Let's get real: the way things are

When healthcare “professionals'' listen to the steps people must take to get healthcare services, and what those experiences are actually like, understanding begins. As these stories unfold there’s opportunity for gaining even greater insight into the surprises and the feelings associated with the “patient” journey.

This is what happened for Julie and Chandlee as each took in what patients had to navigate to get necessary care and support. It was eye opening to say the least, and helped everyone see that the current state of much of healthcare service, this “as is” system, is where the worlds of the “patient-person” and the “professional-person” meet. And, often unhappily. But, this first step is crucial for determining what needs changing. Paul extrapolates from Julie’s and Chandlee’s stories to describe the tools and methods that are helpful to regularly discovering and documenting the current state of the system


Julie Johnson

PhD, MPH,Professor, Department of Surgery and the Center for Health Services Outcomes Research, Northwestern University

Chandlee Bryan

M.Ed, Career Advisor to Undergraduates, Dartmouth College

Supplementary materials

There are many ways to deepen understanding of the “as is” healthcare system that persons we sometimes call “patients” and “professionals” must navigate. There is often a tension between the “assumed” or “as designed” system and the “as is” system—the one in use.

Much is written and many approaches have been helpful as I have tried to expand and deepen my own ways of knowing. Consider these:

  • Asking those whose jobs involve“front line” systems
  • “Walking the journey”
  • Videotaping the journey
  • Identifying the steps in the journey that are emotionally loaded
  • Creating a “swimlane” flow diagram
  • Developing a process to describe the “current state”

Asking those at work in “front line” systems begins by identifying those involved in day-to-day operations of the system. Using “sticky” notes, name the step or process. We don’t usually name processes, so it may sometimes be awkward. In English, the names often end in “ing” like “admitting” or “prescribing”. Display the notes in a time-ordered way (what usually happens first, then what happens next, and so on), so you can visualize the step by step flow or sequence. Sometimes you can learn who might be “in charge” or who “owns” a particular step—the one who keeps data on the performance or who leads the redesign of the step. Once the initial flow is identified, you can clarify the beginning and ending boundaries to the process. (Note: all boundaries are in some way “arbitrary”.) You may also get a sense of how the best of intentions or “goodness” factor into certain steps that, once illuminated and examined, prove to be unnecessary and of little value.

“Walking the journey” involves physically starting at the designated beginning and walking the steps in sequence. As you walk, note the ways in which there are challenges, when there are repeated efforts, who else might need to be involved, or anything related to reliability, safety, predictability.

Videotaping the journey is a simple way to study the “as is'' system with others. Before videotaping others, be sure to obtain their permission and that you’re able to record appropriately. Simple video recordings done with a smart phone are an easy way to start. Replaying with and for others, commenting on the steps you observed and experienced, allows for deeper insight into the variability that’s usually encountered.

Identifying the steps in the journey that have strong feelings associated with them is best done once you have a graphic representation or “map” of the journey. Consider inviting those who’ve experienced the flow to a discussion to recall feelings of uncertainty, fear, anxiety, joy, or mastery that accompanied the journey. Exploring emotions and what might have contributed to them can inform your understanding. Glenn Robert and his colleagues have written about ways to collect and use this information. (“Experience-Based Design: From Redesigning the System Around the Patient to Co-designing Services With the Patient.” Qual Saf Health Care 2006;15:307–310. doi: 10.1136/qshc.2005.016527. He and colleagues have also developed an extensive web-enabled set of resources External link, opens in new window. now available under the auspices of the Point of Care Foundation.

Creating a “swimlane” flow diagram involves the construction of a picture of the time-ordered flow of the process, explicitly identifying the contributions of persons in various roles.There are many ways to create these. I have found it helpful to use different color “sticky” notes —one for each role is a simple way to begin.

Describing the “current state” is commonly done as part of “lean” process analyses. Many texts are available. Especially helpful are those by John Bichenko: Bichenko J & Holweg M. The Lean Toolbox 5th ed. PICSIE Books, Buckingham, England 2016 and Bichenko J. The Service Systems Toolbox: integrating lean thinking, systems thinking and design thinking. PICSIE Books, Buckingham, England; 2012.


a. Some questions that might be useful with a learning partner:

  1. How does “access” occur?
  2. What sequence of steps are involved? How is the “patient-person’s” aim connected?
  3. When is the system most reliable?
  4. When does it fail and/or seem to struggle with reliability?
  5. What gets documented?
  6. Who works in the system?
  7. What are the risks to safety in the system?
  8. What gets measured and who uses the measures that are gathered?
  9. When is the current system most/least resilient?
  10. Where/when is the system most variable?

b. Some approaches to synthesizing the relevant aspects of the “as is” system’s current state:

  1. Consider the desired outcome of the “patient” and the “system”, offering clearest detail for factors that matter to the desired outcomes
  2. Make a short video clip of the possible, detailed “hot spots” that connect system performance with desired outcomes