Table 2 Examples of perceived problems (n = 20)

Phase 1

Problems in patient selection

Eligibility criteria

Late communication of eligibility criteria

Primary care plays an insufficient role in the management of (unbalanced) comorbidities and other eligibility criteria before sending a referral from primary care to a secondary care; referral should not be sent until all indications for surgery are met. Patients should also be informed earlier about eligibility criteria to motivate lifestyle changes (if appropriate).

Lifestyle counseling

There are inconsistencies in municipalities organizing primary healthcare services and in coordinating lifestyle counseling. Patients’ attitudes to lifestyle counseling are variable.

Phase 2

Problems related to referrals

Incomplete referrals

Anamnestic information

Specialists are unable to comprehensively evaluate patients’ eligibility due to lack of anamnestic information (e.g., comorbidities, anticoagulants). In addition, there is a lack of physical performance indicators that would justify surgery.

Radiographic examinations

Sometimes, imaging referrals or relevant radiographic examinations are lacking.

Contact details

Patient’s (e.g., phone number, address), family’s (e.g., name, phone number, and address), and (if appropriate) health service’s (e.g., hospice care, in-home care) contact details are lacking.

Contraindicated referrals

Processing of referrals

There are inconsistencies in sending back incomplete referrals.

Standardized eligibility criteria

Patients are non-eligible for surgery, but they are still accepted regardless of (unbalanced) comorbidities, obesity, oral or skin health, physical performance, and/or smoking due to lack of standardized eligibility criteria/indications for surgery. There are non-eligible patients in the ImplantDB® register.

Phase 2–3

Problems to meet Health Care Guarantee

Scheduling

Complexity

Scheduling according to The Act on Specialized Health Care is a complex task due to non-eligible patients waiting for surgery, unnecessary appointments, cancelations, re-scheduling, and available resources. Availability of different types of appointments is not adjusted to needs (e.g., control visit, referral visit).

Recourses

Staff capacity

Scheduling of specialist assessments and preoperative surgical visits is hampered due to lack of specialists. Correspondingly, scheduling of surgical procedures is hampered due to lack of scheduling times related to physicians’ shifts and vacations.

Bed and room capacity

Scheduling of specialist assessments and preoperative surgical visits is hampered due to lack of rooms in outpatient clinics. Correspondingly, scheduling of surgical procedures is hampered due to lack of operating rooms and departmental closures (e.g., lack of post-surgery beds).

Re-scheduling

Cancelations

Cancelations prior to preoperative surgical visits cause re-scheduling. The most frequent reasons for postponing surgery have been skin problems, medication, oral health, infections, drinking or eating, decreased health status, and/or anticoagulation.

Phase 3

Problems in patient flow

Preparation for surgery

Room capacity

Acute patient cases lead to a lack of free rooms. Elective patients need to wait for pre-surgery preparations and thus surgery.

Documentation

Lack of electronic drug list causes double documentation prior to surgery. Surgery is documented several times. In addition, bone bank eligibility needs to be re-checked from hip-patients by filling in an interview form.

Laboratory results

Lack of laboratory results causes delays and extra work prior the preoperative surgical visits and surgery.

Preparation for discharge

Organization-related barriers

Organization-related implementation barriers (e.g., lack of commitment, placement, knowledge of discharge criteria), scheduling of daily rounds, and/or challenges in information transfer hinder the fulfillment of discharge criteria in a target time.

Patient-related barriers

Patient-related barriers such as bleeding (e.g., hemoglobin mass alterations), lack of motivation, demobilization (e.g., range of motion, obesity), nausea, pain, and/or lack of escort hinder the fulfillment of discharge criteria in the target time.

Phase 4

Problems in homecare

Rehabilitation

Available services

There is a lack of services in rural areas, distances are too long, and resources to offer home-based physiotherapy are lacking. Generally, patients do not have the same rights.

Patient’s compliance

Patient’s compliance with instructions is hampered due to lack of physical activity and motivation.

Responsibilities between organizations

It is primary care’s responsibility to arrange post-surgery rehabilitation, but the control visit is back at the hospital. Possible follow-up visits and additional need for rehabilitation after the control visit are again organized under primary care.

Information transfer

Information transfer from hospital to primary care is challenging, and thus, there can be mismatches in written instructions and lack of knowledge related to rehabilitation instructions given from the hospital.

Early detection of problems

There is a limited possibility to detect problems with rehabilitation between discharge and control visits (e.g., range of motion, walking technique, leg length discrepancy).

Recovery

Swelling

Patients have problems related to swelling and pain which hamper rehabilitation.

Analgesia

Patients stop taking pain killers or pain killers and prescription run out too early. Unrelieved pain can result in chronic pain at a later date. Patients are afraid of drug dependence. Patients do not know how they could get new prescription.

Phase 1–4

Problems in patient counseling

Resources of counseling

Counseling time

Currently, there is less time than previously to counsel patients. This is caused by the optimization of the current journey prior and post-surgery.

Number of patients

Currently, there is almost a double number of patients within the same time for pre-surgery visits.

Counseling material

There is too much written counseling material prior to and post-surgery. Written materials do not include instructions about later life with a prosthetic joint. Paper-based questionnaires lead to double-documentation prior surgery. In addition, they are often returned empty or they have been wasted.

Consistency of counseling

There are inconsistencies in counseling due to lack of understanding, hurry, job rotation, forgetfulness, and discrepancies in the instruction’s prior to surgery.

Implementation of counseling

Timing of counseling

Counseling given too early (6 months prior surgery) or immediately post-surgery (with nausea and pain) which leads to the patient forgetting things. Currently, there is no time to change lifestyle due to late communication of eligibility criteria.

Patient-centered counseling

Currently, written materials and permission forms are not personalized.

Interaction during counseling

There is a lack of two-way communication prior to surgery. Patients are not ready to ask questions.

Information overflow

All the information is provided in 30–60-min prior to surgery (without routine physiotherapist and anesthesiologist visits caused by optimization of the journey) and in 1.5 days post-surgery. Patients lose and forget essential information.

Content of counseling

Counseling before admission

There is a lack of counseling related to bone bank, detailed information about the operation, management of recent changes in eligibility criteria (e.g., symptoms of flu or gastroenteritis, changes in medication, and/or skin problems), anesthesia and analgesia, as well as medicines, and natural remedies. In addition, patients need counseling related to complications even not of all wishes to hear about them. Current instructions of location, management of referrals, phases of the journey, and ward names are insufficient.

Counseling during hospitalization

There is a lack of counseling related to detailed information about the time of the operation. Patients have worries related to their discharge on the second postoperative day. Patients do not know how and when they can go back home (e.g., sitting by car) and how to use aids. Patients need to understand what the target of the discharge is.

Counseling before discharge

There is a lack of counseling related to recovery (e.g., swelling and wound care), expectations, and rehabilitation (e.g., how to exercise bike and for how long to use crutches). In addition, there is a lack of counseling related to pain management which causes limited physical exercises and thus reductions in the range of motion. Patients want to know whether their recovery is normal, better, or worse than others.

Consequences of insufficient counseling

Patient’s preparation for a surgery

Patient’s inadequate preparation for surgery causes delays, extra work, and cancelations because familiarization with instructions is weak. In addition, walking aids and devices are not available and paper-based instructions are left at home/wasted.

Numerous phone calls

There are a lot of phone calls related to the status of referrals, scheduling, timetables, and nature of the visit prior to surgery. In addition, there are a lot of calls to anesthesiologists related to eligibility criteria during pre-surgery visit. During homecare, there are a lot of contact-requests and re-calls (e.g., certificate of sick leave, lack of painkillers/prescription).

Phase 1–3

Problems in transparency

Unawareness of the patient journey

Confusion

Patients do not understand that all eligibility criteria need to be fulfilled prior to scheduling. Sometimes patients do not know, why they have received a referral. Naming of the wards, the reason for each appointment (e.g., specialist assessment, preoperative surgical visit, surgery), necessary examinations taken (e.g., laboratory results, imaging), and variations in waiting times and care givers causes confusion. Schedule (e.g., length of stay, daily rounds of the surgeon and physiotherapist) and actions taken (e.g., pain management, removal of urine catheter) post-surgery are unknown. Patients wonder when they can get pain killers and see the surgeon and physiotherapist.

Phase 1–4

Problems in receiving feedback

Written feedback

Targeted feedback

There is lack of written feedback or received feedback is published in newspapers. Feedback should be addressed to the right place. There is lack of positive feedback and subjective feedback of benefit to the surgery.