patients your followed.

These tools captured patient journey, the physical aspects of movement through a hospital experience; however, I am interested to know other aspects of patient experience. For example, did the hospital context/system facilitate patient understanding of their own condition and care (health literacy)? Could that be a lens you view the data gleaned from shadowing?

Shadowing as a research methodology also requires more analysis in the paper. I don’t get a sense of the ‘rich’ description that the ethnographic shadowing approach should generate. It would be good to see what else that data revealed beside the annotation of components of the hospital journey, given you were trying to capture the broader experience of patients – viz Line 328 - patient mainly feels and remembers, while shadowing highlights what the patient experiences in the different contexts and going through one service and on to another, which professionals do not see since this falls outside the scope of their direct responsibility.

See also Gill, R. (2011). The shadow in organizational ethnography: moving beyond shadowing to spect -acting. Qualitative Research in Organizations and Management: An International Journal, 6(2), 115-133

Line 15 – delete “the’ – definite article.

Line 26 – “professionals” – a possessive?

Line 32 – comma after process

Line 43 – vague reference to “some others”

Line 87 – reference for phenomenological-hermeneutic approach

Line 90 – unless that is the name of the hospital, only ‘Italian’ should have capitalisation; however, your use of the indefinite article makes me think it is not a proper noun.

Use of appendix – perhaps not needed – the table could be condensed and summarised inside a table in the text or using words.

Lines 119-122 This is unclear - we need some researcher reflexivity here – what were the researchers’ roles in the delivery of patient care?

Line 136 – patient’s journey/experience or patients’ journeys/experiences?

Line 140 – can you explain more about sampling decisions for professional staff, esp the nurses

Line 157 – Plutchik’s Wheels of Emotion needs some backgrounding – why is that appropriate and how did it fit with your phenomenological-hermeneutic approach and your research question? Table 2 reveals that patient emotions were captured, but was there any particular part of the 3 different standpoints which captured emotion?

Line 180 – rules of long quotes – over 40 words – indented? Italics?

Line 195 - “they began to experience a lack of autonomy and this could make them nervous (N2)” – Could you clarify what the coding stands for in your results? E.g. N or P or H? Also does one reference (N2) here mean only one person had this experience?

Line 210 – verb aspect – going/gone – delete ‘having’

Lines 233 on – was this data gained from the interviews or shadowing?

? hegemonic/power relationships in that context? Any critical analysis?

Line 227 – The relationship between Table 2 and patient-professional relationships could be clarified further.

Line 373/4 – where was the review of the shadowing methodology challenges?

Reviewer #2: Overall this is an interesting, well written study. The topic of the patient experience is important and new ways of capturing it, and using this information to improve patient care, are central to modern healthcare. Specific points follow.

Page 2, line 15: “hospital patient journey experience” is an ugly noun cluster, please unpack – “the experience of the hospital patient journey”?

Page 4, line 64 and in discussion: you talk a lot about different data collection methods and perspectives on the patient experience and mention a number of them – three complementary forms of which your study covers. However, one rather obvious method and perspective that you fail to mention is a hospital-stay diary completed by the patient themselves. This should at least be mentioned in discussion as another such method. A recent good example of this method is: Webster CS, Jowsey T, Lu LM, et al. Capturing the experience of the hospital-stay journey from admission to discharge using diaries completed by patients in their own words: a qualitative study. BMJ Open 2019;9:e027258. doi:10.1136/bmjopen-2018-027258

Page 4, line 70: “what he/she experiences IN real-time…”

Page 4, line 72: “accurate and real data on the experience” – what does “real data” mean in this context? Who’s definition of real are you using? Better to use a different word here I think.

Page 5, line 92: Line starting “Scheduled surgical patients were…” – this sentence doesn’t make much sense to me.

Page 6, line 108: Sentence starting “Inclusion criteria were scheduled…” – this sentence doesn’t make much sense either. I am unsure how inclusion criteria get scheduled or performed? Do you mean the inclusion criteria were that patients must be scheduled for their procedure for the shadowing phase and must have had the procedure performed for the interviews?

Page 6, line 113: “consent to participation in the study” – should be consent to participate…

Page 7, line 137: “Professionals ranged…” Please make it clear that you are talking about healthcare professionals throughout – there are other kinds of professionals.

Page 8, line 154: In my understanding content analysis and thematic analysis are not the same things – yet here you appear to suggest that they are? It looks more to me that you did a thematic analysis.

Page 8, line 160 (table 1): I am unconvinced that the unit of meaning is a good one to support the significance of the text, or the theme. “I didn’t understand anything”, to me does not demonstrate calming of the patient, or covering professional relationships – I am sure the patient would be much calmer if they did understand what was going on, and this is the anaesthetist’s professional obligation.

Page 9, line 173: “each actor allowed…” who is the actor here? The patients, clinician or researcher?

Page 9, line 186 and elsewhere: I can guess that P1 means patient one (but please define), but what does PJ1, H1 etc mean? Please define on first use of each numbering scheme.

Page 10, line 219: If patients ask the same questions over and over why does the hospital not supply them with a simple written information pack with frequently asked questions (FAQs)?

Page 12, table 2: What is the significance of the filled dots vs the unfilled dots? Please explain or make consistent.

Page 13, 241: we see the same quote as from Table 1 in the text here, why? Why not use another? Also it also seems odd to me that the anaesthetist would not address the patient by her name, rather than calling her “lady”, which actually seems rather rude.

Page 15, line 277: “simple ordinary surgical pathway…” Ordinary in this context sounds strange, do you mean routine?

Page 15, line 296: “had not been passed on.” – or recorded in the notes?

Page 17, line 324: “…perceptions and effectiveness of the information” – surely it is more about the patient’s ability to absorb the information in a stressful situation rather than the effectiveness of the information itself?

Page 18, line 359: “does not allow any generalization of results” – I would say that generalisation maybe limited rather than entirely ruled out. For example, your findings are substantially similar to those in the BMJ Open paper I mentioned previously using the patient diary method.

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Author response to Decision Letter 0

AUTHORS’ RESPONSES TO REFEREES’ AND EDITOR’S COMMENTS

• Literature review - further detail on the theoretical basis of shadowing and rationale for it's use.

We have included more details in the introduction to explain the theoretical basis of shadowing and the rational for its use.

• Methods

Data collection - was there any prior relationship between the researcher and potential participants? How were issues of possible coercion dealt with?

We have added this information in the first paragraph: “There were no prior relationships between researchers and patients; while two researchers knew some healthcare professionals because they worked in the same hospital, though in different units and without patient care roles. The possibility of coercion was minimized by guaranteeing data anonymity, by requesting voluntary participation in the study and by dealing with issues on which the researchers had no power to influence anything or anyone at hospital managerial level.”

Please provide further information on shadowing and how the field notes were dealt with.

We have provided further information on shadowing by explaining in more detail how we collected data.

We have added more details on Plutchik's Model and to its use in our study, in the ‘Data Collection’ section.

• Results

We have included the main demographic characteristics by summarizing them in a paragraph at the beginning of the ‘Results’ section and we have transferred the table from the Appendix to the main manuscript, naming it Table 2.

We have renamed Table 2 as Table 3 and we have added some data in the 'The hospital patient journey' Section to better link the text to the results shown in the table. In this way, data deriving from shadowing are better represented.

The manuscript has been significantly revised in light of your suggestions in order to make its validity clearer.

In accordance with the qualitative nature of the study, all data are now included as part of the main manuscript.

We have had external proof reading of the manuscript carried out by a native English translator.

• Your title is Exploring the patient journey: how can we capture the patient experience?

We have rewritten the title so that it is more consistent with the research questions. The new title is “Exploring the hospital patient journey: what does the patient experience ?”

• The complexity and number of steps in the patient journey decoded by your research is very interesting as were other findings of patient journey. I commend you for using an ethnographic approach to try to capture the lived experiences of the patients your followed. These tools captured patient journey, the physical aspects of movement through a hospital experience; however, I am interested to know other aspects of patient experience. For example, did the hospital context/system facilitate patient understanding of their own condition and care (health literacy)? Could that be a lens you view the data gleaned from shadowing? Shadowing as a research methodology also requires more analysis in the paper. I don’t get a sense of the ‘rich’ description that the ethnographic shadowing approach should generate. It would be good to see what else that data revealed beside the annotation of components of the hospital journey, given you were trying to capture the broader experience of patients – viz Line 328 - patient mainly feels and remembers, while shadowing highlights what the patient experiences in the different contexts and going through one service and on to another, which professionals do not see since this falls outside the scope of their direct responsibility.

We have revised the whole paper in order to give greater value to shadowing and to describe the results obtained from this methodology. At the same time, we have tried to maintain the paper's goal of comparing different methodologies rather than focusing on the effectiveness of shadowing.

Specifically, we added the following points:

- as requested in the previous comments, in the ‘Result’ Section we have better distinguished the data coming from the shadowing from those from the interviews;

- we have included a paragraph in the "The information gap" Section with data collected from the hospital context and their impact on the patient's experience;

- we have included in the “Hospital patient journey” Section further data on what was observed by shadowing patients;

- we have included in the discussion considerations on the potential and limits of shadowing methodology when applied to the patient journey.

• Line 15 – delete “the’ – definite article.

• Line 26 – “professionals” – a possessive?

• Line 32 – comma after process

• Line 43 – vague reference to “some others”

• Line 87 – reference for phenomenological-hermeneutic approach

• Line 90 – unless that is the name of the hospital, only ‘Italian’ should have capitalisation; however, your use of the indefinite article makes me think it is not a proper noun.

• Use of appendix – perhaps not needed – the table could be condensed and summarised inside a table in the text or using words.

We have inserted the table in the main manuscript and we have named it “Table 2”.

• Lines 119-122 This is unclear - we need some researcher reflexivity here – what were the researchers’ roles in the delivery of patient care?

As requested by the editor, we have specified the relationship between researchers and participants in the Methods section. We also have specified in the ‘Data collection’ section that students had no role in patient delivery of care. Moreover, in the discussion we have considered the subjective interpretation of the researcher in the shadowing methodology.

• Line 136 – patient’s journey/experience or patients’ journeys/experiences?

• Line 140 – can you explain more about sampling decisions for professional staff, esp the nurses

We have specified the sampling technique. We introduced further specification in the text.

• Line 157 – Plutchik’s Wheels of Emotion needs some backgrounding – why is that appropriate and how did it fit with your phenomenological-hermeneutic approach and your research question? Table 2 reveals that patient emotions were captured, but was there any particular part of the 3 different standpoints which captured emotion?

As requested by the editor, we have added in the ‘Data Collection’ section more details in reference to Plutchik's Model and the rationale for its use in our study. In the 'The hospital patient journey' Section we have specified that the identified emotions coincide with what was detected by the shadowing and by the interviews with healthcare professionals, but they are different from what the patient reported during the interviews. In the table, renamed table 3, we have specified the column label.

• Line 180 – rules of long quotes – over 40 words – indented? Italics?

We shortened and distinguished the two quotes. We put all quotes into italics.

• Line 195 - “they began to experience a lack of autonomy and this could make them nervous (N2)” – Could you clarify what the coding stands for in your results? E.g. N or P or H? Also does one reference (N2) here mean only one person had this experience?

We have made the subject of each quotation explicit. We codified the number alone by connecting quotes with Table 2 (Subject / Number).

• Line 210 – verb aspect – going/gone – delete ‘having’

• Lines 233 on – was this data gained from the interviews or shadowing?

We revised the paragraph to better define the concept and to specify the source of the data.

• Line 227 – The relationship between Table 2 and patient-professional relationships could be clarified further.

Within the first paragraph of the "The covering patient-professionals relationship" Section, we created a link with the touchpoints represented in the renamed Table 3.

• Line 373/4 – where was the review of the shadowing methodology challenges?

We changed the statement to achieve greater consistency with the results achieved by this study.

• Page 2, line 15: “hospital patient journey experience” is an ugly noun cluster, please unpack – “the experience of the hospital patient journey”?

• Page 4, line 64 and in discussion: you talk a lot about different data collection methods and perspectives on the patient experience and mention a number of them – three complementary forms of which your study covers. However, one rather obvious method and perspective that you fail to mention is a hospital-stay diary completed by the patient themselves. This should at least be mentioned in discussion as another such method. A recent good example of this method is: Webster CS, Jowsey T, Lu LM, et al. Capturing the experience of the hospital-stay journey from admission to discharge using diaries completed by patients in their own words: a qualitative study. BMJ Open 2019;9:e027258. doi:10.1136/bmjopen-2018-027258

We have carefully considered the suggested study and we have updated our analysis by commenting on it in the introduction and citing it in the discussion.

• Page 4, line 70: “what he/she experiences IN real-time…”

• Page 4, line 72: “accurate and real data on the experience” – what does “real data” mean in this context? Who’s definition of real are you using? Better to use a different word here I think.

• Page 5, line 92: Line starting “Scheduled surgical patients were…” – this sentence doesn’t make much sense to me.

We reframed the sentence.

• Page 6, line 108: Sentence starting “Inclusion criteria were scheduled…” – this sentence doesn’t make much sense either. I am unsure how inclusion criteria get scheduled or performed? Do you mean the inclusion criteria were that patients must be scheduled for their procedure for the shadowing phase and must have had the procedure performed for the interviews?

We have clarified the inclusion criteria in the text.

• Page 6, line 113: “consent to participation in the study” – should be consent to participate…

• Page 7, line 137: “Professionals ranged…” Please make it clear that you are talking about healthcare professionals throughout – there are other kinds of professionals.

• Page 8, line 154: In my understanding content analysis and thematic analysis are not the same things – yet here you appear to suggest that they are? It looks more to me that you did a thematic analysis.

Amended. We conducted a thematic analysis.

• Page 8, line 160 (table 1): I am unconvinced that the unit of meaning is a good one to support the significance of the text, or the theme. “I didn’t understand anything”, to me does not demonstrate calming of the patient, or covering professional relationships – I am sure the patient would be much calmer if they did understand what was going on, and this is the anaesthetist’s professional obligation.

The literal translation of the text from Italian may have misrepresented the meaning of what we wanted to report. We have changed the example to report a clearer quotation.

• Page 9, line 173: “each actor allowed…” who is the actor here? The patients, clinician or researcher?

We have specified.

• Page 9, line 186 and elsewhere: I can guess that P1 means patient one (but please define), but what does PJ1, H1 etc mean? Please define on first use of each numbering scheme.

• Page 10, line 219: If patients ask the same questions over and over why does the hospital not supply them with a simple written information pack with frequently asked questions (FAQs)?

Even though it does not emerge from the interviews, the hospital already uses written information material. In our work we want to emphasize that, regardless of the patient's tools and information methods, it is always useful to evaluate whether these are effective and which is the best moment for the patient to receive all the information they need. We made this concept explicit in the discussion.

• Page 12, table 2: What is the significance of the filled dots vs the unfilled dots? Please explain or make consistent.

• Page 13, 241: we see the same quote as from Table 1 in the text here, why? Why not use another? Also it also seems odd to me that the anaesthetist would not address the patient by her name, rather than calling her “lady”, which actually seems rather rude.

We changed the quote in the Table 1. We have replaced the word “lady” with “my dear” to better convey the note of kindness that is meant in the Italian language “Signora”.

• Page 15, line 277: “simple ordinary surgical pathway…” Ordinary in this context sounds strange, do you mean routine?

• Page 15, line 296: “had not been passed on.” – or recorded in the notes?

• Page 17, line 324: “…perceptions and effectiveness of the information” – surely it is more about the patient’s ability to absorb the information in a stressful situation rather than the effectiveness of the information itself?

We have specified in the lines below.

• Page 18, line 359: “does not allow any generalization of results” – I would say that generalisation may be limited rather than entirely ruled out. For example, your findings are substantially similar to those in the BMJ Open paper I mentioned previously using the patient diary method.

Submitted filename: Response to Reviewers.docx

Decision Letter 1

24 Oct 2019

Exploring the hospital patient journey: what does the patient experience?

PONE-D-19-19443R1

Dear Dr. Gualandi,

We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.

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1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

2. Is the manuscript technically sound, and do the data support the conclusions?

3. Has the statistical analysis been performed appropriately and rigorously?

4. Have the authors made all data underlying the findings in their manuscript fully available?

5. Is the manuscript presented in an intelligible fashion and written in standard English?

6. Review Comments to the Author

Reviewer #1: 1. Check for use of Tab instead of Table (see Lines 197 & 281)

2. Sentence (Line 397) doesn’t makes sense to me. Perhaps “In contrast to Gill (I’m still not sure though what the contrast is.)

Unlike what was pointed out by Gill [44], when dealing with the 397 patient journey perspective,

398 shadowing has an important potential for revealing invisible steps and spaces of the journey, more

399 than intimate spaces and micro-processes of the decision.

Reviewer #2: This is an excellent paper, and the authors have carefully addressed my review points.

My only very small remaining suggestion would be to use the Italian "signora" instead of "my dear" - the English translation doesn't really capture the original meaning, and signora is a well known term in English which seems more appropriate in the context of the quote.

7. PLOS authors have the option to publish the peer review history of their article ( what does this mean? ). If published, this will include your full peer review and any attached files.

Acceptance letter

18 Nov 2019

Dear Dr. Gualandi:

I am pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

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on behalf of

Dr. Rosemary Frey

Guide to Conducting Healthcare Facility Visits

by Craig Zimring, Ph.D. Georgia Institute of Technology

Published by The Center for Health Design, 1994

INTRODUCTION

A major medical center is building a new diagnostic and treatment center that will include both inpatient services and expensive high technology outpatient services The center is considering whether to provide day surgery within the diagnostic and treatment center or in a freestanding outpatient facility. They are facing a dilemma. If they locate the day surgery center separately, they can use lower-cost construction. If they combine the functions, they can use the spare capacity that will likely become available in the inpatient operating rooms. This is especially important as outpatient procedures become increasingly complex. The center wishes to evaluate sites that currently operate in fully separate facilities versus ones that provide separate outpatient and inpatient reception and recovery facilities, but share operating rooms.

A large interiors firm has been contacted to conduct a visit of several new children’s hospitals in the Northwest. Eager to get the commission from this major hospital corporation to renovate the interior of a large children’s hospital, the firm arranges visits of hospitals it has designed as well as two designed by other firms.

An architecture firm is renovating a large medical laboratory in an existing building which has a minimal 11-foot-3-inch floor-to-floor height. Concerned that the client may not understand the implications of this tight dimension-which means that the fume hood ventilation system can not easily be installed within this space-the architects arrange visits of other labs with similar floor-to-floor heights, change in healthcare and society is rapid and increasingly unpredictable, bringing an unprecedented level of risk for healthcare organizations facing new projects. This guide discusses a specific tool that healthcare organizations and design professionals can use to help manage uncertainty: the facility visit. In almost every healthcare project someone-client, designer, or client-design team-visits other facilities to help them prepare for the project. A probing, well structured, and well run visit can highlight the range of possible design and operational alternatives, pinpoint potential problems, and build a design team that works together effectively over the course of a design project. It can help a team creatively break their existing paradigms for their current project and can provide a pool of experience that can inform other projects. All of these can help reduce risk for healthcare organizations.

However, current facility visits are often ineffective. They are frequently conducted quite casually, despite the rigor of much other healthcare planning and design. Visits are often costly—$40,000 or more-yet they often fall short of their potential. Sites are often chosen without careful consideration, little attention is given to clarifying the purpose or methods of visits, there is often little wrap-up, and frequently no final report is prepared. Not only is the money devoted to the visit frequently not used most effectively, the visit presents important opportunities to learn and to build a design team. These opportunities are too often squandered.

This guide focuses on what a facility field visit can accomplish and suggests ways to achieve these goals. Although a facility visit may occur in a variety of circumstances, including the redesign of the process of healthcare without any redesign of the physical setting, this guide focuses on situations in which architectural or interior design is being contemplated or is in process.

SCOPE OF THE RESEARCH

The goals of this project were to learn about the existing practice of conducting healthcare facility visits, to learn about the potential for extending their rigor and effectiveness, and to develop and test a new approach. We interviewed over 40 professionals in the fields of healthcare and design from every region of the US, including interior designers, architects, and clients who had participated in design projects, and healthcare professionals who conduct visits of their own facilities. We sampled professionals from large and small design firms, and from large and small medical organizations. To get a picture of both “average” and “excellent” practice we randomly selected members from professional organizations such as the AIA Academy on Architecture for Health and the American Society of Hospital Engineers, and augmented these with firms and individuals who were award winners or were recommended to us by top practitioners. We developed a multi-page questionnaire that probed the participants’ experiences with visits, including their reasons for participating, their methods, and how they used the information produced. We faxed each participant the questionnaire, then followed up with an interview on the phone or in person. The interviews averaged about one-and-a-half hours in length. Every person we initially contacted participated in an interview. Everyone in our sample had participated in some sort of visit of healthcare facilities within the past year.

After conducting the interviews we developed, field tested, and revised a new facility visit method, which is presented in this guide. Throughout this process we conferred with select members of the Research Committee of The Center for Health Design and the Project Advisory Board.

GOALS OF FACILITY VISITS

There are many reasons for doing a facility visit and many different kinds of visits. However, visits roughly fall into three categories: specific visits, departmental visits and general visits. Specific visits focus on particular issues such as the design of patient room headwalls, nursing stations, or gift shops; departmental visits focus on learning about the operations and design of whole departments such as outpatient imaging or neonatal intensive care; general visits are concerned with issues relevant to a whole institution, such as how to restructure operations to become patient-focused. Usually, departmental and general visits occur during programming or schematic design; specific visits often occur during design development, when decisions are being made about materials, finishes and equipment.

More broadly, there are several general reasons for conducting visits: learning about state-of-the art facilities; thinking about projects in new ways; and creating an effective design team.

LEARNING ABOUT STATE-OF-THE-ART FACILITIES

Visit participants want to learn what excellent organizations in their field, both competitors and other organizations, are doing. Participants are often particularly interested in learning how changes in business, technology or demographics, such as increased focus on outpatient facilities or increased criticality of inpatients, might affect their own operations and design. For example, in Story 1, below, a UK team was interested in grafting US experience onto a UK healthcare culture. In another example, hospital personnel at Georgia’s St. Joseph’s Hospital visited five emergency rooms over the course of several weeks before implementing an “express” service of their own. According to planner Greg Barker (Jay Farbstein & Associates, CA) they “use site visits as a method of exposing the clients to a broader range of operating philosophies and methods.” This gives the clients and design professionals a common frame of reference on which to base critical operational and design decisions.

William Headley, North Durham Acute Hospitals, UK

Traditionally, hospital design in the UK has been established centrally, with considerable emphasis placed on standard departmental areas and on a standardized planning format known as “Nucleus.” The 20-year-old Nucleus system is based on a standard cruciform template of approximately 1,000 square meters housing a multitude of departments, which can be interlinked to provide the nucleus of a District General Hospital.

Durham wished to develop a hospital that in its vision would meet the challenges of the 21st Century, and produce a custom-designed hospital solution built to suit the needs of the patient, not just individual departments.

The brief has, therefore, to be developed from a blank sheet of paper and not from standard guidelines. It is also the Trust’s objective to have the brief developed by staff from the bottom up. The purpose of the study tour was to allow frontline staff the opportunity to experience new ideas firsthand and talk to their medical counterparts about some of the philosophies of patient-focused care and to input their findings into the briefing process. We acknowledged the differences in the US and UK healthcare systems, but were interested in ensuring that best US practices, including the patient focused approach, facilities design, and the use of state of the art equipment, was studied and subsequently tailored to suit the new North Durham hospital.

THINKING ABOUT A PROJECT IN A NEW WAY

Participants who are currently engaged in a design or planning project are concerned with using visits to advance their own project. They use a visit to analyze innovative ideas and to help open the design team to new ideas. At the same time they are interested in building consensus on a preferred option. In Story 2, below, a hospital serves as a frequent visit host because it shows how special bay designs can be used in neonatal intensive care, and participants can consider how these designs apply to their current project. Other visit organizers see a visit as an opportunity for focusing the team on key decisions that need to be made, or to help the team focus in a systematic way on a range of strategic options and critical constraints. The visit exposes each team member to a variety of ways of accomplishing a similar program of requirements and thus starts the debate on how to achieve the best results for the facility being designed.

Georgia Brogdon, Vice President Operations, Gwinnett Women’s Pavilion, GA

We get visitors at our facility about once per month. Right now the NICU (neonatal intensive care unit) is the most frequently visited location. The main reason is that Ohmeda uses our unit as a showcase for a special design of NICU bays. People want to see it because most think that Hill Rom is the only vendor of this type of equipment.

Early on, we were also one of the only state-of-the-art LDR facilities around. So if people wanted to visit an LDR unit, they had little choice but to come here. Now, however, people come to see us because we are a freestanding yet still attached facility. Over time the visits have evolved away from the design of the facility and more into programming, services, and operational issues.

We give three types of visits: 1) overview visits for lay people who just want to come see the area; 2) functional visits for other hospital people or architects who want to see the LDR design, mother/baby floor, NICU design, etc.; 3) operational flow visits to learn how the LDR concept impacts operations. In general, we start the visitors wherever the patient would start in the facility.

To arrange a successful visit of our facility, we need to know the interests of the visitors; then we can focus the schedule on that. Also knowing who they are bringing is helpful. You need to have their counterparts available. The types of information needed to conduct facility visits are: 1) what specific operational information to ask for in advance-size, number of rooms, number of physicians, staffing, C-section rate, whether they are a trauma center; 2) how to prepare for the visit; 3) who to bring. We’ve found that periodically the visitors are disappointed because they didn’t bring enough people. Better to have too many than not enough.

CREATING AN EFFECTIVE DESIGN TEAM

Participants use visits as an opportunity for team building. Many visits are conducted early in a design project by a team who will work together for several years. The visit provides participants a useful opportunity to get to know each other and to build an effective team. As Story 3 illustrates, clients often look to a visit to see how well designers can understand their needs; designers use it as a way to learn about their clients and to mutually explore new ideas. A visit can also provide an opportunity for medical programmers to work with designers and clients. This is particularly important if programming and design are done by different firms.

Many visit participants focus on interpersonal issues: spending several days with someone helps build a personal relationship that one can rely on during a multi-year project. A visit also provides the opportunity to achieve other aspects of team building: clarifying values, goals, roles and expertise of individual participants; and identifying conflicts early so they can be resolved. One result for some teams is that it establishes a common vocabulary of operational and facility terms translated to the local healthcare facility.

Bing Zillmer, Director Engineering Services, Lutheran Hospital, La Crosse, WI

Conducting a facility field visit is an opportunity to have that one-on-one contact and find out if the architect “walks the talk or talks the walk.” The biggest benefit is in finding out how the visit team of the architectural firm has been assembled: to see their level of participation, and how they have interacted with and listened to the clients and the hosts. What we look for in a consultant is not a “yes man”; we look for someone who knows more about existing facilities than we do. Our key concerns are how the team worked together, how they listened.

Dennis C. Lagatta, Vice President, Ellerbe Becket, Washington, DC

The main reason for conducting a visit is to settle an issue with the client. The clients usually have only two frames of reference: the current facility and the one where they were trained. These two frames of reference are hard to overcome without a visit. We conduct visits to help settle an issue between various groups within the institution. The visit process tends to be a good political way to illustrate a problem or a solution to a problem. A good example is when you have a dispute between critical care physicians and surgeons. Both parties may be unwilling to compromise. Usually a visit will be a good way to defuse this conflict.

James W. Evans, Facilities Director, Heartland Health System, St. Louis, MO

Responding to the question, what kinds of team-building activities were conducted before the actual visit took place? The functional space program stage is where you start building a team. Functional space programming is a narrative of what you want to do. If the programming includes a laboratory or some other specialty area, you would also want to have the consultant (if you are using one) involved in this process. Between blocks and schematics is when you want to go on any visits. By working together and staying together through big and small projects, you develop a lot of rapport and credibility.

Les Saunders, Nix Mann And Associates, Architects, Atlanta, GA

In the case of marketing visits, we try and present our unique abilities to our clients and to get to know each other better, Our visits are generally tailored to what the client group is trying to accomplish. Our functional experts will go on the visit so they can get to know the client and try to enhance “bonding.”

Facility visits allow healthcare organizations and design professionals to address several important trends in healthcare.

• A visit allows a team to understand the experience of stakeholders who they do not currently serve, and to examine the design and operations of facilities that are more customer-oriented.
• Social changes are resulting in some stakeholder groups gaining importance, such as outpatients involved in more complex procedures, higher acuity inpatients, older people, or non-English speakers.
• A visit can provide quantitative and qualitative data that support future decision making.
• Tighter budgets, shorter design and construction schedules and more complex projects are requiring design teams to form more quickly and work more effectively.
• A visit can be an effective tool for building a design team early in a design project.

FALLING SHORT OF THEIR POTENTIAL

In a design project, the client healthcare organization generally pays for a visit, either directly or as a part of design fees. Do healthcare organizations usually get good value for their investment? Do visits generally achieve their ambitious goals of learning about competition and change, moving the design project along, and building teams? We found very different answers. Despite the usual rigor of healthcare planning and programming, many current visits are very casual. Whereas some planners of visits do careful searches of available facilities to fit specific criteria, most choose sites to visit in other ways— sites participants happen to already know because they have been written about in magazines, or sites where there is a contact that someone on the team knows. Though these ways of choosing sites may be appropriate, they raise a question as to whether most participants are visiting the best sites for their purposes.

In many cases visit teams simply do not spend much time structuring the visit. Most teams do not even meet in advance to decide the major foci of the visit. We did not find many groups who use checklists or sets of questions or criteria when they go into the field. Whereas some teams compile the participants’ notes, and one team actually created a videotape in a large project, most teams do not create any kind of written or visual record of their visit. Many teams hold no meeting at the end to discuss the implications of the visit, although many participants felt that they emerged in subsequent programming or design meetings.

Despite the apparent casualness of these visits, designers and clients alike almost without exception felt they were a valuable resource.

Simply visiting a well-run facility can be vivid and exciting. It is fascinating to see how excellent competitors operate, to talk to them and learn of their experience. (It is also an excellent opportunity for administrators and designers to get away from their daily routine and talk to professional counterparts.)

But there are large opportunity costs in the way most current visits are run, and they represent considerable lost value for the healthcare organization, designer, and design project.

COMMON PITFALLS

Opportunity costs of current visits come from several common pitfalls.

LOW EXPECTATIONS LEAD TO LIMITED BENEFITS

Often, participants see field visits as a way to get to know other team members and simply to see other sites, but have no clear idea about what information can be helpful to the project at hand. They don’t think through how the visit can help the goals of their project or organization.

TOO BUSY TO PLAN

The planner of a visit faces multiple problems. Often the visit is seen as a minor part of the job of most participants and doesn’t get much attention in advance; schedules and participants may change at the last minute. In many cases, no one is assigned to develop the overall plan of the visit, and to ask if the major components-choice of sites, choice of issues to investigate, methods for visits, ways of creating and disseminating a report-match the overall goals of the organization and project. This is especially ironic because participants are often advocates of careful planning in other areas.

TOO FOCUSED ON MARKETING

Many visits, and especially designer-client visits, are billed as data gathering but are in fact aimed at marketing. A design firm may literally be marketing services or may be trying to get a client to accept a solution that they have already developed: marketing an idea. This may lead to an attempt to create a perfect situation in the facility being visited, one without rush, bustle, or everyday users and the information they can provide. For designer-client teams, we heard many designers complain that they couldn’t control their clients, that they couldn’t keep them focused on prearranged ideas or keep them limited to prearranged routes. (This is often the result of not enough advance work aimed at understanding what interests the participants have and not enough time spent building common goals.)

CLOSING THE RANGE OF DESIGN OPTIONS TOO EARLY

Many visits occur early in the design process or when an organization is considering significant change, a perfect time to consider new possibilities or address issues and solutions not previously considered. This timing, and the chance to see and discuss new options in a visit, presents an opportunity for a design team to open its range of choices and consider novel or creative alternatives. However, many visit participants feel strong pressures to “already know the answer” when they start the visit. Many designers and consultants feel that their clients do not want them to genuinely explore a range of options, that they were hired because they know the solution. Similarly, some medical professionals establish positions early to avoid seeming foolish or uninformed. As a result, the team may choose sites that bring only confirmation, not surprise, and people will be interviewed who bring a viewpoint that is already well established. This is not simply a matter of the individual personalities of people who set up visits, but rather a problem of the design of teams and the context within which they operate. It is often important for a design firm to show a client the approach it is advocating and for them to jointly explore its suitability for the client’s project. However, if the client expects a designer to know the answer before the process starts, rather than developing it jointly with the client, the designer is forced to use the visit to exhort rather than to investigate.

TOO LITTLE STRUCTURE FOR THE VISIT

Whereas no one likes to be burdened with unnecessary paperwork before or during a visit, it is easy to miss key issues if there is not an effort to establish issues in advance, with a reminder during the visit. Seeing a new place, with lots of activity and complexity, makes it easy to miss some key features. Many team members come back from visits with a clear idea of some irrelevant unique feature such as the sculpture in the hallway, rather than the aspect of the site that was being investigated.

INTERVIEWING THE WRONG PEOPLE

Often, out of organizational procedure or courtesy, a site being visited will assign an administrator or person from public relations to be the primary guide. It is almost always preferable to interview people familiar with the daily operations of the department or site.

MISSING CRITICAL STAKEHOLDERS

Almost every healthcare facility is attempting to become more responsive to customers, both patients and “internal” customers such as staff. Patients often now have a choice of healthcare providers, and staff are costly to replace. Despite these trends, many visits miss some key customer groups such as inpatients, outpatients, visitors, line staff, and maintenance staff. It is very important that these groups or people who have close contact with them be represented in visits.

A DESIGNER PROVIDING TOO MUCH DIRECTION DURING A DESIGNERCLIENT VISIT

In an effort to control the outcome, a designer may attempt to ask most of the questions during interviews. In addition to the problem of focusing exclusively on “selling” ideas described above, clients do not like to feel that their role is usurped.

MISSING OPPORTUNITIES FOR TEAM BUILDING

Teams are most effective when everyone understands the values, goals, expertise and specific roles of others on the team. Teams are also most effective when the team understands the process and resources of the team, the nature of the final product, how the final product will be used: who will evaluate it, and by what criteria the success of the product will be evaluated. Although management consultants routinely recommend making such issues explicit at the beginning of team building, we found few visit teams that deal with these issues directly. Many teams do not even get together before a visit to discuss these issues.

NOT ATTENDING TO CREATING A COMMON LANGUAGE

Multidisciplinary design teams often speak different professional languages and have different interests and values. Designers are used to reading plans and thinking in terms of space and materials; healthcare administrators are used to thinking in terms of words and operational plans. Unless a field visit team is conscious about making links between space and operations, there can be little opportunity to establish agreement.

LACK OF AN ACCESSIBLE VISIT REPORT

Most current visits produce no report at all; some produce at least a compilation of handwritten notes. We heard a repeated problem: no one could remember where they saw a given feature.

CHAPTER 1:  MAJOR TASKS

The healthcare facility visit process has three major phases, divided into specific team tasks that are conducted before, during, and after a visit. These phases, and the 13 major tasks that comprise them, are below. The process we propose is quite straightforward, but compared to most current visits it is more deliberate about defining goals, thinking through what will be observed, preparing a report, and being clear about the implications of the visit for the current design project.

PREPARATION

TASK 1. SUMMARIZE THE DESIGN PROJECT

In this task the project leader or others prepare a brief description of the goals, philosophy, scope, and major constraints overview of the design project that the visit is intended to aid. It should include the shortcomings that the design project is to resolve: space limitations, operational inefficiencies, deferred maintenance, etc.

The overview helps focus the facility visit, and can be provided to the host sites to help them understand the perspective of the visit. This summary should be brief, only a few pages of bulleted items, but should clearly identify the strategic decisions the team is facing. For example, a team may be considering whether to develop a freestanding or attached woman’s pavilion. It is also important to identify key operational questions in the project summary. Focusing on design solutions too early may distract the team from more fundamental questions that need to be resolved. The purpose of the summary is to establish a common understanding of goals, build a common understanding of constraints, and allow the visit hosts to prepare for the visit.

The summary of the design project may focus on several topics:

• How do these critical purposes link to key business imperatives, such as “broadening the base of patients” or “allowing nurses to spend more time delivering patient care”?
• What measurable or observable aspects of the design relate to these key purposes? For example, one team may be interested in whether carpeting leads to increased cleaning costs or increased infection rates; another team may be interested in visitor satisfaction with a self-service gift shop.

Key issues in summarizing the design project:

• It should identify the full range of stakeholders who affect the current design.

Note: Many visits ignore this critical up-front work. Depending on the schedule and scope, the summary can be circulated to the team in advance of the brainstorming meeting.

TASK 2. PREPARE BACKGROUND BRIEF

More than most building types, healthcare facilities have a large body of literature providing descriptions of new trends, research, design guidelines, and post-occupancy evaluations. Many design firms and healthcare organizations have this material in their library or can get it from local universities or medical schools. In this task the visit organizer creates a file of a few key articles or book chapters describing the issue or facility type being visited. These are then distributed to the team, allowing all team members to have at least a minimal current understanding of operations and design.

The team leader also prepares an Issues Worksheet. This is a one-page form that is distributed along with the Background Brief to all members of the visit team prior to their first meeting. (See Figure 2 for a sample Issues Worksheet.) It encourages them to jot down what is important to them, and to discuss issues with their coworkers. It works most effectively when the visit organizer adds some typical issues to help them think through the problem. Participants should be encouraged to bring the Worksheet with them to the team meetings.

Key issues in preparing the Background Brief:

• Providing a few current background articles on the kind of department, facility, or process being visited helps create at least a minimum level of competence for the team and helps establish a common vocabulary prior to the visit.
• The Issues Worksheet, along with the Project Summary and Background Brief, allows participants to develop a picture of the project and to brainstorm ideas.

TASK 3. PREPARE DRAFT WORK PLAN AND BUDGET

Once the team leader or others have summarized the design project and prepared the Background Brief, a draft work plan outlining the major components of the field visits can be prepared. At this stage, it is important to establish a tentative budget for the visit. It is also important to make sure that the major components of the draft work plan, such as choosing visit sites and developing critical issues, match the overall goals of the organization and project. The draft work plan provides a tentative structure for the field visits, which can be modified by other team members.

Key issues in preparing the draft work plan:

TASK 4. CHOOSE AND INVITE PARTICIPANTS

The effectiveness of the team is, of course, most directly related to the nature of the participants. Field visit teams are sometimes chosen for reasons such as politics, or as a reward for good service, rather than for their relevance to the project. For healthcare organizations field visit teams are usually most successful if they mix the decision makers who will be empowered to make design decisions with people who have direct experience in working in the area or department being studied. For design firms, teams are often most successful if they include a principal and the project staff. In both of these cases, the team combines an overall strategic view of the organization and project with an intimate knowledge of operational and design details.

Key issues in choosing participants:

• Participants should be chosen with a clear view of why they need to participate and what their responsibility is in planning, conducting and writing up the visit.
• Site hosts say that teams larger than about seven tend to disrupt their operations.

TASK 5. CONDUCT TEAM ISSUES SESSION

It is usually advisable to hold a team meeting early in the visit planning process to: 1) clarify the purposes and general methods of the field visit; 2) build an effective visit team by clarifying the perspective and role of each participant; 3) ‘identify potential sites, if the visit sites have not already been selected. Some resources and methods to select sites are discussed further in the next section, “Critical Issues in Conducting Facility Visits.”

The issues session is often a “structured brainstorming” meeting aimed at getting a large number of ideas on the table. (This is particularly important during departmental and general visits, and if team members don’t know each other.) The purpose is opening the range of possible issues rather than focusing on a single alternative.

This meeting is typically aimed at building a common sense of purpose for all team members, rather than marketing a preconceived idea. This meeting also serves the purpose of making critical decisions regarding the choice of sites and identifying who at the sites should be contacted.

Each participant should bring his or her Issues Worksheet along to the meeting. The initial task is to get all questions and information needs onto a flip chart pad or board before any prioritization goes on. Then the leader and group can sort these into categories and discuss priorities. These categories and priorities may be sorted in the form of lists which include: 1) a list of critical purposes of the departments or features being designed; 2) a list of critical purposes of the departments or features being evaluated at each facility during visits; 3) a list of existing and innovative design features relevant to these purposes. The critical purposes of the departments or design features at existing facilities can be charted at different spatial levels of the facilities, such as: site, entrance, public spaces, clinical spaces, administrative and support areas. Some typical architectural design issues are provided in the appendix.

The issues session may be run by the leader or the facilitator. Because one of the purposes of this meeting is to get balanced participation, it may be useful to have someone experienced in group process run the meeting, rather than the leader. His or her job is to make sure everyone participates, allowing the leader to focus on content.

This meeting may also provide an early opportunity to identify potential problems in conflicting goals, values or personalities on the team. For instance, a healthcare facility design project may have significant conflicts between departments, or between physicians and administrators. The meeting may also allow the team to agree on basic business imperatives and to be clear about the constraints that are of greatest importance to them, such as “never having radioactive materials cross the path of patients.”

Key points in running an issues session:

• Everyone should be able to participate without feeling “dumb.”
• The leader and group should try to understand the range of interests and priorities represented.
• Brief notes of the meeting should be distributed to all participants.

Note: This meeting is successful if participants feel they can express ideas, interests, and concerns without negative consequences from other members of the team. There is no such thing as a stupid question in this meeting.

TASK 6. IDENTIFY POTENTIAL SITES AND CONFIRM WITH THE TEAM

Based on the work plan which established the visit objectives and the desires, interests and budget of the team, the visit organizer chooses potential sites, and checks with the team. If possible, he or she provides some background information about each site to help the team make decisions.

The team may know of some sites they would like to visit, and these might have emerged in the issues session. Otherwise there are a range of sources for finding appropriate sites to visit: national organizations such as the American Hospital Association, as well as the American Institute of Architects Academy on Architecture for Health Facilities, and a range of magazines that discuss healthcare facilities. (See the section below entitled “Choosing Sites.“)

Different teams pick sites for different reasons. Some may pick a site because it is the best example of an operational approach such as “patient-focused care.” Others may look for diversity within a given set of constraints, such as different basic layouts of 250-bed inpatient facilities.

Many visit leaders complain that the team sometimes is distracted by features outside the focus of the tour, and particularly by poor maintenance. Wherever possible, it is advisable for the visit organizers to tour the site in advance of the group visit and to brief the hosts in person about the purposes of the visit. Although it is rare, some sites now charge for visits.

A key issue in choosing sites:

• The selection of sites should challenge the team to think in new ways.

Note: Sites are often chosen to provide a clear range of choices within a set of constraints provided by operations, budget, or existing conditions, such as “different layouts of express emergency departments” or “different designs of labor-delivery-post-partum-recovery rooms.”

TASK 7. SCHEDULE SITES AND CONFIRM AGENDA

The leader or facilitator calls a representative at each host site to schedule the visit. He or she confirms the purposes of the visit, confirms with the host sites the information needed before and during the field visit, and confirms who will be interviewed at the site. Healthcare facilities are sometimes more responsive to a request for a visit if they are called by a healthcare professional or administrator rather than a designer: if someone on the team knows someone at a site, he or she may want to make the first phone call. Many teams also find that if they arrange for a very brief visit, this may be extended a bit on site when the hosts become engaged with the team. When confirming the schedule for the visit with the host facilities, the visit organizer should specify that the visit team would prefer to interview people familiar with the daily operations of the department or site.

Key issues in scheduling sites:

Note: Sites are often proud of their facilities and often enjoy receiving distinguished visitors. However, they often find it difficult to arrange interviews or assemble detailed information on the spot.

TASK 8. PREPARE FIELD VISIT PACKAGE

Visits are more effective if participants are provided a package of information in advance: information about schedule, accommodations, and contact people; information about each site, including, where possible, brief background information and plans; a simple form for recording information; and a “tickler” list of questions and issues.

a) Prepare visit information package

The organizers should provide participants information about the logistics of the field visit: schedules, reservation confirmation numbers, phone numbers of sites and hotels.

b) Prepare site information package

The site information package orients participants to the site in advance of the visit. Depending on what information is available, it may include: plans and photos of each site; basic organizational information about the site (client name and address, mission statement, patient load, size, date, designers, etc.); description of special features or processes or other items of interest. Whereas measured plans are best, these are not often available. Fire evacuation plans can be used. A sample site information package is provided in the Appendix. Many teams find it useful to review job descriptions for the host site, and many organizations have these readily available.

c) Prepare Visit Worksheet

Facility visits are often overwhelming in the amount of information they present. It is useful for the organizers to provide the participants with a worksheet for taking notes. We have provided a sample worksheet as Figure 3 below, and blank forms are provided in the Appendix. The purpose of the checklist is to remind participants of the key issues and to provide a form that can easily be assembled into the trip report.

Note: A successful worksheet directs participants to the agreed-upon focal issues without burdening them with unnecessary paperwork. Participants should understand the relationship between filling out the checklist and filling out the final report.

FACILITY VISIT

TASK 9. CONDUCT FACILITY FIELD VISIT

The actual site visit typically includes: 1) an initial orientation interview with people at the site familiar with the department or setting being investigated; 2) a touring interview where the team, or part of it, visits the facility being investigated with someone familiar with daily operations, asking questions and observing operations; 3) recording the site; 4) conducting a wrap-up meeting at the site. (Each of these steps is discussed individually below.) The interview sessions are focused on helping the team understand a wider range of implications and possibilities. If appropriate, the wrap-up session may also be used for focusing on key issues that move the design along.

Note: Participants often like to speak to their counterparts: head nurse to head nurse, medical director to medical director, etc., although everyone seems to like to talk to people directly involved with running a facility such as a head nurse. People who know daily operations are often more useful than a high-level administrator or public relations staff member.

a) Conduct site orientation interview

During the orientation interview the visit team meets briefly with a representative of the site to get an overall orientation to the site: layout and general organization; mission and philosophy; brief history and strategic plans; patient load; treatment load; and other descriptions of the site. Many teams are also interested in learning about experiences the healthcare organization had with the process of planning, design, construction and facility management: What steps did they use? What innovations did they come up with? What problems did they encounter? What are they particularly proud of? What do they wish they had done differently?

b) Conduct a touring interview

The touring interview was developed by a building evaluation group in New Zealand and by several other post-occupancy evaluation researchers and practitioners. (See the post-occupancy evaluation section of the Bibliography.) In the touring interview, the team, or a portion of it, visits a portion of the site to understand the design and operations. Conducting an interview in the actual department being discussed often brings a vividness and specificity that may be lacking in an interview held in a meeting room or on the phone. One of the great strengths of the touring interview is the surprises it may bring, and the option it provides to consider new possibilities or to deal with unanticipated problems. As a result, it often works best to start with fairly open-ended questions:

• What works well here? What works less well?
• What are the major goals and operational philosophy of the department?
• What is the flow of patients, staff, visitors, meals, supplies, records, laundry, trash?
• Can they demonstrate a sample process or procedure, such as how a patient moves from the waiting room to gowning area to treatment area?
• What are they most proud of?
• What would they do differently if they could do it over?

These questions also provide a nonthreatening way to discuss shortcomings or issues that are potentially controversial. The team may then want to focus on the specific concerns that were raised in the issues session.

A difficult, but critically important, thing to avoid in a touring interview is to become distracted by idiosyncratic details of the site being visited. Often operational patterns or philosophy are more important than specific design features that will not be generalized to a new project: how equipment is allocated to labor-delivery-recovery-postpartum rooms in the site being visited may be more important than the color scheme, even though the color may be more striking.

Large multidisciplinary teams are particularly hard to manage during a touring interview. A given facility may have a state-of-the-art imaging department that is of great interest to the radiologists on the team but may have a mediocre rehabilitation department. In these cases, some of the touring interviews may be focused on “what the host would do differently next time.”

Key issues in conducting the touring interview:

Note: It is important to include people familiar with daily operations on the touring interview, both on the team side and on the side of the site being visited. A frequent problem is that some stakeholder groups such as patients or visitors are not represented; special efforts should be taken to understand the perspectives of these groups.

c) Document the visit

The goals of the visit dictate the kinds of documentation that are appropriate. However, most visits call for a visual record, sketches, and written notes.

In most cases it is useful to designate one or more “official” recorders who will assemble notes and be sure photos are taken, measurements made, plans and documents procured, etc. For designer-client visits, it is often useful to have at least two official recorders to look after both design and operational concerns. However, because a team often splits up, most or all participants may need to keep notes.

It is quite rare for teams to use video to record their visit, although this seems to be increasing in popularity. Editing videos can be very costly: it may take a staff member several person-days in a professional editing facility to edit several hours of raw video down to a 10- or 15- minute length. However, this time may be reduced with the increased availability of inexpensive microcomputer-based editing programs.

Key issues in recording the facility:

Many departmental and general visit teams find it useful to photographically record key flows, such as patients, staff and supplies, and location of waiting rooms and other patient amenities.

Note: If the method of creating the documentation is established in advance it can easily be assembled into a draft report.

d) Conduct on-site wrap-up meeting

Whereas the visit interview is focused on opening options for the team and identifying new problems and issues, the wrap-up meeting is often more focused on clarifying how lessons learned on the visit relate to the design project, and how they begin to answer the questions the team established. It is often useful to have a representative of the host site present at the wrap-up meeting to answer questions, if their time allows.

Key issues in conducting wrap-up meetings:

TASK 10. ASSEMBLE DRAFT VISIT REPORT

A draft visit report may take many different formats. The simplest is to photocopy and assemble all participants’ worksheets and notes, retyping where necessary. Alternatively, the organizers or a portion of the team may edit and synthesize the worksheets and notes. Though more time consuming, this usually results in a more readable report. A somewhat more sophisticated version is to establish a database record that resembles the form used to take notes on-site in a program such as FoxPro, Dbase, or FileMaker Pro. Participants’ comments can be typed into the database and sketches and graphics can be scanned in and attached.

These are then provided to all participants.

A key issue in assembling the draft report:

• Simplicity is often best; simply photocopying or retyping notes is often adequate, especially if photos and sketches are attached.

TASK 11. CONDUCT FOCUS MEETING

Upon returning home, the team conducts a meeting to review the draft trip report and to ask:

Unlike the issues session held early in the visit planning process, which was primarily concerned with bringing out a wide range of goals and options, this meeting is typically more aimed at establishing consensus about directions for the project.

A key issue in conducting the focus meeting:

• The purpose of the focus meeting is to establish the lessons learned for the design project.

Note: The leader should carefully consider who is invited to the focus meeting. This may include others from the design firm, consultants, healthcare organization, or even representatives from the site.

TASK 12. PREPARE FOCUS REPORT

The focus report briefly summarizes the key conclusions of the visit for the visit team and for later use by the entire design team. It is an executive summary of the visit report which may provide a number of pages of observations and interview notes.

Key issues in preparing the focus report:

• The focus report should be a clear, brief, jargon-free summary.

TASK 13. USE DATA TO INFORM DESIGN

The key purpose of a facility visit is to inform design. Whereas this can occur informally in subsequent conversations and team meetings, it is best achieved by also being proactive. For example, the team can:

Key issues in using data to inform design:

• Reports and materials collected on visits should be available to all participants in the design process and should be on hand during subsequent meetings. A central archive of materials should be available and should be indexed to allow easy access for people involved in future projects.

CHAPTER 2:  TOOL KIT

TASK CHECKLIST

The team leader prepares a brief summary of the goals, philosophy, scope, and major constraints of the design project to help focus the field visit.

• Prepare a list of design or operational features related to these critical purposes.

The team leader prepares a file of a few key articles or book chapters that provide descriptions of new trends, research, design guidelines and post-occupancy evaluations of the facility type, department or issue being studied. He or she also prepares Issues Worksheets for team members to make notes on prior to the initial issues brainstorming session.

• Assemble current literature on existing facilities. Prepare the Issues Worksheet.

The draft work plan clarifies the values, goals, process, schedule and resources of the visits.

In this task the team leader builds a team. The ideal team combines a view of the overall strategic perspective of the organization and project with an intimate knowledge of daily operations.

The team issues session has three purposes: 1) clarify the purposes and general methods for the field visit; 2) build an effective team; 3) identify potential sites. The issues session is often a “structured brainstorming” meeting aimed at getting a large number of ideas on the table, and at understanding the various perspectives of the team.

• Clarify the resources available to the team and the use of the information collected.

TASK 6. IDENTIFY POTENTIAL SITES AND START FACILlTY VISIT PACKAGE

Based on visit objectives and the desires, interests and budget of the team, the visit organizers choose potential sites and check with the team. If possible they provide some background information about each site.

• If field investigation sites are already selected, provide fact sheets about each site to the participants.

In this task, the purposes and schedule of the visit are confirmed with the sites. This should occur at least two weeks before the visit.

The field investigation package includes the following components, which are used for conducting the visit:

• Tour information package (tour itineraries, transportation and accommodation details, list of contact people at each facility).
• Site information package (description of the sites, background information, facility plans).
• Site Visit Worksheets for notetaking.

TASK 9. CONDUCT FIELD VISIT

The interview sessions are focused on opening: helping the team understand a wider range of implications and possibilities. If appropriate, the wrap-up session may also be used for focusing on key issues that move the design along. Conduct site orientation interview.

• Collect any additional information from the host site.
• Conduct touring interview with people familiar with daily operations and a range of stakeholders.
• Document the visit through notes, sketches and photos.
• Conduct on-site wrap-up meeting with team members.

The draft report is a straightforward document allowing others to benefit from the investigation and providing the team a common document to work from.

The team conducts a focus meeting to ask: What are the major lessons of the investigation? What does it tell the team about the current project?

The Focus Report briefly summarizes the key conclusions of the visit for the visit team and for later use by the entire design team. It is an executive summary of the Visit Report which may provide a number of pages of observations and interview notes.

• Prepare and distribute a brief Focus Report.

The purpose of this document is to inform the design process.

• Write a brief newsletter about the design project that includes key findings from the visit.

SAMPLE FACILITY FACT SHEET (see PDF version)

CHAPTER 3:  CRITICAL ISSUES IN CONDUCTING FACILITY VISITS

Selecting visit sites.

One of the most important steps in conducting healthcare facility visits is the selection of appropriate sites. However, there is no single source of information on healthcare facilities, and site selection is not an easy task. It is difficult to locate sites with comparable features in terms of workload, size, budget, operational facilities and physical features. Without this information, the tendency is to choose sites based on other criteria, such as location and proximity, or the presence of a friend or former coworker at specific host facilities.

However, depending on the nature of the facility visit, there are several resources that can be consulted for site selection. Some healthcare and design professional associations periodically publish guides and reference books which are helpful in selecting sites for facility visits. The following sources can be referred to before selecting specific facilities for field visits:

NATIONAL HEALTHCARE ASSOCIATIONS

American Hospital Association (AHA) AHA Resource Center, Chicago, (312) 280-6000

AHA database for healthcare facilities in the state of Missouri. : Missouri Hospitals Profile . Listed price: $27.50.

AHA Guide to locating healthcare facilities in the US . The listed facilities are classified according to the city/county with a coded format for the number of beds, admission fee, etc. Listed price: $195 for nonmembers and $75 for members.

AHA Health Care Construction Database Survey . Contact Robert Zank at the AHA Division of Health Facilities Management, (312) 280-5910.

Association of Health Facilities Survey Agency (AHFSA) Directory of the Association of Health Facilities Survey Agency. AHFSA, Springfield, IL.

National Association of Health Data Organizations (NAHDO) Some states collect detailed hospital-level data. To obtain information on states with legislative mandates to gather hospital-level data, contact Stacey Carman at 254 B N. Washington Street, Falls Church, VA 22046-4517, Telephone: (703) 532-3282, FAX: (703) 5323593.

NATIONAL ASSOCIATIONS FOR DESIGN PROFESSIONALS

American Institute of Architects (AIA) AIA Academy on Architecture for Health 1735 New York Avenue NW Washington, DC 20006

(202) 626-7493 or (202) 626-7366, FAX (202) 626-7587 To order AIA publications: (800) 365-2724

Hospital Interior Architect .

Hospital and Health Care Facilities, 1992. Listed price: $48.50 for nonmembers; 10% discount for members off listed price.

Hospitals and Health Systems Review, July 1994. Listed price: $12.95 for nonmembers; 30 % discount for members off listed price.

Hospital Planning . Listed price: $37.50 for nonmembers; 10% discount for members off listed price.

Hospital Special Care Facility , 1993.

Organizational Change: Transforming Today’s Hospitals, January 1995: Listed price: $36.00 for nonmembers; 30% discount for members off listed price.

Health Facilities Review (biannual), 1993. Listed price: $20 for nonmembers; $14 for members.

PERIODICALS DESCRIBING SPECIFIC HEALTHCARE FACILITIES

Modern Healthcare. This national weekly business news magazine for healthcare management is published by Crain Communication, and holds annual design awards. In conjunction with AIA Academy of Architecture for Health, this periodical announces annual competition and honors architectural projects that build on changes in healthcare delivery. Contact Joan Fitzgerald or Mary Chamberlain at 740 N. Rush Street, Chicago IL 60611-2590, (312) 649-5355.

American Hospital Association Exhibition of Architecture for Health , 1993.

For further information contact Robert Zank at the Division of Health Facilities Management, (312) 280-5910.

Journal of Healthcare Design . This journal illustrates 20-40 exemplary healthcare facilities in each

annual issue. Free list of previously-toured exemplary facilities (available by calling The Center).

Æsclepius . Æsclepius is a newsletter discussing a range of design issues relevant to healthcare facilities.

TEAMBUILDING

Many people who conduct healthcare facility field visits use them as a way to build an ongoing design team. This is particularly true of designer-client-consultant teams who conduct visits early in a design project. According to organizational researcher and consultant J. Richard Hackman, 1 teams often spend too much time worrying about the “feelgood” aspects of interpersonal relationships and not enough time focusing on other key issues such as choosing the right people for the team, making roles and resources clear, specifying final products, and clarifying how the final product will be used.

Participants are often chosen because they are upper-level administrators or because they deserve the perk. It may not be clear what their function is on the visit or how they would contribute to any later decision making about the design project. Likewise, visit teams often don’t know what resources are available to them: Can they visit national sites? Can they call on others to help prepare and distribute a visit report?

• Some key team building steps include:
• Select visit participants with a clear idea of why they are participating and how they can contribute.
• Keep the team small; visit teams of more than seven or eight people are hard to manage.
• Provide each participant a clear role before, during and after the actual site visit, and negotiate this role to fit their interests and skills. Roles should be clearly differentiated and clear to all participants.
• Make the final product clear: simple photocopying and assembly of notes and photos taken during the visit; brief illustrated written report; videotape, etc.
• Clarify how the visit findings are to be used: what key decisions are the major focus?

ROLES IN CONDUCTING FACILITY VISITS

There are several key roles in the process. Depending on the size of the team and the nature of the visit, each role may be taken on by a different person, or they may be combined.

LEADERSHIP TASKS:

• Restate current need and parameters of the design project.
• Develop some background information on the issues or setting types being investigated, and distribute to team members.
• Conduct a brainstorming meeting to understand the expertise, interests, values, and goals of each team member.
• Identify potential visit team members, and invite them.
• Summarize the goals of the design project, clarify how the field visit might advance these goals, and communicate these to the team.
• Identify roles for each team member.
• Develop a work plan and budget.
• Clarify the criteria for choosing sites.
• Prepare and/or review major documents: site-specific protocols; checklists and lists of questions and issues; information about each site being visited; overall plan for the visit; visit report; focus report.
• Conduct wrap-up meeting at each site.
• Conduct focus meeting on returning home.

SUPPORT TASKS:

• Assemble a few key articles or other documents to help the team understand the key issues in the setting types, processes or departments being visited.
• Identify potential sites, with some information about each site candidate so the leader and team can make final choices.
• Confirm with sites, and clarify what information the team will need in advance and what will be collected during the visit.
• Prepare draft materials (Background Brief, site information package, visit information, interview protocol) for review by the leader.
• Organize any trip logistics that are not done individually by participants: car rentals, hotel reservations, air tickets, etc.
• Write thank-you letters to site participants.
• Prepare a Draft Visit Report for review by the leader and team.
• Draft a Focus Report for review by the leader and the team.

FACILITATION TASKS:

When the team is attempting to get broad input into the process, such as when the team meets initially to set direction, it is often useful to have someone run the meeting who has the role of simply looking after the process of the meeting, rather than the content. He or she is charged with making sure that everyone is heard without prejudice, and that all positions are brought out. It often works poorly to have a senior manager in this role. Even if he or she has good facilitation skills, it is intimidating for many people to speak up in a meeting led by their boss.

Specific tasks:

• Conduct the initial brainstorming session that establishes the direction, issues and roles for the visit.
• Conduct any additional sessions where balanced participation is important to increasing the pool of ideas or getting “buy-in” from all team members.

RECORDER TASKS:

During the actual site visit, one or more people are typically charged with maintaining the “official” records of the visit (individuals may keep their own notes as well). This may include written notes, audio or video records, or photographs. If the team breaks up during the visit, a recorder should accompany each group.

Specific tasks include:

• Procure any required recording devices and supplies, such as cameras, tape recorders, paper forms, etc.
• Make records during the visit.
• Edit the record and assemble into a report.

TEAM PARTICIPANTS TASKS:

INTERVIEWING

Interviews vary greatly in the amount of control exercised by the interviewer in choosing the topic for discussion and in structuring the response. An intermediate level of control over topic and responses, often called a “structured interview,” is usually appropriate in a facility visit. In a structured interview, the interviewer has an interview schedule which is a detailed list of questions or issues which serves as a general map of the discussion. However, the interviewer allows the respondent to answer in his or her own words and to follow his or her own order of questioning if desired. The interview is usually aided by walking through the setting or by having plans or other visual aids during seated sessions.

The use of fixed responses, in which respondents have to choose a “best” alternative among several presented, allows rapid analysis of results and may be appropriate if a large number of people are interviewed during a visit. The cost-effectiveness of interviews needs to be considered by the architect or manager when designing the process. Individual interviews are useful because people being questioned may be more forthcoming than if friends or colleagues are present.

However, individual interviews are expensive. With scheduling, waiting time, running the interview, and coding, a brief individual interview may involve several hours or more of staff time.

In summary, interviews are valuable because people can directly communicate their feelings, motives and actions. However, interviews are limited by people’s desire to be socially desirable or by their faulty memories, although these problems may not be too serious unless the questions are very sensitive.

CHAPTER 4:  CONCLUSIONS

Unfortunately, many design processes do not do a good job at controlling risks, costs, and inefficiencies. A design project may have a big influence on the future of an organization, but critical operational and design decisions often receive too little attention. And problems or new ideas are often discovered very late in a design process, when they are difficult and costly to accommodate. It is not hard to understand the source of these difficulties. The crises of everyday life go on unabated during design and distract people from design, short-term politics continue, and many people are comfortable with what they already know. Many design team participants representing healthcare organizations want to reproduce their existing operation, even if they can recognize its flaws.

A healthcare design team is too often more like a raucous international meeting than like an effective task-oriented organization. Participants speak different professional languages, have different experiences, have different short-term objectives, hold different motivations for participating, and hold different values about what constitutes a successful project. The team may be far into a project before it understands the different viewpoints represented on the team.

A facility visit is a unique opportunity to address some of these problems. It provides an extended opportunity for a design or planning team to get together outside the pressures of daily life, to critically examine the operations of an excellent facility, to rethink its own ideas, and to build the basis of a team that may function for several years. It is often the longest uninterrupted time a team ever spends together, and the best chance to think in new ways.

A visit has three goals: to establish a situation for effective critical examination of state-of-the-art operations and facilities; to think about the project in new ways; and building a team. These goals are intertwined. A well-structured facility visit may help build a team more effectively than an artificial “feel-good” exercise of mountain climbing or simulated war games. A team that looks at a facility from different perspectives, and in which participants forcefully argue their viewpoint based on evidence from a common visit, can learn each other’s strengths, preferences, and priorities quickly and in a way that builds a bond that is closely related to their own project.

Many teams, however, do not provide enough structure for either critical examination or team building. Critical examination requires an understanding of what key issues are to be examined and how they might apply to the current design problem. Team building requires that a team clearly establishes the role of each team member, makes the resources, process, and schedule clear, is explicit about the form and use of the final report, and establishes a common language.

Healthcare designers and consultants can develop better facility visits, but the responsibility for improving this practice rests with healthcare clients. For a visit to reach its potential, clients must demand an improved process, hold the organizer accountable-and be willing to pay for it. The healthcare client must see design and planning as a process open to mutual learning, and make it happen.

APPENDIX A: BIBLIOGRAPHY

See PDF version for bibliography.

APPENDIX B: EXEMPLARY MICRO-CASES

See PDF version for micro-cases.

Copyright © 1994 by The Center for Health Design, Inc. All rights reserved. No part of this work covered by the copyright herein may be reproduced by any means or used in any form without written permission of the publisher.

The views and methods expressed by the authors do not necessarily reflect the opinions of The Center for Health Design, or its Board, or staff.

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Unplanned Hospital Visits, Complications, and Deaths

Outcome measures indicate what happened after patients with certain conditions received hospital care. The mortality rates focus on whether patients died within 30 days of their hospitalization. The rates of readmission focus on whether patients were hospitalized again within 30 days. Mortality rates and rates of readmission are indications of a hospital's effectiveness in preventing complications, instructing patients at discharge, and enabling patients to make a smooth transition to their home or another setting such as a nursing home.

The hospital mortality rates and rates of readmission are based on people with Medicare who are 65 and older. These rates are calculated using Medicare enrollment and claims records, and a complex statistical procedure. The mortality rates and rates of readmission are "risk-adjusted" (i.e. the calculations take into account how sick patients were when they went in for their initial hospitalization). When the rates are risk-adjusted, it helps make comparisons more meaningful.

Mortality Rates

The 30-day death (mortality) measures are estimates of deaths from any cause within 30 days of a hospital admission, for patients hospitalized with one of several medical conditions or surgical procedures. The 30-day death rate for coronary artery bypass graft (CABG) surgery patients measure counts deaths from any cause within 30 days of the date of the surgery date. Deaths can be counted in the measures regardless of whether the patient dies while still in the hospital or after discharge. CMS chose to measure death within 30 days instead of inpatient deaths to use a more consistent measurement time window because length of hospital stay varies across patients and hospitals. Also, death over longer time periods (like 90 days) may have less to do with the care gotten in the hospital and more to do with other complicating illnesses, patients' own behavior, or care provided to patients after hospital discharge. Hospital Compare reports on the following 30-day mortality measures:

• coronary artery bypass graft (CABG) surgery
• heart attack (acute myocardial infarction [AMI])
• heart failure (HF)

A hospital's mortality rates are compared with U.S. National rates to determine whether patients admitted to the hospital have mortality rates that are lower (better) than the U.S. National rate, about the same as the U.S. National rate, or higher (worse) than the U.S. National rate, given how sick they were when they were admitted to the hospital. For some hospitals, the number of cases is too small (fewer than 25) to reliably tell how well the hospital is performing, so no comparison to the national rate is shown.

Unplanned Hospital Visits

Readmission rates are calculated from Medicare data and do not include people in Medicare Advantage plans or people who do not have Medicare. A "readmission" occurs when a patient who had a recent hospital stay needs to go back into a hospital again within 30 days of their discharge. Patients may have been readmitted back to the same hospital or to a different hospital or acute care facility. They may have been readmitted for the same condition as their recent hospital stay, or for a different reason.

Readmission rates are calculated for specific categories of patients and a hospital's rates of readmission are compared to the U.S. National Rate. For some hospitals, the number of cases is too small (fewer than 25) to reliably tell how well the hospital is performing, so no comparison to the national rate is shown.

Hospital Return Days is a measure of the average number of unplanned days patients spend back in the hospital soon after they are discharged. Hospital Return Days include time spent in the emergency department, under observation, or in an inpatient hospital unit. Hospital Return Days are calculated for specific categories of patients.

Admissions and ED Visits for Patients Receiving Outpatient Chemotherapy is a measure to assess the care provided to cancer patients and reduce the number of potentially avoidable inpatient admissions and ED visits among patients receiving outpatient chemotherapy. Potentially preventable clinical conditions that are frequent side effects of chemotherapy include anemia, dehydration, diarrhea, emesis, fever, nausea, neutropenia, pain, pneumonia, or sepsis.

Hospital Visits after Outpatient Surgery is a measure of the predicted to expected number of all-cause, unplanned hospital visits within 7 days of a same-day surgery. There are well-described and potentially preventable adverse events that occur after outpatient surgery, which can result in unanticipated hospital visits. Similarly, direct admissions after surgery that are primarily caused by non-clinical patient considerations, such as lack of transport home upon discharge, or facility logistical issues, such as delayed start of surgery, are common causes of unanticipated yet preventable hospital admissions following same-day surgery.

Surgical Complications

A CMS measure for complications of hip/knee replacements is an estimate of complications within an applicable time period, for patients electively admitted for primary total hip and/or knee replacement. CMS measures the likelihood that at least 1 of 8 complications occurs within a specified time period. CMS chose to measure these complications within the specified times because complications over a longer period may be impacted by factors outside the hospitals' control like other complicating illnesses, patients' own behavior, or care provided to patients after discharge. This measure is separate from the serious complications measure (and is based on the following potential complications:

• Heart attack (acute myocardial infarction [ AMI ]), pneumonia, or sepsis/septicemia/shock during the index admission or within 7 days of admission;
• Surgical site bleeding, pulmonary embolism, or death during the index admission or within 30 days of admission; or
• Mechanical complications or periprosthetic joint infection/wound infection during the index admission or within 90 days of admission.

Other measures of surgical complications are drawn from the Agency for Healthcare Research and Quality ( AHRQ ) Patient Safety Indicators ( PSIs ). The overall score for serious complications is based on how often adult patients had certain serious, but potentially preventable, complications related to medical or surgical inpatient hospital care. This composite or summary measure is based on the following measures:

• Pressure sores (pressure ulcers)
• Collapsed lung that results from medical treatment (Iatrogenic pneumothorax)
• Infections from a large venous catheter (central venous catheter-related blood stream infection)
• Broken hip from a fall after surgery (postoperative hip fracture)
• Blood clots, in the lung or a large vein, after surgery (perioperative pulmonary embolism or deep vein thrombosis)
• Blood stream infection after surgery (postoperative sepsis)
• A wound that splits open after surgery (postoperative wound dehiscence)
• Accidental cuts and tears (accidental puncture or laceration)

Healthcare Associated Infections

The healthcare-associated infection (HAI) measures show how often patients in a particular hospital contract certain infections during the course of their medical treatment, when compared to like hospitals. These infections can often be prevented when healthcare facilities follow guidelines for safe care. To get payment from CMS, hospitals are required to report data about some infections to the Centers for Disease Control and Prevention's (CDC's) National Healthcare Safety Network (NHSN). Information for CMS reporting is currently collected through NHSN about central line-associated bloodstream infections, catheter-associated urinary tract infections, surgical site infections, MRSA Bacteremia and C.difficile laboratory-identified events.

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Definition of outpatient

Examples of outpatient in a sentence.

These examples are programmatically compiled from various online sources to illustrate current usage of the word 'outpatient.' Any opinions expressed in the examples do not represent those of Merriam-Webster or its editors. Send us feedback about these examples.

Word History

1715, in the meaning defined above

Dictionary Entries Near outpatient

Cite this entry.

“Outpatient.” Merriam-Webster.com Dictionary , Merriam-Webster, https://www.merriam-webster.com/dictionary/outpatient. Accessed 21 May. 2024.

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Tips to avoid trouble with subsequent hospital visit codes

If you overuse level 3 codes to describe hospitalized patients, you may attract the attention of federal auditors

Published in the September 2004 issue of Today’s Hospitalist

As a hospitalist, using the ever-popular subsequent hospital visit codes (CPT 99231-99233) can be a daunting task. While choosing the correct code is confusing for physicians, subsequent visit codes can attract the attention of the Office of Inspector General (OIG). Unless you know how to use these correctly “particularly the level 3 codes “you could be setting yourself up for problems in the future.

Related article: Updated ICD-9 Codes for 2012-2013

In this article, I’ll provide a primer on how to use subsequent hospital visit codes, along with tips to steer clear of increasing scrutiny from federal regulators.

Level 3 codes

If there is one point you should take away from this article, it is this: Hospitalized patients who are stable or improving do not meet the requirements for the highest level subsequent hospital care code, CPT 99233. This code was not meant to describe a “courtesy visit”.

Critical care codes not only provide higher reimbursement, but they better reflect the services you’re providing.

Unless your hospitalized patient’s condition is deteriorating or critical (which should be indicated by appropriate diagnosis codes), you should use either a level 1 (99231) or level 2 (99232) code. This means that patients who are recuperating in the hospital ” a large number of your patients “likely qualify for low to moderate visits.

Exactly when can you use CPT 99233? CPT lists the elements you need to qualify for each of these codes. (See “CPT criteria for subsequent hospital visit codes,” this page, for a full list of criteria for all three levels of service.)

For the highest level subsequent hospital visit code, for example, you need to meet or exceed two of the three following elements: a detailed history (four-plus elements in the HPI and two to nine elements in the ROS), a detailed exam (five to seven elements), and a high complexity of medical decision-making.

In order to establish the process of medical decision-making, you must consider the following elements: number of diagnoses or management options, amount or complexity of data to be reviewed, and risks of complications and/or morbidity or mortality.

After using an admission code, you would typically use the higher levels of subsequent visit codes (99222 and 99233) in the patient’s hospitalization, tapering down to an improved, stabilized patient ready for discharge. Your goal is to improve patients’ health until they are discharged, and your coding should reflect that progress.

However, if the patient’s health takes a turn for the worse “hypertension worsens and requires increased management “you can consider using higher level subsequent hospital visit codes. Once the patient has stabilized, consider using moderate to low levels of service.

If your hospitalized patient becomes critically ill, consider using critical care codes. (When using these codes, remember to document total duration of time.) Critical care codes not only provide higher reimbursement, but they better reflect the services you’re providing. If the patient doesn’t qualify for greater than 30 minutes of critical care time but is still facing serious health issues, consider using 99233.

Other considerations

Here are some other issues to consider when using subsequent hospital visit codes:

• Time. A single provider “or more than one physician from the same group “can’t bill more than one subsequent hospital visit code in a calendar day. You should instead combine the services provided during multiple visits and then bill for the highest level of service you can support through documentation.
• Clustering. When using subsequent hospital visit codes, coding “clusters” will attract the attention of auditors. Clustering occurs when physicians tend to use the similar codes in patterns. An example of this is using an admission code then 99232 every day until the patient is discharged, regardless of the patient’s health. When auditors detect this type of pattern, they are more likely to conduct an audit.
• Concurrent care. Some payers limit the number of physicians that can bill for a subsequent care visit in one day. If a hospitalist, a cardiologist and a pulmonologist all see a patient on a certain day and bill a subsequent hospital visit, the payer may reject one of those codes, depending on how many it allows. It is important to know your payers’ guidelines, as this will avoid any unnecessary denials hindering the reimbursement process.

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Slovakian Prime Minister Robert Fico shot in assassination attempt

The populist prime minister of Slovakia, Robert Fico , was "fighting for his life" Wednesday after he was shot multiple times in an "attempted assassination," his party's officials said.

Slovak Defense Minister Robert Kaliňák told reporters that doctors operated into the evening and that Fico's condition was extremely serious.

"We've experienced a very tragic day, which means the prime minister is fighting for his life," Kaliňák said, according to local reports.

Late Wednesday, Deputy Prime Minister Tomas Taraba offered an update to the BBC, saying Fico was "not in a life-threatening situation at this moment."

Interior Minister Matúš Šutaj Eštok earlier reporters that the gunman shot Fico five times. A suspect was arrested, officials said; a motive was not immediately clear.

Šutaj Eštok said an initial investigation found “a clear political motivation.”

Fico’s Facebook page said he was taken to a hospital in Banská Bystrica rather than in the capital, Bratislava, because "it would take too long considering the urgency of the matter."

At a news conference after the attack , President Zuzana Čaputová confirmed an arrest of a suspect and said police would provide further information.

“Until then, let us not pass quick judgments, please,” she said.

A reporter for the Slovak news agency TASR said several shots were fired in the town of Handlova, about 110 miles northeast of Bratislava. Fico was greeting members of the public after a government meeting, it reported.

Čaputová confirmed the attack on Fico, 59, shortly after the news broke.

“Utterly shocked by today’s brutal and reckless attack on #Slovakia ’s Prime Minister Robert Fico, which I condemn in strongest possible terms,” she said in a message on X . “I wish him lot of strength in this critical moment and early recovery. My thoughts are also with his family and close ones,” she added.

Photos on news agencies showed a man appearing to be detained in Handlova. Video captured at the scene and shared on social media showed another man being carried into a car by security staffers in dark suits.

Fico was elected in October as leader of the leftist Smer party, meaning “direction,” standing on a pro-Russian and anti-American populist platform.

He had already served as prime minister twice before he returned to the role last year as part of a power-sharing deal with two other parties. Fico faced criticism this month as thousands of Slovaks rallied against a plan to overhaul public radio and television in the country of 5.4 million, sparking fears of government control and a shift away from pro-Western ties.

Fico has found common cause with Viktor Orbán , the right-wing authoritarian leader of Hungary, Slovakia's neighbor to the south, in ending support for Ukraine's defense against Russia's invasion and criticizing Western support for Kyiv. Slovakia also shares a border with Ukraine.

Both Ukrainian President Volodymyr Zelenskyy and Russian President Vladimir Putin gave public support to Fico.

Putin said in a letter to Čaputová shared by the Kremlin that the "heinous crime cannot be justified," and Zelenskyy post ed on X that "every effort should be made to ensure that violence does not become the norm in any country, form, or sphere."

President Joe Biden also wished Fico a "speedy recovery" and said in a statement that the U.S. Embassy was in contact with the Slovakian government and "ready to assist."

Ursula von der Leyen, president of the European Commission, the executive body of the European Union, also strongly condemned the attempt on Fico's life.

“Such acts of violence have no place in our society and undermine democracy, our most precious common good,” she said in a post on X .

Slovakia is an E.U. member.

Slovakia’s main opposition parties canceled a planned protest against a plan to overhaul public broadcasting that they say would give Fico's government full control of public radio and television, according to The Associated Press.

“We absolutely and strongly condemn violence and today’s shooting of Premier Robert Fico,” Progressive Slovakia leader Michal Šimečka said. “At the same time we call on all politicians to refrain from any expressions and steps which could contribute to further increasing the tension.”

The country’s incoming president, Peter Pellegrini, a close Fico ally, said the incident represented "an unprecedented threat to Slovak democracy."

He added, "If we express different political opinions with guns in the squares and not in polling stations, we endanger everything we have built together in 31 years of Slovak sovereignty."

Patrick Smith is a London-based editor and reporter for NBC News Digital.

Weekend Director of Platforms, NBC